Drawing has been a very positive influence on my development as a surgeon. Naturally, I wanted to share that with others in our Division. The premise being that visual notes are useful for learning, communication and medical documentation.
The plan was to have two medical illustrators and a staff/mentor lead a workshop on visual note-taking for our colleagues. When those three could not do it at the last minute, I was Plan D! I cobbled something together and here’s what it looked like:
Warm up exercise
- First, draw from memory and then, from a reference object
Discussed the question “Why Draw?”
Discussed the notion that “I can’t draw!”
- Emphasized that this session is not about drawing in the artistic sense but rather, visual note-taking.
- Shared drawings/visual notes from some of my residents and my own sketchbook, which gave them an idea that it doesn’t always have to be representative or artistic. It just has to be a visual reminder for the draw-er.
- Gave pointers on what to draw. I made up an acronym “STAIRS” just to be cute.
- Traction (e.g. traction sutures, retractors)
- Instruments and hands
- Relationships (i.e. between anatomical landmarks)
- You might ask what does “Symbols” mean? It is just a way of representing common objects, like one would use simple icons. Scissors could be drawn as:
Answered the question, “Why not just take photos or watch videos on YouTube?”
- This is a very good question from a senior colleague. I think the difference here is that there is a very active component to drawing. As you trace out the anatomy, you experience the image very differently than merely looking at it.
Finally, we ended with drawing exercise.
- I chose a YouTube video of a kidney transplantation. Not only is the anatomy clear and well-defined, it can also be the most satisfying operation to perform (I recall all the times that patients literally cried out of happiness when their new kidney made urine).
- We divided the surgery into 12 parts and each of us were assigned a step to draw
- Watched the video and drew our assigned step
- Presented our own drawing (in sequential order)
- I was so proud of everyone at the end, when we had a full panel from start to finish of this operation! It proved that they all can draw!
Overall, it was an enjoyable experience to share this with my colleagues. I don’t know if it will change the hardcore skeptics but I think it made a few consider drawing in the future. A week later, I saw one of my co-workers make a small sketch in his clinic notes for the first time and it made me smile.
To date, I’ve spoken to three groups of surgeons and trainees, as well as other individuals about the use of drawing for surgical education, documentation and generally “figuring stuff out”. The most common response is, “I can’t draw.” This is coming from surgeons who have two fully-functioning hands, trained for years to operate and have fine motor skills better than the majority of the general population. And yet, the act of drawing is what they do with the scalpel or Bovie (a.k.a. electrocautery tool) in the operating room. For me, I had an inherent fear of drawing until my early thirties. In the end, it took an influential mentor, supportive family and friends, an art class, a sketchbook and the will to try.
It was a mental hurdle, rather than a lack of ability.
Here are 10 steps for anyone to overcome their fear of drawing:
- Forget about perfection.
- Buy a notebook – Something that is nice enough that you’ll want to use it but not so expensive that you’ll be afraid to use it (ahem, Moleskin). I started off with a regular $2 lined notebook from Staples. I made both written + visual notes and found the lines were less intimidating than blank pages.
- Get into a routine of drawing (daily if possible) – This could mean taking 5 minutes at the beginning or end of your day. The key is making it a habit.
- Roughly outline the image(s) first and fill in the finer details later – Do this without erasing anything at first. You can always return to this later with a darker pencil or pen over your outline, erasing mistakes later. The key is getting it down when your memory is fresh.
- Draw from reference photos or other stationary objects – Learning to draw is not just about mark-making but also honing your skills of observation. Photos and stationary objects will give you more time to observe. For instance, those who are learning to draw figures might go to a museum or gallery to learn on statues first.
- Listen to music – This might help for some distraction and “loosen” you up.
- Take beginner drawing class or buy a beginner drawing book – I prefer the art class, since it gave me a chance to be among other beginners and realize that I’m not totally off. They might get you to do some exercises to loosen up and be freer with your drawing, depending on the instructor. I found this to be immensely helpful.
- Show your work to (supportive) family and friends – Depending on who they are, you might have to be a bit selective on this one. People are generally very encouraging and not expecting you to be Michelangelo.
- Deconstruct your subject – Breaking down the object into simple geometric shapes is what many experienced artists still do and makes drawing much more accessible to novices. Then for shading, breaking tones down into 5-6 discreet tones will add realism (but not a necessity at this stage).If you can simplify it, then do so.
