Innovation and Creativity in Surgery

“Innovation and Creativity in Surgery,” a favorite topic of Dr. Carl Snyderman, MD, MBA, is the title of the Eye & Ear Foundation’s webinar, held on December 5. “I think it is something that will be of interest to everyone,” Dr. Snyderman said at the outset. “It has lessons for everybody, no matter what you do.”

Dr. Snyderman is a Professor in the Departments of Otolaryngology-Head and Neck Surgery, Neurological Surgery, and Bioengineering. He is also Co-Director of the UPMC Center for Skull Base Surgery, as well as founding member and advisory board member of Pittsburgh CREATES and founder and CTO of Respair, Inc.

Cranial Base Surgery

On a daily basis, Dr. Snyderman works in a very specialized area called cranial base surgery. He described it as the juxtaposition of two surgical specialties: otolaryngology and neurosurgery.

A tumor at the base of a brain is a difficult area to reach, but with endoscopic technology, many of these tumors can now be taken out in a minimally invasive way through the nasal passage. A big advantage is that there is no manipulation of the brain with this approach. It is also more effective and has better patient outcomes.

Evolution of Skull Base Surgery

“I’ve been very fortunate to be sort of at the Center of the universe for this type of surgery, going way back to the early pioneers, Dr. Eugene Myers, former Chair of our Department, and Dr. Joe Maroon, a neurosurgeon,” Dr. Snyderman said. They first collaborated in the 1970s doing skull base surgery, and in fact, did the first one at UPMC. Then they had a vision of establishing a skull base center. Dr. Snyderman was the first trainee and has now been doing this work for over 40 years.

The Center has been at the forefront of two major paradigm shifts in surgery. One was the introduction and development of open skull base surgical approaches, in which big operations were done to access tumors, taking apart the face and skull to get to them. The second paradigm shift was the introduction of endoscopic technology where a minimally invasive approach through the nose is used to take tumors out.

“Now when you think about surgery, you might think that it’s like an assembly line and a cookie cutter operation, where everyone’s the same,” Dr. Snyderman said. Certainly, there are surgeons who do the same thing over and over, but every surgery is different. “That’s really one of the things I love about surgery – you’re always problem solving,” he said.

Dr. Snyderman showed a video of a very difficult aneurysm that was clipped through the nose. The Center was one of the first in the world to do this type of surgery and has the largest experience with it. These surgeries are challenging and unpredictable. “You have to be ready to try something new, to problem solve, and figure out a different way of doing things,” Dr. Snyderman said. “That’s one of the joys of doing surgery, is that you’re constantly [doing this].”

Surgery & Music

The Ancient Greeks realized that surgery is very similar to music; both are performance arts. Both require:

• Accuracy in motor performance
• Integration of multimodal sensory and motor information
• Coordination between eye and hand
• Spatial visualization
• Intense concentration
• Quick reaction time
• Efficient mental rotation

Skull Base Surgery & Jazz

In particular, surgery has been compared to jazz music.

A surgical team and a jazz band have:

• Different specialists
• Highly interdependent
• Fast, irreversible decisions
• Uncertainty of outcome
• Willingness to take risks
• Mutual trust

Both involve a dynamic process. And innovation, like music, is on a continuum:

• Interpretation: taking minor liberties
• Embellishment: rephrased but recognizable
• Variation: new elements
• Improvisation: little resemblance to the original

It is the same with surgery. As an example, the Center was the first in the world to perform an endoscopic surgery for epilepsy (in 2020). Dr. Gonzalez-Martinez, MD, PhD, was one of the neurosurgical epilepsy surgeons. Working with him, they developed a new endoscopic approach through the sinuses that allowed them to take out part of the brain that was damaged. This was the source of the patient’s seizures. By doing this through the sinuses, they were able to spare the normal brain that is over the surface of this area. This means a more effective surgery and less damage to the brain.

“So, we’re still coming up with new and better ways to do things,” Dr. Snyderman said.

Innovation & Creativity

Innovation can be described as a process of creating value by applying novel solutions to meaningful problems. “If innovation is the cell, then creativity is a nucleus of the cell,” Dr. Snyderman said. Creativity is “any act, idea, or product that changes an existing domain, or that transforms an existing domain into a new one.”

Albert Einstein – who has lots of great quotes about innovation – famously said, “Creativity is seeing what everyone else has seen and thinking what no one else has thought.”

Why should we care about innovation? As Einstein said, “If you always do what you always did, you will always get what you always got.” That is how progress is made.

