Ness, Roberta B. MD, MPH
Innovation, defined as creativity with a purpose, is widely considered to be the engine of scientific progress. A blue ribbon committee from the National Academies of Science recently assessed the state of America's “principal ingredients of scientific innovation and competitiveness—knowledge capital, human capital, and a creative ecosystem”—and found them to be sorely lacking.1 The committee's report, entitled Rising Above the Gathering Storm, Revisited, reported that the United States is losing its international hegemony. Indeed, a 2010 report from Thomson Reuters published in Science demonstrated that the United States was surpassed in annual publication output by the European Union in 1995 and by Asian-Pacific countries in 2008.2 Individual countries, such as Canada and the United Kingdom, now have higher scientific publication rates per 1,000 people than does the United States.
It is disheartening to imagine that the United States is losing its position as the worldwide leader in medical science discovery. Typical solutions proposed to address this problem have been to provide more funding for scientific research and to enhance secondary science education. In this commentary, I propose an additional solution—that academic health centers in the United States adopt established pedagogical approaches to creative thinking into professional health science education. As a model, I present here the creativity training program, Innovative Thinking, that I helped to develop at the University of Texas.
An Overview of Creativity Training Programs
In academic medicine, traditional approaches to innovation training include group discussions, seminars, mentoring sessions, and other informal formats. Formal creativity instruction seems to be less widely available. In lectures on innovative instruction that I have given at the Association of American Medical Colleges, the Institute of Medicine, and over a dozen top-tier academic health centers, I have asked for examples of formal classroom education in creativity and innovation and have yet to find any such programs.
Thoughtfully constructed creativity training programs have been developed and used in K–12 classroom settings, undergraduate instruction, and business schools. The content of these programs typically includes instruction in: (1) divergent thinking (fluency, flexibility, originality, and elaboration), (2) problem solving (novel solution finding), and (3) performance (creative production). Instructional formats that have been shown to elicit the best outcomes are an admixture of lectures, discussion, and guided practice.
Two recent meta-analyses3,4 of evaluations of creativity training programs reiterated the results of earlier meta-analyses5,6—Creativity training program participants showed increased verbal and figural originality on a validated, standardized test of divergent thinking. Clapham3 reviewed 40 studies published since 1984, half of which looked at adolescents/children and half of which looked at adults. The 10 studies of college students specifically demonstrated that, after participating in programs of 10 to 15 sessions, students' test scores on fluency and flexibility improved, but these results may have been related to motivation rather than to instruction. However, that the students in the noncontrol groups typically scored two to three times higher on originality in thinking than those in the control group is likely attributable to creativity instruction. Clapham3 also considered creative training programs employed in business settings. These demonstrated that weeks after several-day training courses, participants demonstrated a greater preference for novel problem solving, stronger acceptance of creativity in their attitudes and behaviors, and more original idea generation in the performance of work tasks.
Scott and colleagues4 surveyed 70 evaluations of creativity training programs that were selected on the basis of having standardized training procedures and well-described outcome measures. They found numerous well-designed programs that yielded sizable improvements across the four criteria assessed (divergent thinking, problem solving, performance, and attitude/behavior). In every demographic studied, irrespective of age, gender, intellectual capacity, and professional or academic setting, creative thinking improved. In addition to improving divergent thinking, participants involved in these programs gained skills in critical thinking, constraint identification, and the use of analogies.
From the results of their meta-analysis, Scott and colleagues4 suggested that the elements necessary to produce a successful training program are (1) the program provides valid and discrete heuristics for developing originality in problem solving (see below for more information), (2) the program is relatively lengthy and challenging (most programs are 20–30 contact hours), (3) the program involves discipline-specific illustrations using “real-world” cases, and (4) the program involves exercises that afford an opportunity for practice.
Applying the Constructs of Existing Programs to Creativity Training for Academic Medicine
A few examples of the discrete heuristics employed by well-designed creativity training programs from the worlds of K–12 education and business schools follow. For each, I provide illustrations and exercises from my own health sciences instructional program, Innovative Thinking, at the University of Texas.
The first tool is “Broadening the problem.”7 To broaden a classroom question like “How can we get children to eat better?” students might ask, “Why are foods of low nutritional value generally less expensive than those of high nutritional value?” or “What effect do agricultural subsidies have on obesity?”
“Narrowing the perspective” is a second tool, familiar to clinicians, who limit the number of potential diagnoses by identifying salient aspects of a patient's history and physical exam. In my program, students are given an exercise wherein they must break down the problem of how to achieve worldwide smallpox elimination. This requires recognition of the nodal characteristics that made eradication achievable, including the lack of a nonhuman reservoir, that the virus did not readily mutate, that infection created lifelong immunity, and that the newly invented bifurcated needle could be used by lay professionals in a mass vaccination campaign.
Third, “Reversing assumptions” involves turning a negative into a positive. Alexander Fleming, the father of antibiotics, noticed that mold growing on a petri dish inhibited the growth of bacteria. Rather than discarding the experiment as a failure, he focused on successfully understanding this mold's bactericidal properties. In class, we transform the question, “How do we treat disease?” into “How do we ensure the absence of disease?”