- Accept that you will never be done – Along the same vein as “Forget about perfection”, there is always something that you could add or change. If you accept that you’ll stop at (arbitrarily) 50% or 75% or 80% of completion, then it will allow you to move on.
Do you have any other tips to share? If so, leave a comment or share them with me @SurgicalArt on Twitter. Oh yes, I’m on Twitter now. Something I never thought I would say.
The other day, I was contacted by a pediatric surgery resident from Portugal whom I had met months ago. He was wondering if I could do a few drawings for a presentation. It would cover different aspects of his training, including urgent surgery, neonatal surgery, abdominal surgery, thoracic surgery, urology, head and neck, burn care and oncology. It would be pro bono and it might get some exposure to the faculty at his hospital. Being early January, I was faced with ethics paper deadlines, research projects and setting up my private practice upon graduation. Nevertheless, I cannot say no.
Given the time constraints, I plan to send him six rough sketches and two completed sketches from my portfolio. Here’s a rough sketch that illustrates midgut volvulus in a newborn baby. It is very “visual pathology”, as my Portuguese colleague put it.
When learning new skills, some struggle to learn the basics while others pick it up (seemingly) effortlessly. A friend and mentor recently sent me this article:
Why Are Some People Better At Drawing Than Others?
The article states that people who draw well are able to properly “see” their subject and have an innate ability to recognize proportions, light/shadows, etc. In contrast to those who struggle with drawing, who may not properly take in these subtle features. It is no surprise that skilled artists develop an “eye” for detail. Parallels can be drawn for skilled surgeons as well. The medical student may recognize obvious anatomical features. As they progress through their training, they learn to recognize normal versus abnormal characteristics. Further on, they recognize “planes” which broadly describe the natural spaces that occur between tissues. An operation can go well if you get into the right “plane” and the first step is recognizing it.
Fortunately, there is hope for us all!. Practice is the key to improving one’s skill, whether in art or surgery. In addition to the repetitive act of practicing, the important step is also reflecting on the last art piece or the last surgical case and thinking, continuously, how one can improve. In learning either discipline, people have a misconception that practice involves repeatedly “going through the motions”. In other words, “If I just do 100 cases of x, I will be an expert!” That is simply not true or even feasible as a trainee in this day and age. The phrase that comes to mind is, “Insanity is doing the same thing over and over again and expecting different results.” Reflection is integral to practice and without it, one cannot hope to improve. There is often this pressure to do more cases, hurry up!!! It takes every bit of my effort to slow down. Be mindful. And reflect.
The paradigm of surgical training is what educators like to call “graduated responsibility”. As we progress through our training, we incrementally ramp up what we are permitted to do in the operating room. I don’t know when this happened but somewhere in the past few months, I’ve felt a “switch”. For lack of better word, it is when one goes from being a surgical trainee with an attending staff always being in the room to being the surgeon. It is during a case when you realize that the most experienced surgeon in the room is you. It is when you stop yourself mid-sentence, as “the resident/fellow working for doctor so-and-so” to “the surgeon”. Families arrive at the surgical waiting area asking for you (who me?).
Of course, I am fortunate that this has occurred during fellowship and not during my first day of independent practice. I am grateful that more experienced help is only a phone call away. Mind you, this has come after years of surgical training. While most young surgeons are confident in their skills by this point, it is normal to feel some apprehension. For me, it has made me acutely aware of all the tiny details that I used to take for granted. It has made me a little obsessive-compulsive, too but one can hardly be faulted for that. My sketching and note-taking has also become a bit more refined as well. It covers not so much the basics but little nuggets of wisdom from my mentors that I would hate to forget as I move into practice. Seemingly minor points that allows the surgery to look effortless (which would otherwise be a struggle)! The other day, I noticed that the content of my drawings have changed and probably around the time that this so-called “switch” happened.
Typically, surgeons review imaging (Xray, ultrasounds, CAT scans, MRI scans, etc.) preoperatively to help plan for surgery. At the AMI conference, physicians and illustrators discussed how art and technology can help with preoperative planning. During one presentation, a plastic surgeon showed 3D reconstructions of skull imaging to help plan a facial transplantation. During surgery for craniosynostosis (premature fusion of the suture lines of the skull), another presenter showed how 3D printing could be applied. Here, the goal of that surgery is to recreate a normal shape of the skull in children with craniosynostosis. 3D printouts of the skull with pre-planned markings for the bone grafts were sterilized and used to mark out the grafts intraop. All grafts were designated with a letter, eg Graft A. These grafts were then placed into a second template that showed where they would sit. Very cool.