Why are we creative? If you look at a population of people, Dr. Snyderman said, we vary in our risk tolerance, interest in other things, and willingness to try new things. But within any tribe or civilization, you need those individuals who are going to explore, take chances, and discover new things. That is important knowledge that is brought back to the tribe to perhaps provide some survival advantage, whether that’s a new food source or new technology.

But there is more that drives us. Seeking fame or fortune are not good motivators, especially when talking about creative activities. Intrinsic rewards are the most motivating. Paying somebody more money to do a better job often has the opposite effect on performance.

Surgical Innovators

A book by economist David Galenson, Old Masters and Young Geniuses: The Two Life Cycles of Artistic Creativity, talks about two types of “geniuses:” Conceptual innovators and experimental innovators. Galenson looked at people who were geniuses or great innovators within a variety of disciplines. Based on when they did their seminal work, he divided them into conceptual vs experimental.

Conceptual innovators do their best work when they’re young. These are people that we consider the typical geniuses who have these eureka moments where they have a great idea and are forever known for it. Some examples are:

• Literature: The Great Gatsby, F. Scott Fitzgerald, age 29
• Painting: Les Demoiselles d’Avignon, Pablo Picasso, age 26
• Filmmaking: Citizen Kane, Orson Welles: age 26
• Architecture: The Vietnam War Memorial, Maya Lin, age 23
• Music: The Marriage of Figaro, Wolfgang Mozart, age 30

In contrast, experimental innovators are people who sort of plod along and do not necessarily know where they are going to end up. They are constantly experimenting, getting better, and do their best work at a later age. Examples include:

• Literature: Huckleberry Finn, Mark Twain, age 50
• Painting: Chateau Noir, Paul Cezanne, age 64
• Filmmaking: Vertigo, Alfred Hitchcock, age 59
• Architecture: Fallingwater, Frank Lloyd Wright, age 70
• Music: Symphony N. 9, Ludwig von Beethoven, age 54

The lesson is that it is never too late. In comparing these two types of innovators, however, there are some differences.

Conceptual

• Sudden inspiration
• Simplicity and generality
• Irreverent, iconoclastic
• Certainty
• Specific goal
• Deductive
• “Sprinter”
• “Young genius”

Experimental

• Gradual progression
• Superb craftsmanship
• Respect for traditions
• Uncertainty
• Imprecise goal
• Inductive
• “Marathoner”
• “Old master:” wisdom and judgment

Dr. Snyderman shared this quote: “Great experimental innovators may add substantive content to a discipline, while great conceptual innovators may change the domain.” He also shared one from the Greek poet Archilocus: “The fox knows many things, but the hedgehog knows one big thing.” The fox is the experimental innovator.

“If I look at my own area of work in skull base surgery, we have a mixture of both these concepts,” Dr. Snyderman said. “There have been some conceptual moments when there was a paradigm shift, a sudden transition to open and then endoscopic. But within each of these eras, you have experimental innovation, slow building on what’s come before, gradually improving the process, developing new surgical approaches.”

Conceptual innovation would describe open skull base surgery and endoscopic endonasal skull base surgery. Experimental innovation would be the contralateral transmaxillary approach.

Creative Personality

Is there a creative personality? This may be something we develop and are not born with. It may develop during a critical period of our childhood. If you grew up in Dr. Snyderman’s era as a baby boomer, then you grew up playing Lincoln Logs and Tinkertoys. Dr. Snyderman spent a lot of time doing puzzles, which might have been important in his development as a surgeon. “Maybe it helps me develop certain visual spatial skills or problem-solving abilities that have made me more creative,” he surmised.

The modern area, with electronics, may result in a different set of skills. There is some concern that it may limit creativity because the same hands-on experience with materials is not as common.

A book by Adam Grant, Originals, looks at people who have achieved great things, like Nobel Prize winners.

“You can see there is an overwhelming prevalence of an artistic hobby,” Dr. Snyderman said. “So, if you won a Nobel Prize, you were much more likely to be involved in performing arts than other innovators. You see similar results when you look at entrepreneurs and other types of inventors.”

This rejection letter is probably a clue as to why Einstein was able to achieve what he did.

Curiosity is probably the most important thing in a creative personality – the individual who is always asking “why” questions or wants to know more about everything. Creative people may display one or more complexity-contradictory extremes. Naivete, or immaturity, perseverance, and convergent vs divergent thinking are also characteristics of a creative personality.

Creativity is not the same as being a genius; it is not necessarily a measure of IQ, Dr. Snyderman cautioned.

