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Innovation

# Bringing Minds Together

- John Abele

From the July–August 2011 Issue

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Bringing Minds Together

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###### July–August 2011 Issue

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#### Executive Summary

Reprint: R1107F

Boston Scientific founder John Abele has been party to his share of groundbreaking innovations over the years. But the revolutionary advances in medical science that these breakthroughs brought about were not the efforts of one firm alone, let alone one inventor.

Abele tells two fascinating stories of collaboration—one about Jack Whitehead’s upending of hospitals’ blood and urine testing procedures and the other about Andreas Gruentzig’s success in bringing balloon catheterization into the cardiology mainstream. Both Whitehead and Gruentzig spearheaded the emergence of entirely new fields, bringing together scientist-customers to voluntarily develop standards, training programs, new business models, and even a specialized language to describe their new field.

The process of collaboration, Abele says, is fraught with contradictions and subtlety. It takes consummate leadership skills to persuade others to spend countless hours solving important problems in partnership with people they don’t necessarily like. Moreover, managing egos so that each person’s commitment, energy, and creativity is unleashed in a way that doesn’t disadvantage others requires an impresario personality. Finally, true authenticity—something that few people can project—is critical for earning customers’ trust and convincing them that their valuable contributions won’t be used for anything other than moving the technology forward.

#### The Idea in Brief

Some projects that are touted as collaborations are like Potemkin villages—great facades without much substance behind them. Meanwhile, some of the best collaborative efforts aren’t even seen as collaborations. For instance:

- Automated chemistry analysis is known as Jack Whitehead’s great accomplishment at Technicon—but his real gift was in assembling the early adopters who would advance the technology as a community.

- Andreas Gruentzig invented an ingenious technique for balloon catheterization. But the real breakthroughs wouldn’t have come without the input of many other innovators—and the humility he displayed about what had so far been achieved.

- The Live Demonstration Course is seen by most as a surgical training method—and a controversial one at that. Its real value, though, lies in the “wisdom of crowds” approach to advancing and proliferating the best new techniques.

Software tools for collaboration abound, but it’s the soft skills that bring minds together.

Artwork: Geoffrey Cottenceau and Romain Rousset, Recrutement, 2008

When I was invited to submit an article to this spotlight on collaboration, the first question I asked was whether the other contributors and I would have the chance to interact and perhaps integrate our ideas on the topic. I knew that Harvard Business Review was deeply rooted in a scholarly tradition—and that worried me. Academic collaboration, I’ve learned over the years, is something of an oxymoron. More often than not, what is described by that term is really non-collaborative, or worse, pseudo-collaborative work, driven by the long-standing rituals of institutional seniority and the professional and financial incentives to build higher silos with thicker walls. That’s a shame since it is our universities that are supposed to have the intellectual force and license to find bold solutions to important problems. On the bright side, there’s an extraordinary opportunity for those of us nonacademics who, unconstrained by those customs, see value in getting silos to collide.

The individuals in the stories you are about to read were naturally skillful silo-colliders. Their success in breaking down barriers between and within the scientific, medical, academic, and business communities taught me most of what I know about making progress through collaboration.

#### Community Building, Establishment Bucking, and Collaboration

Community building begins with convincing people who don’t need to work together that they should. This depends on:

- Inspiring them with a vision of change that is beyond any of their powers to bring about individually

- Convincing them that the other collaborators are vital to the effort and equal to the challenge

- Preventing any one party from benefiting so much that the others feel their contributions are being exploited

Establishment bucking can’t be avoided. When a group collaborates on a new solution, there’s usually another, bigger, group invested in the way things are done today. Be sure to:

- Recruit some of their respected players into your vanguard

- Create your own center stage to prevent your star project from being pushed into the wings

- Downplay, rather than underscore, the threat your breakthrough poses to their livelihood

Collaboration is the natural by-product of leaders who are

- Passionately curious—who crave new insights and suspect that others have them

- Modestly confident—who can bounce ideas off brilliant collaborators, without turning it into a competition

- Mildly obsessed—who care more about the collective mission than about how achieving it will benefit their personal fortunes

…and may be the only leadership mode that produces breakthrough results.

