Let me echo the earlier welcome to the University of North Carolina for the thirty-second Annual Residents' Conference and say how very pleased I am to be with you for the presentation of your research—an event that I hope will be repeated often during your professional lives.
As proud as I am to be part of this program, you are the ones being honored. If people can be classified as those who make things happen, those who watch things happen, and those who just wonder what happened, there is no doubt where this group fits: you made it happen—and orthopaedic patients will be the beneficiaries of your efforts.
The American Orthopaedic Association deserves special recognition and gratitude for its initiation and continued support of these conferences. Encouraging the development of the abilities and initiative of young scientists is one of the soundest investments that we can make in the future.
Having reached a time in life when both vision and memory are dimming, and having no glasses for my memory, I will speak from notes—keeping their beginning and their end as close together as possible to minimize any ill effects on your postprandial physiology.
I did manage to avoid slides, encouraged in that decision by the story of an attorney, an orthopaedic surgeon, and a scientist who died and went to hell. Greeting them at the gate, the Devil said, "I'll grant you one last request before you come through the doors," at which point the attorney said, "I would like to have one final night of wine, women, and song." The Devil said, "Fine. It's done." When asked what he would like, the orthopaedic surgeon said, "I would like to be able to give one last lecture to an audience, with slides, double screens, a laser pointer, and everything else that I'll need for a talk." The Devil said, "Fine. You've got it." Turning to the scientist, he asked, "What would you like?" The scientist replied, "Well, I'd just like to be allowed to go to hell before the orthopaedic surgeon speaks."
I should, perhaps, explain the title of my address. When I was asked for the title several months ago, I had not decided what I was going to talk about, let alone what to call it, and since there is so much more room to say what a talk is not about than what it is about, it seemed safer to title it "No Tempests, No Teapots," since I knew that I would not be speaking on either of those subjects.
Later, in the sessions of sweet, silent thought, staring at a blank page and a reluctant pencil, I was struck by the paradox of someone near the end of his career addressing those whose professional lives were just emerging. Since this seems to be the rule rather than the exception, I take it to signify a search for perspective—for someone who might, by facing backward, enable others to go forward with direction and purpose, analogous perhaps to a person rowing a boat, looking to what is past in order to move ahead.
Reflecting on the importance of the residency years to our professional lives, my thoughts drifted back to the origin of graduate medical education at the Johns Hopkins Hospital in the late 1800s, when the term resident was coined from the expectation that junior physicians would reside in the hospital on essentially a full-time basis. The enormous expansion of this educational domain since, both in breadth and depth, is a tribute to the creative insights of Osler, Halstead, and Welch, who perceived its great value to both learner and teacher.
However, explosive growth is never free of trouble, and graduate medical education has been no exception. Supervision, work hours, funding, the balance between service and education, and territorial disputes are issues that have defied complete or final answers. Another issue, which is especially germane to this occasion, is the role of research in the education of residents—an area of particular concern in the field of orthopaedics, which has distinguished itself among medical disciplines in the clinical and educational arenas but has not had a commensurate impact in research. Partial justification for this shortcoming may be the heavy clinical responsibilities of the discipline. However—and this is my thesis—some capacity for creation exists in everyone, and the enhancement of this creative potential is not only possible but a necessary and proper function of all who participate in the education of physicians.
Creativity has been variously interpreted. My use of the word is in the sense of bringing something new into existence by recognizing a relationship between previously unassociated elements. Implicit in this definition are a product and the notion that human creation results not ex nihilo but from the use of existing material in unusual ways.
Creativity may be further described by the traits most often associated with it. Curiosity is a prime requisite for a career of exploration. It has been condemned as a condition that kills, and theologians have testified that it cost us paradise; nevertheless, curiosity is the mainspring of seekers, of people who want to know. Creative individuals are also more likely to be observant, sensitive, and persistent and to possess the capacity for intense concentration, a high tolerance for ambiguity, and the faculty for divergent thought. Divergent thought, which enables one to perceive similarities among previously dissimilar elements, is more critical to the creative process than convergent thought, which depends on recall and application of learned material. Aptitude for convergent thought and high intelligence are frequently associated. However, above an intelligence quotient of 120, intelligence has not been shown to be related to creativity.
Further shape may be given to the concept of creativity by understanding what it is not. For example, the simple enumeration of facts increases our knowledge but produces no remarkable insight or novel design. By counting, one may determine the number of seeds in an apple, thereby obtaining factual information, but, by determining the number of apples in a seed, one obtains knowledge of greater moment.
