Innovation and Design Experiments in Academic Surgery (I.D.E.A.S.)

Meghal Shah, MD

<p>I embarked on my year of academic development with the goal of <a href="https://www.themodernsurgeon.org/blog-2-1/adding-insult-to-injury-w6rcf?ref=ideasurg.pub">making operating less painful for surgeons</a>. The field of surgical ergonomics is nascent, and while there is an appetite for technological solutions, behavioral interventions are one of the only effective (albeit limited) tools available to us right now. With this understanding, my first project was to implement intraoperative microbreaks (short, 90 second pauses taken intermittently during an operation to stretch and break up sustained positions without breaking scrub) as a department wide intervention. While microbreaks don't prevent injury, they have been shown in some studies to <a href="https://pubmed.ncbi.nlm.nih.gov/28059962/?ref=ideasurg.pub">reduce pain and improve focus</a>. Moreover, I thought that such a low cost, low tech solution would be easy to implement. What I didn&#x2019;t realize was that not only was culture change itself an ambitious goal, &#xA0;but also that achieving it required a relentless extroversion formidable to my introverted self. I quickly realized that this endeavor would be one of the most challenging things I have ever had to do.</p><p>Before implementing microbreaks, I wanted to understand how much pain surgeons were in. We chose a series of ten operations to start with and decided to send surveys to surgeons and residents before and after each instance of one of the selected cases. Even with this, I faltered. How can we ask busy, overworked, and burnt-out surgeons and residents to fill out a survey with seemingly no immediate benefit? I remember as a clinically active resident, I loathed every survey that appeared in my inbox and resented every person who asked me to do <em>just one more thing</em>. I even enrolled in a study in which I got a free smartwatch, but categorically refused to take on the extra work of setting it up and never used it. From the very start of this year&#x2019;s journey, I felt like a hypocrite.</p><p>Keeping this in mind, I tried to make my &#x201C;pain surveys&#x201D; as painless as possible. The goal was to get the answer to just two questions: 1. Do you have pain? And if the answer is yes 2. Where and how much? I tried many different modalities and iterations. I printed out cards with body maps and left them in the operating room, but no one filled them out. Then, I tried running between rooms to catch teams as they were finishing and asked them directly. This was effective, but impossible to scale and sustain over the long term. Finally, I developed a survey on Qualtrics that utilizes the &#x201C;hot spot&#x201D; function on an image of a body map, and got feedback that residents and faculty enjoyed the clickable, touch-screen interface. </p><p>In the first couple of days, I manually created Qualtrics links daily and personally texted them to each surgeon and resident I was studying, constantly eying the OR board to figure out when to send the pre and post-operative surveys. Realizing that this too would not be scalable, I taught myself Python by watching a YouTube tutorial and wrote a program that could automatically create custom Qualtrics links with the surgeon name and operation pre-filled and <a href="https://youtube.com/shorts/1mOdN9xTKKY?feature=share&ref=ideasurg.pub">send them out at specified times</a> using Twilio, an automated text messaging service. There were two problems with this approach. First, the times I programmed in were the scheduled case start and case finish times which did not account for delays or schedule changes. I knew these times could be inaccurate but it was a limitation I had to live with given my current lack of resources, technical expertise, and inability to integrate my program with the Epic EHR. The second problem was that I often didn't know which resident would be scrubbing the case when I ran my program the night before to generate the links. Cases were not always assigned at the beginning of the week and last minute switches were frequent especially on some of the more unpredictable services. As such, surveys would often be sent to the wrong resident. I finally embedded myself in the case assignment emails for some of the services which alleviated this issue to a degree.</p><p>To my great surprise, attendings loved the survey and responded most of the time. I'm not sure why they participated enthusiastically - perhaps this survey was filling a void that had been unaddressed for too long. Residents - not unexpectedly - rarely responded. When not operating, residents are seemingly constantly playing catch up with floor updates. Perhaps incentivizing this process for residents, whereby their cases can be logged automatically in the ACGME case log, could improve response rates. This is a direction we could pivot to or explore in our next iteration. In retrospect, the correct thing would have been to observe residents as they received the notifications and understand their behaviors - using this to understand why people weren't responding and appropriately pivoting the approach. Overall, we have collected 1000 data points since rolling out the automated surveys six months ago.</p><p>Throughout the process, I confronted my fear &#x201C;bothering others&#x201D; constantly. Iteratively improving on the survey design and delivery process required me to interrupt residents at work, watch them go through the survey, and ask them to share their insights and feedback with me. But the end result speaks for itself. Far from a finished product, it is still a massive step forward from doing and measuring nothing.</p><p>With the pre-intervention data collection process semi-automated and underway, it was time to design and implement the microbreaks themselves. I looked into existing resources, such as <a href="https://orstretch.mayoclinic.org/?ref=ideasurg.pub">OR-Stretch from the Mayo Clinic</a>, a web-app on which the surgeon programs an alarm at set intervals that prompts and guides the OR team through a microbreak. I shared this freely-available resource with many of our surgeons for feedback and learned that 1) surgeons didn&#x2019;t want an alarm going off in their OR that would rely on the circulator staff to manage and 2) we had no reliable way to display the web-app's video on screens in the OR. However, surgeons did note that they would be willing to take microbreaks during predetermined natural break points in the case. With this feedback, I went back to the drawing board to design a resource that would better fit the needs of our surgeons.</p><p>I collaborated with physical therapy faculty at Columbia to curate a set of exercises to counteract the unique stressors of operating that can be completed in under two minutes without breaking scrub. In parallel, we designed a user-friendly poster depicting these exercises with minimalist drawings, a process that was fun and fulfilling, especially when the final design came together beautifully. We went through several iterations of the design, taking into account user feedback (four votes for yellow, two votes for green, preference for stick figures rather than human depictions) and improving on the exercises initially chosen.</p><figure class="kg-card kg-image-card kg-width-wide kg-card-hascaption"><img src="https://www.ideasurg.pub/content/images/2023/05/Group-93--1-.png" class="kg-image" alt loading="lazy" width="2000" height="664" srcset="https://www.ideasurg.pub/content/images/size/w600/2023/05/Group-93--1-.png 600w, https://www.ideasurg.pub/content/images/size/w1000/2023/05/Group-93--1-.png 1000w, https://www.ideasurg.pub/content/images/size/w1600/2023/05/Group-93--1-.png 1600w, https://www.ideasurg.pub/content/images/size/w2400/2023/05/Group-93--1-.png 2400w" sizes="(min-width: 1200px) 1200px"><figcaption>We iterated on the poster design multiple times, incorporating feedback from residents and surgeons.</figcaption></figure><p>The poster serves as a visual cue for microbreaks and is currently hanging in ten of our operating rooms, as well as in all of the operating rooms of a nearby hospital where our residents operate. We hired a freelance graphic designer to make an explanatory video to go hand in hand with the poster. All of these resources are compiled and freely available <a href="https://intraopresets.framer.website/?ref=ideasurg.pub">here</a>.</p><p>Emerging from this period of creative productivity felt refreshing - I developed skills (Figma, video editing) and designed resources with cross disciplinary experts.</p><p>However, I soon found myself again in my least favorite position - asking surgeons to do something for me. If I were to implement microbreaks in the most effective way, I would be in the ORs, interrupting cases, training surgeons, guiding them through the breaks myself. But just as easily I started the project, I came to a halt. It seemed I had initially underestimated my own social anxiety and fear of being seen as a &#x201C;disruptor&#x201D;, or worse, fear of not being taken seriously. How can I possibly walk into an OR and ask the team, who may be focused on the operation, to stop what they are doing and take a &#x201C;microbreak&#x201D;?</p><p>And so I stalled. I tried to rationalize - culture change is too difficult, behavioral interventions are not effective, there are more important fulfilling things I want to focus on. But if I am being honest, I&#x2019;m scared of this next step because it forces me out of my comfort zone and forces me to face my social fears head on. In truth, my actual fear is 200 years of surgical culture, and not the people I work with. In fact, the mentors, faculty, and residents around me have been extremely supportive, especially when I&#x2019;ve doubted myself the most. Perhaps my biggest fears and limitation may also be my opportunity for greatest growth. 1I&#x2019;ve driven to the edge of the cliff, and the only thing left to do is take a leap of faith.</p><hr><p>I took that leap of faith and the end result was beautiful. While I was laughed out of only one or two ORs, the overwhelming responses from OR teams were supportive. I found surprising allies in senior attendings including division chiefs, and the perioperative nursing staff even invited me to run a tutorial at their skills day. Over the past few months, countless people have told me their OR did a microbreak, even from departments outside of my own. Text messages like the one here have brought me endless joy and fulfillment. Here is a <a href="https://youtu.be/Awp987dhnd4?ref=ideasurg.pub">video</a> of our surgeons leading their teams through microbreaks.<br></p><figure class="kg-card kg-image-card"><img src="https://www.ideasurg.pub/content/images/2023/05/data-src-image-5e2aa6b7-27c7-43df-9bf7-b2efd738b821.png" class="kg-image" alt loading="lazy" width="828" height="893" srcset="https://www.ideasurg.pub/content/images/size/w600/2023/05/data-src-image-5e2aa6b7-27c7-43df-9bf7-b2efd738b821.png 600w, https://www.ideasurg.pub/content/images/2023/05/data-src-image-5e2aa6b7-27c7-43df-9bf7-b2efd738b821.png 828w" sizes="(min-width: 720px) 720px"></figure><p>My story highlights a common hurdle that stymies progressive culture change. Often, to create change, we have to ask people in power to change the way they do things. It doesn't even matter if the people in power agree with the change (often they do!) - the nature of this hierarchy makes the task daunting, regardless of the intention or goal. But clearing this hurdle opens the floodgates to culture change. How might we create ways to bother people more effectively? I do not have the full answer but here are a few ideas on how to implement a behavior change intervention such as a microbreak:</p><p>Minimally disruptive - If you have the access to the EHR then you can build data collection and educational tools into the existing workflow. If, like me, you do not have this access, then we will be publishing our code to automate text message delivery at preset times. While imperfect, it does automate the creation of a somewhat personal and timely touch to any intervention.</p><p>Make things mandatory - As residents, we complete an enormous amount of administrative work, from periodic mandatory trainings on central line safety and human resource slide decks. All of these things contribute to burnout and are undoubtedly disruptive to our schedules, but we get it done because it is mandatory. Perhaps cutting down on these administrative burdens and instead building participation in program improvement efforts into the requirements can be effective and improve wellness.</p><p>Reward participation - Reward incentives such as Amazon gift cards or meal vouchers are frequently used to boost participation in surveys. It's only a matter of finding the right incentive for our cohort in that case. In our work, we realized that the most prescient incentive would be to automatically submit cases into the ACGME case log on behalf of residents based on their survey responses. This works even better if there is EHR integration, in which the case data includes the residents who were scrubbed in the case.</p><p>Protected time for participation - Many residency programs build protected time into the resident schedules for personal use, administrative tasks, academic work, or any of the above. Similarly building in protected time for quality improvement efforts, exploring human centered design projects, and resident wellness will only serve to cultivate more well rounded, creative, and fulfilled residents.</p><p>Finally, sometimes we just have to take the plunge and bother people a little bit. That doesn't mean accosting busy surgeons when things are not going well in a case. But within reason, there is no harm in asking. Some may laugh, some may refuse to participate, some may ignore your presence altogether. But in my experience, most most will be supportive to the extent they are able. And that is how the gears of this slow, painful, and messy process of culture change begin to turn. At the end of the day, I guess disruption does require being a little disruptive.<br><br></p>