My perspective is that of an entrepreneur whose entire career has involved breakthrough innovations, mostly in the scientific and medical domains. This wasn’t “serial entrepreneurship”—it was long-slog enterprise building in an environment where much of what my colleagues and I did was viewed as politically incorrect. We were developing new approaches that had huge potential value for customers and society but required that well-trained practitioners change their behavior. Despite the clear logic behind the products we invented, markets for them didn’t exist. We had to create them in the face of considerable resistance from players invested in the old way and threatened with a loss of power, prestige, and money. Prospects had to be sold on not just our solution but our reframing of the problem, requiring from them a lot of learning—and unlearning of old techniques. Any of the products could have served as the poster child for what Clay Christensen calls “disruptive innovation.”

## Cash Up Front and Build It Yourself

I got my first glimpse of that kind of collaboration many decades ago, but it continues to teach me lessons to this day. Shortly after I graduated from college (Amherst ’59), I went to work for a small company in the Boston area called Advanced Instruments. The lab instruments it made—an osmometer that measured particle concentrations in solutions and a flame photometer that measured ions in solutions—were new to the marketplace, so we regularly invested in booths at the major conferences and trade shows. When traffic in the booth was slow, we’d spend time getting to know folks from neighboring exhibits. At one of those conferences, in 1960, I met Jack Whitehead, the CEO of Technicon. I subsequently came to know his company pretty well. Its success is more than just a surprising business story. It’s the kind of effort Margaret Mead had in mind when she said, “Never underestimate the power of a small dedicated group of people to change the world. Indeed, it’s the only thing that ever has.”

Technicon was originally a maker of tissue-processing equipment, and that was a nice business, but slow growing. Jack had been on the lookout for new technologies that would allow him to dramatically expand his business. He made the bold decision to buy the patents and prototypes for a machine that automated the process of analyzing certain chemicals. The doctor who’d invented the machine was a clinical chemist—the person who runs the hospital lab that tests blood, urine, and other body fluids—and his creation was truly amazing. The liquid samples poured into it were transported through transparent tubing made of hydrophobic (water-repelling) materials. Each sample beaded up in the tube rather than spreading out. Air bubbles separated the samples and prevented cross-contamination. Along their journey through the “bubble machine,” the samples would pass through a spectrometer, a device that determines the absorption of various wavelengths of light in a liquid sample and thereby indicates what chemicals, and in what quantities, are present.

The inventor was, naturally, proud of his achievement. But when he tried to sell it to the big laboratory supply companies of the time, he was turned down flat. That may seem baffling, given the fact that such instruments now constitute a multibillion dollar business, with millions of tests being carried out daily. But this was the early 1960s, when physicians were ordering very few tests, and there were plenty of lab technicians to do them. Even the leading instrument makers couldn’t see the point of automating the process. More important, the professional societies weren’t on board. Not only did they believe that no more tests were needed, they were downright hostile to any outsider who had the temerity to tell them otherwise. To say that this was a new and disruptive technology without a defined market would be an understatement. And although the big companies were pretty good at selling accepted products, they were not (and still are not) up to that kind of challenge. Even if they could envision the change such a machine would usher in, they couldn’t manage the culture-changing activities that go with creating new markets. But Jack could.

His outgoing personality and powers of persuasion worked in his favor, but he also came up with a radical sales process. Pointing out that the instrument was new and would remain unique because it was protected by lots of patents, he told all interested buyers that they’d have to spend a week at his factory learning about it—and that payment was required in advance. The training would cover how the instrument worked, what might go wrong, how to fix it, how to use it for different applications, and how to develop new applications. Customers even had to put their own machines together.