A fourth tool, common in science, is “Using analogy,” which allows for the extension of lessons from one situation to another. Edward Jenner, noticed that, while milkmaids developed cowpox, they rarely became infected by smallpox, and so he used cowpox pus to create the first smallpox vaccine. Classroom exercises challenge students to find nonobvious similarities; for instance, I ask, “How is a marriage like a matchbox?” Students' answers have included “They can both be incendiary”; “They both have eight letters starting with the letter m”; and “Either can be picked up in a bar.”
Fifth, “Brainstorming” entails a free, rapid, and nonjudgmental emoting of ideas. Groups can be powerful problem solvers. Recently, Woolley and colleagues8 demonstrated that group performance on intelligence tasks is less dependent on the individual IQs of the members than it is on the inclusiveness of group interactions. A good brainstorm generates over 100 ideas an hour. Convergent considerations involving categorizing and prioritizing, which are necessary but intrinsically limit the range of ideas, come only afterwards.
Finally, to these traditional creativity heuristics, my own Innovative Thinking class adds methods for “thinking outside the box.” “Inside the box” thinking represents our habitual cognitive patterns, termed frames. Frames are the assumptions and expectations that we use to interpret new information. For example, at a restaurant, we expect to be served politely. If, when we order, the waitress were to reply, “Go to the kitchen and get it yourself,” we would be shocked. This scenario demonstrates three aspects of frames: (1) frames (situational expectations) are ubiquitous, (2) frames are contextual: at home, such behavior by a sibling would be unsurprising, and (3) out-of-frame experiences evoke a negative visceral response. Frames in science are our paradigms: the evidence-based beliefs that direct the questions that we ask and the approaches that we undertake.
Paradigms and frames allow us to efficiently understand new information, but they are constraining. Joseph Goldberger, who discovered that pellagra was caused by a nutritional deficiency, was dispatched in 1914 to investigate asylum-based outbreaks of the disease, which was presumed to be infectious. Goldberger shifted frames on noting that the “spread” of pellagra did not follow normal patterns of contagion: Spread was limited to patients. Ultimately, Goldberger wondered if the disease could be related to the poor quality of food offered to inmates. When he fed patients nutritious foods, he cured the disease. Previous investigations of pellagra had been constrained by the assumption that epidemics must be of infectious origin.
In class, students practice identifying frames and their limitations, then finding alternative strategies. One exercise is to find limitations to the frame “the war on cancer.” One limitation to this frame is that eradicating all cancer cells often means harming normal cells and sometimes even killing the patient. An alternative approach might be “Disease as neighbor,” an adaptation of the frame from Robert Frost's poem “Mending Wall” that “Good fences make good neighbors.” This alternative strategy implies containment. Bolstering the immune system to limit growth and metastasis of cancers is a novel, growing area of research.
Frames also influence what we observe. Overwhelmed with sensory information, we selectively observe the world around us through the filter of our expectations. Why is it that Robin Warren, co-winner of the Nobel Prize in physiology for linking Helicobacter pylori to peptic ulcer disease, was the only pathologist to report that half of patients harbored the bacteria in gastric tissue? He used only a standard silver stain and a clinical microscope. Perhaps others dismissed the finding because textbooks said that the highly acidic stomach was sterile.
Students learn to improve their observational skills through drawing. They also learn to recognize observational frames by watching real people use technology in real-life situations. In so doing, they appreciate the design flaws that we normally accept and for which we accommodate without even realizing that that is what we are doing.
Moving previously designed creativity training programs into the academic medicine classroom should include translating idea generation into the scientific process. The steps that I believe are best suited to creative problem solving in science are (1) define the problem, (2) review the literature and make observations, (3) separate raw inputs from their frames, (4) generate alternative original ideas, (5) converge on potentially transformational insights, and (6) develop steps for future action.
This process is practiced through group projects. For example, one Innovative Thinking student project centered on the question of how to increase the proportion of patients with advance directives. The group conducted literature reviews and interviews with providers and families. The factor that they found most limiting to the adoption of advance directives was hesitancy among families to talk about death because death often represents fear and guilt. Students devised an alternative metaphor: “Death and taxes.” From this, they designed a “U.S. Advanced Directive Claim Form,” formatted like a tax form and meant to be submitted annually along with one's completed tax forms. Their innovation involved shifting the frame of advanced directives out of the realm of guilty avoidance and into the realm of bureaucratic compliance.
Overall, my experience adapting creativity training to the health sciences classroom has been that instruction not only improved scores on standardized creativity tests but that students developed an enthusiasm for and sense of empowerment around novel ideation. Moreover, as demonstrated by the project above, participants demonstrated an ability to put innovation into professional practice.
Why does medicine need creativity and innovation training? Simply put, if innovation is the engine of discovery, then academic medicine should look for all possible avenues to maximize it. Although technical inventions in the last generation have transformed everyday life, novel solutions to some of the greatest threats to health (cancer, Alzheimer disease, obesity, and the rising cost of and lack of universal access to health care in the United States, to name a few) remain less forthcoming. Ample evidence suggests that creativity training programs improve creative thinking and novel idea production. The most useful programs are those containing discipline-specific illustrations and exercises. The Innovative Thinking program at the University of Texas is an example of one such health science innovation training program that has already been developed and implemented. Whether innovation training occurs in premedical curricula, medical/health sciences schools, or postdoctoral training programs, I believe it is worth implementing, evaluating, and, if it is successful, disseminating creativity instruction as a means of enhancing scientific innovation in the United States.