I embarked on my year of academic development with the goal of making operating less painful for surgeons. The field of surgical ergonomics is nascent, and while there is an appetite for technological...

Fumbling at the Five Yard Line

Tejas S. Sathe, MD

<figure class="kg-card kg-image-card kg-width-wide kg-card-hascaption"><img src="https://www.ideasurg.pub/content/images/2023/04/Residency-Scorecard-Light-Mode--7-.png" class="kg-image" alt loading="lazy" width="2000" height="1127" srcset="https://www.ideasurg.pub/content/images/size/w600/2023/04/Residency-Scorecard-Light-Mode--7-.png 600w, https://www.ideasurg.pub/content/images/size/w1000/2023/04/Residency-Scorecard-Light-Mode--7-.png 1000w, https://www.ideasurg.pub/content/images/size/w1600/2023/04/Residency-Scorecard-Light-Mode--7-.png 1600w, https://www.ideasurg.pub/content/images/size/w2400/2023/04/Residency-Scorecard-Light-Mode--7-.png 2400w" sizes="(min-width: 1200px) 1200px"><figcaption>My prototype for a Residency Visual Abstract</figcaption></figure><div class="kg-card kg-callout-card kg-callout-card-grey"><div class="kg-callout-text">This tool represents my own ideas and is not currently in use or endorsed by any institution.</div></div><p>Medical students applying to residency often have to grapple with an incredible amount of information when evaluating prospective training programs. The increased number of applications and interviews inherent to the Zoom era further exacerbates this issue. At the same time, programs need to find ways to communicate a great deal of information to applicants. Due to the proliferation of social media, this communication is both more extensive and more longitudinal than a one hour presentation on interview day.</p><p>The traditional interview day presentation is a slide presentation that provides several factual details about a program. While each program is slightly different, most of these presentations cover common ground - including where residents rotate, what services they do, where alumni match into fellowship, examination pass rates, and information on professional development and research activities. These presentations can often be long (I once helped edit a slide deck that had 60 slides in it!) and difficult to recall. Furthermore, updating these slides from year to year is a time consuming challenge. Finally, most of these presentations are done in a traditional bullet point format with few slides reserved for photos. Few are designed in a way that optimizes user experience.</p><p>In my opinion, the most important quality of the program is how well a prospective applicant fits in with the resident culture. Though it is impossible to put into numbers, it has an outsized impact on a resident's experience and wellness. Furthermore, it is even harder to intuit in the absence of an in-person interview experience. Nevertheless, there are important quantitative metrics that applicants consider and programs want to showcase. However, there is not yet a standardized, accessible, and visually appealing format to do so. Given the challenges in communicating these details as well as the growing power of social media , I wanted to design a new way that programs can effectively and efficiently display and disseminate this information so that applicants can be more informed and programs can better utilize their interview days to convey the critical intangibles.</p><p>In the distinct but not quite distant field of surgical research, the visual abstract has already proven to be an excellent means of distilling a research study filled with details into an easy-to-digest and visually pleasing format. Developed by Dr. Andrew Ibrahim and colleagues, the visual abstract has already been adopted by 50 journals, and a study by the creators <a href="https://journals.lww.com/annalsofsurgery/Citation/2017/12000/Visual_Abstracts_to_Disseminate_Research_on_Social.36.aspx?ref=ideasurg.pub">demonstrated</a> that the presence of a visual abstract can more than double article visits and increase impressions more than seven-fold. An excellent primer discussing how to develop a visual abstract and highlighting its use in academic journals is available <a href="https://static1.squarespace.com/static/5854aaa044024321a353bb0d/t/5a527aa89140b76bbfb2028a/1515354827682/VisualAbstract_Primer_v4_1.pdf?ref=ideasurg.pub">here</a>. </p><p>A variant of the visual abstract has also been used by residency programs on social media in the past. An example from the Duke Surgery Residency program is shown here:</p><figure class="kg-card kg-embed-card"><blockquote class="twitter-tweet"><p lang="en" dir="ltr">We&#x2019;re so excited to meet <a href="https://twitter.com/hashtag/GenSurgMatch2023?src=hash&ref_src=twsrc%5Etfw&ref=ideasurg.pub">#GenSurgMatch2023</a> applicants over the next few months! Check out our latest <a href="https://twitter.com/DukeSurgRes?ref_src=twsrc%5Etfw&ref=ideasurg.pub">@DukeSurgRes</a> <a href="https://twitter.com/hashtag/VisualAbstract?src=hash&ref_src=twsrc%5Etfw&ref=ideasurg.pub">#VisualAbstract</a> <a href="https://twitter.com/hashtag/ByTheNumbers?src=hash&ref_src=twsrc%5Etfw&ref=ideasurg.pub">#ByTheNumbers</a>. We hope you can visualize your <a href="https://twitter.com/hashtag/SutureFuture?src=hash&ref_src=twsrc%5Etfw&ref=ideasurg.pub">#SutureFuture</a> at <a href="https://twitter.com/DukeSurgery?ref_src=twsrc%5Etfw&ref=ideasurg.pub">@DukeSurgery</a>. <a href="https://twitter.com/hashtag/SabistonSquad?src=hash&ref_src=twsrc%5Etfw&ref=ideasurg.pub">#SabistonSquad</a> <a href="https://twitter.com/hashtag/SurgTwitter?src=hash&ref_src=twsrc%5Etfw&ref=ideasurg.pub">#SurgTwitter</a> <a href="https://twitter.com/hashtag/MedTwitter?src=hash&ref_src=twsrc%5Etfw&ref=ideasurg.pub">#MedTwitter</a> <a href="https://twitter.com/hashtag/SurgEd?src=hash&ref_src=twsrc%5Etfw&ref=ideasurg.pub">#SurgEd</a> <a href="https://twitter.com/hashtag/ILookLikeASurgeon?src=hash&ref_src=twsrc%5Etfw&ref=ideasurg.pub">#ILookLikeASurgeon</a> <a href="https://t.co/6ZqnfFrWE5?ref=ideasurg.pub">pic.twitter.com/6ZqnfFrWE5</a></p>&#x2014; Duke General Surgery Residency (@DukeSurgRes) <a href="https://twitter.com/DukeSurgRes/status/1587460003941810179?ref_src=twsrc%5Etfw&ref=ideasurg.pub">November 1, 2022</a></blockquote>
<script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>
</figure><p>Inspired by this format, I tried to design a version tailored towards prospective surgery trainees. I wanted to see if I could boil down the complexity of a program into the fewest pieces of data possible and present them in a user-friendly interface. </p><h3 id="the-visual-abstract">The Visual Abstract</h3><p>The abstract contains six different categories: demographics, operative volume, education, research, fellowships, and other. The goal is to capture relevant information regarding the tripartite mission of academic surgery as well as understand a program's strengths in diversity and inclusion and career preparation. For each category, discrete data points were chosen which can easily allow applicants to contextualize a program's strengths and weaknesses. The other category contains a checklist of features that applicants seem to care about (based on observations and conversations though certainly not proven scientifically). Finally, there is a space for QR codes to link to the program website as well as a copy of the contract that matched applicants will need to sign (as <a href="https://www.nrmp.org/wp-content/uploads/2022/09/2023-MPA-Main-Match-Program-FINAL-3.pdf?ref=ideasurg.pub">required</a> by the National Resident Matching Program).</p><p>Of course, the tool comes with a dark mode!</p><figure class="kg-card kg-image-card kg-width-wide"><img src="https://www.ideasurg.pub/content/images/2023/04/Thumbnail--2-.png" class="kg-image" alt loading="lazy" width="1924" height="1084" srcset="https://www.ideasurg.pub/content/images/size/w600/2023/04/Thumbnail--2-.png 600w, https://www.ideasurg.pub/content/images/size/w1000/2023/04/Thumbnail--2-.png 1000w, https://www.ideasurg.pub/content/images/size/w1600/2023/04/Thumbnail--2-.png 1600w, https://www.ideasurg.pub/content/images/2023/04/Thumbnail--2-.png 1924w" sizes="(min-width: 1200px) 1200px"></figure><h3 id="what-this-is">What this is</h3><p>This visual abstract can provide a semi-standardized format for programs to share important information with applicants allowing them to compare important metrics in a comprehensive, &#x201C;easy&#x201D; way. It is important to note that each of these data points is meant to be an objective measure without any comment on its intrinsic value. For example, one program may have a significantly higher case volume than peer institutions but less protected education time. Another may have a robotic curriculum but not have any recent chiefs who matched into Pediatric Surgery. None of these are independently good or bad, but applicants should have an easy way to understand the factors so that they can make the most informed decision. If a significant number of programs adopt the visual abstract, it will naturally create incentives for programs to share and improve on these metrics with transparency. In this manner, healthy competition can actually generate an incentive to improve program offerings for current residents as well (though this can have unintended consequences&#x2026;see limitations).</p><p>Some may question the wisdom of putting these numbers out in the open - especially if they are not where a program wants them to be. However, some of the information is publicly <a href="https://www.absurgery.org/xfer/3yr_summary.pdf?ref=ideasurg.pub">available</a>. Many of these data points are already reported on during the interview process. Moreover, most applicants want to know this information and value transparency. Ultimately, no program is perfect, and how a program chooses to address perceived strengths and weaknesses reflects its core values.</p><h3 id="what-this-is-not-and-other-limitations">What this is not and other limitations</h3><p>No visual abstract, slide deck, or document will be able to capture the full picture of a residency program - which at its core is a collection of human beings. It is worth repeating that the most important consideration students should make when choosing a program is missing from this work. Furthermore, the exact data points used may not be correct. At one point, I considered putting a box for ABSITE pass rate, however I thought this was antithetical to the ABSITE's stated aim of being a <a href="https://www.absurgery.org/default.jsp?certabsite=&ref=ideasurg.pub">formative</a>, not a summative, assessment. Furthermore, there is no box specifying the number of LGBTQ residents in a program. While this is an essential component of diversity, equity, and inclusion, it was omitted due to the fact that some of these residents may not be publicly out and this would lead to an inaccurate representation. Another missing box is the number of residents with children, given that family support is an increasingly recognized feature that students are looking for in training programs.</p><p>I would like for this to be even less cluttered - and user feedback can drive further reduction of content such that the distilled final version is even more elegant. Currently, the vision for this project is that of a grassroots project, where individual programs can choose to use, improve, and modify this template to broadcast important information to applicants. However, I am wary of the general principle that once quantitative metrics are used by a central authority to rank, there is a natural tendency to gamify those metrics whether or not the underlying feature they seek to estimate is actually affected.</p><h3 id="what-to-do-with-this-template">What to do with this template</h3><p>In short, whatever you would like. The template was built in Figma, which has become the industry-standard in visual design. It is free to make a basic Figma account, and the full suite of features is also available for free with proof of affiliation with a university. Figma offers the ability to comment on a template as well as duplicate or "remix" the template for personal use. I would appreciate your feedback on how to make this template better. Moreover, I encourage you to take it, modify it, improve it, and share your changes publicly. Together, we can continue to iteratively design this initial prototype and develop a robust, user-friendly tool that provides values to students, residents, and programs alike.</p><h3 id="comment-remix-make-it-your-own">Comment, remix, make it your own!</h3><p><a href="https://www.figma.com/community/file/1226056013352001653?ref=ideasurg.pub">https://www.figma.com/community/file/1226056013352001653</a></p>

