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.
With the advent of digital photography and falling costs of DSLR cameras, high quality photography has become more accessible to the masses. Intraoperative photography can be useful for documentation, capturing a rare finding and for patient or trainee education. It has become so ubiquitous that it is integrated into the consent process when surgeons discuss surgery with patients. Obtaining explicit photography consent should be the norm.
Photography is more common in medical specialties where visual documentation is essential, e.g. dermatology, plastic surgery, pathology, etc. We used to page the medical photographer to the OR whenever there was a rare finding or new technique. This was back in the era of film and he would give the surgeon physical prints. For better or worse, we have moved from professionals to surgeons taking photos.
I had the pleasure of following around two dedicated medical photographers for a day. They answered questions, demonstrated their workflow (from photographing to editing), let me use the equipment and gave feedback. I left with a better understanding of photography and changes that I could employ without buying anything new. There were a few equipment recommendations that I could invest in later, if I wanted to.
The OR presents unique challenges (e.g. artificial lighting, time constraints, distance from the subject, etc.) that can be overcome with a few simple tips. Here’s the gear I use:
- Camera – I recently purchased an entry-level Nikon D3200 DSLR with my credit card points (retails at $450 USD, including lens kit) that I keep at work for this purpose. It has a sharp image sensor and all of the functions that you would want in a DSLR. That being said, the gap in photo quality between point-and-shoot cameras and DSLR cameras is narrowing. If you want a light, compact and relatively inexpensive camera, point-and-shoot is the way to go. If you want more control over camera settings and are looking for an investment piece, DSLR is great for that. I was told that you can invest in some nicer lenses and change out the body every few years.
- Lens – The lens kit that came with my camera is meant to be cheap and versatile (AF-S DX NIKKOR 18-55mm VR II Lens Kit). For close-up photos, a macro lens is far better but it would be an investment. Given that it is super light and can zoom in decently, I am going to stay with my current lens for now.
- Hand strap – Great for hand-held photography. I removed the neck strap because it was cumbersome, awkwardly too long and short. Also, I would not want to fall into the sterile field.
- SD card – I upgraded from my 1GB to a faster, larger 64GB SD card. A larger card ensures you don’t run out of memory. In most instances, you won’t have the luxury of stopping to transfer photos off the card.
- White balance card – Most ORs don’t have windows. Sunlight has colors from across the light spectrum and gives some of the nicest photos. The issue with artificial light is that it has a narrower spectrum. Often, my brain knows that the “color temperature” is off but I can’t quite figure out how. Take the guess work out of it by using a white balance card and taking a photo with the same light source beforehand. It will help a lot in the editing phase.
- Camera cleaning kit + caviwipes
Stuff that I might get some day but I happy to do without:
- Macro lens – much better for capturing details up-close
- Plastic diving bag – something that both protects the camera and I can wipe with caviwipes or even sterilize, to get a little closer to the sterile field. Right now, I keep my distance for these reasons.
- Ring flash – handy for photographing in a deep and/or small incision or space
- Polarizing lens – reduces glare off of shiny tissues.
Here’s my current workflow:
- Take a photo using the overhead OR lights + white balance card on the OR table. Before the patient comes in the room, obviously. Will help in post-production.
- Ensure photography consent has been obtained from the patient or substitute decision-maker.
- If I am not scrubbed in the case, I like to move around and take photos from different angles. If I am, I’ll often ask someone else in the room.
- Shoot in RAW mode, rather than JPEG. When shooting in JPEG, the camera automatically compresses the file into a JPEG file – then that data is lost forever! If you have the data storage capacity, photos in RAW format are way easier to edit later.
- I found that for the given OR lights, the settings on Manual that usually work for me are as follows: ISO 100, shutter speed 1/250, f/8. Shooting on Manuel seems to give far more consistent photos, which is better if you edit your photos as a batch later. I decided on these settings after reviewing my photo settings on Auto and seeing which ones gave the best photos.
- I changed the focus from Auto to a Single Focus in the center of the image. Usually, that’s where I want it to focus. It can be annoying when the camera focuses on the hands or instruments, rather than the tissue at the center of the image.
- If you have an L-shaped ruler to place in the surgical field, it will automatically make you frame the photo properly and be square with the ruler.
- Occasionally, I ask people to stop for literally a second so I can take the shot. Us surgeons can be very impatient! It will pay off when you don’t end up with photos of only your colleagues’ hands.
In Part II, I’ll discuss my workflow for photo editing and post-production.
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.
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.
As I write this, I am sitting on a weathered wooden bench in a park, at the center of the huge medical campus that is the Cleveland Clinic. I’ve had an amazing time here at the Association of Medical Illustrators Annual Meeting, learning new ideas and getting inspired by the works of art in the Salon and thought-provoking lectures, seminars and discussions.
Initially, I had my doubts about how much I would get from this conference as a physician. I met up with the only other non-illustrator that I know here for a brief research meeting. It just so happens that he is married to a medical illustrator and they attend one another’s conferences. Yet, the scope of the conference has been so broad that is has been very accessible to someone like myself. I identify as someone who is a physician primarily, enjoys art as a hobby and often thinks about the intersection of the two disciplines. In addition, there have been talks that have tapped into the deep recesses of my memory, such as 1st year anatomy, differential calculus and quantum physics! Just the mention of these topics and I was like, “oh yeah, I used to know this”. I love how medical illustrators are link between the worlds of art and science, and how much potential there is for their unique skill sets + problem-solving abilities.
Here are my favorite talks thus far: