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Is drawing a valuable skill for surgeons? I asked 100...

Is drawing a valuable skill for surgeons? I asked 100...

This is a Green Open Access version of my article: “Is drawing a valuable skill in surgical practice? 100 surgeons weigh in.” published by Taylor & Francis in The Journal of Visual Communication in Medicine on 18/2/19, available online: https://doi.org/10.1080/17453054.2018.1558996

While working on Plastic and General Surgery rotations I noticed the surgeons drawing a lot.. in operation notes, for patients on ward rounds, and in clinics. 


Although it seemed to be a commonly done thing, there was essentially nothing written about it in the literature when I went to find out more. Why/what/when/for who do they draw? I wanted answers! So I did some digging into it and this paper is the result…

Abstract

The author noted surgeons frequently drawing in routine practice. Literature review revealed no prior study of this activity. This research was conducted to examine the prevalence, purpose, and perceived value of this practice. Surgeons' experiences and opinions regarding drawing in surgical practice were canvassed via an online survey. One-hundred surgeons participated. 92% valued drawing routinely in practice. Utility was reported across domains of consent, communication, patient care, medico-legal, education, and planning operations. Free-text feedback is discussed, and learning points from this data were summarised. This paper establishes the collective professional opinion of 100 surgeons regarding the value of drawing, which plays a thriving role in current surgical practice. The utility of this skill transcends merely documenting visual information, allowing surgeons to quickly visualise simplified, dynamic representations of reality. This facilitates communication between professionals, and with their patients. The efficiency and availability of this medium allows drawing to maintain a distinct role in medical communication amongst other imaging modalities available. This paper is the first to document the prevalence of drawing amongst surgeons, substantiates an informed professional opinion supporting this practice, and demonstrates widespread enthusiasm for further training in these skills.

Introduction

Image-making has played a role in human communication for over 35,000 years, predating our earliest written languages by at least 30,000 years (Aubert et al, 2014; Woods, Teeter, & Emberling, 2015). Today, drawing skills are recognised as an important developmental milestone in healthy children, coming both earlier and more naturally to us than reading and writing (Dosman, Andrews, & Goulden, 2012). This means drawing has evolved as an innate skill for visual communication that we all share. Perhaps this is unsurprising given that vision is the dominant sense through which we experience the world.

Drawing has played a key role in the development and dissemination of Medicine and Surgery. Prior to the Renaissance in Europe (14–17th Century), for 1300 years our understanding of human anatomy had been almost exclusively been extrapolated from animal studies created by Galen, physician to the Roman Emperor in his time (Gomes, da Moscovici, & Engelhardt, 2015). These went essentially unquestioned, and so Medical and Surgical practice were based on many flawed assumptions about our internal structures and their functions. This limited medical progress for generations.

In the 16th Century the practice of human dissection was revived, allowing Renaissance physicians to link patient history and examination findings to anatomy and pathology. Artists played a crucial role in medical progress by making this new knowledge accessible to physicians who could not attend live dissection events. Meticulous observation resulted in art with an unprecedented level of accuracy in the anatomical texts which followed, beginning notably with ‘De Corpus Humani Fabrica’ in 1543. This was a revolutionary treatise featuring detailed medical illustrations often set in whimsical scenes, attributed to John Stephen of Calcar (Figure 1). These were informed by the dissections of Vesalius, a Professor of Surgery and Anatomy by whom the treatise is authored. This challenged the long established dogma, and introduced a scientific approach informed by evidence rather than theory.

Figure 1. Pages from De humani corporis fabrica, 1543, which was likely illustrated by John Stephen of Calcar, based on the dissections of the author, Andreas Vesalius. This anatomical text represents a pivotal shift in the approach to dissection, depiction of anatomy, and dissemination of medical knowledge. Images adapted from the Wellcome Collection, used under creative commons licence (CC BY 4.0).

