An Expert on Entrepreneurship Tackles Health Care Innovation

October 7, 2024

For 35 years, Amar Bhidé taught entrepreneurship—at Harvard, Chicago, Tufts, and Columbia, where he was Lawrence D. Glaubinger Professor of Business. He has written dozens of case studies, synopses of real-world scenarios crafted to spur vigorous classroom conversation, books on entrepreneurship, innovation, and the financial system, and op-eds on public policy issues for the Wall Street Journal, the Financial Times, and The New York Times.

In recent years, he’s increasingly delved into foundational questions about the complex, dynamic advances in productive knowledge. “It’s not just science” he quips. “The steam engine did far more for the laws of thermodynamics than laws of thermodynamics did for the steam engine.”

In January 2024, Bhidé accepted an appointment as a professor in Columbia Mailman’s Department of Health Policy and Management. He teaches the course “Lessons from Transformational Advances,” which digs into a series of case histories Bhidé developed to probe the complex, protracted processes that produced life-altering drugs, devices, and practices.

One case describes how despite a long history and contemporary clinical promise—the widespread use of fecal microbiota transplant to treat gastrointestinal disease has been stymied by regulatory hurdles and provider resistance. The case on tamoxifen shows how tamoxifen became a gold-standard treatment for breast cancer—after failing as a contraceptive.

The overarching goal is to inspire, not just inform students about how new treatments and practices evolve. “The cases show how contributing to progress offers great scope for personal flourishing, whatever your role and whatever your financial reward may turn out to be,” says Bhidé.

Is there a core theme in your work?

Bhidé: I’ve gone from looking at things principally from a businessperson’s, an entrepreneur’s point of view, to trying to understand the overall process of how productive knowledge advances. But the core theme has been the human striving for change and betterment that cannot be reduced to an algorithmic formula.

How did you make the pivot to advances in medicine?

Bhidé: As it happens my mother was a pioneering cancer researcher, and my sister is an oncologist. But, with my general interest in productive knowledge, I could have written about anything—advances in computer science. I didn’t. I wrote about medical innovations. This was lucky. Health care is a broad arena but nonetheless has some common features.

What do you hope your students take from the case studies?

Bhidé: The process of practical advances is complicated, protracted, and involves a large cast of characters. There is instrumental and humanistic value in appreciating these processes: We could do things better in the future if we understand how past advances come about. They also teach us what makes us human.

In December, Oxford University Press will publish your fifth sole-authored book, Uncertainty and Enterprise: Venturing Beyond the Known(link is external and opens in a new window). How did it come about?

Bhidé: The book represents the culmination and synthesis of much of my writing and research. There are also many points of overlap with the seminar on transformational advances I’m currently teaching. The case studies have informed the book and the ideas that I’ve tried to distill in the book have informed how I’m teaching the course.

What are the foundational principles of Uncertainty and Enterprise?

Bhidé: We cannot or should not be sure of anything. We cannot be sure of what is or what was, and even less what could be or what should be. We can have only conjectures, provisional hypotheses that combine imagination and evidence. And inevitably, our conjectures diverge while much of our actions are interactive. We can’t act unilaterally. Imaginative yet grounded discourse plays a crucial role in aligning our conjectures.

Who is your target audience?

Bhidé: I want to persuade mainstream economists that there’s a broader way of looking at the world that—if they adopted it—could be beneficial to themselves and to society. A second target is the intellectually curious, possibly “highbrow,” general reader about the rewards, challenges, and reasonable ways of dealing with uncertainty that is so central to our lives, yet are often ignored in economics and decision theory. I don’t however want to pick a fight with mainstream economics or provide cookbook recipes to general readers.

This fall, Project Syndicate published your op-ed calling large learning models “mendacious talking horses(link is external and opens in a new window).” Another for Barron’s(link is external and opens in a new window) calls out the current AI investment craze a mania. What sparked your ire?

Bhidé: Writing my Uncertainty book has a lot to do with it. I tried to use LLMs to research, edit, and illustrate the book—it was a source of unending frustration, though “earlier” AI was invaluable. I also studied the evolution of AI for my book. AI grew out of a “fork” in the cognitive revolution of the 1950s and 1960s which conceived of the mind as a computer, often relying on statistical models to recognize patterns. A second fork treated the mind as a “meaning constructor” where meaning was highly contextual, historical, and cultural. Both forks have value.