A graphical, user-friendly tool for programs to highlight important data to prospective applicants

The Residency Visual Abstract

GPT-4

We asked OpenAI's latest large language model (GPT-4) to opine on the biggest challenges in academic surgery and how to solve them.

GPT-4 on the Biggest Challenges in Academic Surgery

<div class="kg-card kg-callout-card kg-callout-card-grey"><div class="kg-callout-text"><strong>Abstract</strong><br>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.</div></div><h2 id="introduction">Introduction</h2><p>The word surgery derives from the Greek roots khei&#x301;r (&#x201C;hand&#x201D;) and e&#x301;rgon (&#x201C;work&#x201D;). 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.</p><p>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&#x2019;s lived experience. In this paper, we present design thinking as such a framework.</p><h2 id="what-is-design-thinking">What is Design Thinking?</h2><p>Design thinking is a problem solving approach in which participants:</p><ol><li>Identify a problem by deeply understanding the needs of people affected by that problem</li><li>Generate as many potential solutions as possible through divergent ideation</li><li>Iteratively test and refine prioritized ideas through prototyping, rapid experimentation, and user feedback</li></ol><p>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!).</p><p>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 &#x201D;wicked problems&#x201D; 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.</p><p>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.</p><h2 id="how-do-we-do-this">How Do We Do This? </h2><h3 id="start-with-what-works">Start With What Works</h3><p>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</p><p>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.</p><h3 id="incorporate-design-thinking-into-clinical-training">Incorporate Design Thinking Into Clinical Training</h3><p>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&#x2013;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.</p><h3 id="use-design-for-quality-improvement">Use Design for Quality Improvement</h3><p>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.</p><h3 id="legitimize-design-work-in-surgery">Legitimize Design Work in Surgery</h3><p>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 &#x201D;how&#x201D; 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 &#x201C;experiments&#x201D; 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<br>and should be rewarded for doing so. Moreover, incorporating design work would help build core ACGME competencies such as &#x201D;practice based learning and improvement&#x201D; which are currently difficult to cultivate and assess.</p><h3 id="conclusions">Conclusions</h3><p>"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.</p><p>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.</p><table>
<thead>
<tr>
<th>Program</th>
<th>Description</th>
</tr>
</thead>
<tbody>
<tr>
<td><a href="https://surgicalinnovations.ucsf.edu/education-training/resident-training/biodevice-innovation-pathway.aspx?ref=ideasurg.pub">UCSF Surgical Innovations Biodevice Innovation Pathway</a></td>
<td>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.</td>
</tr>
<tr>
<td><a href="https://biodesign.stanford.edu/programs/fellowships/innovation-fellowships.html?ref=ideasurg.pub">Stanford Biodesign Innovation Fellowship</a></td>
<td>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.</td>
</tr>
<tr>
<td><a href="https://www.childrenshospital.org/research/departments/surgery-research/surgical-innovation-fellowship?ref=ideasurg.pub">Innovation Fellowship at Boston Children&#x2019;s Hospital</a></td>
<td>A two year research fellowship for residents that comprises a core curriculum, longitudinal projects in device and software innovation, and clinical research</td>
</tr>
<tr>
<td><a href="https://medicine.umich.edu/dept/surgery-research/centers-initiatives/center-surgical-innovation/surgical-innovation-fellowship?ref=ideasurg.pub">Surgical Innovation Fellowship at the University of Michigan</a></td>
<td>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.</td>
</tr>
<tr>
<td></td>
<td></td>
</tr>
</tbody>
</table>
<p><sub> <strong>Table 1.</strong> A non-exhaustive list of surgical innovation programs geared towards residents. The descriptions were written by the authors based on material from each program&#x2019;s website, and links to each program have been provided for reference. <sub></sub></sub></p>
<p></p><p></p><div class="kg-card kg-toggle-card" data-kg-toggle-state="close"><div class="kg-toggle-heading"><h4 class="kg-toggle-heading-text">Author Disclosures</h4><button class="kg-toggle-card-icon"><svg id="Regular" xmlns="http://www.w3.org/2000/svg" viewbox="0 0 24 24"><path class="cls-1" d="M23.25,7.311,12.53,18.03a.749.749,0,0,1-1.06,0L.75,7.311"/></svg></button></div><div class="kg-toggle-content"><p>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.</p><br></div></div><h3 id="references">References</h3><ol><li>Henry Sanoff. Multiple Views of Participatory Design. Focus, 8(1), April 2011. ISSN 15493776. doi: 10.15368/focus. 2011v8n1.1.<br><a href="http://digitalcommons.calpoly.edu/focus/vol8/iss1/7?ref=ideasurg.pub">http://digitalcommons.calpoly.edu/focus/vol8/iss1/7</a></li><li>Horst W. J. Rittel and Melvin M. Webber. Dilemmas in a general theory of planning. Policy Sciences, 4(2):155&#x2013;169, June 1973. ISSN 1573-0891. doi: 10.1007/BF01405730.<br><a href="https://doi.org/10.1007/BF01405730?ref=ideasurg.pub">https://doi.org/10.1007/BF01405730</a></li><li>Richard Buchanan. Wicked Problems in Design Thinking. Design Issues, 8(2):5, 1992. ISSN 07479360. doi: 10.2307/ 1511637. <a href="https://online.hbs.edu/blog/post/%20design-thinking-examples?ref=ideasurg.pub">https://www.jstor.org/stable/1511637?origin=crossref</a></li><li>Donald A. Norman. The Design of Everyday Things. Basic Books, A Member of the Perseus Books Group, New York, revised and expanded edition edition, 2013. ISBN 9780465072996. OCLC: 860902830.</li><li>5 Examples of Design Thinking in Business | HBS Online, February 2022. <a href="https://online.hbs.edu/blog/post/%20design-thinking-examples?ref=ideasurg.pub">https://online.hbs.edu/blog/post/ design-thinking-examples</a></li><li>Faster, More Accurate Spinal Surgery, 2012.<br><a href="https://www.ideo.com/case-study/%20faster-more-accurate-spinal-surgery?ref=ideasurg.pub">https://www.ideo.com/case-study/ faster-more-accurate-spinal-surgery</a></li><li>Veeshal H. Patel, Michael R. Harrison, Elizabeth A. Gress, Shuvo Roy, Prashant Chopra, Stacy S. Kim, and Hanmin Lee. Creating a Multidisciplinary Surgical Innovations Group at an Academic Medical Center to Stimulate Surgery Faculty Technology Development. In Mark S. Cohen and Lillian Kao, editors, Success in Academic Surgery: Innovation and Entrepreneurship, Success in Academic Surgery, pages 185&#x2013;194. Springer International Publishing, Cham, 2019. ISBN 9783030186135. doi: 10.1007/978-3-030-18613-5_13.<br><a href="https://doi.org/10.1007/978-3-031-07524-7_8.?ref=ideasurg.pub">https://doi.org/10.1007/978-3-030-18613-5_13</a></li><li>Akemi Kawaguchi and KuoJen Tsao. Quality Improvement in Pediatric Surgery. In Peter Mattei, editor, Fundamentals of Pediatric Surgery, pages 79&#x2013;85. Springer International Publishing, Cham, 2022. ISBN 9783031075247. doi: 10.1007/ 978-3-031-07524-7_8.<br><a href="https://doi.org/10.1007/978-3-031-07524-7_8.?ref=ideasurg.pub">https://doi.org/10.1007/978-3-031-07524-7_8</a></li><li>Thomas M. Krummel. Try again. Fail again. Fail better. Journal of Pediatric Surgery, 50(1):5&#x2013;14, January 2015. ISSN 0022-3468, 1531-5037. doi: 10.1016/j.jpedsurg.2014.10.026.<br><a href="https://www.jpedsurg.org/article/S0022-3468(14)%2000676-9/abstract?ref=ideasurg.pub">https://www.jpedsurg.org/article/S0022-3468(14) 00676-9/abstract</a></li></ol><p></p>

