Design Health thinking in surgery is of utmost importance as it focuses on holistically identifying and defining the problem which alone leads to a sustainable solution. The design health thinking approach helps the surgeon decide when to do research, when to do innovations which is an improvement on the status quo, when to do inventions which makes the innovation disruptive, and when to work around the problem through a Jugaad innovation, which is a smart fix amid the cost and time constraints that deny a comprehensive ideal resolution.
What is the framework all about?
The Design Thinking framework has two critical elements:
1. Possibility to Actuality Paradigm
The possibility to actuality paradigm encompasses the stages of surgical innovation.
Defining the problem context
The first stage is defining the problem context before turning our attention to design the solution. What is the problem all about? Is it related to a surgical technique? Is it related to a decisive step within a larger surgical process? Is it related to the generic aspect of the disease in terms of surgical diagnosis? Or is it related to a surgical device intervention aimed at patient rehabilitation?
Defining the problem statement
The exact problem statement needs to be defined within the larger governing context. The surgical problem statement of any of the contexts defined above is invariably one of the two; either a generic challenge related to conventional methods in vogue or a diagnostic step in clinical practice. Let’s study them in greater depth:
2. Actuality to Sustainability Paradigm
This paradigm comprises five key critical pre-requisites of innovation, which we discussed in the earlier Oasis instalment - namely, Funding, IP, Regulatory compliance, Market access, and Market intelligence.
In the context of the problem statement of the Possibility to Actuality paradigm, what are the generic challenges you are referring to?
I will elaborate with examples for the sake of clarity.
Generic challenge related to conventional methods in vogue
I have found in the guiding light of my surgical experience that this problem often identifies itself in the course of the surgical procedure, largely due to the temporal relationships involved.
To cite a case in point is a carotid body tumor surgery where a casual discussion paved the way for disruptive innovation. For any surgery, I adopt a procedure founded on innate logic rather than textbook learning. I have not delved deep into the reasons for my preference given the ease of my dissection by virtue of what comes naturally to me. In this particular case, the cardiothoracic surgeon asked me why I prefer to dissect the internal carotid artery first, when the textbooks clearly recommend dissecting the external carotid artery first, given that it is where the feeder vessel comes from. It is also easier to dissect and less prone to adverse consequences.
My rejoinder was that it is more logical to attend to the internal carotid artery first as it has no branches extending to the neck, and it is better to deal with its complexity of life-threatening possibilities (like torrential bleeding or patient’s death from stroke) while the surgeon is fresh than when fatigued after having dealt with the external carotid artery first. More importantly, a cardiovascular surgeon is needed while attacking the internal carotid artery which is main blood vessel connecting the heart to the brain, and being a scarce resource, his or her wait times and work times need to be optimally decided. Based on this experience, I wrote an article titled: The "INT-EX Technique": Internal to External Approach in Carotid Body Tumour Surgery in an indexed, peer-reviewed journal and is globally accepted as a standard procedure.
Taking the same Carotid body tumour example further, I would like to cite a case of my residency days where I was studying the carotid body tumour in the context of the 1974 Shamblin’s classification based on the complexity as grade I (small tumor with minimal attachment to carotid vessels), grade II (large tumor with some arterial attachment) and grade III (large tumor encasing the carotid vessels). The conclusions were based on intraoperative findings and post-operative pathology reports. I argued in the international forum that this classification being post-operative does not help pre-empt the condition to achieve life-saving outcomes rooted in prevention. My study focus was on the possibility of generically pre-empting and planning for the treatment based on the degree of encasement which could be either of the three: type I 0 to 180 degree, type II 180 to 270, and type III 270 and above.
So what were your conclusions?
My generic conclusions were thus: Type I did not call for a cardiovascular surgeon and the head and neck surgeon could manage the surgery end to end. Type II mandated to have the cardiovascular surgeon waiting in the coffee lounge and for Type III, the head and neck surgeon would be waiting in the coffee lounge while the cardiovascular surgeon would be in the operating room to do the critical bypass shunt before the surgery can be done.
This generic handbook showed its practical value in the living waters of surgery. For a referral case of carotid body tumor concerning a poor lady patient in a small nursing facility with no ICU that was located in a remote district, I was able to look at the scans and recommended that the surgery did not call for a cardiovascular surgeon as it was a case of type I. Accordingly, I did the surgery and the patient had a good outcome. Based on these findings, I published another article: Carotid Body Tumors: Objective Criteria to Predict the Shamblin Group on MR Imaging which was accepted by the American Journal of Neuroradiology. So, what was essentially a student hypothesis generation led to an interventional change with measurable practical application in clinical settings.
Similarly, there are generic challenges with respect to a diagnostic step and medical devices?
Absolutely! Let us examine the typical ones.
Generic challenge related to a diagnostic step
This problem can be attacked though the power of observation rooted in holistic thinking. The problem here is the missing gap owing to compartmentalised thinking with no cross talk between different disciplines. To cite a case in point, whenever I used to dissect certain parts of a spinal accessory nerve, I found a classical pattern of anatomical cross-linkage which I intuitively called the X pointer as I saw two nerves crossed into each other as a standard pattern. The article I wrote based on it was published in a reputed journal as: The X-pointer: A forgotten anatomical relationship of spinal accessory nerve and its role for trainee surgeons.
Generic challenge related to a medical device
My invention ‘Aum Voice Prosthesis’, a one-dollar speaking device for throat cancer patients considered among the 100 global social innovations across the globe, was essentially born out of an intraoperative challenge resolution but eventually translated into a medical device innovation. The proctoscope conventionally used for dissecting the anus was used by me for the pharynges in the Aum innovation. The ENT surgeon used a probe which I found very useful for my OT needs.
To cite another point, constraint is a key incentive for innovation. In the course of my robotic surgeries, a financial constraint bothered me as the instrument to do the neck dissection was cost-prohibitive and I had to resort to innovation as a need. The outcome was an indigenous retractor called Ravi Retractor which was essentially the brainchild of my anaesthetist who was doing the rounds across all disciplines like gynaecology, and gastroenterology while I was fixated on my speciality which is head & neck. The gynaecology retractor can be used in head and neck surgery.
All these problem resolutions attacked the problem on lateral ways, paving the way for disruptive innovation which eventually makes it possible to touch lives at the patient level.
Can a surgeon proactively guard against pitfalls in the context of surgical innovations?
Surgery is a highly intricate endeavour, and much of the thought and action happen on the spur but I would humbly suggest the following:
Never build the solution before you identify and define a problem holistically.
Don’t ignore the empathy factor in healthcare interventions – it is crucial to design an empathy-centric design in innovation which touches human lives through desirable and sustainable outcomes.
Make collaboration your focal point rather than competition – this merits a cross talk between methods and practices of disparate disciplines and cultivating the art and science of looking for solutions in the unlikeliest of avenues, domains and spheres.