Long before LLMs, statistical AI had proven its worth in many applications. But reducing all thought and speech to a mindless statistical model is absurd. Yet that’s what many LLMs try do. The LLM mania also ignores the protracted trial and error through which cost-effective AI applications have emerged over the last 70 years. The mania also shows how ignorance of how transformational technologies like AI evolve can become a social menace.

The office is small and windowless. No matter. I would have been happy with a carrel.

My first academic office in AY 1979-80 was also windowless. I was an “Associates Fellow” – a glorified HBS case writer. I shared the office with a doctoral student, now a famous professor of International Business, who was prone to play his flute at midnight (when we were both swotting away).

I had some truly splendid offices when I became a “real” academic. One, a corner office in Baker Library at HBS, overlooked the tennis courts. Apart from the fine view, I could keep an eye on the courts and spontaneously rustle up a tennis game. It was also an easy dash to the gym (which I could also see).

My most recent office at Tufts – also a corner one – had an even better view — of a greensward. I believe Tufts has the prettiest campus in the Greater Boston area, thanks to the hilly topography. But I never really took advantage. I was a WFH trailblazer.

Yet for all that, the year in my first windowless office was the happiest of my academic career. I was mighty productive and loved my shared space and the camaraderie of the other case writers.

I hope what is past will be prologue – and that giving up a chaired professorship will be worthwhile. The goal — to make the writing and teaching of case histories of transformational advances in medicine and beyond – may be a foolhardy capstone/post-retirement project. But the grey hair notwithstanding – I hope there is still some fight left in this old chap. And if anyone wants to consider teaching a case history course, give me a shout. I am eager to help!

In April 2015 I had dinner with an old friend in Paris, who also happens to be the retired founder of a storied biotech company.  He looked in unusually splendid shape and being a competitive sort I was most curious why.  He told me elliptically that much of what we know about nutrition is wrong.  I eventually wheedled out of him the information that he had converted to a Paleo (very low carb/sugar) diet.

That dinner conversation was life altering — well at least diet altering. I gave up all deserts, bread, rice, potatoes, oatmeal breakfast, cranked up on pumpkin seeds and almonds and began to ferment my yogurt for at least 24 hours (to reduce sugar content).

Later that year, in September I decided to take a glucose/lipid test.  Horrors: my total and bad cholesterol had gone up. It had always been highly variable and borderline high, so I consulted a cardiologist. She wanted to put me on statins immediately, but I asked for an angio-CT (basically x-rays of my coronary arteries)

It showed a low single digit calcium score (which I’m told is good) but also mild arterial plaque.

And apparently I had the bad kind of bad cholesterol (small molecule) and the not so good kind of good cholesterol (again small molecule)

The cardiologist of course saw this as proof positive that I should be on statins. 

I refused.  Another physician friend of mine then suggested I look into the Esselstyn diet http://www.dresselstyn.com/site/

This is supposed to have the potential to *reverse* plaque but it would also require further measures, namely going vegan – and giving up oil and nuts.

I then happened to be in Stockholm and discovered that oatmeal yogurt is “thing”. Further investigation suggested that yogurt making bacteria can pretty much chow down on anything with carbs or sugar, so my new breakfast routine became “yogurt” created by blending oatmeal, quinoa, chia seeds, hemp protein and bananas and letting that blend ferment for several days….

Lunch comprises cake whose “batter” consists of fermented quinoa, spiced up Indian style, and baked with no oil or butter.

Dinner? I don’t eat dinner. A glass of red wine does the trick.

Sticking to the diet is no easy task but the results have been remarkable. I also lost about 20 pounds..

This is *not* a recommendation.  Worked for me and may not work for anyone else…

Fortunately, miraculously, by the end of the term, I thought it was the most substantive course I had ever taught, but it was far from the smoothest and I was on tenterhooks about what the student evaluations would say.

They did not disappoint. I have never received so much feedback about case quality. That to me was also the biggest unknown (I believe that after 30+ years I’m now an adequate teacher): could really dense, technical/historical cases with no protagonist “work” in an HBS class? Fortunately, the answer at least for students who chose to stick with the course seems to be yes – though a lot of work remains to realize the potential.

But where?

It’s a pity that after investing heavily in the offbeat experiment, HBS can’t/won’t see a way to continue it. Anticipating just this, I had started talking to places where there might be a better fit for the course even before I started teaching it. I hope the evaluations help, and as Mr. Micawber said, something is bound to show up!

I said at the end of the last class that teaching my entrepreneurship course is like being a tour guide at Disneyland. I know every ride, there are no surprises, virtually ever.

