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.

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.).

Case studies documenting how similar problems were overcome in the past can provide reminders of forgotten solutions. And, for unprecedented problems, historical analyses may improve our understanding of why these problems did not previously arise and suggest ideas for what might be done to solve them now.

Studying “who did what, when, and why” should be particularly useful in addressing problems of bottlenecks and linkages. Scholars of technological innovation have shown that the successful development and widespread use of new products and services is the result of extended interactions between many individuals and organizations. These include scientists, engineers, designers, marketers, financiers, regulators, and not the least, users, who contribute different kinds of skills, knowledge, and resources and solve related but different problems. Technological advances are thus the result of what one of us (Amar) has previously called an ongoing, massively multiplayer game.

Bottlenecks and incongruencies are inevitable in such a game. In medicine, for instance, fundamental scientific breakthroughs may run ahead of the development of treatments. And the best treatments under well-controlled experimental conditions may be inferior in large-scale deployment (for instance, because of inadequate mechanisms to ensure patient compliance). Case studies encompassing multiple players and how they interacted with each other, and over time, to resolve bottlenecks and incongruencies should provide useful rules of thumb about effective rules for reforming the current medical advances game.

More broadly, studying medical advances could improve our understanding of “productive knowledge.” Scholars of the history of technology like Vincenti have persuasively argued that engineering is not merely applied science, although it often draws on – and contributes to — the natural sciences. Natural sciences focus on discovering “how the world works” in ways that may not be suited to fields such as engineering, medicine, business, education, and public administration, whose principal purpose is to develop artifacts that don’t exist in nature and are intended to make the world a better place. Thus both the natural sciences and fields of useful knowledge may aspire to be evidence-based, but the kind of data collected and how it is used can be materially different.

In medicine, for instance, Gawande’s WHO team blended expert hypotheses with rough and ready iterative testing to develop surgical checklists. Medical devices are also developed through similar processes. These would not be considered good practice in traditional scientific research.

Understanding and highlighting the distinctive features of useful medical research (as has already been done in engineering) should help prevent the dogmatic misapplication of the scientific method and possibly improve appropriate alternative practices. Moreover, the benefits could extend beyond medicine into fields such as economic development and financial regulation. The recent fashion for randomized experiments in the social sciences, if not appropriately bounded, has the potential for considerable waste of resources and even outright harm.