Divergent Thinker

Always maintaining a child’s perspective is important, as children see the world in a different way. They have yet to accumulate all the biases and lazy mental habits adults have that keep us from considering new ways of thinking about things. Look at the way someone solves problems. Are they a convergent or divergent thinker? A convergent thinker thinks directly for a solution, and quickly settles in on one. A divergent thinker considers all the possibilities and then chooses the best one. In his interviews for medical students and residents, Dr. Snyderman looks for divergent thinkers.

You can take common household objects such as a clothespin, band-aid, light bulb, or paperclip and ask someone to list all the different things that you could do with each and see how many answers they can come up with. The quality of their answers can be graded by looking at their fluency (large number of responses), flexibility (produce ideas that are different from each other), and originality (rarity of ideas produced).

To see if you can be a divergent thinker, the Dead Ninja puzzle is a good test.

The solution is to return to the room you started in; that is the only way to get through the maze and get all the ninjas.

Another test is this common ethical dilemma with a runaway trolley. If you do nothing, it will go straight and kill five people. You can divert the train onto another track and save the lives of those five but will sacrifice one individual. Which choice would you make? It can be weighted more by saying the single individual is a young person or other factors.

A very creative solution that Dr. Snyderman had not thought of is a morbid twist but good example of a divergent thinker.

The Creative Process

How do we innovate? How does the creative process work? “We sort of know where we started and where we end,” Dr. Snyderman said. “But what goes on in the middle isn’t always apparent. First, we have to destroy our old ways of thinking.” He shared a quote: “Every act of creation is first an act of destruction.” Mizuta Masahide, a 17^th century poet and samurai has a great quote that applies here: “My barn having burned down, I can now see the moon.”

“We often think that progress occurs on a nice straight timeline, but is it incremental like the fossilized prints of the dinosaurs and evolution?” Dr Snyderman asked. “Or does it occur in giant leaps like a man walking on the moon? In reality, there are periods of acceleration and deceleration. It’s not a straight timeline. Sometimes you can’t get to where you want to be unless you take a step backwards.”

In medicine and surgery, this is common. When at the pinnacle of what could be done with open skull base surgery, the Center could not do better unless they took a step back, learned how to work with the endoscope and new technology, and solve new problems. In the interim, their outcomes were worse, and they had more complications. They had to learn how to deal with those, but eventually solved them and are now providing care at a much higher level than what they could do before.

Oftentimes there is a lot of criticism during those early years. But this is when you have to depend on a few brave pioneers who are willing to take those risks or are able to tolerate the criticism from the medical community in order to push things to a higher level.

The creative process goes through a cycle: preparation, incubation, insight, evaluation, elaboration. Oftentimes the incubation phase is long and looks like nothing is going on, but it is percolating in the back of the brain. You are thinking about it on a subliminal level, and then might have a sudden insight that leads you to test something, evaluate it, and then you can build upon it. The process then starts all over again with another incubation period and new insights. It is an iterative process that is constantly improving.

Necessary Ingredients for Creativity

A base of knowledge is necessary, as you cannot look up everything on the computer. Technical skills are important, as is improvisation. As Charlie Mingus the jazz musician says, “You can’t improvise on nothing; you’ve gotta improvise on something.”

Catalysts of Innovation

• Questioning – Always asking questions about why do we do it this way? Is there a better way to do this? How can we do this differently?
• Observation – Keen observer of what’s going on around you, looking at the world through a child’s eyes
• Associations – Looking for associations or links between different things. How could they work together? How do they interact with each other?
• Networking – with other individuals, learning about other disciplines, seeing what others have already done, learning about new things and new ways of doing things by understanding how other people are solving problems
• Experimentation – Doing little experiments to see what works and doesn’t. Can keep building on those experiments

Dr. Snyderman created his own mnemonic to help remember these five catalysts of innovation: QuOANE.

What does it mean to observe? Research shows that people can be trained to be better observers. Amy Herman has a book, Visual Intelligence, that addresses this. She is an art historian and lawyer who trains people to study art to make them better observers of things in real life. This has been done extensively with people in law enforcement to make them better at reading crowds and recognizing a problem before it occurs. Dr. Snyderman thinks the same things can be applied to medicine. Herman has trained medical students to make them better observers of patients and detect things that would not be obvious to the casual observer.

Creative Environments

Sometimes innovation occurs in the most creative of environments. A creative environment should include mentorship that is free from dogma, a fee flow of ideas, culture of innovation, support from family and colleagues, and resources, like funding for time and equipment and a sufficient volume of patients. Dr. Snyderman said he has been very fortunate to spend his whole career at UPMC, which was the ideal environment for what he has achieved. “These things could not have happened elsewhere,” he said. “I think that’s why Pittsburgh has been a leader in skull base surgery for the last four decades.”