Teaching this was like being a rookie whitewater rafting guide in class 4 or class 5 rapids: Thrilling, but at any moment could end in disaster.

And you have to make it up, moment by moment.

The final class was no exception. The case was on Cicely Saunders’s founding of the modern hospice movement, as told by her brother, Christopher. (He’s an HBS MBA 1950 who has been a friend for several decades now.)

Christopher, now 94, attended class via Zoom as did his daughter, Kate. Kate is Chair of Trustees at the Arthur Rank Hospice in Cambridgeshire.

Christopher was tired — or the connection was bad perhaps. But his daughter filled in splendidly.

The Big Surprise was my HBS ’79 classmate, Tom Dickerson. Tom used to be a health care VC and more importantly, as he told me on a walk on Sunday, his wife had died in a hospice. So, I had invited Tom to class. As always, he was eloquent and engaging. (He is a 3 H after all).

Of course, that meant completely changing my teaching plan on the fly.

I think it – and the course — worked. But my taste isn’t everyone’s taste. Most curious what the students will say.

As of next Thursday, I had hoped to have taught all 15 in my Transformational Medical Innovations course. (Teaching a new full credit elective with all new cases might be a record too).

Regardless, yesterday’s class upset the plan. I assigned two cases — and invited a superstar cancer researcher Michel Sadelain, as the guest for the first of them. I thought I’d teach the case for about 45 minutes, turn it over to Michel for 15-20 minutes and then move on to the next case. (I had been told Michel didn’t have much time).

About 30-40 minutes into the case discussion, I asked Michel if he could stay a little bit longer.

He said he was finding the discussion fascinating so I should take as long as I liked.

Long story short. Never got to the second case. And Michel was inspirational. Just stellar.

And it may be the best class I have ever had. It is a high that’s hard to describe.

The other guests and classes have been uppers as well.

I am one lucky dude to have had this chance, if only once.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7528968/?report=classic

Ends and Means.

Popular media routinely tout imminent breakthroughs that often fizzle. Our case histories of treatments and tests that actually revolutionized medical practice in the last quarter of the 20th century, reveal patterns still common in medical innovation today. They show how protracted, multiplayer innovations – not solitary breakthroughs – typically produce transformational results. Yet venturesome individuals who won’t follow the crowd remains crucial.

The case histories present a vast number of facts through engaging stories which make the facts more memorable and easier to recall. Yet the course treats learning new facts mainly as a valuable byproduct. Rather we use the case histories to support innovators in two more subtle ways, namely:

Developing skills and judgment, particularly in recognizing opportunities and anticipating problems, adapting ideas from other domains, evaluating alternatives and so on. Learning by personally doing – or by personally watching – is often crucial for developing ‘skills of the hand,’ such as changing a car tire. But for many ‘skills of the mind and heart,’ learning from past instances is more practical and feasible. Studying historical wars and battles has long been an important part of training military leaders for example. Moreover, the skills and judgment emphasized go beyond particular techniques (which may become obsolete) and support more than just medical innovations.

Sharpening goals and aspirations. The case histories include stirring stories that showcase the romance of human progress. But they do not preach or sugarcoat: they include controversies about the marketing of antidepressants and the overuse of expensive procedures. Great adventures, they remind us, require great risks and difficulties and succeeding in what’s safe and easy – or just financially rewarding — is not always uplifting. In the coronary bypass case for example we encounter a German researcher who fails to “meet the scientific expectations” of his boss, loses his job, switches from surgery to urology, joins the military, and becomes a prisoner of war. Eventually he gets a Nobel prize, but can never secure a professorship because he had not finished his PhD. Another surgeon who performs the first successful bypass is forbidden from doing another. An Argentinian who then does many bypasses at the Cleveland Clinic and comes to be known as the ‘father’ of the surgery, ends up committing suicide after the institute he starts in his homeland cannot pay its bills.

The case histories may therefore discourage some from attempting risky leaps, but they should nevertheless inspire even those with cautious natures. Unlike hagiographies of larger-than-life innovators, the stories have ‘ensemble’ casts. Stars appear but don’t dominate. Rather the stories show how innovation accommodates a wide range of talents and temperaments. Prudent contributions we will see can make a difference. Therefore, the course should help stimulate your aspirations – for any kind of accomplishment — but not past your personal breaking points.