Those might sound like terms that would discourage people from buying the machine. A week is a long time for busy scientists, and the factory was nothing fancy. Demanding the money up front seemed pretty aggressive. But every field has its early adopters, and Jack was good at finding them.

The real magic of the approach, however, was in the extraordinary dynamic it created among the participants. Working in Technicon’s factory, thinking about applications, they didn’t feel like customers, they felt like partners. They got to know Jack and his staff. They worked like the devil during the day and played pretty hard at night—sometimes the reverse. They got to know one another very well. They became a kind of family.

When the week ended, those relationships endured and a vibrant community began to emerge around the innovation. The scientist-customers fixed one another’s machines. They developed new applications. They published papers. They came up with new product ideas. They gave talks at scientific meetings. They recruited new customers. In time, they developed standards, training programs, new business models, and even a specialized language to describe their new field.

It wasn’t long before Jack’s “band of brothers” had become sufficiently large and was producing so many new ideas that he decided to convene what he called the Technicon Symposium. This was pretty heretical since academic societies planned and sponsored all the scientific conferences at the time; companies like Technicon were relegated to the exhibit halls. But the symposium served a clear need, and over the years it grew in size and prestige until it rivaled the professional societies’ meetings in quality and reputation. Jack had formed a “user group” long before that strategy had been conceived. He had created a culture in which everyone was both a leader and a follower. It wasn’t about money; it was about being a pioneer in a new field.

Watching how this unique strategy helped the field advance and Technicon succeed had a profound effect on me. Most of my colleagues saw what Jack was doing as creative marketing and aggressive business strategy. But I saw it differently, and by now I know that something much bigger was actually going on. He was launching a new field that could be created only by collaboration—and collaboration among people who had previously seen no need to work together. Thanks to Jack’s efforts, a group of scientist-customers self-organized to do something he never could have done on his own: advance the responsible development of automated chemical analysis.

Jack was launching a new field that could be created only by collaboration among people who previously had no reason to work together.

As I watched this experiment evolve, and later applied its lessons in my work and philanthropic activities, I came to realize that the kind of collaboration Jack made look simple is in fact a process fraught with contradictions and subtlety. It takes a great collaborative leader. Persuading people to contribute countless hours of effort in partnership with people they don’t necessarily like to solve important problems requires consummate leadership skills. Managing egos so that each person’s commitment, energy, and creativity is unleashed in a way without disadvantaging others demands an impresario personality. Earning customers’ trust and convincing them that their valuable contributions won’t be used for anything other than moving the technology forward requires an authenticity few people can project.

The interaction and progress Jack enabled was never heralded as collaboration, though that is what it was. Indeed, I’ve learned that some of the best collaborative efforts don’t look like collaborations. And some projects that are touted as collaborations are Potemkin villages—great-looking facades with no substance behind them.

## Two Inventors, One Breakthrough

In 1967 I left Advanced Instruments on friendly terms. Having risen from a sales engineer to general manager of that privately owned company, I was eager to strike out on my own. I soon bought a fledgling start-up called Medi-Tech, which later became Boston Scientific. Its product was a steerable catheter—an amazing integration of chemical, polymeric, metallurgical, mechanical, and processing technologies that allowed users (practitioners in radiology, cardiology, gastroenterology, and urology) to use fluoroscopic imaging to remotely guide a catheter or device to any location in the body. To advance the technology and build a market for it, I turned to Jack Whitehead’s strategy of creating a community of users to share applications, education, and research. Although the field wasn’t that big, our technology was visibly impressive to brilliant inventor-physicians, and our collaborative strategy differentiated us. We lacked the resources and name recognition that many of our competitors had, but we became known as trustworthy innovators who would listen, share, and ask good questions. Our competitors vied to take opinion leaders out to dinner. Opinion leaders took us out.

