Promoting Creativity and Innovation in a Structured Learning Environment

Innovation has not always been considered favorable. In “A Proclamation against Those that Doeth Innouate,” Edward VI, the King of England, declared in 1548 that those who innovate “shall incure his highness indignation, and suffer imprisonment, and other grievous punishementes.”¹ Nearly three centuries later, as a result of scientific and engineering progress leading to invention during the Industrial Revolution, innovation was positively redefined.² In this new sense, innovation involved either the creation or optimization of products or services to provide value. Ultimately, due to his work in the early 20th century, economist Joseph Schumpeter was credited as having identified innovation as a significant source of economic change. Indeed, this observation continues to hold true today, and significant focus is now being directed at increasing innovation efficiency, or simply the amount of innovation output relative to resource input.³ In medicine, a field that relies heavily on innovation for the development of device technology, pharmacological therapy, and strategies for optimizing health care access and delivery, a realistic solution to increasing innovation efficiency would need to fit within the cost-boundaries of an already complex and constrained system. Could incorporation of explicit instruction in the art of innovation during medical school be a simple yet sustainable approach to increasing innovation in health care?

The education of medical students in the United States continues to evolve as the way in which knowledge is acquired and care is delivered continues to change. As part of clinical curriculum reform, medical schools are using modalities such as problem-, case-, team-, and evidence-based learning in their attempt to help students better apply knowledge in the provision of clinical care. Although each of these approaches benefit the learner when applied appropriately, they primarily focus on training students on how best to integrate available information to solve defined problems rather than prepare students to identify ingenuity gaps and opportunities to formulate creative solutions through the application of their growing knowledge of biomedical sciences and clinical medicine. Given this, we designed the Innovation, Design, and Emerging Alliances in Surgery (IDEAS) project as a structured opportunity through which medical students were challenged to identify a problem and propose an innovative solution during their core surgical clerkship.

From August 2011 to July 2014, third-year medical students rotating on their surgical clerkship at an academic medical center were posed with a challenge to identify ingenuity gaps in the diagnosis or treatment of a surgical disease or in the delivery of care for the surgical patient in the operating room, floor, or clinic. Students worked toward the following: (1) identifying a problem relevant to the surgical patient, (2) explaining why this problem is important, and (3) exploring possible approaches to solving the problem. To guide the students, a single faculty champion of the IDEAS project met with them for four to six 90-minute sessions during which an innovative method for problem identification and solving was introduced and practiced. Although the curriculum has evolved, the current structure seeks to promote an understanding of behavior that underlies creative acts within the clinical domain of surgery, as well as an opportunity for students to apply this framework in the identification and solving of gaps in clinical care recognized during their core surgical clerkship. This framework of behavior follows most closely that recently outlined by Sawyer, which includes: (1) asking the right questions, (2) learning through constantly seeking out knowledge, (3) looking while being aware, (4) playing through freeing your mind by imagining alternative realities, (5) thinking and generating ideas, (6) fusing by finding combinations and links between thoughts, (7) choosing by applying the right criteria, and (8) making by turning an idea into a reality.⁴ Because learning innovation arises through incorporating the creative thinking process within everyday life, students were given short assignments between sessions that allowed them to exercise their understanding of each step, while providing an opportunity to incrementally apply these new skills in their daily practice. Ultimately, at the conclusion of the 12-week surgical clerkship, medical students were expected to present their final projects at the IDEAS poster session to faculty and trainees of the Department of Surgery.

Over the 3-year study period, 134 medical students rotated through the surgical clerkship in 11 distinct groups. All the medical students participated in the IDEAS poster session yielding 134 projects. Each project was categorized based on the problem space addressed, including diagnosis, therapy, patient safety, communication, education, or clinical data acquisition. In addition, projects were classified according to the proposed solution scheme such as a device, application, or service. Overall, the largest proportion of projects aimed at developing therapeutics (29.1%), followed by a number of projects focusing on optimizing communication (21.6%) and safety (17.9%) (Fig. 1A). With regard to solution space, the majority of proposed projects were devices (57.5%) or applications (18.7%), with only a minority working toward providing a service (4.5%) (Fig. 1B). Interestingly, 21% (28/134) of the projects addressed seven specific problems: optimizing surgical lighting (6), providing medical students self-education during the clerkship (6), ureter identification (4), provider ergonomics (3), electrocautery smoke evacuation (3), laparoscopic visualization (3), and wire detangling in the operating room (3). As no specific objective test presently captures change in creativity,⁵ qualitative outcomes were used to assess the impact of the program of study. Specifically, overwhelmingly positive feedback in support of the curriculum was received on student evaluations at the completion of the clerkship. Students were enthusiastic in their support of a curriculum devoted to the development of a learned framework for innovative thinking, as well as the opportunity to focus on research projects, which complemented their acquisition of core content in surgery and in a number of cases led to the continuation of projects after the surgical clerkship. We are currently developing methods and metrics to more quantitatively assess domain-specific student creativity and innovative problem solving, as well as approaches for meaningful long-term participant follow-up.

FIGURE 1: Categorization of IDEAS projects by (A) problem space and (B) solution space.

In the education literature, initiatives similar to the IDEAS project are being conducted, but broad scale incorporation into medical education has yet to occur. Examples of such programs include the Stanford Biodesign Innovation Fellowship directed at postdoctoral candidates with an MD or PhD degree, as a 10-month immersion in learning innovation principles through a project-based approach.⁶ Likewise, the Innovative Thinking Curriculum at the University of Texas School of Public Health is a 14-week curriculum focused on the recognition of barriers to creativity, enhancing observation skills, and nonlinear thinking.⁷ Shorter intensive programs have also been developed, such as the Business Engineering Surgical Technologies course in Strasbourg, France, which consists of an initial online series of didactic lectures on business, engineering, and surgery followed by a 5-day onsite experience to promote the application of course concepts.⁸ Despite the successes of these programs, the common goal of enhancing the ability of students to apply acquired knowledge in a creative manner so as to solve existing problems through a structured educational framework of principle and practice has yet to be broadly integrated into medical school curricular reform. In addition to the common misconception that innovation cannot be taught, other reasons for the lack of widespread incorporation of such an effort may include concerns that establishment of an innovation curriculum is a resource intensive investment. In addition, there may be some unease that the addition of this curriculum would impose a significant burden or distraction to students whose schedules and course requirements, including standard didactic lectures, clinical conferences, and small group tutorials, are already quite substantial. We recommend that a full-time or intensive curriculum that is distinct from the current program of study is not necessary. Rather, the integration of a focused curriculum into current clinical rotations can be easily achieved by a designated clinician champion, which would provide much needed exposure to all students of the learned behaviors that underlie the creative process in clinical medicine. Inherently, the earlier students gain an understanding and appreciation of these behaviors, the more opportunity exists for focused practice. Although further studies using validated objective instruments to assess the impact of the curriculum are needed, we believe that student learning of the core principles in the biological, physical, and social sciences that frame many clinical problems is enhanced and decision making in the care of patients improved.

In a recent article focused on the importance of innovation in academic medical centers, Dzau et al⁹ lay out a 3-step framework for fostering innovation in the health care setting—teach it, support it, and implement it. Although there are multiple levels on which this framework could be applied, incorporation of an innovation curriculum into medical school education is both a logical and critical first step. As a start, we propose implementation of a low-resource, faculty-directed initiative that both educates students in the behaviors that form the basis of creative problem solving and provides a supportive environment in which these behaviors may be practiced. Through directed effort on a broad scale, incorporating such a curriculum into medical education may be, at the very least, a component of the solution to increasing innovation in health care through lifelong learning, scholarship, and problem solving.