The course’s emphasis on skills, aspirations, and stories reflects my experience of teaching and researching entrepreneurship for more than thirty years. Conversations with former students suggest that the emotional and visceral aspects and stories of startups leave a more profound and lasting impression than the analytical aspects. When I surveyed self-employed graduates of HBS’s MBA program (Links to an external site.) I asked what they wished they had better learned. Most responses related to skill development (learning to sell, for example) and exposure to the stresses of starting a business.[a]  Similarly, my research on high-growth companies (Links to an external site.) suggests that a startup’s success depends more on the founder’s skill and determination than on creative business ideas and models.[b]

That said, we will use a framework I previously developed for a seminar on practical knowledge as a “simple walking stick.”  The framework, described in detail in my Note on Productive Knowledge, treats innovation as a multiplayer process undertaken by and for the many, rather than as an elite or exclusive activity. The Note also classifies the common tasks of multiplayer innovation (into categories such as goals setting, evaluation and testing, codification, and communication). Like tags and playlists in a music collection, the categories can help us sharpen, order, and retrieve observations and inferences made from the case histories. The categories should also continue to support your learning and development long after the particulars of this course are forgotten.

The analytical framework (like the skill and attitudinal development targeted in this course) is designed to be useful in a wide range of domains. As the readings show, broad based, multiplayer (rather than ‘star-centric’) advances have become a crucial feature of innovation, as have its common tasks and challenges. Similarly, although the specific case histories we analyze are medical, class discussions will include broader conversations about the general challenges of multi-player innovation. For instance, we may (as time permits) discuss goal setting and problem specification tasks along with the Tamoxifen case history. A few additional readings (see the daily assignments section of this syllabus) and a more extensive optional reading list will stimulate these broader discussions.

Pre-class submissions.

The case histories contain specific questions after each section and at the end. Students are required to enter very brief answers (less than ten words) to the questions on an online form by 9 am of the day of each class. I will create power point slides from the submissions which I will use to start the class (instead of the traditional student ‘opening’) and to continue the class discussion.

The submissions require less than an hour of additional work over the course of the term.

My experience since 1991 (when I first started requiring such submissions at HBS) suggests that this modest additional effort provides attractive returns, including: 1) Practice in confronting the uncertainties that innovators typically face. 2). Classes with fewer superficial comments because students are better prepared and, more importantly, have a point of view. 3). Broader participation:  I can draw in the quieter, well-prepared students with prior knowledge of their perspective on the case. 4) The elimination of anxiety about being asked to open a class.

If you do not submit a response, I will assume you have also not prepared the material. However, if you have a technical problem, do not waste too much time trying to submit your response. Just send me an email telling me that you tried but could not; I will take you at your word. Likewise, if you cannot submit because of a personal emergency, please let me know.

(As with traditional case courses, the assignments for each class include questions raised by the case histories that will provide the basis for discussions about the broad ‘takeaways.’)

Final Paper.

Instead of a final exam, self-selected groups (of up to 3 students) will write papers describing and analyzing the development of a noteworthy (medical or non-medical) advance that has already proven its practical value. Like the final papers written for my entrepreneurship class (see the compilation, Tales from Successful Entrepreneurs) the papers should include: a description of what happened (the “story”); analysis of specific choices (that reflects what you learned in this); and general reflections and takeaways. (A companion memo describes detailed guidelines, non-negotiable rules, and the criteria I will use to evaluate the papers).

Grading.

My grading favors regular and conscientious contribution over occasional brilliance and values learning over sharply “objective” grading. Thus, for example, I would not use a “difficult” exam instead of a final paper, merely to produce more “defensible” grades. I also have greater confidence in my ability to evaluate final papers than class participation but recognize that participation contributes more to the “common good.”

Accordingly, I will divide class participation and final papers into five roughly equal “buckets”, A through E. I will then use the sequence of bucket combinations shown below to assign Category Is and IIIs to reach the maximum Is permissible and the minimum IIIs required.

Sequence for assigning Category Is and IIIs (going from the top down)

Note: Failure to meet requirements will lead to an automatic Category III, or in extreme cases, a Category IV.  Specifically, more than two absences or missed pre-class submissions (out of the 12 classes remaining after the add-drop period ends) without good cause, as defined by the MBA program, (Links to an external site.) constitute a failure to meet requirements. If you choose to miss class for other reasons, your absence will be counted towards your “quota” of two classes.

[a] Bhidé. 1996. “The Road Well Traveled: A Note on the Journeys of HBS Entrepreneurs.” HBS Case 396-277 (Links to an external site.).

[b] Bhidé 2000. The Origin and Evolution of New Businesses. New York, NY: Oxford University Press, 2000 (Links to an external site.).