One Small Step for Surgeons, One Giant Leap for Surgery

Teach Design to Surgical Trainees

<div class="kg-card kg-callout-card kg-callout-card-grey"><div class="kg-callout-text"><strong>Abstract</strong><br>The institutional knowledge required for residency is vast, complex, and frequently changing. Most institutions do not have a resource that serves as a singular source of truth for this information. Furthermore, since information is mostly presented on static documents such as emails or PDFs, there is no easy way to update and share the information in real time. In this article, we present our use of the Notion platform to solve these problems. Using this technology, we created a centralized knowledge hub for the residency. We use this platform to house an intern guide, publish service specific workflows and protocols, and track quality improvement initiatives. While we aim to continually refine the platform, our experience can serve as a template for other institutions attempting to create a one-stop shop for resident productivity and well-being.</div></div><h2 id="introduction">Introduction</h2><p>Surgical residents are responsible for learning and remembering a vast amount of information. While much of this information relates to the science and practice of surgery, a large portion is institutional and related to process. Most institutions do not maintain this information in a centralized and accessible format. Though exploratory conversations and surveys, we found that information was often organized piece-meal across a combination of paper, email, and cloud platforms such as Google Drive, WhatsApp, or Dropbox. While some programs did have central knowledge platforms, they were difficult to update in real-time. Here, we present our vision for a digital source-of-truth for such institutional knowledge - an operating system for residency.</p><h2 id="methodology">Methodology</h2><p>First, we analyzed the pain points that residents experienced accessing and organizing institutional knowledge. This information was previously siloed on multiple different platforms. Service and surgeon-specific protocols were uploaded to Google Drive, buried in text threads, or printed on paper depending on the service. Finding administrative forms often required searching through emails. Resident and faculty contacts were available on a Google sheet while hospital numbers were printed on a paper card. Furthermore, when such information could be found, it was often out-of-date, as no mechanism existed to update and disseminate knowledge in real-time.</p><p>After evaluating these pain points, we developed the following user requirements to guide the design of a new platform. First, the solution had to be mobile-friendly - as residents always have their phones on hand. Second, the solution had to be easy to update - as the annual review process previously in place was inconsistent and left too many outdated protocols in circulation. Third, the solution had to be intuitive - easy to use with minimal training. Fourth, the solution had to be low cost - as there was no funding for this project.</p><p>There are multiple software options that offer the functionalities we were looking for. Ultimately, we decided to use Notion to build our platform. Notion allows users to build custom, collaborative workspaces consisting of documents and databases. It is used by individuals and organizations across industries to create wikis, manage projects, write documents, and build internal tools. It is available as a web, desktop, and mobile application. Users can update any of the content in real-time. <a href="https://notion.so/?ref=ideasurg.pub">Notion</a> is offered for free to educational institutions for up to 100 guest users at present. Additional features are available at a charge. Perhaps its most useful feature is the ability to update information in one place and have that update reflected elsewhere. For example, if you update a surgeon's email address on the 'Contacts' page, the updated address will automatically appear on the pages of any services or committees with which that surgeon is affiliated. As such, there is always a single source of truth for any piece of information.</p><h2 id="implementation-of-the-platform">Implementation of the Platform</h2><p>First, we created a digital version of our 'Intern Survival Guide.' Each topic from the physical paper guide &#x2013; representing a clinical scenario that an intern may encounter &#x2013; was transformed into a digital card containing the relevant steps in triage and work up. Issues requiring escalation to a senior resident or attending surgeon were highlighted.</p><figure class="kg-card kg-embed-card kg-card-hascaption"><iframe width="200" height="113" src="https://www.youtube.com/embed/Z-mlK5LN7w8?feature=oembed" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen title="Notion Intern Guide Demo"></iframe><figcaption>Video demo of the Intern Survival Guide</figcaption></figure><p>Next, the disjointed resources containing service-specific protocols were adapted to the Notion platform. In a multi-week effort, content was systematically transferred, and post-operative protocols were standardized in a tabular format. Tutorials detailing how to enact these protocols in the electronic health record (EHR) were constructed in parallel - including step-by-step screenshots of common tasks including pre-rounding, placing orders, and admitting or discharging patients.</p><figure class="kg-card kg-embed-card kg-card-hascaption"><iframe width="200" height="113" src="https://www.youtube.com/embed/nKQXLAlv5Dg?feature=oembed" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen title="notion pathways"></iframe><figcaption>Video Demo of a Typical Service Page and Ability to Quickly Access Post-op Care Pathways</figcaption></figure><p>Next, the contact directory was migrated to Notion. This effort consolidated information that was previously housed on Google sheets and index cards. Moreover, users could now make calls directly from the Notion app (rather than retyping or copying and pasting the number), reducing wasted time and potential errors.</p><p>Over the following year, we launched Logistics and Wellness committees to lead projects to continually improve the program. The committees meet a few times per year to determine priorities and share updates. We are now utilizing Notion&#x2019;s project management features to organize our work. These features include the ability to create Kanban boards, build progress bars, and assign tasks to projects and projects to committees. We have already seen this help us achieve better focus during meetings and leave participants with specific actionable tasks.</p><p>Through built-in analytics, we are able to track view counts for the entire workspace and each individual page. Over the last 90 days, the platform was viewed 1,241 times. The platform also maintains full version history which allows us to track who is making edits and what changes are made. In the last month, 90 edits were made including the addition of new pages and database items, modification of existing content, and changing user permissions. The high level of active and passive engagement is encouraging to the viability of the platform.</p><figure class="kg-card kg-image-card kg-card-hascaption"><img src="https://www.ideasurg.pub/content/images/2023/03/Xnapper-2023-03-04-15.18.55-1.png" class="kg-image" alt loading="lazy" width="1990" height="1110" srcset="https://www.ideasurg.pub/content/images/size/w600/2023/03/Xnapper-2023-03-04-15.18.55-1.png 600w, https://www.ideasurg.pub/content/images/size/w1000/2023/03/Xnapper-2023-03-04-15.18.55-1.png 1000w, https://www.ideasurg.pub/content/images/size/w1600/2023/03/Xnapper-2023-03-04-15.18.55-1.png 1600w, https://www.ideasurg.pub/content/images/2023/03/Xnapper-2023-03-04-15.18.55-1.png 1990w" sizes="(min-width: 720px) 720px"><figcaption>Screenshot of built-in analytics function. Blue line represents total views while yellow line represents unique views.</figcaption></figure><p>Minimal training is needed to use the platform effectively. Incoming interns receive a one-hour onboarding session which is practical in nature (interns are given questions simulating common resident tasks and asked to use Notion to figure out how to achieve them). Following this, questions about application use are answered on an as-needed basis through our residency group chat or email.</p><h2 id="limitations-and-future-directions">Limitations and Future Directions</h2><p>Our Notion instance is a work in progress and several improvements will be necessary to achieve our vision of a 'one-stop shop' for resident education and well-being.</p><p>While residents frequently update content on various service pages, it is difficult to maintain adherence to a standardized format. As everyone is responsible for maintaining the integrity of the platform, the burden of oversight falls to no singular individual. As such, we have not yet systematized a process to review existing information. Page bloat and content disorganization occur as content is added, but efforts to address these issues are currently being discussed.</p><p>We have not completely solved the issue of multiple platforms, though the total number of information sources is reduced. The resident schedule continues to be maintained on a Google sheet and capabilities to incorporate it into Notion are limited. Our program previously used a proprietary platform to host instructional videos for operations, and migration of these videos to Notion is in progress. Our goal is to make Notion a hub for resident education, where didactic content as well as operative videos can be easily accessed.</p><p>Fundamental questions remain surrounding data governance and access. We currently give all residents and faculty members complete edit access to democratize the information ecosystem. As a result, information is updated with much greater frequency, and these updates are immediately reflected to all users. Yet, this amount of access carries risks. While inadvertent edits are made (which can easily be seen and undone through version history), to this day, there have been no malicious edits that negatively impact patient care. While the decentralized model optimizes ease of editability, it does forgo a traditional hierarchical structure that previously existed.</p><h2 id="conclusions">Conclusions</h2><p>In the past few years, collaboration applications such as Notion have flourished to facilitate asynchronous information sharing. Such platforms are addressing challenges that organizations have faced for years but have grown in complexity in the COVID era. We are using Notion to create a digital operating system for residency. We champion an approach that embraces technology and empowers each resident to take ownership of the collective knowledge of the program. Our vision is to have all the information of residency in the palm of your hand, in three clicks or less. While any technology has its limitations and raises new issues, we believe this platform can revolutionize the way our trainees access, interact with, and learn the information of residency.</p><div class="kg-card kg-toggle-card" data-kg-toggle-state="close"><div class="kg-toggle-heading"><h4 class="kg-toggle-heading-text">Responses to Reviewers</h4><button class="kg-toggle-card-icon"><svg id="Regular" xmlns="http://www.w3.org/2000/svg" viewbox="0 0 24 24"><path class="cls-1" d="M23.25,7.311,12.53,18.03a.749.749,0,0,1-1.06,0L.75,7.311"/></svg></button></div><div class="kg-toggle-content"><p>Our paper was submitted for publication and rejected during the peer review process. We asked the journal if we could publish the reviewer comments and our responses but were denied permission. Instead, we will attempt to paraphrase the comments and our rebuttals here.</p><p>One reviewer felt that many programs had similar platforms in place. We did not find this to be true in our exploratory analysis. We conducted informal surveys and spoke to residents at national conferences. A majority of survey responses indicated that residents did not have centralized knowledge sharing platforms in place. Further, while some residents were using such platforms, they differed from ours because they were not directly editable in real-time. The reviewer also felt our paper constituted an advertisement of one software option. We want to emphasize that none of the authors received financial compensation from Notion or any other company in this space. Finally, we accept that there are many platforms that could be used to organize the institutional knowledge of residency. While we present one, we would be excited to hear about the experiences that other institutions have with other platforms and collaboratively work towards designing the best optimal technology stack to teach and train residents. For that reason, it is even more important that technologies like this are discussed in the academic literature.</p><p>Another reviewer brought up the reasonable criticism that we are attempting to create a technological solution to a cultural problem and questioned whether residents would actually use the platform. We added data on both platform viewership (1241 views over last 90 days) and number of edits made (90 in the last month) to the Implementation section.</p><p>Many people - including one of the reviewers and people we speak to at conferences - want to know who is in charge of updating the information and making sure it is correct. We have deliberately chosen a decentralized approach that gives residents autonomy to maintain information. Before we implemented Notion, there was no routine faculty review of paper-based guides. Ultimately, there is a trade-off between conducting an overview of every piece of information posted on the platform and keeping the platform up-to-date. We chose to focus on the latter. We are also introducing faculty onto the platform and giving them edit access so that they can make edits and provide whatever oversight they feel is necessary.</p><p>Our central hypothesis in creating this platform was that providing residents a technical solution to access and organize information would allow them to quickly develop working knowledge of rote tasks and protocols and spend more time learning how to take care of patients and operate. Certainly, future work will need to be done in order to understand whether we are successful. Today, we can confidently say we have built a user-friendly, fast system that is frequently used and updated.</p></div></div><div class="kg-card kg-toggle-card" data-kg-toggle-state="close"><div class="kg-toggle-heading"><h4 class="kg-toggle-heading-text">Disclosures</h4><button class="kg-toggle-card-icon"><svg id="Regular" xmlns="http://www.w3.org/2000/svg" viewbox="0 0 24 24"><path class="cls-1" d="M23.25,7.311,12.53,18.03a.749.749,0,0,1-1.06,0L.75,7.311"/></svg></button></div><div class="kg-toggle-content"><p>None of the authors received financial compensation from Notion or have any disclosures relevant to this paper.</p></div></div>

