Creative thinking in medicine: can we learn it from the masters and practice it?

Lydia Usha
Rush University Medical Center, Chicago, Illinois, United States (Summer 2009)

 

Discovery consists in seeing what everybody has seen and thinking what nobody has thought.
Albert Szent-Györgyi

What is creative thinking?

Although many great medical discoveries have been the result of creative thinking, they have often been attributed in retrospect to logical or scientific reasoning. These two ways of thinking, though complementary, are different: scientific reasoning is based on something already known or assumed; creative thinking can arrive at something nobody had suspected. The Merriam-Webster dictionary defines creative thinking as a new way of seeing or doing things, characterized by fluency (generating many ideas), flexibility (shifting perspective easily), and originality (conceiving of something new). Edward De Bono, a notable contemporary author and an authority in teaching creative thinking in business, describes creative thinking as both a method and an attitude.

Many terms have been used interchangeably to denote these two forms of thinking. Logical reasoning has been described as scientific, linear, vertical, analytical, critical, or L-directed (directed by the left hemisphere). Creative thinking is often called lateral, non-linear, or R-directed (directed by the right hemisphere).

We conceive an innovative idea by creative thinking and verify its validity with scientific reasoning. In medicine, as in every day life, logical thinking is sufficient most of the time. Some problems, however, require creative thinking and cannot be solved by scientific reasoning alone.

We need creative thinking because our knowledge is limited. We do not know what we do not know, and also how much we do not know. In some respects we are like the blind man who grabbed a tiger by his tail and declared: “A tiger is a rope.”

Knowledge is limited. Imagination encircles the whole world.
Albert Einstein

In medical practice, difficulties in making the correct diagnosis or prescribing the right treatment arise because we do not have all the necessary information. Yet we often do remarkably well, without systematically going over all the options, by applying “rules of thumb,” intuition, and other rapid cognition tricks, albeit subconsciously. This kind of thinking does not usually produce novel results. But if we discover a new disease not previously reported, or a new explanation of an observed phenomenon, then we are using creative thinking. A classic example of such creative thinking is using a known drug to treat a different disease (so called re-purposing), such as using a hypnotic drug, thalidomide, to treat multiple myeloma.

As medicine is based on science, physicians are supposed to know physiology and mechanisms of disease, but also to manipulate nature for the benefit of the patient. Yet our knowledge of diseases and of drugs is limited. For this reason, medicine is really a combination of science and invention.

Philosophers of the past tried to explain the world; our goal is to change the world.
Karl Marx
We often think that a scientific discovery is determined by new tools or technologies. Yet many examples speak to the contrary. Thus, William Harvey discovered the blood circulation  not by employing tools unavailable to Galen or Hippocrates, but by using different models of study. Using cold-blooded and warm-blooded animals as well as vivisection in addition to dissection, he showed that the liver could not synthesize the amount of blood pumped by the heart with each beat, as was thought before him. He therefore concluded that blood must be circulating throughout the body.

Once the technology is developed, one might suppose that discovery would become inevitable and emerge logically, possibly from different persons. Yet, in the history of science simultaneous discoveries are really rare. More likely, either two individuals discovered different things, such as the fundamentally different calculus of Newton and Leibnitz; or they were not truly independent, so that one scientist directly or indirectly influenced the other one. Thus, a scientific discovery reflects the individuality of the discoverer as much as a masterpiece of art.

Comparison of logical/vertical thinking and creative/lateral thinking (De Bono)

Logical/Vertical Thinking Creative/Lateral Thinking
Selective Generative
Follows the most likely path Explores the least likely path
Seeks only relevant information May utilize irrelevant information, ideas, memories, images
Used to dig the same hole deeper Used to dig a hole in a different place
Refines patterns and establishes their validity Changes patterns and provokes new ones (re-patterning)
Analytical Playful
Sequential Can make jumps
Vertical Thinker: “I know what I am looking for.” Lateral Thinker: “I am looking, but I won’t know what I am looking for until I have found it.”
Categories, classifications, labels are fixed. Categories are fluid.
Definitive Probabilistic
Can always logically explain a solution reached by lateral thinking in retrospect (It is obvious after it has been found.) Partially unconscious (intuition)
Must be right at each step Can be wrong at some stage to arrive at a correct solution

 

Stages of creative thinking

The stages of creative process are quite consistent. First described at the beginning of the twentieth century by Graham Wallas, they consist of preparation, cultivation, incubation, illumination, and verification.

In the Preparation Phase, the problem is chosen and ideally embraced with a passion, then defined and re-defined to expand the spectrum of possible solutions. Also in this phase information is stored that would help solve the problem. Such information could be directly relevant or even seemingly irrelevant, and could indeed be based on one’s entire previous life experience. The crucial knowledge, skill, and experience (generally not available to one’s peers) could come from a previous profession or hobby (“preparing the mind” – Louis Pasteur). Thus Dr. Robin Warren, a pathologist in Australia, used the knowledge acquired from his hobby of photography to apply the silver stain to histological sections of the stomach. This allowed him to discover Helicobacter pylori and differentiate it from surrounding tissues at the time when it was believed that the bacteria could not live in the acidic environment of the stomach. It is also important in the Preparation Phase to become intensely focused on the problem, even to become obsessed to the point of thinking about it night and day (saturation).

In the Cultivation Phase, creative thinking techniques are applied and alternative ideas generated. It is often recommended to have a pre-set quota of how many alternatives are to be generated. The more alternative solutions are at one’s disposal, the more likely that one would be successful.

