Creativity in Medicine
The discussion of creativity in medicine is well under way in the blogosphere. Doctor and blogger Kevin Campbell wrote about it on KevinMD. So did Dr. Vineet Arora. Dr. Danielle Ofri blogged about it in the New York Times. Illana Yukiewicz, a writer and blogger who researches medical ethics at Harvard, talks about it in the Scientific American blog. The subject is popping up in other venues as well. Jacob Scott, an oncologist and mathematical theoretician, talks about it in a TedMed talk, as does creativity and education expert Sir Ted Robinson. Family medicine doctor and medical commentator John Hallberg discusses it on Minnesota public radio. Even the June issue of Psychology Today has an article on creativity. It’s everywhere.
Some of the discussion has been spurred by the advent of electronic medical records and the push for Big Data. Some has arisen because of frustrations with regulation and standardization that have been imposed in the name of healthcare reform. David Shaywitz and Martin Ausiello, who research new approaches to medical training, put it well:
“The great paradox here is that the same reforms that are improving our current care may also be endangering our future health. As medicine has become more standardized and increasingly regulated, it turns out there is much less room for innovation. The spirited pursuit of the unknown—so long a defining quality of medicine—now seems seriously endangered. The new world of rapid throughput and endless documentation provides little time to reflect upon important clinical problems and consider fresh approaches. If anything, thinking about a patient or a question too much is now implicitly discouraged because it slows doctors down; contemplation is bad for productivity.”
Creativity can be defined in several related ways. Leading behavioral scientists Richard Sternberg and James Kaufman define creativity as the ability to produce work that is both novel and appropriate. Theresa Amabile, a creativity expert at Harvard Business school, defines creativity as the production of novel and useful ideas in any environment. Ted Robinson defines creativity as the process of having different ideas that have value.4 The common threads of these definitions are that creative ideas are NOVEL and USEFUL. We are talking here about work- related creativity, as distinct from the more general creativity seen in the arts.
Creativity has been studied from the viewpoint of psychoanalysis, cognition, personality, and environment. Freud suggested that creativity arises from the tension between conscious reality and unconscious drives, that is, creativity is a way to express what you really want in a socially acceptable or useful way. Creativity has been described as a combination of primary and secondary processes: the primary process is the conscious or unconscious idea or intrusion of a thought, followed by the secondary process of reworking the primary process in the real world. This is psychology-speak for generating an idea in your head and then producing a product based on that idea.
One theory of creativity that makes sense in the context of medicine is Sternberg and Lubart’s “investment theory”. According to this theory creativity results from the confluence of six things: 1) intellect; 2) knowledge; 3) styles of thinking; 4) personality; 5) motivation; 6) environment. Intellectually, creative people have the synthetic ability to see problems in new ways, recognize which ideas are worth pursuing, and the ability to persuade others their new way is useful. Such people have the background knowledge to apply their ideas within an appropriate context. Thinking style is a complicated concept out of the bounds of this discussion but involves thinking well along new lines. Personality, as is suggested below, involves self-efficacy and the ability to take sensible risks and tolerate ambiguity. Creative people are internally motivated. Finally, creativity has to be supported by the environment in which the creation is accomplished.
Niamh Kelly, a professor at the University of British columbia, suggested in this journal that discussing creativity and asking about creative endeavors would create an environment conducive to creativity. It turns out this is not to be the whole story. According to Dr. Amabile there are several conditions within the work place that are required for fostering creativity. Encouragement is the first, and certainly Dr. Kelly outlined a number of ways we can be encouraged to create. The second is a high degree of daily autonomy, that is, a person is given a lot of choice in how to accomplish the task they are given. Here is where our beloved EMR and various regulatory agencies are letting us down. Resources, either real or perceived, is the third variable to creative workplaces. People should have, or at least think they have, time and materials necessary for creative endeavors. On a practical level this relates to the amount of freedom med students are given in choosing electives and defining their own learning goals, or to the amount of non-clinical time physicians are given to pursue outside but related interests. The final ingredient is the right amount of pressure. Too much pressure, i.e., an excessive workload, is absolutely counter to any creative process. The right amount of pressure is one in which the person feels challenged, not overwhelmed.