AbstractThe institutional knowledge required for residency is vast, complex, and frequently changing. Most institutions do not have a resource that serves as a singular source of truth for this information....

An Operating System for Residency

<p>One of the most counter-intuitive principles when applying design thinking to healthcare and surgery specifically is the idea that <a href="https://www.charterworks.com/ideaflow-utley-klebahn/?ref=ideasurg.pub">quantity</a> of ideas is initially more important than quality of ideas. Then there is the even stranger notion that ideas that seem "out there", "impractical", or even "bad" are still worthy of consideration, experimentation, and evaluation.<sup>1</sup> As healthcare providers, our traditional research methodologies often focus on refining ideas against known constraints prior to experimentation rather than throwing everything against the wall to see what sticks. "That will never work" is a common refrain in brainstorming sessions. However, to understand the true potential of divergent ideation and creative brainstorming, we need only look inwards at one of the most essential players in our field: <em>the antibody</em>.</p><p>Antibodies are without a doubt one of the miracles of human life (and that of other species - as they <a href="https://ashpublications.org/blood/article/112/5/1570/25424/B-lymphocytes-how-they-develop-and-function?ref=ideasurg.pub">evolved</a> in jawed vertebrates 500 million years ago). The principal function of the antibody is to recognize non-self particles and direct the immune response to neutralize them. At the risk of over-simplification, foreign agents such as bacteria and viruses contain unique surface molecules. Oftentimes, these surface molecules are used to gain entry into host cells and cause infection. However, these molecules also serve as unique signatures (keys) that distinguish the invading agents as foreign. Antibodies bear unique counter-signatures (locks) that can recognize and bind foreign keys. Once bound (key-lock combination), the antibody neutralizes the offending agent and directs the immune response towards agents bearing a similar key signature. How then, can an antibody generate a lock for an infinite number of keys - none of which it has yet encountered? </p><p>Antibodies are made by B cells, named eponymously for their origin in the <em>bone marrow</em>. Each B cell contains in its DNA the code for one unique antibody. Antibodies are <a href="https://ashpublications.org/blood/article/112/5/1570/25424/B-lymphocytes-how-they-develop-and-function?ref=ideasurg.pub">Y shaped</a> molecules.<sup>2</sup> While the legs of each Y are shared among all antibodies, the tips of each prong are variable and contain docking sites (locks) for potential foreign keys. The shape of its docking site is what makes each antibody unique. The structure of each docking site is made up of three types of building blocks. Rearrangement and reassortment of the DNA encoding these building blocks creates unique combinations that translate into different shapes - a process called <em><a href="https://www.sciencedirect.com/science/article/pii/0092867478900788?via%3Dihub=&ref=ideasurg.pub">recombination</a></em>.<sup>3</sup> But that is only part of the magic. Small errors made in the DNA fragments that bind each permutation of blocks together <a href="https://pdf.sciencedirectassets.com/272197/1-s2.0-S1074761300X01185/1-s2.0-1074761395901248/main.pdf?X-Amz-Security-Token=IQoJb3JpZ2luX2VjECoaCXVzLWVhc3QtMSJGMEQCIFUKIi3AgY9Vj8qNPkgm6xoWs%2FKEtqygJZaPAtnYADkSAiBWnGejxCqOJ9Rp2IW93VInfh%2FhxXhdtaWxNdPDLIH+eirVBAiT%2F%2F%2F%2F%2F%2F%2F%2F%2F%2F8BEAUaDDA1OTAwMzU0Njg2NSIMN7DXrRbve059blNFKqkE7pX34wP++3Hr+VPzbc+8NOdiR0bQ2bKWw+ZjszYFsi2AwCWBL8Ynfbyo0Umu5OJ9nlXyM9%2FWhvZOBCEhBAj39CJ0nX3H+JM3qvyxT1sKI54cTbYIHSiDy4piUtwfXpx347kZZGB94Ykp8M8R5UsNc3FotF0pnZfP3gQfAWuCFeMvKFS4kI6wDl1iWDpPecqAgnTG1iGHB1fmmocfhe%2FOkfJ3WmID2YU2Z+CqFDy5SzRZ7wX43eWzLqKaPhwF4zjG6ugi25w2cM7zTxoFRdRtSnEyh29onz20Z9C1qAwBHT0TqUWDTMmctk4HbuBGekGGevkhqbzfdZ%2FPd1A0vIMoQvZL1EStA1ubjN0pJXou+Anu9fmbAjbylPArJAWb5CwTFd917gBDad9+CFvwlo8wiE+PVOHo46+kMiR8O+auxDFHdao8gFGTw5rDymbcIjyZKr5jHVdwNt4tbGnSggZrCOVg+6Vwju3MI1LC0cLF%2F8G4jWHxhFg2tGc0uorbFHYj1ZvVQqhS3AY682Ta%2FxHrFp8yNaYEUBpWqDRHBWtGOtfuYLpNoLHIHMWfIoWV4fIk4M1%2FCVzQ9gc5dPLKZm9GyJtMINcBYZSXjTGgiFlXBc8PCiOdWVYqJQgpjOQWkFLLfL0RqWWnD8%2FbNxyQcsc%2FwHsPR0t%2F5j3AO5vO2jkclxFQJWGAHruzxofN6rYU1yd8JuhN0ysitkyw0tvYB7t24zGTPl1gJls4ejD6qaueBjqqAS7D+6CMWH+aO8g%2F0mFoDHLLqLf0JDDL+6kajQXYxgh%2FHg+yHsbguk6CCyIq7C%2FupQbh%2FquJAK2JL%2Fkf0jc50LzQ5C5hnqFj38bMzbJ3zXrdYHGK1GPcn8kxcO3%2FAyCCYJgH5HjLQRVHSm6NQPPAjpF+D68gEt4cXv56Vv2nwt41a455CxKm74SuLvMFfpj5SelR57KkkhxVSo8yF9ZOCcY5xcqmO2lXIwcC&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20230120T185744Z&X-Amz-SignedHeaders=host&X-Amz-Expires=299&X-Amz-Credential=ASIAQ3PHCVTYY44TWN5Q%2F20230120%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Signature=2d6a9db043647e79c5191df790cdd1200b3d15abdbb1d44d23f33020517d83e0&hash=cbfc28c653cc034f4fd107cc8bf28d1ca6314f78b762ed48e972ee13488ae2c4&host=68042c943591013ac2b2430a89b270f6af2c76d8dfd086a07176afe7c76c2c61&pii=1074761395901248&tid=spdf-1d6984f5-902f-427b-a213-2d5a3a542f4c&sid=2fd78a288581c341f17b6d959110bd05d55cgxrqa&type=client&tsoh=d3d3LnNjaWVuY2VkaXJlY3QuY29t&ua=0f1650590d065359580200&rr=78ca099ed99ce70c&cc=us&ref=ideasurg.pub">generates</a> a limitless repertoire of possible locks. The process is tightly regulated &#x2013; left uncontrolled, it can lead to cancer or autoimmune dysfunction. But when orchestrated with precision, it allows for the immune system to adapt to nearly any pathogenic foe. &#xA0;</p><p>Once a corpus of diverse antibodies is created, the body needs to figure out which potential locks are useful and which are useless or even potentially harmful. During infection, immature B cells display their unique antibody on the cell surface and are exposed to foreign molecular keys. Cells bearing antibody locks that match the keys are allowed to replicate, those that do not die off. Conversely, cells producing locks to self keys are also prevented from replicating. This process is known as <em><a href="https://www.cabdirect.org/cabdirect/abstract/19592701490?ref=ideasurg.pub">clonal selection</a></em>.