Not everyone can find an isolated mountaintop to do their great work, but we can seek out our own environments that are more conducive to thinking and innovating. Aesthetics of a creative environment in the macroenvironment include resources, nucleus of people, and natural beauty. Allow time for reflection. Indulge in a semi-automatic activity like going for a jog, bicycling, or driving – things where you do not really have to think while doing them. This is a great time to let your mind run and ruminate about problems.

In terms of the microenvironment, personalize your space (feng shui) and routine.

Problems are everywhere. You just have to look. Dr. Snyderman notices them every day in the hospital setting, so he is always thinking about how to do something better. Bioengineering students are often brought into their operating rooms to see what they notice. People outside of medicine will see things in a different way.

Donald A. Norman wrote The Design of Everyday Things, which looks at simple everyday things like ovens and doors, and the mistakes people make in their design. The author is known as the grandfather of modern design. An example is two different doors – one opens outwards, and one opens inward. It is confusing just looking at the door design to know which way it goes. Norman has provided so many examples of bad door design that there is now a name for it: Norman door (n): 1. A door where the design tells you to do the opposite of what you’re actually supposed to do. 2. A door that gives the wrong signal and needs a sign to correct it. “So, pay attention the next time you’re out,” Dr. Snyderman said.

If you want to really innovate, you have to generate a lot of ideas but choose only the best to pursue. Winston Churchill said it best: “You will never reach your destination if you stop and throw stones at every dog that barks.”

You want lots of ideas and to write them all down. Dr. Snyderman suggested keeping a little memo pad or phone by your bed. He keeps a file on his computer desktop full of ideas for inventions or research. As chemist Linus Pauling said, “The best way to have a good idea is to have lots of ideas.” It is amazing how often you will go back to these things even years later and pick them up with a new insight, Dr. Snyderman said.

Dr. Snyderman regularly makes pitches to bioengineering classes. Many are dead ends, but acoustic monitoring of drills has a patent. The second one highlighted was the genesis for a company. “Sometimes these take hold and really can change things,” he said.

Flow

One of the wonderful things about innovation is you find these magical moments where you are in the flow, or in the zone. This is being “fully immersed in a feeling of energized focus, full involvement, and enjoyment in the process of the activity.” You ignore what is around you and have no sense of time. It is great intrinsic motivation.

Mihaly Csikszentmihaly wrote Creativity/Flow and the Psychology of Discovery and Invention, which Dr. Snyderman recommends as a good read. He talks about flow and how to achieve it.

Procrastination and Creativity

Procrastination is often thought of as a negative thing, but studies show that people do their best work when they procrastinate. If you knock off a project as soon as you get the assignment, it will not have the same level of creativity as if you let it ruminate in the back of your mind for a period of time. After your brain has worked on it all this time, you will end up with a better project when you sit down to finalize it. Mark Twain said, “Never put off till tomorrow what you can do the day after tomorrow.”

Adam Grant has a TED talk on the surprising habits of original thinkers. He said, “Procrastination gives you time to consider divergent ideas, to think in nonlinear ways, to make unexpected leaps.”

Dr. Snyderman’s contribution to the creative universe:

If you want to be innovative
You need time to be contemplative
Procrastination
Begets salvation
Give time for your thoughts most creative

One of his favorite expressions that he learned during COVID is hurkle-durkle, a 200-year-old Scottish term that means to lounge in bed long after it is time to get up. Do not just jump out of bed and start your day right away; just lay there for a bit and think about your day. What is going to happen? What do you need to work on? This is how you might solve some of your problems.

There has been a backlash against filling our lives with electronics and scheduling things every minute of the day. There is value in having downtime, bored time when you are not really doing anything but letting your mind wander and daydream. “It’s amazing the insights you can have with this unstructured time,” Dr. Snyderman said. He recommended a couple of books on this topic: Bored and Brilliant by Manoush Zomorodi and How to Do Nothing by Jenny Odell.

Control your time. Manage, focus, avoid, and limit. This means controlling work time as well. Triage what is urgent vs not urgent, important vs not important. Set limits so you are not putting out fires all day. The Stephen R. Covey books are a great way to start if you want to learn about time management techniques.

Inhibitors of Innovation

A culture has to tolerate risk, accept failure, be receptive to change, and collaborate, to facilitate innovation. Super-specialization and isolation can be inhibitors, along with excessive oversight and regulation, limited resources, and conflicts of interest. Every institution has its own culture. Dr. Snyderman was fortunate to be in an institution that had a culture of innovation.