Our collaborative outreach led us to a young angiologist by the name of Andreas Gruentzig, who had developed a balloon catheter (a tube with a sausage-shaped balloon at the tip) for the purpose of enlarging narrowed arteries without surgery. He actually built the devices in the kitchen of his apartment, using a razor, tubing, and adhesive.

The basic idea of opening arteries with a catheter, called percutaneous transluminal angioplasty, had been pioneered a decade earlier by a doctor from Oregon, Charles Dotter. But Dotter’s technique never took off. Why? In the first place, he used a tapered catheter that simply “snowplowed” the obstructing material to the side or sometimes just pushed it downstream. Gruentzig’s balloon was much less traumatic and more effective. Just as important, Dotter’s stance toward his potential community pretty much ensured that he would not get the feedback he needed to improve the technology. A classic inventor, he was an exciting speaker but tended to exaggerate claims. He also loved telling surgeons that they’d be out of business in the near future—not a good strategy if he hoped for their help.

Andreas was just as passionate about his ideas, and a magnetic speaker in his own way, but he was understated, careful, and curious. He was an inventor, a technician, an excellent clinician who connected with patients, and a good experimentalist who knew how to design a well-thought-out trial. I should also note that, as a junior physician at the University Hospital in Zurich, he had very little personal or professional authority. Much of his early access and influence was thanks to his friendship with a world-famous cardiac surgeon named Ake Senning, the father of the pacemaker, who had moved from Sweden to Switzerland for tax reasons. Senning’s patronage was the reason that Andreas had patients on which to try his new procedure. (Of course, Andreas didn’t start with patients; he spent years practicing in the lab on dogs and then cadavers before taking on low-risk patients who could be easily moved to surgery if the procedure was unsuccessful.)

Andreas won over surgeons—the very people whose work he was disrupting and thus who were his potential enemies.

Andreas turned out to be an extraordinary collaborative leader. He presented his ideas in ways that cried out for input from other brilliant minds. Instead of proclaiming that his ideas were revolutionary breakthroughs that would change medicine, Andreas referred to them as incremental advances. He was always the first to point out the deficiencies in the tools he pioneered and was constantly on the lookout for signs that they were flawed. He sought ideas from anyone who might be able to help address problems. He won over surgeons—the very people whose work he was disrupting and thus who were his potential enemies—by presenting all his data in an understated way. People responded in part because of Andreas’s unusual willingness to share credit for whatever was achieved. He used the word “we,” not “I,” when describing the efforts that had made the breakthroughs possible.

## A Course Becomes a Cause

In the fall of 1976, Andreas presented a poster on his animal work at the American Heart Association’s annual meeting, advancing the powerful but controversial idea that balloon catheterization could be used to open coronary arteries. I introduced many of my cardiology and surgeon friends to him at the meeting. Their conversations were so compelling that a number of physicians made plans right then to fly to Switzerland and see firsthand what he was doing. In fact, so many people visited him or invited him to their institutions to demonstrate his procedure that his boss in Zurich put a moratorium on visits and trips.

Undeterred, Andreas found a way around the restrictions. He created a course that would bring all the parties together. He used the then-new capabilities of video to transmit images from the cath lab where he would conduct the procedure to a lecture theatre at the hospital. His innovative approach was a smashing success. It allowed him to share with the audience every detail of how the technology worked, including any problems that arose. To make sure that everyone was engaged, he would periodically ask participants, via video, what they thought he should do next. That willingness to take direction communicated his belief that he and his scientist-customers were equals and this wasn’t his project alone. On the last evening of the course, dinner was served on a local hilltop, and a bonfire and torches provided light as the sun went down. At the end of the evening Andreas led his guests in a torchlight parade down the hill. The symbolism was powerful: Everyone was royalty. This group was going to change the world.