Development of the printing press in this period allowed mass reproduction of these illustrated books, dramatically increasing the spread of this information. The medical field accelerated at an unprecedented rate as doctors could more readily build upon the collective experience of their peers. It is unlikely coincidence that surgery soon emerged as a distinct organised medical profession in the UK (Himmelmann, 2007; Jones, 2012; Encyclopedia.com, 2001).

Medical illustration has played a role in Surgery ever since, predominantly in the communication of anatomy, pathology, surgical techniques and concepts, and research. Although professional art is predominantly created by medical illustrators today (Figure 2), there have occasionally been surgeons who illustrated regularly. Notable examples include Scottish Surgeon Sir Charles Bell, and Harvey Cushing ‘the father of modern Neurosurgery’, both who kept beautifully illustrated journals of their operative techniques and findings (Dmetrichuk, Pendleton, Jallo, & Quiñones-Hinojosa, 2011; Del Maestro, 2007). A contemporary example is Mr Donald Sammut; a Hand Surgeon in the UK who routinely draws in practice at home and abroad on Charitable missions to Nepal with ‘Working Hands’ (Figures 3,4,5) (Sammut, 2018).

Figure 2. Surgical illustration by Dr Ciléin Kearns (Artibiotics), designed for Brainbook.

Figure 3. ‘Trapezectomy and stabilisation’ illustrated operation note drawn by Mr Donald Sammut, Consultant Hand Surgeon, UK, (Working Hands).

Figure 4. ‘Tendon transfer and graft to restore flexors of the right hand’ illustrated operation note created by Mr Donald Sammut, Consultant Hand Surgeon, UK, (Working Hands).

Figure 5. ‘Fusion IPJ right index and ring fingers’ illustrated operation note created by Mr Donald Sammut, Consultant Hand Surgeon, UK, (Working Hands).

The 21st century has brought photography and medical imaging technology to medicine, which are routinely used to create detailed pictures. Despite availability of these modalities, the author noted many surgeons would draw routinely in practice. This occurred when consenting patients for operations, teaching, and documenting post-operative notes (Figures 6,7). Attempted literature review revealed no prior study of this practice. This research was conducted to examine the role of drawing for modern surgeons, including prevalence, purpose, and perceived value.

Figure 6. Examples of post-operative drawings from a Plastic Surgeon (who wished to remain anonymous), including (a) nasal skin lesion excision closed with bilobed flap, (b) finger laceration extended with Brunner’s incisions for exploration, and (c) auricular wedge excision of a skin lesion. These types of drawings are often used in post-operative notes to help summarise pathology findings and surgical intervention. They can be useful for post-operative care of the patient, including ward rounds, wound management, physiotherapy, follow-up clinic, and future surgery.

Figure 7. Drawings made to explain pathology and surgical intervention, including (a) cholecystectomy, and (b) hernia repair, by Mr Dimitris Damaskos, Consultant General Surgeon. Sketches like this are made in clinic and while on ward rounds. They can help patients understand their diagnosis and potential surgery, which is necessary to give informed consent. Drawings like this evolve dynamically in real time with the surgeons’ explanation, and are tailored to a patients questions and level of understanding.

Methods and materials

Literature review was conducted via PubMed using combinations of the search terms ‘surgery’, ‘drawing’, ‘sketching’, ‘draw’, and ‘art’. This revealed 2470 papers, none of which related to surgeons drawing for patients, in operative notes, or in their routine practice. To gather information an online survey was designed (using Survey Monkey) to canvas the professional opinions of surgeons. This was disseminated amongst local surgical departments via direct email to Consultants, who were encouraged to cascade the survey through their departments’ surgeons via email. Responses were collected over a period of 6 months.

Results and discussion

One-hundred surgeons completed the survey. 92% reported creating drawings routinely, and felt this added value to their practice. A breakdown of responding surgeons by speciality is shown in Figure 8, which predominantly represents General, Plastic, and ENT surgeons. The ‘Other’ category contained 13 surgeons representing Neurosurgery (2), Urology (2), Vascular (1), Paediatric (1), Dental (1), Ophthalmology (1), and unspecialised surgical trainees (5). Senior surgeons were well represented; 50% were Consultants, 44% Speciality Registrars in their respective fields. The remaining 6% were doctors in Core Surgical Training.

