Long before Clayton Christensen became a towering figure in business theory, a celebrated Harvard professor, and the father of “disruptive innovation,”1 he faced a defining moral crossroads as the starting center for the Oxford University men’s basketball team. His team had made it to the championship game, but it was scheduled for a Sunday—a day he had vowed to observe as the Sabbath. In a decision that caused a ripple effect far beyond the court, Christensen chose not to play. Although his decision may seem insignificant, it reflected an important lesson about the nature of compromise. He later reflected that “it’s easier to hold to your principles 100 percent of the time than 98 percent,” suggesting that each small concession can unravel the values we claim to uphold.2 Christensen’s work is useful for the medical profession, which must adhere to ethical practices and solve various problems. The lessons learned from Christensen are applicable in the current health care system as it grapples with new challenges, such as the advent of telemedicine and debates on equity. This editorial considers 2 crucial lessons from Christensen’s work: the need for disruptive innovation and maintaining human integrity. DISRUPTIVE INNOVATION IN HEALTH CARE Christensen’s theory of disruptive innovation, introduced in The Innovator’s Dilemma, revolutionized how we understand the concept of progress. Disruptive innovation occurs when smaller companies cater to an underserved sector of a consumer market that more established companies overlook (Fig. 1). This innovative and purposeful targeting helps the smaller companies gain the resources needed to displace and overtake the established competitors.Fig. 1.: Disruptive innovation.Honda provides an example of disruptive innovation in the motorcycle industry. Honda motorcycles were initially considered low-end products; however, Honda began to manufacture easy-to-use and affordable motorcycles, such as Super Cubs, which targeted the lower-income market segment that other established companies neglected. This helped Honda further refine its products and start targeting the upper end of the market, thus disrupting the industry.3 Christensen’s idea that systems in place should always seek to be disrupted in pursuit of improvement is relevant to the current health care environment. For example, telemedicine—initially a forced stopgap measure during the COVID-19 pandemic—has become a pillar of modern care, particularly in underserved communities.4 The examples of Honda motorcycles and telemedicine embody Christensen’s idea of starting small and scaling to meet unmet needs.5 Disruptive innovation applies to more than technology. Take, for instance, the growing use of palliative care and lymphedema treatment. These fields, once on the fringes, are now challenging preexisting notions of what is considered a medical specialty, thus forcing the industry to face its limitations and possibilities. Another example of disruptive innovation is supplied by Dr. Paul Farmer, who changed the practice of health care delivery to low-income communities by implementing community-based health care and tuberculosis treatment. Farmer’s community care approach, besides providing medication, supplied patients with food packages and a professional who offered emotional support. Farmer’s approach led to a 100% cure rate for Haitian patients with tuberculosis, proving the importance of a multifaceted medical approach in underserved communities.6 Dr. Gazi Yaşargil, a Turkish neurosurgeon, played a key role in the advancement of modern neurosurgery, mainly through the development of microsurgical techniques. He invented the floating microscope, the self-retaining adjustable retractor, and ergonomic aneurysm clips and appliers. The invention of these instruments revolutionized surgery, making cases that were previously considered untreatable by cerebrovascular neurosurgery, such as brain aneurysms, possible to remedy.7,8 To become a disruptive innovator, it is essential to ask the right questions and conduct thorough research (Fig. 2). The first step is identifying unmet needs in the current market, seeking to discover where solutions are lacking and what customer segments remain underserved.Fig. 2.: Steps in disruptive innovation.This groundwork helps pinpoint opportunities for innovation, which typically fall into 2 categories: low-end disruption or new-market disruption. Low-end disruption occurs when innovators develop a product or service that initially offers inferior performance compared with existing high-end competitors. These offerings are targeted at price-sensitive customers or those who prioritize affordability over performance. Over time, as the product improves, it begins to attract higher-end customers, challenging established companies and their products. New-market disruption creates a new market that sees to unserved or latent needs. These innovations attract a new customer base, expanding the market while potentially drawing customers away from traditional companies. This shift challenges established businesses as the new market grows in popularity and profitability.9 Both types of disruption begin by seeking to uncover market gaps. Innovators must determine whether they are creating a new sector within an existing market or establishing a new market. They must also investigate how products can be simplified, made more accessible, or priced lower to broaden their appeal. Leveraging emerging technologies can facilitate innovative solutions to close these gaps. Beyond profitability, innovators should