What Andreas couldn’t have known in that first year was how his idea of a live demonstration course would evolve. Other physicians started their own live demonstration courses on the same principles. When audiences became too large for hospital lecture halls, they began meeting in hotel ballrooms and in convention centers. A moderated panel of contrarian, independent experts would provide play-by-play critical analysis for everyone’s benefit. Outside speakers were invited to present slide talks during the downtime between cases. The leading physician educators used audience-response technology to engage participants on difficult issues.

Most strikingly, it proved to be only a short hop hosting on-site meetings to conducting off-site and offshore ones. For example, American medical specialists were eager to learn about technologies not yet approved by the FDA, and the performance and price of video technology made it feasible to view live coverage of cases being performed in other countries. Some courses today assemble many thousands of physicians and involve more than 100 different live cases beamed in from cities around the world.

At that scale, the live demonstration course tends to be thought of as a learning experience, pure and simple, but I would describe it as one of those collaborations that doesn’t look like one. All sides of issues and a wide range of perspectives are presented, and controversy is welcomed. (See the sidebar, “Live Surgical Demonstrations as a Collaboration Tool.”) As in Andreas’s first course, the goal is a collective one: to advance the field through the sharing of research, best practices, trial status, clinical status, and what’s coming next.

#### Live Surgical Demonstrations as a Collaboration Tool

The live demonstration course is a collaborative model pioneered in the late 1970s to enable a medical community to learn about, critically assess, and advance the development of new technologies faster so that benefits of the best of them can be made available to more patients sooner. Organized by an independent body of physicians, live demonstrations use a “wisdom of crowds” process for harnessing the intelligence of many minds that elevates the model from training to collaboration.

## Live Demonstration

Medical procedures are performed by expert surgeons in cities around the world and transmitted live to many hundreds or thousands of physician-learners at a single location using two-way audio and video technology.

## Expert Panel

A panel of contrarian experts analyzes and critiques the procedure as it’s being conducted. This is real-time, unblinded peer review.

## Audience Interaction

Remote Locations

Audience members use mobile devices (laptops, smartphones, and so on) to answer polling questions anonymously, ask questions of the surgeon or panel of experts, or contribute recommendations or expertise. It’s a second level of real-time peer review.

Technology

Multiple cameras follow the physician, medical staff, and patient, showing the procedure from all angles. The patient’s vital signs, medical records, and other relevant information are provided electronically. Close-ups, replays, slow motion, telestration, and other tools are used to engage the audience and enhance understanding. Summaries of recent trials or articles on the procedure, both positive and negative, are available.

## Creating the Basis for Progress

Perhaps the most important collaborative approach Andreas introduced was the creation of a voluntary registry of the cases he and a few of his U.S. colleagues treated. In contrast to the stultifying record keeping required by “official” bureaucratic entities, this was a way to track results independent of any traditional professional society or academic or government institution. At that time, the FDA had the authority to regulate medical devices, but it was a long way away from figuring out the process details for doing so. That first registry was conceived to generate a body of data that could help the community understand which factors were the most important for success, what needed to be improved, and how the instruments might be modified to safely treat more types of blockages. Cardiologists doing these procedures were pressured by peers to produce careful documentation. Perhaps, as a result, most were a bit less likely to behave recklessly. It is no exaggeration to say that the rapid sharing of experience and techniques enabled by the registry saved many lives and prevented untold complications. There was no long wait, as in a drug trial, for lessons to be extracted; clinical users could take advantage of new information as soon as it came in. Problems were discovered and solutions were offered almost on the fly. And when it came time to publish papers, Andreas and his closest collaborators made sure to spread the intellectual wealth. They developed guidelines for which papers would be published by which authors and when.

By the time the registry was picked up by the National Institutes of Health, several years later, it was well-established as a powerful new methodology in itself. This was the first time that so many physicians had collaborated on a new technique, and it was clear that the collaboration had accelerated both the development of the technique and the learning about it. The approach has since been adopted in many other fields.