Likewise, the simple act of discovery is not creation. Finding an apple that has fallen from a tree is not creative, but, by connecting the forces that caused the apple to fall with those required to keep the moon in its orbit, Newton made an inductive leap that is the essence of creativity.
Finally, it is important to distinguish creation from interpretation. Although the renowned actor may receive more acclaim than the author of the play, it is the latter who created the piece in which the actor performs, however skillfully.
Creativity has both vertical and horizontal dimensions. The vertical plane encompasses the levels of creativity, ranging from simple, expressive originality (a clever phrase or a new dance movement) to complex forms of abstraction. Between the expressive and abstract levels is innovation, wherein the application of known principles, devices, or information provides a better way of doing something, of controlling the world around us.
The horizontal dimension embraces the types of creativity. Although the urge to create is largely independent of professional training, creation in artistic fields differs from that in science by having a smaller canon of technology and fact between the creative spark and its expression. Thus, artistic creation is less influenced by conscious thought than is scientific discovery, although the flash of illumination that springs from the well of subconscious cerebration occurs in both. The "Eureka!" of Archimedes as he stepped into the bathtub resulted from a spontaneous apposition of thought and inspiration similar to that which produced a Shakespearean sonnet. Such inductive leaps, however, being intuitive, are sometimes wrong. In science, the generalizations that result must be followed by hypothesis and experiment—the scientific method—which entail conscious connections, logic, and analytical thought.
It is, then, a blend of inspiration and analysis that has produced the peaks of creative achievement in medicine. We may be justly proud of past accomplishments, but a steady decline of physician-investigators clouds the future of medical discovery. That the causes for this decline are not based on genetic incompetence is suggested by the report by Gough, whose studies showed that medical students had greater creative potential than did architects, engineers, mathematicians, and research scientists3. Thus, the influences must be external, and they probably start much earlier than we realize—perhaps the first time that we offer a child an ice-cream cone as a reward for building a sand castle, and, by this careless introduction to the marketplace, encourage him or her to work for external rewards rather than for the inner pleasure of doing.
Further discouragement often occurs in elementary school, where to be different is to be disorderly or disruptive. The need for structure and discipline encourages convergent rather than divergent behavior. Exceptional sensitivity and skill are required of a teacher to preserve classroom order and simultaneously allow creative minds to expand. The student who, when asked to draw a house, depicts its inside rather the expected outside should be praised, not criticized, for this deviation from the ordinary.
Another characteristic of those bent toward medicine, whether innate or acquired, is a hypertrophied work ethic. While the essentiality and value of hard work are undeniable, continued focus on the next course or the next patient reduces the time for free association and creative thought. This preoccupation with task completion—with becoming rather than being—narrows perspective; other dimensions disappear. An initially diverse group of medical students, homogenized by traditional forms of language, practice, and dress, come to sound, act, and look alike.
Embryological research has shown that organisms act on their environment before reacting to it, so perhaps the inclination to work is congenital. But creativity, like many natural phenomena, is a cyclic process in which effort and relaxation, work and play, are balanced. Unfortunately, our culture equates relaxation with idleness, perceiving it more as a reward for work than its necessary diastole. Virtue and achievement are measured by the length of time for which effort can be sustained. However, such unrelieved activity has an undesirable side effect: it reduces the time for wonder, for understanding the world around us, and for seeing the unusual in the ordinary.
Even our nonprofessional pastimes tend toward competitive and self-improvement modes. Our Judeo-Christian training tells us that we are supposed to be producing something, making things add up, getting ahead. Doing nothing isn't easy; it takes courage and intelligence of a high order, and it takes practice. Of course, the more you do it, the easier it gets, and, after a while, even the guilt subsides.
Creativity is further constrained by the educational experience. The traditional authoritarianism of medicine, an enormous amount of factual material, and the pervasive multiple-choice test encourage a black-or-white, yes-or-no type of thought that allows little room for ambiguity. No one relishes intellectual purgatory, but we need to realize that some questions have many answers, others none, and to understand that uncertainty and anxiety are inevitable, and therefore acceptable, emotions. Perhaps, as Cohen suggested, we should have uncertainty rounds that deal only with patients whose problems have no single or best answer1.
Finally, the student escapes the stultifying effects of classroom and mentor. What then? Some enter practice, where stereotypical behavior is fostered by societal expectations and peer pressure. Others become faculty members, and their creative lives become emasculated by bureaucratic detail, Sisyphean labors, and the quest for elusive grant support. To be successful in today's world, the medical scientist must be not only Homo sapiens (man the thinker) but also Homo laboris (man the worker) and Homo miserium (man the miser). Of course, if confusion is a condition of creativity, the university environment is certainly more asset than impediment.
