Joseph Schumpeter - 1883-1950 - was a political scientist and (whisper it not) economist, who coined the phrase Creative Destruction.
This seems a useful idea to me - what I get from it (not necessarily what Schumpeter meant) is that institutions are not reformed, they are replaced.
Of course institutions change - but who knows whether this is improvement or degeneration? How can one balance the advantages and the disadvantages, over the short versus long term - how can these be quantified and mathematically summed?
But sometimes institutions are replaced - the horse and cart was replaced by the motor car, the player piano was replaced by the gramophone, and so on.
This came to mind in relation to medicine and doctors - the 'doctor' is a relatively recent, late 1800s, idea - i.e. the idea that there was a unified medical profession sharing a common education and qualification process.
Before doctors (in Britain) there were high status physicians (gentlemen with university degrees) who did not touch the patients (maybe felt the pulse) - sometimes did not even see the patient - and who wrote prescriptions. They were classically educated, learned, wrote papers and books, mixed in the highest circles... But there were not many of them outside of the capital cities and their major satellites.
Apothecaries who were middle class, apprenticed, and made up prescriptions and sometimes treated patients on the basis of speaking with them and visiting them (but not examining them).
Druggists who were upper working class retailers and medicine wholesalers (these were the forerunners of modern pharmacists).
Surgeons who also treated the skin (including dermatology and venereal disease), and who were middle class apprenticed craftsmen. (skilled manual laborers).
And a multitude of gentry (including priests) who treated the lower orders, and midwives (working class, semi-skilled - not formally apprenticed), and healers, cunning men, wise women and so on.
From the late 1700s there were a few high status 'man midwives' the first of which was William Hunter (from Glasgow) who had a degree, and became *enormously* wealthy delivering the babies of the upper classes (I seem to recall his fee was 100 guineas - 1.05 Pounds Sterling - per 'confinement'; at a time when the average wage was much less than a guinea a week). This began to bring Obstetrics into medicine.
Physicians, surgeons, man midwives and apothecaries were unified as doctors in the medical profession as it evolved (changed) in the late 19th century.
But medicine is now, again, falling apart - due to sheer size, as much as anything. There is a continual reduction in the skill, status, average pay, and so on.
The mess that is medical education is not reformable - although it does undergo continual change.
At some point, therefore, we will see 'Creative Destruction' and doctors will be replaced. Not the whole set of functions now done by doctors, but some of them, will in future be done by some other kind of profession or job - and that aspect of being a doctor will wither away to an insignificant level.
Same with universities and colleges - higher education. The situation is so big as to be unreformable - at some point they (or some big section of their activity) will be replaced.
One point I take from Schumpeter is that we waste too much time on schemes of reform - do they ever work, I wonder?
We would be better thinking how to start something new and different, with which to replace what is not working.