## A Different Kind of Leadership

One thing that has become clear in the course of this proliferation of registries is how dependent they turn out to be on the capabilities of their leaders. The ability to lead leaders is a rare skill, and Andreas, like Jack Whitehead, was a great role model. In a sense, he was the Linus Torvalds or Jimmy Wales of angioplasty. Just as Torvalds helped spawn the open source movement, and Jimmy Wales spearheaded the Wiki phenomenon, Andreas had created a community of change agents who carried his ideas forward far more efficiently than he could have done on his own.

The key was the dynamic between Andreas and his followers. This was a group of big personalities, full of independent, ego-driven, enormously self-confident men. On top of that, they were rivals. But all of them loved working at the cutting edge of medicine and had dreamed of taking part in a groundbreaking endeavor. When Andreas came along, they saw that possibility. And that’s one of the crucial ingredients of collaboration. None of the participants would have said Andreas had the right to give them orders, yet they respected him and were confident he was taking the right steps to ensure that the technology was properly assessed as it was developed. He had earned that confidence, paradoxically, by never presuming to have all the answers. He carefully explained why he did things the way he did, but he always allowed that others might choose alternative methods. Just as Jack Whitehead did with his early band of brothers, Andreas built a corps that prided itself on boldly taking the risks and doing the hard work needed to turn a compelling vision into reality.

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With that dynamic established, Andreas didn’t need to exert much authority. In fact, he purposely ceded control and applied himself to keeping trust levels high. He role-modeled the investigational discipline that would allay doubts about the process. And he expertly managed the various personalities in the group to keep jealousies or interpersonal friction to a minimum. He encouraged members to continually question and teach one another. He made sure that problems were rooted out, not glossed over, the more quickly to arrive at solutions.

## Is It the Tools?

Mention the word “collaboration” to businesspeople today and they immediately think you’re going to talk about software. The tech world is boiling over with new tools that enable groups large and small to instantly and easily share complex information and that facilitate and track contributions from many participants. But true collaboration requires more than handy applications—in fact, the same tools can just as easily derail or outright destroy collaboration. The availability of so much software doesn’t so much solve our need for collaboration as heighten the difficulty of managing it. To make matters worse, rules and laws that inhibit collaboration continue to shift and clash. The world becomes bumpier in some ways as it becomes flatter in others. In the science domain, the information explosion has led to more silos, not fewer.

True collaboration requires more than handy applications—in fact, the same tools can just as easily derail it.

For all these reasons, it’s more critical than ever to understand the complex soft elements, such as emotional intelligence, that are the makings of a strong collaborative culture. Many people go through the motions, but few know how to really collaborate. I am often struck by the behaviors of otherwise bright people who poison potentially rich collaborations, seemingly without realizing it.

Jack Whitehead and Andreas Gruentzig were true collaborative leaders. There have been people like them in every field throughout history. It may be an exaggeration to compare Jack and Andreas with Gandhi, Mandela, or Martin Luther King, Jr., but let’s list the challenges they all faced: Silos with different cultures. Strong egos, messenger killers, and pontificators. Hidden agendas, cynicism, and groupthink. Diverse levels of understanding and a whole range of biases. All these factors make it hard to harness the collective intelligence of great (or even not so great) minds. These leaders overcame the obstacles.

You can be sure that Jack and Andreas didn’t get it all right. They had their catastrophes along the way. But their default mind-set was inclusive and questioning, confident and humble. Both had a great sense of theater and used it effectively. They knew how to set the stage for collaboration and employ ritual, symbolism, or humor to disarm and inspire. They recognized that diversity is an antidote to groupthink.

When will these approaches start catching on in boardrooms, mayors’ offices, and universities? Look around you. I think you’ll see that they already are.

A version of this article appeared in the July–August 2011 issue of Harvard Business Review.

John Abele cofounded Boston Scientific in 1979. Having retired from its board in May 2011, he now serves as director emeritus. He owns The Kingbridge Centre and Institute, a conference center in Ontario.

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