Figure 8. Breakdown of the specialties represented by participating surgeons.

What do surgeons draw?

Surgeons reported drawing routinely in post-operative notes to document pre-operative examination findings (e.g. wound site, size, and surface contour); intra-operative pathology found (e.g. location of colon tumours), schematics of patients’ anatomical variation (e.g. vascular arrangement, or structures involved in a dupuytren’s case), and surgical interventions performed (e.g. the harvest site of a flap, sites of port insertion for laparascopic surgery, and the lie of a pedicle and vascular arrangement for surgical flaps). They often also noted relevant details about the post-operative state (e.g. new anatomical arrangement of structures like bowel, and locations of drains). Sketches were felt important for facilitating surgical care by effectively communicating large amounts of information quickly and clearly between colleagues managing post-operative care in the ward setting, and decisions about future interventions in an outpatient clinic setting. This form of documentation was felt to also aid other interdisciplinary team members, with cited examples of nurses, hand physiotherapists, neonatologists, and pathologists.

Why do surgeons find drawing valuable to practice?

The questions in Table 1 and Table 2 were asked to all surgeons participating. These results, in combination with subjective analysis of free-text responses, elicited several domains across which drawing has value to surgeons.

Table 1. Surgeons opinions of the value of drawings used in different aspects of surgical practice.

Regarding the value of drawing in surgical practice, please rate how much you agree with the following: Agree Neutral Disagree
Drawings improve patient care/follow up 71 14 14
Drawings are useful for medico-legal purposes 63 20 17
Drawings improve patient communication 86 9 4
Drawings improve professional communication 82 9 8

Table 2. Surgeons opinions of the value of drawing in their personal practice.

Regarding the value of drawing skills for surgeons, please rate how much you agree with the following: Agree Neutral Disagree
Drawing helps me study/make notes (eg anatomy) 83 10 7
Drawing helps me communicate with patients 92 4 4
Drawing helps me communicate with peers 80 13 7
Drawing helps me plan surgery 48 29 23

Communication with colleagues

82% per cent of surgeons reported that drawing helped them communicate with other professionals, and 80% agreed it helped them communicate with their peers. Drawings were described to serve as ‘aid memoires’, which help recollection of the pathology and procedures done, useful for postoperative care on ward rounds, and follow-up care planning further operative intervention.

‘drawings are particularly valuable to the team providing post-op care, as they communicate detailed, anatomically relevant information should the patient need to go back to theatre’.

Drawings were considered useful to colleagues in other disciplines such as Pathologists to help orientate specimens sent from theatre, and for mapping biopsies of large tumours, for the planning of definitive treatment. Moh’s micrographic surgery was an example cited by skin surgeons, where precise orientation is important to extend the correct tumour margins in further surgery. Allied healthcare professions including nurses and hand physiotherapists were considered, where drawing was felt to enable rehabilitation postoperatively, and help nurses manage dressings.

Clarification of written and verbal information

39% per cent of participants reported that drawing improved the clarity and ease of communication, over written and verbalised descriptions. This was for numerous reasons, including that images were easier to visualise intraoperative findings with, than illegible hand-written notes. Drawings were noted to be particularly useful for communicating visuo-spatial information including shape, size, orientation, and position in space. In Psychology literature, these are concepts which are thought to be more efficiently communicated by images than words (Glenberg & Mcdaniel, 1992; Jackendoff & Landau, 1991).

‘[drawings] demonstrate far more clearly and concisely what has been done or found compared to written text’ – ENT Consultant

Time efficiency

Surgeons reported that drawing facilitated more efficient patient care, as they could explain clinically relevant information such as intra-operative findings more quickly than with writing, making them useful adjuncts in postoperative notes. Schematic diagrams were praised for lack of detail, which made them easier to assimilate. Frank Netter was a defining medical illustrator of the 20th Century, and had a useful explanation of this concept: ‘the picture serves as a shortcut…it saves us from having to translate the image into words, and the reader from having to translate the words back into a mental image’ (Netter, 2013). Visuo-spatial information is challenging to describe accurately, and interpret when reading, compared to when it is shown.