<sup>4</sup> Even after the antibody is activated by a match with the key of a foreign pathogen, it continues to undergo refinement. As selected cells replicate, random changes are introduced in the variable prongs of the antibody. Over several rounds, this <em><a href="https://www.annualreviews.org/doi/10.1146/annurev.genet.41.110306.130340?ref=ideasurg.pub">somatic hypermutation</a></em> yields some docking sites that better fit the foreign key. The stronger the affinity between the lock and key, the more the cell bearing that antibody is allowed to replicate &#x2013; a<em> </em>phenomenon known as<em> affinity maturation</em>. Over time, the strength of the initial lock-key combination is increased <a href="https://www.biorxiv.org/content/10.1101/2021.07.26.453765v1.full?ref=ideasurg.pub#ref-3">thousand-fold</a>. (For a much more detailed view into the relationship between the immune system and creativity, read <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107273/pdf/fpsyg-12-582083.pdf?ref=ideasurg.pub">this</a> paper).<sup>5</sup></p><p>We can learn a lot from the example of the antibody. <em>Recombination</em> demonstrates that instead of trying to find a winning idea, it is better to come up with as many ideas as possible. Rearranging existing ideas is a useful place to start, but some reliance on randomness is just as important. The principles of <em>clonal selection</em> and <em>affinity maturation</em> teach us that prototypes should be tested and refined iteratively. Experimentation, not intuition, should pick winners and losers. From <em>somatic hypermutation</em>, we learn that even initially successful ideas should not be immune to further brainstorming and refinement. As educational psychologist Gary Cziko <a href="https://www.google.com/books/edition/Without_Miracles/v1JEypylerUC?hl=en&gbpv=0&ref=ideasurg.pub">wrote</a>, "the immune system does not attempt to predict the antibody structure that will bind with an antigen, but rather uses a type of shotgun approach that sends in a diverse army to meet the invaders". Aspiring design thinkers too must send a diverse army of ideas to meet the pressing problems of our time.</p><p>Design thinking is a relatively new, experimental field. Though it has an established track record of spurring innovation in industry, its introduction to healthcare and surgery remains nascent. To those who remain skeptical of its promise, it may be helpful to think of it as a model based on a biological principle nearly 500 million years old, described by multiple Nobel prize winning scientists, and essential to our very survival. To extend the metaphor, the antibody's most impressive feat is to generate immunologic solutions to a pathogenic problem it has not yet encountered. While rigorous testing against the pathogen itself will lead to refinement, propagation, and dissemination of winning solutions, it must first exist as a rudimentary prototype within the immunologic substrate. Applying this logic to our ideation process against challenges in healthcare, perhaps divergent and broad ideation can help generate a form of creative immunity - the ability to design for the challenges of both today and tomorrow.</p><p><sup>1. These and other principles of design thinking are captured in the book <em><a href="https://www.ideaflow.design/?ref=ideasurg.pub">Ideaflow</a> </em>by Jeremy Utley and Perry Klebahn.</sup></p><p><sup>2.</sup> <sup>The structure of antibodies was discovered by Gerald Edelman and Rodney Porter, who shared a Nobel Prize in 1972 for this discovery Link to papers <a href="https://www.pnas.org/doi/abs/10.1073/pnas.51.5.846?ref=ideasurg.pub">here</a> and <a href="https://watermark.silverchair.com/19-3-197.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAvAwggLsBgkqhkiG9w0BBwagggLdMIIC2QIBADCCAtIGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQM7wQ6UBOLSz8jQJOoAgEQgIICo_nEu5f757rLYJA28dCuSs4Z__mByeHpkPcScQqs0_NrdOCNCFBYOqkTOvvIl3JPoAiDcEaukw_N-64ERJv7cwyfZ6aBDQ9Btza9Lpd_tKIeK4uRZi7y-ZikGbHeFTEilJ_b6_DSIEnRRFLEUAvcvqM1LGho96Y1-mAY35t1qsZHANLDmqMLMSp6SgzxohZfPituUmDFr4sKJpZoNChmhCJRrDIYHC0wX9t1Xghj4FWqaXpn4XfOsi2wvKRsMaSevIysWGY2Kp06FQEslluRtQm13hEIppx4Zckdp6b8Gshf_gD6ZMVMPniOivxZEmnNVXZOyAdIctjX9U36rJeH0qgPkg-NNi5Ek4jZp5MsOALMucXPxRizfGiW71rjGVgnNR0d_6OTyFXMXOVFaqwE69kDLhj4xjkXjS_o65iEKNFvHNZHaDfFtgXgITjCU6LXX49Kz9kxZcfuLjRRQW2cwoC5KeiHB-0UiIqMA05Thp4uGu64_Ol78qsuBjoFme8UPjr9xxt0n_IFC1XcLPKAWT7n3Xl63ae89jP_oo-z9Nj4DQjJ35RXAkvlrXnsFcipAj7yZSfl3yqd36uys4PdU9Lm9DKWSwokJMYSwNg6meO54_VQd9dayPUoqPaB2IR-pzK0K4F27lmxva_vuKqw8G0QOsMCp1CxgkX8PqcqfXf6udMFVegCkMK6Ofjv9GbVPGMTsSqjYDHl54pOT7dWAS__9SlyVRd1HOlIRjw_6B_ZRr1aofpyH8PtP0fh-Uzy075shYp3jABIM4CrH1EjrH9xbgW6oMM8aj1_q5BsOuNawwbtQHrm78hDHjYKhOzw7dt84FtmeTwONWsH7pmes-zXO8fWQ-9uTVfdNbhKXSQKqCaSJX-Y-RlVXlRjNDe0GnzcPQ&ref=ideasurg.pub">here</a>.</sup> &#xA0;</p><p><sup>3. This process is formally known as VDJ recombination. It was discovered by Susumu Tonegawa, who won the Nobel Prize in Physiology or Medicine in 1987. The proteins responsible for orchestrating this recombination were discovered by David G. Schatz and Marjorie Oettinger, and David Baltimore. Interestingly, Baltimore had already been awarded the Nobel Prize for previous contributions to virology.</sup></p><p><sup>4. The theory of clonal selection was developed by immunologists Niels Jerne and Frank Macfarlane Burnet who won the Nobel Prize in Physiology or Medicine in 2960 and 1984, respectively.</sup></p><p><sup>5. In doing research for this essay, I came across the paper <em>How the Immune System Deploys Creativity: Why We Can Learn From Astronauts and Cosmonauts </em>written by Henderika De Vries et. al. The paper provides a much more detailed and scientific description of the relationship between the immune system and creativity.</sup></p><p><sup>6. RE: all of the above, should I be studying immunology!?</sup></p><p></p><p></p>