Clearly, many of these lesions are remediable. Perhaps the first step is to identify those who are unusually imaginative, since the innovative applicant is not set apart by present methods of selection. Psychometric indices of creativity should be incorporated into the Medical College Aptitude Tests (MCATs) or even the Scholastic Aptitude Tests (SATs). The critical-incident technique might also be used to identify students possessing the traits that are most highly associated with creative behaviors.
We must also insist on greater undergraduate diversity so that students can maintain their horizontal dimension for as long as possible. Verticality will come soon enough. Although facts are the raw material of ideas, research is more than collecting data and drawing conclusions. Perspective shapes the content of observation, and, to the extent that perspective is rooted in worldview, science is informed by nonscience. Special emphasis should be given to baccalaureate courses that stress concepts and principles, logic and analysis, and metaphoric activity. Both analytical and metaphoric processes are needed by the creative scientist. Analysis divides, categorizes, and emphasizes differences; metaphor relates, unites, and stresses similarities. Philosophy is vital because it encourages analysis and discipline and, above all, a search for truth. And, lest we forget, a course in expository writing should be emphasized, so that the rest of us will not have to hack our way through the obligatory obfuscation of medical writing.
After the native inventiveness and the intellectual breadth of a student are ensured, the spark is fanned by exposure to role models who reflect their enjoyment of research and by a period of time for investigative work, free from clinical responsibilities. But a neophyte investigator should not simply be taken off the wards and told to "do some research." Guidance, financial support, technical help, and access to equipment are necessary for a positive and productive experience in the laboratory. Direction is particularly critical in framing the questions for study and in planning the experiments to test hypotheses generated by these questions. Considerable experience and knowledge of the field are necessary to set in the other pieces of the puzzle that determine the size and shape of those being sought.
One's experience in the laboratory is likely to bear fruit in proportion to one's powers of observation, objectivity, and patience. Accurate observation depends on a receptive mind. It is easy to overlook the unfamiliar, whereas one readily perceives the familiar. Thus, we are often prone to see what lies behind our eyes rather than what appears before them.
Objectivity entails the honest acceptance of data that arise in the course of investigation, even if it results in the slaying of a beautiful hypothesis by an ugly fact.
Finally, as most of you have learned, patience is essential to enable the investigator to surmount the jungle of hindrances that lie in his or her path; occasionally, overcoming these obstacles gives rise to results as important as those originally sought. Of course, there is always the possibility that what has been imagined is quite impossible to prove, or too difficult to prove by available means, in which case persistence becomes foolish—what Emerson called "the hobgoblin of little minds."
Nascent researchers must understand too that if, as often happens, the research period produces no "Eureka!" experiences and the Nobel prize goes to another, the enhanced appreciation of scientific methodology and the ability to examine with a more critical eye are justifiable outcomes. Although a positive experience is perhaps more likely if the interest and enthusiasm of the investigator are captured in the project, it does not matter greatly whether the research is in basic or applied science if the problems are addressed through rigorous application of the scientific method. The axiom that research in basic science is needed to advance the understanding of clinical medicine brooks no credible opposition; however, it is not, as is often implied, a one-way process. Groundbreaking innovations come from clinical research as well as from fundamental science, although the border between the two is sometimes blurred. It is, after all, rather shortsighted to create a distinction between the health of the fruit and that of the tree that bears it. The ways of looking at problems are, or should be, very much the same whether one is engaged in research or in practice. What is needed is a stronger sense of partnership, mutual respect, and commitment to standards of intellectual rigor in both clinical and basic fields. The scientific method is for both a conduit to the summit of professionalism, the creation of new knowledge. We cannot create from nothingness, which must be left to a higher being, but may we not hope, as in the majestic passage from The Divine Comedy2, for the power to leave one spark of God's glory to the race to come?
*Address to the Annual Residents' Conference of the American Orthopaedic Association, Chapel Hill, North Carolina, March 12, 1999. Portions of this address, which were previously published in the essay "Creativity in Medicine" in Symbols and Symptoms, Indianapolis, Guild Press, 1995, are reprinted with the permission of the University of North Carolina, the holder of the copyright on this material.
†Department of Orthopaedics, University of North Carolina School of Medicine, Campus Box 7055, Burnett-Womack Building, Chapel Hill, North Carolina 27599.