Innovation Journey

Dr. Snyderman’s research has focused on understanding surgical cognition. How do surgeons interpret their visual environment? How do they perceive things? How can their visual perception be improved? He hopes this will translate into improved methods for surgical training. In recent years, since he got his MBA, he has become interested in entrepreneurship and developing medical devices. He is now involved in two companies with new medical deviceS: SPIWay, LLC and Respair, Inc.

His startup company, Respair, grew out of a problem he observed. There were problems with endotracheal tubes moving in the airway, not functioning properly, and sometimes resulting in airway emergencies. Dr. Snyderman pitched the idea to a bioengineering class, and they started working on the issue together. He was paired with Dr. Coyan, a cardiothoracic surgeon who was finishing his training at the time. They pivoted and decided that the biggest problem with endotracheal tubes is they do not prevent aspiration. This results in what is known as ventilator-associated pneumonia.

During the COVID pandemic, people didn’t die from COVID. They died from the complications of COVID, from getting pneumonia from being on the ventilator too long. They came up with a new type of tube that is an innovative change. The green stuff is infected material that would be trickling into the lungs. A balloon cuff on a normal tube does not prevent that, and that is why pneumonia is the result. The baffle design tube is very effective in preventing aspiration and hopefully will also prevent ventilator-associated pneumonia. The company is working towards FDA submission.

Pittsburgh CREATES

The Department of Otolaryngology-Head & Neck Surgery is very interested in helping surgeons develop their ideas. Pittsburgh CREATES is a pipeline for surgical innovation. Peter Santa Maria and Mohit Singhala came from the Stanford Biodesign group, which has been the leader in the country in translational research and medical innovation. Working together, they are helping to create a pathway that will help surgeons identify their ideas and translate them into a product. They are using new software to help with this innovation process.

Another Einstein quote fits here: “When I have one week to solve a seemingly impossible problem, I spend six days defining the problem. Then, the solution becomes obvious.”

Four steps are involved: Inquire, identify, invent, implement. The process can be started at any stage:

1. No thoughts
2. An idea of a problem you want to solve
3. An idea of a solution to address a problem
4. A mature idea that needs help with development

The hope is to really help people through these early stages where there is often a lack of resources to get started. The University of Pittsburgh and the Pittsburgh community are very good in supporting later stages of development.

Take Home Advice

“What do I get from all this?” Dr. Snyderman asked. “This is something that really adds a lot of joy to my career; it’s one of the reasons I still come to work every day. I love working with the people I work with. There is this opportunity for creativity, problem solving, discovering new things, and trying out new things. There are still a lot of opportunities for flow in my work activities.”

Maximize your creativity!

• Be curious about everything
• Reject the status quo
• Discover other domains – Look for new experiences
• Network within your field
• Shape your space; control your time
• Create flow in your activities

In Curiosity by Alberto Manguel, each chapter is dedicated to a single thinker, scientist, artist, or other figure who demonstrated in a fresh way to ask “Why?”

Can we foster creativity? This can be done by providing a foundation of domain knowledge and technical expertise, establishing a creative environment that is multidisciplinary and has networking, and selecting medical students and residents with creative potential.

There are some personality characteristics associated with creativity. In a paper by Fiona Patterson and Lara Dawn Zibarras, “Selecting for creativity and innovation potential: implications for practice in healthcare education,” they identified “motivation to change” as the best indicator of innovation potential. Of the Big Five personality dimensions (neuroticism, extroversion, openness to experience, agreeableness, and conscientiousness), openness to experience was most associated with creativity.

There are also some tests that measure someone’s creative thinking, like the TICT Torrance Tests of Creative Thinking. You give someone a card with blank circles and ask how many different ways they can make drawings using these circles, and you can see some innovative ideas.

Another example is to choose one of these starts and ask what someone can make from that little squiggly line.

There may be a role for psychedelics. “It is said that we wouldn’t have Silicon Valley if it weren’t for the psychedelics that many of those company founders were experimenting with,” Dr. Snyderman said. He shared a couple of quotes, one by Humphry Osmond, “To fathom Hell or go angelic/Just take a pinch of psychedelic.” Another by Michael Pollan, in his book How to Change Your Mind, “Psychedelics increase ‘openness to new experiences,’ a hallmark of the creative mind.”

“There has been a rebirth of research into the use of psychedelics to treat medical illness such as depression and drug addiction, but also using microdoses to sort of improve our innovative potential,” Dr. Snyderman said as he closed out his talk. “Something to think about.”