The Incubation Phase is the rest and recovery phase, usually after intensive work on the problem, when no conscious attention is paid to the problem. Incubation implies temporarily abandoning the idea. However, the unconscious mental activity continues and helps intuition to work. There is strong evidence that high cortical arousal, typical of conscious problem solving, narrows the associative field and suppresses the emergence of remote associations; a lower degree of cortical arousal allows these remote and unusual associations to emerge, during rest and even sleep. For example, Otto Loewi, an Austrian pharmacologist conceived in a dream a simple and elegant experiment that proved chemical mediation of a nerve impulse and led to the discovery of acetylcholine – a discovery responsible for securing him the Nobel prize.

In the Illumination Phase, the solution comes, often as a sudden insight, a flash of light, seemingly out of nowhere. How is the truth, significance, or usefulness of the idea recognized by a creative thinker? Sometimes by its beauty (esthetic appeal), sometimes by its simplicity, sometimes by its ability to solve related problems previously unresolved.

It has not escaped our notice that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material.
J.D. Watson and F.H.C. Crick (Molecular Structure of Nucleic Acids: A Structure for Deoxyribose Nucleic Acid, 1953)

In the Verification Phase, logical or critical thinking returns to the scene. However, it is important not to kill the new idea and suspend judgment, especially on whether it is going to work and whether it is new.

 

Creative thinking techniques

Is creativity such a spontaneous phenomenon that no “techniques” can be applied to it? I maintain, and research in cognitive psychology has shown, that creative thinking can be learned and used successfully. Such techniques do not eliminate the mysterious, deeply spiritual nature of creativity, nor do they negate the role of personality. Indeed, research has found that at the heart of creativity lie certain personality traits and attitudes such as optimism, courage, perseverance, sense of humor, passion, playfulness, and faith. But knowing the principles and techniques of creative thinking helps get rid of the pre-conception “I am not a creative person” and facilitates finding solutions.

Many of these creative thinking techniques intend to identify an escape from the prevailing paradigms that interfere with finding a solution lying outside them. These prevailing paradigms are represented by a dominant idea and a crucial factor (De Bono). A dominant idea is the organizing theme, usually undefined, a way of looking at a problem: “Why are we always looking at the problem in the same way?” A crucial factor is some element that must always be included no matter how one looks at the problem: “What is holding us up? What is keeping us to this old approach?”

Other creative thinking techniques guide the imagination in ways more likely to generate a solution to the problem.

For instance:

  • Working backwards – imagining an ideal solution and going back from it to the problem
  • Trying to solve a more general problem (the so-called “inventor’s paradox” – solving a more general problem can be more successful than solving a more narrow problem)
  • Finding or imaging an analogy or association between two ideas or phenomena previously not felt to be connected

One example of discovery from analogy is the discovery of phagocytosis by Elie Metchnikoff, a zoologist experimenting on the larvae of starfish. He observed under the microscope how larvae consumed the nutrients from the surrounding water through their surface. By analogy he proposed the radical theory that certain white blood cells could engulf and destroy harmful bacteria.

Among chosen combinations the most fertile will often be those formed of elements drawn from domains which are far apart.
Henri Poincaré

Is the product of creative thinking necessarily right? Not always, but neither does scientific reasoning guarantee freedom from blunders. The wrong hypothesis can be falsely confirmed by meticulous application of scientific reasoning. For example, Dr. John Hunter “confirmed” the hypothesis that syphilis and gonorrhea are caused by the same agent by inoculating himself with syphilis and gonorrhea. He was a surgeon to King George III and one of the most celebrated anatomists (he gave detailed descriptions of the body’s lymphatic system) and medical teachers of his day. In 1767 at the age of 39, he took pus from an infected patient and injected it into his penis in an attempt to understand gonorrhea. Two days later he developed signs of gonorrhea but a few weeks later he developed the characteristic sores of syphilis. He concluded therefore that the same agent caused both diseases. Hunter died from aortic aneurysm at 65, likely a result of syphilis.

Conversely, the right hypothesis can be falsely refuted. For example, in the 1890s the bubonic plague swept across Asia killing millions of people. In 1894, during an outbreak of disease in Hong Kong, Alexandre Yersin, a French physician and bacteriologist, discovered the plague bacillus – which was later named Yersinia pestis in his honor. However, Yersinia pestis cannot enter the body through healthy, unbroken skin (but can penetrate through the intact mucosa). Therefore, the microbe is generally dependent on the flea to reach new hosts. In the 1890’s, scientists began to present evidence that the flea was involved in the transmission of plague, but the “flea theory” was greeted with such skepticism that members of the British Plague Commission in Bombay carried out experiments to prove that fleas did not transmit plague. They “proved” their hypothesis because they assumed that “a flea is a flea is a flea,” i.e. any flea can transmit the microorganism. Further progress in “fleology” revealed that all fleas are not created equal. Out of about 2,000 different species of fleas, the black rat’s flea, Xenophylla cheopsis, was the most efficient vector of plague, but at least eight species of fleas could transmit the microbe to humans.

Creativity became a “buzz-word” during the 21st century. There is a growing body of literature on the expanding social and economic impact of creativity. Many social thinkers assert that creativity is the most critical factor to sustain the role of the United States as the spearhead of scientific progress in the world. Surprisingly, although the teaching of creative thinking is widespread in business, there is very little teaching on creativity in medicine and academia. In this paper, I presented arguments for the existence of creative thinking on the examples of discoveries in medicine and made a case for learning creative thinking not as a luxury, but as a necessity.

 

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DR. LYDIA USHA is an Associate Professor in the Division of Hematology and Oncology at Rush and the Director of Rush Inherited Susceptibility to Cancer Clinic at Rush University Medical Center. She has been interested in the subject for about 10 years and has given lectures and facilitated creative thinking workshops at Rush, UIC, and Mount Sinai hospitals.

 

Highlighted in Frontispiece Summer 2009- Volume 1, Issue 4

Hektorama  | Science