Research/Education

Some surgeons used drawings in research publications, presentations, teaching, and training to illustrate surgical concepts. 83% of surgeons reported they drew when studying or making notes, making it a common language in surgical education.

Additional dimensions of communication

Surgeons wrote that drawing allowed communication of additional dimensions of information that could not be captured by other modalities. This included time (showing before/after intervention), ‘shining through’ structures to reveal hidden elements (e.g. the biliary tree behind and within the liver), sensations like the location of pain, and sounds auscultated on examination.

‘a photograph only presents a snapshot of one instant. One (or a couple) of good diagrams can summarise the key points of even a 10 hour operation. Anyone looking after that patient can instantly see what has been done without even having to read the full op note’ – Consultant Plastic surgeon

Filtering information

Detail in photographs is often high and unselectively distributed, resulting in increased time to identify relevant information. Drawing was noted to add surgical interpretation of information, by direct control of filtering out unhelpful distracting ‘noise’ from an image, such as extraneous tissues, organs, and blood. This results in greater clarity of the relevant visuals. The author has previously described this aspect of visual communication in the context of medical illustration; simplified representations of reality enable the non-expert (such as a patient or trainee), to have an ‘experts view’, where only the relevant structures are apparent (Kearns, 2018). In this way, drawings can make concepts faster to ‘read’ and easier to recall, which is useful in the time-pressured environment of clinical practice.

Stylisation

One surgeon reported that in photographs it can often be difficult to distinguish ‘normal’ from ‘mildly abnormal’, speaking to the role and benefit of accentuating key information for a clearer message. The 3D arrangement of structures was felt to be clearer in drawings than photographs, where a constructed sketch allowed emphasis of the layered arrangement. The embellishment of important details combined with elimination of extraneous ones is a core aspect of medical illustration. Dr Frank Netter also spoke on this topic: ‘the illustrator can discriminate between important items and the nonessential items in the picture, and make the important items stand out…what is left out of the picture is of great consequence in emphasising the remaining parts’ (Netter, 2013).

‘a diagram illustrates construction better than reality’ – Consultant General Surgeon

In summary, drawing was praised over photography for convenience and control of creation; logistical ease of arranging and reviewing; clarity through simplicity, schematic representation, and accentuation of information; and the ability to depict additional dimensions of information.

Why is drawing still valuable despite modern clinical imaging modalities?

Photography and radiological imaging allow rapid capture of detailed images and videos. They have clearly defined roles in healthcare, including clinical investigation and diagnosis for radiology, and medico-legal documentation for photography. Some Consultant Surgeons liked using photography to teach, document wound healing, and show patients their problem postoperatively. Others reported showing their patients radiology when discussing diagnosis and surgery.

With the widespread use of medical photography and increasing access to clinical radiology, one might imagine the relevance of (often crude) surgeon’s drawings would have diminished in the 21st Century. Interestingly this was not the case; respondents reported clear utility over these modalities in certain situations. Drawing was felt to be quick, easy, and more readily available than other forms of imaging. The logistics of arranging medical photography were felt to be often be prohibitive in a busy clinical setting, e.g. the paperwork required to request and consent patients, and computer equipment required to review imaging, which both introduce delays in obtaining/retrieving an image. Photographs were reported to often be confusing when viewed out of context, where orientation, location, and scale, could be difficult to interpret, and simple labels could not be placed on the images. It is worth noting that accurate observational drawing which is potentially identifiable (e.g. a patients’ face or hand), should be formally consented for as any photograph would require. The vast majority of drawings described by surgeons in this study however were schematic in nature, of non-identifiable internal structures and processes.