Principles of design thinking share an interesting origin with mechanisms of adaptive immunity

Design Thinking: A Method for Building Creative Immunity

<div class="kg-card kg-callout-card kg-callout-card-grey"><div class="kg-callout-text">A digital reference guide to sutures and needles (adapted from Twitter Thread)</div></div><p>As a student and junior resident, I didn&#x2019;t understand how surgeons decided when to use each suture/needle. I tried to pick up on patterns but the info was never in one place. This is an attempt to solve that problem using &#xA0;<a href="https://twitter.com/NotionHQ?ref=ideasurg.pub">@NotionHQ</a></p><figure class="kg-card kg-image-card kg-width-wide"><img src="https://www.ideasurg.pub/content/images/2022/12/Guide1.png" class="kg-image" alt loading="lazy" width="1920" height="1080" srcset="https://www.ideasurg.pub/content/images/size/w600/2022/12/Guide1.png 600w, https://www.ideasurg.pub/content/images/size/w1000/2022/12/Guide1.png 1000w, https://www.ideasurg.pub/content/images/size/w1600/2022/12/Guide1.png 1600w, https://www.ideasurg.pub/content/images/2022/12/Guide1.png 1920w" sizes="(min-width: 1200px) 1200px"></figure><hr><p>In one click, you can see details about each suture and needle type and convert between brands <a href="https://twitter.com/Ethicon?ref=ideasurg.pub">@Ethicon</a> <a href="https://twitter.com/Medtronic?ref=ideasurg.pub">@Medtronic</a></p><figure class="kg-card kg-image-card kg-width-wide"><img src="https://www.ideasurg.pub/content/images/2022/12/Guide4.png" class="kg-image" alt loading="lazy" width="1920" height="1080" srcset="https://www.ideasurg.pub/content/images/size/w600/2022/12/Guide4.png 600w, https://www.ideasurg.pub/content/images/size/w1000/2022/12/Guide4.png 1000w, https://www.ideasurg.pub/content/images/size/w1600/2022/12/Guide4.png 1600w, https://www.ideasurg.pub/content/images/2022/12/Guide4.png 1920w" sizes="(min-width: 1200px) 1200px"></figure><hr><p>Using filters and tabs, display the information in a way that makes sense to you</p><figure class="kg-card kg-image-card kg-width-wide"><img src="https://www.ideasurg.pub/content/images/2022/12/Guide2.png" class="kg-image" alt loading="lazy" width="1920" height="1080" srcset="https://www.ideasurg.pub/content/images/size/w600/2022/12/Guide2.png 600w, https://www.ideasurg.pub/content/images/size/w1000/2022/12/Guide2.png 1000w, https://www.ideasurg.pub/content/images/size/w1600/2022/12/Guide2.png 1600w, https://www.ideasurg.pub/content/images/2022/12/Guide2.png 1920w" sizes="(min-width: 1200px) 1200px"></figure><figure class="kg-card kg-image-card kg-width-wide"><img src="https://www.ideasurg.pub/content/images/2022/12/Guide3.png" class="kg-image" alt loading="lazy" width="1920" height="1080" srcset="https://www.ideasurg.pub/content/images/size/w600/2022/12/Guide3.png 600w, https://www.ideasurg.pub/content/images/size/w1000/2022/12/Guide3.png 1000w, https://www.ideasurg.pub/content/images/size/w1600/2022/12/Guide3.png 1600w, https://www.ideasurg.pub/content/images/2022/12/Guide3.png 1920w" sizes="(min-width: 1200px) 1200px"></figure><hr><p>I'm sure I didn't get it all right and that some info is missing or incorrect. I suspect number of knots and use cases vary among surgeons.</p><hr><p>Thanks to everyone who has already given feedback, including students, residents, and faculty from <a href="https://twitter.com/ColumbiaSurgery?ref=ideasurg.pub">@ColumbiaSurgery</a> and <a href="https://twitter.com/UCSFSurgery?ref=ideasurg.pub">@UCSFSurgery</a></p><hr><p>Using <a href="https://twitter.com/hashtag/humancentered?src=hashtag_click&ref=ideasurg.pub">#humancentered</a><a href="https://twitter.com/hashtag/design?src=hashtag_click&ref=ideasurg.pub">#design</a> principles, I hope to iteratively improve this tool with feedback from the <a href="https://twitter.com/hashtag/SurgTwitter?src=hashtag_click&ref=ideasurg.pub">#SurgTwitter</a><a href="https://twitter.com/hashtag/SurgEd?src=hashtag_click&ref=ideasurg.pub">#SurgEd</a> community!</p><figure class="kg-card kg-video-card"><div class="kg-video-container"><video src="https://www.ideasurg.pub/content/media/2022/12/giphy.mp4" poster="https://img.spacergif.org/v1/3242x1764/0a/spacer.png" width="3242" height="1764" playsinline preload="metadata" style="background: transparent url('https://www.ideasurg.pub/content/images/2022/12/media-thumbnail-ember250.jpg') 50% 50% / cover no-repeat;"></video><div class="kg-video-overlay"><button class="kg-video-large-play-icon"><svg xmlns="http://www.w3.org/2000/svg" viewbox="0 0 24 24"><path d="M23.14 10.608 2.253.164A1.559 1.559 0 0 0 0 1.557v20.887a1.558 1.558 0 0 0 2.253 1.392L23.14 13.393a1.557 1.557 0 0 0 0-2.785Z"/></svg></button></div><div class="kg-video-player-container"><div class="kg-video-player"><button class="kg-video-play-icon"><svg xmlns="http://www.w3.org/2000/svg" viewbox="0 0 24 24"><path d="M23.14 10.608 2.253.164A1.559 1.559 0 0 0 0 1.557v20.887a1.558 1.558 0 0 0 2.253 1.392L23.14 13.393a1.557 1.557 0 0 0 0-2.785Z"/></svg></button><button class="kg-video-pause-icon kg-video-hide"><svg xmlns="http://www.w3.org/2000/svg" viewbox="0 0 24 24"><rect x="3" y="1" width="7" height="22" rx="1.5" ry="1.5"/><rect x="14" y="1" width="7" height="22" rx="1.5" ry="1.5"/></svg></button><span class="kg-video-current-time">0:00</span><div class="kg-video-time">/<span class="kg-video-duration"></span></div><input type="range" class="kg-video-seek-slider" max="100" value="0"><button class="kg-video-playback-rate">1&#xD7;</button><button class="kg-video-unmute-icon"><svg xmlns="http://www.w3.org/2000/svg" viewbox="0 0 24 24"><path d="M15.189 2.021a9.728 9.728 0 0 0-7.924 4.85.249.249 0 0 1-.221.133H5.25a3 3 0 0 0-3 3v2a3 3 0 0 0 3 3h1.794a.249.249 0 0 1 .221.133 9.73 9.73 0 0 0 7.924 4.85h.06a1 1 0 0 0 1-1V3.02a1 1 0 0 0-1.06-.998Z"/></svg></button><button class="kg-video-mute-icon kg-video-hide"><svg xmlns="http://www.w3.org/2000/svg" viewbox="0 0 24 24"><path d="M16.177 4.3a.248.248 0 0 0 .073-.176v-1.1a1 1 0 0 0-1.061-1 9.728 9.728 0 0 0-7.924 4.85.249.249 0 0 1-.221.133H5.25a3 3 0 0 0-3 3v2a3 3 0 0 0 3 3h.114a.251.251 0 0 0 .177-.073ZM23.707 1.706A1 1 0 0 0 22.293.292l-22 22a1 1 0 0 0 0 1.414l.009.009a1 1 0 0 0 1.405-.009l6.63-6.631A.251.251 0 0 1 8.515 17a.245.245 0 0 1 .177.075 10.081 10.081 0 0 0 6.5 2.92 1 1 0 0 0 1.061-1V9.266a.247.247 0 0 1 .073-.176Z"/></svg></button><input type="range" class="kg-video-volume-slider" max="100" value="100"></div></div></div></figure><hr><figure class="kg-card kg-embed-card kg-card-hascaption"><blockquote class="twitter-tweet"><p lang="en" dir="ltr">&#x1F9F5;about &#x1FAA1;<br>Hi <a href="https://twitter.com/hashtag/SurgTwitter?src=hash&ref_src=twsrc%5Etfw&ref=ideasurg.pub">#SurgTwitter</a>, I am building a digital guide to sutures and needles and would love your feedback! <a href="https://twitter.com/hashtag/SurgTwitter?src=hash&ref_src=twsrc%5Etfw&ref=ideasurg.pub">#SurgTwitter</a> <a href="https://twitter.com/hashtag/SurgEd?src=hash&ref_src=twsrc%5Etfw&ref=ideasurg.pub">#SurgEd</a> <a href="https://twitter.com/hashtag/gensurgmatch2023?src=hash&ref_src=twsrc%5Etfw&ref=ideasurg.pub">#gensurgmatch2023</a><a href="https://twitter.com/SAGES_Updates?ref_src=twsrc%5Etfw&ref=ideasurg.pub">@SAGES_Updates</a> <a href="https://twitter.com/AcademicSurgery?ref_src=twsrc%5Etfw&ref=ideasurg.pub">@AcademicSurgery</a> <a href="https://twitter.com/AmCollSurgeons?ref_src=twsrc%5Etfw&ref=ideasurg.pub">@AmCollSurgeons</a> <a href="https://twitter.com/Surg_Education?ref_src=twsrc%5Etfw&ref=ideasurg.pub">@Surg_Education</a> <a href="https://twitter.com/BehindTheKnife?ref_src=twsrc%5Etfw&ref=ideasurg.pub">@BehindTheKnife</a> <a href="https://twitter.com/modern_surgeon?ref_src=twsrc%5Etfw&ref=ideasurg.pub">@modern_surgeon</a> <a href="https://t.co/hp9OnBDBvz?ref=ideasurg.pub">https://t.co/hp9OnBDBvz</a></p>&#x2014; Tejas Sathe (@tssathe) <a href="https://twitter.com/tssathe/status/1586073932867653632?ref_src=twsrc%5Etfw&ref=ideasurg.pub">October 28, 2022</a></blockquote>
<script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>
<figcaption>Original Twitter Post</figcaption></figure>

A digital reference guide to sutures and needles (adapted from Twitter Thread)

What's the Stitch?