Here’s an example. In 1960 R.E Maizell did a study of creativity in a group of chemists. A creative chemist does one thing a less-creative chemist does not do. The creative chemist reads more technical literature, literature that is more difficult, reads more extensively, and consults both old and new materials, and reads about broader cultural interests. In order to have this time to read the chemist must have a lot of autonomy on how he spends his time, the resources to access information, and a work load that does allows for extensive background investigation.
Physicians and students are familiar with any number of other real-life examples. Suppose a colleague wanted to develop a new way to give sedation for procedure X. For whatever reason the standard drugs aren’t working for this particular type of procedure. He has the information about the procedure and the difficulties specific to it. He may have encouragement from the chair of anesthesia, who is tired of hearing the surgeon complain about the inadequate operating conditions. He also better have full say in how the sedation is done, i.e., autonomy. He will need to be given access to any new drugs that may be on the market that might work in any doses he requires. He also needs to be given leeway by the surgeon to experiment within the context of safe sedation. Finally, he needs to have maybe one or two procedures in a day at least for a few days in a row without getting add-ons and production pressures so that he can try different things. It is evident that allowing one person to be creative involves the departments of anesthesia, surgery, scheduling, and pharmacy, as well as individual coordination with maybe 10 people. Being creative in any complex system takes investment by the whole system.
Can creativity be taught? It’s unclear. Certain personality traits have been associated with creative people, which implies that there are inherent aspects of creative people that are not learned. Creative people have a tendency towards independence of judgement, self-confidence,an attraction to complexity, an aesthetic orientation, and a penchant for risk-taking. These characteristics presumably cannot be taught. But there are also cognitive elements of the creative person that perhaps are amenable to training. These include the ability to cope with complexities, problem-solving skills, and the ability to sustain a concentrated effort. There doesn’t seem to be much evidence that exposing people to traditionally creative fields of interest such as art, music, and theatre makes them more creative.
The above discussion is by no means an exhaustive review of the literature on creativity. But it does provide some ideas on how to promote and sustain creativity within the medical profession. These include:
- Identification. Find the creative people in the department. Find out what they’re thinking about, what motivates them, and what frustrates them.
- Time. Give the creative people time to explore possibilities. This might involve freeing someone from production pressures or providing time away from clinical duties.
- Flexibility. People have to be OK with the idea there is more than one way to do things. This one is especially problematic in medicine because it is so protocol-driven. It takes a certain amount of trust in the skills and education of employees. Residents, especially new residents, are particularly uncomfortable with this.
- Inclusion. Medical schools have to continue to increase the variety of backgrounds of admitted students. Unusual backgrounds provide new perspectives and different assumptions. Being able to ace multiple choice exams should not be the only criteria.
- Revision. Medical school curriculums need to back away a little from rote memorization of facts, especially in the third and fourth years. As well as the usual clinical rotation schedule students should have the access to people working in allied fields such as technology and business.
- Resources. Nothing is more crushing to creativity than repetitive and redundant externally- imposed tasks. Providing doctors with appropriate clerical and technical support will give them time to think and explore.
- Safety. Students have to feel that new ideas are welcome without fear that they will fail some test. Doctors have to feel that they can try something new without fear of institutional disapproval or litigation. As Ted Robinson puts it, “if you’re afraid to be wrong you’ll never create anything.”
Innovation is the way businesses and societies move forward. Medicine should cherish it’s creative types; they will provide the future for all of us.
- Shaywitz DA, Ausiello DA. Preserving Creativity in Medicine. PLoS Med 1(3): e34. doi: 10.1371/journal.pmed.0010034, 2004.
- Sternberg, RJ and Kaufman, JC. The Cambridge Handbook of Creativity. Cambridge university press, 1999.
3. Amabile, TM. The Social Psychology of Creativity. NY: Springer-Verlag, 1993.
- Robinson, Sir Ted. http://www.ted.com/talks/ken_robinson_says_schools_kill_creativity.htm. 2006.
- Lubart, TI and Sternberg, RJ. An investment approach to creativity: theory and data. In SM Smith, TB Ward and RA Filke (Eds.) The creative cognition approach. Cambridge, MA, MIT Press, 1995.
- Kelly, Niamh. What are you doing creatively these days? Academic Medicine 87(11): 1476, November 2012.
7. Amabile, TM, et al. Assessing the work environment for creativity. The Academy of Management Journal: 39(5), Oct 1996, pg 1154-1184.
8. Maizell, RE. Information gathering patterns and creativity, a study of research chemists in an industrial research laboratory. American Documentation 11(1): 9-17, January 1960.