consider the broader benefits their product or market might offer, such as creating jobs, enhancing infrastructure, expanding technological advancements, or fostering new industries. Focusing on these long-term benefits from the outset can help ensure a sustainable and impactful disruption. The health care industry can apply Christensen’s disruptive innovation framework to assess and challenge the status quo, conduct research, track patient results, and test new ideas. For instance, artificial intelligence diagnostics or virtual reality surgical training can enhance the efficiency and effectiveness of treatment.10 Christensen’s approach of engagement, involving multiple stakeholders and encouraging multistakeholder conversations, provides a clear strategy for sustainable innovation.5 PERSONAL INTEGRITY AND VALUES Disruptive innovation drives change, and ensuring that innovation is conducted ethically is essential.11 In an era where speed and profit increasingly compete with integrity,3 Christensen’s steadfast belief in personal integrity feels almost radical. Modern pressures to suppress integrity for personal or financial gain will lead some people to make extreme decisions with severe consequences. The opioid crisis was initially driven in large part by overprescription of opioids. Most clinicians prescribed these drugs in good faith to treat their patients’ pain, but in some cases, physicians have been convicted of illegal prescribing practices and fraudulent billing for financial gain, with devastating consequences.12 Research fraud leads patients to distrust physicians and the health care system.13 As an example, Scott S. Rueben, an anesthesiologist with financial ties to manufacturers of COX-2 inhibitors, fabricated data in at least 21 studies endorsing COX-2–inhibiting drugs for postoperative pain management in orthopedic surgery, which may have prolonged recovery periods for the patients receiving this therapy. Once the fraud was discovered, pain management practices in orthopedic surgery needed to be reconstructed, and patient confidence in their doctors, and the health care industry, was undermined.14 As Christensen warned, small compromises can unravel the fabric of trust that underpins fields like medicine and health care.14 His reflections in How Will You Measure Your Life? underscore this message.2 Amid stories of corporate executives and fellow Harvard alumni who achieved outward success but faced personal and ethical failures, Christensen challenges readers to pause and reassess their own trajectories.2 For physicians, the stakes are incredibly high: cultivating patient welfare, fostering a culture of accountability, and upholding ethical standards are nonnegotiable.15 There needs to be a prioritization of ethical behavior from the outset to avoid compromising values and ensure sound decision-making.16 This requires fostering a culture of integrity that permeates all aspects of the workplace,17 starting with hiring practices. Organizations should actively seek candidates who demonstrate qualities of integrity through targeted interview questions and background checks.18 Moreover, fostering a workplace culture that is centered on trust and respect is essential. This means ongoing conversations about integrity and adherence to key policies, such as the Health Insurance Portability and Accountability Act, to safeguard sensitive information and prevent data breaches. Implementing accountability and promoting risk awareness further reinforces this commitment.19 To maintain high ethical standards, employees should be held to rigorous expectations, with systems for regular feedback and self-reflection in place to encourage continuous improvement.19 A workplace culture that prioritizes integrity must also emphasize clear communication about risks and discourage cutting corners. By setting a high bar and consistently reinforcing these principles, organizations can create an environment where ethical decision-making is easy to uphold.20 Disruptive innovators must be willing to put personal ethics and long-term benefits before personal and financial gain. Christensen’s teachings remind us that progress and principle need not be at odds. The most enduring innovations often arise from a foundation of integrity. Christensen’s lessons are challenging and motivating for health care professionals to think, change, and focus on the human being amid change. When faced with challenges—such as the integration of artificial intelligence or the correction of inequities—Christensen’s wisdom provides a direction. The future of medicine depends not just on the brilliance of its practitioners but on their willingness to embrace disruption while holding steadfast to the values that matter most. In the words of Christensen: “Doing deals does not yield the profound rewards that come from building up people.”2 As for Christensen’s teammates who suddenly found themselves without their 6’8” center? They won the championship without him. “Which means, I guess, I wasn’t that important to the team. But you know, as time has passed … it looms as one of the most important decisions I have ever made.”21 DISCLOSURE Dr. Chung receives funding from the National Institutes of Health (NIH), and book royalties from Wolters Kluwer and Elsevier. The remaining authors have no financial interest to disclose. No funding was received for this work. acknowledgment The authors thank Mike Stokes, staff vice president of communications at the American Society of Plastic Surgeons, for peer review and edits.
Mirza et al. (Wed,) studied this question.