<p>Imagine that you want to read a paper. You probably either search the subject area of interest on PubMed or Google Scholar. Perhaps you were directed to the paper from an interesting Twitter thread or other social media site. Or maybe you were assigned the paper for a journal club or weekly educational activity. </p><p>If you're trying to read the paper from within your institution's network, the process is usually seamless. However, if you're trying to read from your house or on your phone, you will typically have to use a virtual private network (VPN) or undergo some institutional log-in procedure.</p><p>Finally, you're ready to read the paper. And almost always we instinctively hit the 'Download PDF' button. I continue to do this even though I haven't owned a printer in years. Maybe the PDF makes it easier to share the paper with colleagues, drop it into a reference manager, or maintain access to it without repeatedly accessing the paywall.</p><p>In some sense, PDFs are a paper relic in an otherwise digital age. The text does not easily scale on different screen sizes. The fonts and colors are chosen by the publisher, not the user. There is no way to read the article in dark mode or utilize any other accessibility features. </p><p>Moreover, tables and figures are often presented as static images, rarely taking advantage of dynamic features available on modern web interfaces. In addition, critical data is either buried in a supplementary section or omitted altogether. Common examples of this include code used to run statistical analysis or the survey instrument used in survey studies. While maintaining supplemental information separately made sense at a time when publishers were constrained by page numbers and the marginal cost of printing another page, this is no longer true in digital formats.</p><p>In my experience, the user experience falls short of the joy of reading excellent journalism, following an academic conversation on Twitter, or listening to a podcast about a current hot topic. And making papers easier to read is only half the battle.</p><p>There are also a lot of pain points in writing papers. After you finish writing the manuscript, you have to submit it to a journal. Submission portals are usually made with outdated technology and submitting is a tedious experience. Once the process is complete, it can take several weeks before a decision is reached. </p><p>The peer review process is typically opaque. For most papers, readers do not know who the reviewers were, what comments they had, or what changes resulted from those comments. Furthermore, there is more uncertainty today about whether the institution of peer review is achieving its stated mission of ensuring that only high quality research gets published. Adam Mastroianni <a href="https://open.substack.com/pub/experimentalhistory/p/the-rise-and-fall-of-peer-review?r=4sgwp&utm_campaign=post&utm_medium=web&ref=ideasurg.pub">writes</a> about this in his Substack blog <em>Experimental History. </em></p><figure class="kg-card kg-bookmark-card"><a class="kg-bookmark-container" href="https://open.substack.com/pub/experimentalhistory/p/the-rise-and-fall-of-peer-review?r=4sgwp&utm_campaign=post&utm_medium=web&ref=ideasurg.pub"><div class="kg-bookmark-content"><div class="kg-bookmark-title">The rise and fall of peer review</div><div class="kg-bookmark-description">Why the greatest scientific experiment in history failed, and why that&#x2019;s a great thing</div><div class="kg-bookmark-metadata"><img class="kg-bookmark-icon" src="https://bucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com/public/images/36c752b6-28bc-4862-82e8-e4d2a5f2cdbc/apple-touch-icon-1024x1024.png" alt><span class="kg-bookmark-author">Experimental History</span><span class="kg-bookmark-publisher">Adam Mastroianni</span></div></div><div class="kg-bookmark-thumbnail"><img src="https://substackcdn.com/image/fetch/w_1200,h_600,c_limit,f_jpg,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F24ab2184-c024-44c5-81cc-4bc14851b965_1762x1173.jpeg" alt></div></a></figure><p>Once an article is published, there is no easy way to change the article (unless it has to be redacted). Rather than being a dynamic node in a scientific conversation around a topic that can be modified or refined as more data becomes available, it is a static post. </p><p>Finally, the financial structures around academic publishing are very different from any other mode of content creation. Neither the scientists who create the work nor the reviewers who screen it get paid for their efforts. Some say that introducing financial motives into academic publication would reduce the quality and integrity of the science. This point of view would be valid if research was truly a not-for-profit enterprise, but this is far from reality.</p><p>Papers cost money to read. Most often, publishing companies charge high fees to institutions for the rights to their content. While they provide a standard format and online and paper versions of these articles (with limitations as discussed above), they do not pay for the science they are publishing. Much of the research they publish is funded by governments (and by extension taxpayers) and the peer review they rely on to maintain research quality is also done on a volunteer basis. While an argument can be made that the value added by the publisher is in standardizing formatting, this can be achieved at zero cost with modern digital publishing tools. </p><p>The journals on the other hand are far from altruistic. The total market for academic publishing was 29 billion dollars in 2019. Moreover, the top publishing companies had higher profit margins than Apple, Google, and Facebook. In a report titled <em>Against Parasite Publishers</em>, the Basic Research Community for Physics reviews the current state of publishing and providers recommendations for promoting open access content. </p><figure class="kg-card kg-bookmark-card"><a class="kg-bookmark-container" href="https://zenodo.org/record/7212922?ref=ideasurg.pub"><div class="kg-bookmark-content"><div class="kg-bookmark-title">Against Parasite Publishers: Making Journals Free</div><div class="kg-bookmark-description">The fruits of academic research mostly take the form of articles that are published in specialised journals. The majority of these journals are owned by a small number of commercial publishers, who benefit from public money to achieve record profits. This situation is detrimental to research and cal&#x2026;</div><div class="kg-bookmark-metadata"><img class="kg-bookmark-icon" src="https://zenodo.org/static/apple-touch-icon-144-precomposed.png" alt><span class="kg-bookmark-author">Zenodo</span></div></div><div class="kg-bookmark-thumbnail"><img src="https://zenodo.org/static/img/logos/zenodo-gradient-round.svg" alt></div></a></figure><p>They perform a detailed financial analysis of revenues and profit margins of leading publishers. Some of the data has been reproduced in the graphs below.</p><iframe src="https://rows.com/embed/1D1vWtFOP1Q6AxbYgVYGNU7vIyRk1DXB4e1NYFwE84k7/71ea0ad0-d205-4d32-adf0-d5e66f3f580d" class="rows-embed" frameborder="0" width="662" height="450" style="max-width: 100%; border: 0px solid #EAEAEA; border-radius: 4px;"></iframe><iframe src="https://rows.com/embed/1D1vWtFOP1Q6AxbYgVYGNU7vIyRk1DXB4e1NYFwE84k7/3649937f-844c-450f-a7a8-f2f562c820ad" class="rows-embed" frameborder="0" width="662" height="450" style="max-width: 100%; border: 0px solid #EAEAEA; border-radius: 4px;"></iframe><p>More and more journals are offering an 'Open Access' publication model. In this model, articles are free to read. However, the lost subscription costs are simply transferred to the author in the form of article processing charges (APC) which can be prohibitively expensive for new investigators without established funding. I searched for the top surgery related journals on Google Scholar and obtained APC data for the top 20 surgery journals by h-index. Data is shown in the following table. </p><iframe src="https://rows.com/embed/1D1vWtFOP1Q6AxbYgVYGNU7vIyRk1DXB4e1NYFwE84k7/7c5cd87d-91a5-48e1-b565-f2f457332fe7" class="rows-embed" frameborder="0" width="100%" height="450" style="max-width: 100%; border: 0px solid #EAEAEA; border-radius: 4px;"></iframe><p>In addition, some scientists, especially in fields such as physics, directly publish their content on free pre-print servers such as <a href="arXiv.org">arXiv</a> even before they are reviewed. Pre-print services such as arXiv and biorXiv and medrXiv (the versions for biology and medical research, respectively) have also advanced open science. However, they still utilize PDFs as the basic format in which academic papers are consumed.</p><p>Sebastian Mayoni writes the following summarizing this scheme in a piece written for the <em>University Post.</em></p><blockquote>First, the university pays (often mostly supported by government) its academic staff to conduct research and write articles. Then the researchers send the article to a journal, which in some cases even demands fees to publish the article &#x2013; so-called Article Processing Charges (APC). In some prestigious cases, the price for being published in, say, Nature costs USD 10,000 an article. If you want to be published in The Lancet Global Health, it may cost up to USD 5,000. Then the researcher often loses copyright to their articles, which the publisher subsequently can make money off in their subscription scheme.</blockquote><figure class="kg-card kg-bookmark-card"><a class="kg-bookmark-container" href="https://uniavisen.dk/en/scientific-publishers-are-reaping-huge-profits-from-the-work-of-researchers-and-the-universities-are-paying-for-it/?ref=ideasurg.pub"><div class="kg-bookmark-content"><div class="kg-bookmark-title">Scientific publishers are reaping huge profits from the work of researchers, and the universities are paying for it &#x2014; University Post</div><div class="kg-bookmark-description">They net bigger profit margins than Google, Amazon and Apple from exploiting the free labour of countless researchers. One critic says the scientific publishers are commercial behemoths that are limiting the free flow of knowledge.</div><div class="kg-bookmark-metadata"><img class="kg-bookmark-icon" src="https://uniavisen.dk/wp-content/themes/uniavisen_universitetsavisendk/assets/favicons/feature_article/apple-touch-icon.png" alt><span class="kg-bookmark-author">University Post</span><span class="kg-bookmark-publisher">Sebastian Mayoni</span></div></div><div class="kg-bookmark-thumbnail"><img src="http://uniavisen.dk/wp-content/uploads/2022/12/nature_science1.jpg" alt></div></a></figure><p>Why do we do this? Why do we willingly give up copyrights to our self-generated content so that a third party can profit? It is because we have invented a prestige economy on which we base our academic capital. Number of publications as well as the impact factor of the associated journals is a key component of evaluation for medical school, residency, faculty positions, and academic promotion. I do not mean to say this system has no value. It has created an incredible amount of scientific and medical advancements that have saved lives. Rather, since we made this up ourselves, we also have the power to change it for the better.</p><p>Today, I am launching a new platform called <em><strong>Innovation and Design Experiments in Academic Surgery</strong> &#x2013; </em>or I.D.E.A.S. for short. </p><p>The designer Maggie Appleton writes about the concept of a Digital Garden. I think this is a compelling model for academic publishing. Instead of projects ending once you hit the submit button, academic media can take the form of living repositories of knowledge that grow over time. When applied to an entire field such as academic surgery, the digital garden can represent a collective spirit of building knowledge in public. I.D.E.A.S. can be thought of as part blog, part garden, part prototype of what a journal of the future could look like. I'm not exactly sure where this project is going to go - if anywhere. But it seems to be an exciting space that is ripe for innovation. And I have some free time.</p><figure class="kg-card kg-bookmark-card"><a class="kg-bookmark-container" href="https://maggieappleton.com/garden-history?ref=ideasurg.pub"><div class="kg-bookmark-content"><div class="kg-bookmark-title">A Brief History & Ethos of the Digital Garden</div><div class="kg-bookmark-description">A newly revived philosophy for publishing personal knowledge on the web</div><div class="kg-bookmark-metadata"><img class="kg-bookmark-icon" src="https://maggieappleton.com/images/favicon/apple-touch-icon.png" alt><span class="kg-bookmark-author">Maggie Appleton</span><span class="kg-bookmark-publisher">Abbey Perini</span></div></div><div class="kg-bookmark-thumbnail"><img src="https://maggieappleton.com/images/og/e8be85c4f66d83dd0e482b9862d461f2.png" alt></div></a></figure><p>As a current Surgical Innovation fellow, I will use this forum to maintain drafts of papers I am working on or that have been submitted awaiting peer review. I will provide my own ideas and commentary on technology, innovation, and design in surgery. I will also use it as a forum to discuss small scale projects and experiments (including failed experiments) that may not be easy to publish in traditional journals.</p><p>I welcome anyone who wants to contribute as well. The Ghost platform on which this blog is written allows for multiple authors to contribute to a publication. Initially, the only content moderation will be to make sure none of the content is offensive. </p><p>My vision is to create a robust, modern interface for sharing ideas, experiments, and data that is relevant to academic surgery - a platform to make good quality science accessible and fun.</p><p>There's a lot that hasn't been figured out. Here is our roadmap &#x2013; </p><p>First, we need to build a system for reference management. The current standard of parenthetical citation or footnotes linking to a reference list at the end of the page is also a relic of print publishing. Modern web interfaces allow for hyperlinking and dynamic previews (as seen earlier in this article). At the same time, too many previews would increase clutter and reduce the readability of the paper. We will need to creatively design a reference system for modern web-first journals. </p><p>Second, we will need to figure out how to handle peer review. Since each article allows comments, we could utilize the commenting feature as a prototype and build from there. In addition, it would be ideal to have some sort of version history so that readers can understand how peer review influenced changes in the manuscript. Furthermore, readers can see how new data or knowledge from the author changed the paper as well.</p><p>Third, we will need to find a way to assign a Digital Object Identifier (DOI) to each article published. The DOI is a unique and permanent alphanumeric code that is attached to a manuscript (unlike website URLs which can change over time). DOIs are assigned by third party providers such as CrossRef for a fee. In my preliminary research, this seems to be the largest barrier preventing anyone from turning their personal blog into a journal. This article was manually assigned a DOI using the Zenodo service. To make a DOI entry, I uploaded a PDF containing a link to this article. Certainly, an an automated solution will be required to make this scalable. Individual articles can be published under a Creative Commons 4.0 licence which allows sharing and adapting original content with attribution.</p><p>Finally, we will have to figure out a way to create a sustainable future for this and similar publications. The Ghost platform charges 11 dollars per month. We currently do not have any plans for soliciting advertisements and will start out as a free publication. The vision of making this a true Diamond Open Access forum (no readership fee, no article processing charge) is attractive. Should we ever charge a subscription fee, it will be something accessible to every student and resident. Furthermore, if we go in the paid subscription route, then we can brainstorm a system in which the content creators share in the profits. </p><p>All in all, technology can improve the way that science is consumed, created, and financed. I would appreciate any ideas, feedback, or contributions. As Thomas Edison once said, "There are no rules here &#x2013; we&#x2019;re trying to accomplish something."</p><pre><code class="language-python">https://doi.org/10.5281/zenodo.7500519</code></pre>

I am by no means an expert on the future of academic publishing. But I'd like to join the conversation.