The field of surgery faces complex, systemic challenges that will require new academic frameworks. In this paper, we propose design thinking as a useful problem solving technique to apply to such challenges. We define design thinking and provide a brief history of this practice. Finally, we offer suggestions to introduce design thinking to surgical trainees, drawing from the experience of innovation programs that have incorporated this technique.
Introduction
The word surgery derives from the Greek roots kheír (“hand”) and érgon (“work”). It has since its origins been a hands-on enterprise. It has also been a crucible for innovation. From the origin of aseptic technique to development of the robotic arm, surgery is saving more lives with smaller incisions in faster time than ever before. While advances in surgical science and instrumentation continue, new problems have emerged. Health systems struggle with massive staff shortages while reeling from a once-in-a-century pandemic. Surgical trainees face increased levels of burnout and depression. Duty hours are chastised as the culprit for reduced autonomy while still being violated routinely. The electronic health record and telemedicine, though essential, have increased the distance between provider and patient. Surgeons suffer in silence from the pain of long hours spent operating in uncomfortable positions as hospitals grapple with the enormity of the waste they produce - demonstrating the tenuous sustainability of both practitioner and craft.
Surgical innovation flows from academic research. However, the systemic challenges faced by our field are not easily solved by the traditional research tools that surgeons have mastered. Addressing them will require a new academic approach that is leaner, faster, more creative, and more grounded in people’s lived experience. In this paper, we present design thinking as such a framework.
What is Design Thinking?
Design thinking is a problem solving approach in which participants:
- Identify a problem by deeply understanding the needs of people affected by that problem
- Generate as many potential solutions as possible through divergent ideation
- Iteratively test and refine prioritized ideas through prototyping, rapid experimentation, and user feedback
Design thinking - like surgery - is a hands-on practice. In the problem definition phase, designers often observe or experience the problem directly in addition to interviewing stakeholders. Prototypes, whether digital or physical, are bespoke and designed to solve the problem at hand. The very stakeholders who helped define the problem are then called upon to test and guide improvement of each prototype. Arguably the most important feature of design thinking is maintaining proximity to the problem one is trying to solve. And no one is more familiar with the problems and frustrations of modern surgery than residents - often the very people forced to find workarounds and temporary fixes (or as we would say in design thinking, early prototypes!).
The origins of design thinking are nebulous. Plato was an early practitioner of participatory design when asking for citizen input in community decisions (1). In that sense, leaders of the American Revolution - who prototyped a new form of government based on citizen pain points and iteratively amended it based on voter feedback - were early design thinkers too. In the mid-twentieth century, design transitioned from a way to make things look better into an approach for problem solving. Design theorists Horst Rittel and Melvin Webber characterized design as a tool to solve ”wicked problems” that were complex, evaded simple solutions, and affected multiple stakeholders (2). Herbert Simon introduced new methodologies for prototyping and simulation (3). Don Norman made the user experience central to the design process (4). Finally, David Kelley and colleagues institutionalized the practice of design within the consultancy IDEO in 1991 and the teaching of design within the Hasso Plattner Institute of Design at Stanford (d.School) in 2004.
Design thinking empowered the development of the first Apple mouse, Netflix, AirBnB, and Uber Eats (5). In healthcare, it inspired novel devices such as a wearable breast pump, surgeon-friendly spine instrumentation, and a user-friendly defibrillator as well as services such as a birth control support network for women (6). Still, it has not been formalized as a teaching within academic surgery. Doing so would unleash the creative abilities of students and trainees to tackle the "wicked problems" of culture, process, and systems that challenge our field today.
How Do We Do This?
Start With What Works
In recent years, some institutions have developed surgical innovation programs based on design thinking principles. The UCSF Surgical Innovations fellowship brings together faculty, residents, and engineers to work on a variety of projects from device design to improving patient safety7. Additional examples are outlined in Table 1. As new innovation programs are developed, we must build on their successes and address their limitations. To date, most programs are limited in
size and accessible to few trainees per year. Moreover, the majority focus on building devices with commercial potential. Future iterations should aim to broaden both the reach and scope of design thinking education to include clinically active residents and address systems problems, respectively.
Incorporate Design Thinking Into Clinical Training
There are many books, articles, and videos that teach design thinking. However, clinical residents have limited time for extracurricular reading as is. Nevertheless, there are ways to incorporate design into the existing clinical workflow. The Morbidity and Mortality (M&M) conference already offers a structured format for surgeons to discuss complications and adverse events. This forum can serve as an excellent source for capturing pain points - many of which stem from systems issues that design thinking can address. One possibility for practicing design thinking is to dedicate one M&M per month to brainstorm ideas to prevent the given complication. Each idea can be tested and progress can be discussed at the following session. Even for trainees unsure about practicing design, exposure to it may be helpful. At UCSF, we hold a weekly innovator forum in which a start–up or academic group pitches their idea to our diverse group of surgeons, engineers, and business experts. Presenting teams benefit from the clinical context and experience we provide, and we benefit by being exposed to new ideas. The ubiquity of remote conferencing makes this idea accessible to any program regardless of infrastructure or geography.
Use Design for Quality Improvement
Design thinking shares common features with existing approaches already used in surgical research, most notably Quality Improvement (QI). Established frameworks for QI include lean, six-sigma, and Plan-Do-Study-Act (PDSA) (8). However, these approaches are ideally used in processes that can be measured. Furthermore, the stakeholder alignment that is required to develop the initial QI plan ("Do" phase of PDSA) often requires top-down buy-in. Design thinking adopts a similar iterative framework but can be applied to problems that are more difficult to measure and also be performed in a more grassroots manner. Just as prior techniques from manufacturing and management have found their way into the healthcare lexicon, design thinking can provide another set of tools that can be applied to academic surgery.
Legitimize Design Work in Surgery
Research is a core mission of academic surgery and is increasingly necessary for residents matching into competitive fellowships. While the acceptable definition of research has broadened to include disciplines such as health services research and surgical education, the ”how” of research - publication in peer reviewed journals - has not. Imagine if a researcher publishes a work in which they explore a difficult problem through stakeholder interviews, describe prototypes of varying form and feasibility, and present preliminary results from “experiments” to test each prototype. Though few prototypes would reach full-scale implementation, all would likely yield valuable insights to our community. There are currently few venues to support and disseminate this work. Contrastingly, tech founders are increasingly building prototypes in public and sharing early, buggy versions for feedback. Surgical trainees are uniquely able to take academic risks
and should be rewarded for doing so. Moreover, incorporating design work would help build core ACGME competencies such as ”practice based learning and improvement” which are currently difficult to cultivate and assess.
Conclusions
"Measure twice, cut once" is a common adage in surgery. On the other hand, design thinking embodies the words of Samuel Beckett: "Ever tried. Ever failed. No matter. Try again. Fail again. Fail better." In fact, the legendary surgeon innovator Thomas Krummel referenced this quote in the title of his presidential address to the Association of Pediatric Surgeons (9). As surgeons, we are trained not to fail. And when holding a delicate blood vessel or bile duct, it is clear why that is the case. Perhaps the necessary emphasis of safety in surgery has promoted a culture resistant to change and averse to risk. Contrastingly, design thinking places a special importance on not rejecting far-reaching or unconstrained ideas, as they can often serve as unexpected vehicles to previously inaccessible solutions. Thus, creating a safe psychological space for creative ideation may unlock innovations that improve patient quality and safety in the long term.
Engineers, entrepreneurs, and early adopters within healthcare have embraced the potential of design thinking. A new generation of surgeons and trainees, with an appetite for innovation, is ready to rethink the status quo in fields like education, wellness, and sustainability. If we give them the right tools and culture, we can turn the very people burnt out by modern surgery into the innovators best equipped to transform it.
| Program | Description |
|---|---|
| UCSF Surgical Innovations Biodevice Innovation Pathway | A one to two year research fellowship in which residents work with surgeons, bioengineers, and business experts on a variety of innovation projects ranging from device development to quality and safety improvement. |
| Stanford Biodesign Innovation Fellowship | A 10 month program in which individuals with clinical, engineering, and business backgrounds work in teams to learn a repeatable process for innovation including needs assessment, prototyping, and commercialization. |
| Innovation Fellowship at Boston Children’s Hospital | A two year research fellowship for residents that comprises a core curriculum, longitudinal projects in device and software innovation, and clinical research |
| Surgical Innovation Fellowship at the University of Michigan | A fellowship for residents to work on innovation projects that advance education, research, or clinical care under the guidance of a surgical faculty, engineering, and business mentors. |
Table 1. A non-exhaustive list of surgical innovation programs geared towards residents. The descriptions were written by the authors based on material from each program’s website, and links to each program have been provided for reference.
Author Disclosures
Hanmin Lee, MD is a medical consultant to Sira Medical which does advanced, 3D imaging. He is also a co-PI for the UCSF/Stanford Pediatric Device Consortium grant. Dorothy Ho, MD works at IDEO.
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https://www.jpedsurg.org/article/S0022-3468(14) 00676-9/abstract