Others felt radiology imaging was unsuitable for most patients due to overwhelming detail, and difficulty of interpreting the images, e.g. 2D slice representations of 3D forms. Operative photography was noted to be potentially unsettling for lay audiences, and the anatomy difficult to understand. This emotional response to graphic imagery could be detrimental when attempting to empower patients to make informed consent about treatment options.

‘[photography] from theatre may look good but not necessary mean anything to your patients; they gain much better understanding from drawings’ – Obstetrics & Gynaecology Consultant

Drawing allows surgeons to record simplified representations of specific information. It exists as an efficient, dynamic, and readily available tool, which facilitates communication of surgical information between professionals, and with their patients. This distinct role continues to thrive amongst the other imaging modalities in medicine.

Informed consent, medico-legal value

There appeared to be a consensus that drawings could be an effective tool when consenting patients, to explain pathology and operative intervention. These drawings were often taken home for later reference, and to help patients pass on information to relatives. Skin and plastic surgeons drew on paper (or their patients) to indicate wound size, course, and reconstruction options such as local flaps that would follow the excision of cancerous lesions. Some surgeons explained operative risks with diagrams, and others documented operative sites, ‘e.g. on a scalp with multiple lesions, to identify the correct one’, which may save time, and help to prevent intervention on the wrong lesion, and thus the sequelae of progression of missed disease.

clear figures allow explanation and allow the patient to take the messages home to the family’ – Consultant General Surgeon

Better clinical outcomes

Seventy-one per cent of surgeons felt drawing improved patient care and follow up. One Urology surgeon noted research which demonstrated objectively improved TURBT outcomes (fewer recurrences of disease) when a diagram was used at the point of diagnosis to indicate the sites of tumours in the bladder (Brausi, 2013). The reason for this is not yet understood, but it is an interesting finding.

Template illustrations

Some ENT, Gynaecology, and Ophthalmology respondents mentioned their departments printed template drawings for use in clinics and theatre. These saved time as doctors could draw over a pre-made base image, adding only details which varied by patient, such as pathology or repair performed. Examples cited included of the tympanic membrane, vulva, and retina. Some surgeons supported the use of template illustrations where surgeons’ drawing skills were poor. Variation in patient anatomy, operative site, and angle, are example situations which may not lend themselves to a prepared template, such as in trauma and reconstructive surgery. Generic templates may inherently avoid a patient-centred approach, eliminate the pace-control that comes with drawing while explaining to patients, and miss opportunities to streamline and adapt information for a specific patient.

Going forward: improving practice with critique

Without formal training, guidelines, or feedback available to surgeons who make drawings, there is presumed variation in utility. To appreciate this and consider potential ‘best practices’, participants were asked to critique drawings encountered in clinical practice that were created by other surgeons.

Praise was offered for good depiction of anatomy and clear orientation through labels. Frustration was expressed for poor anatomical understanding and illegible labelling. Colour was sometimes used well to highlight important areas of a drawing. Useful drawings were described as having ‘clear, effective, clean lines’, and being ‘neat, clear and accurate’. Comments were mostly positive about drawings regardless of quality, where surgeons generally found them helpful, however crude they may be.

no drawing with illegible words in an op note are not just unattractive, they can be dangerous too’. – ST5 Plastic Surgery

Surgeons valued shading to show depth, perspective, separate structures, and indicate three dimensional form. However, several reported difficulty creating these effects. 71% of surgeons expressed interested in further training in drawing skills. Perhaps training in the depiction of perspective, 3D form, lighting and labelling conventions, separating objects in space with depth cues, and other medical illustration techniques, would be of value to surgeons wishing to communicate their intent more accurately when drawing. Suggested efforts to build upon this work include a scoring system for the ‘communication effectiveness’ of drawings. This could be used to identify effective and ineffective drawings for further study, and establishing ‘best practices’. A scoring system could test objectively for communication benefit following training in specific drawing techniques to help guide education design for surgical curricula. As this study focussed on professional opinions exclusively, there would be also be benefit in studying the value of drawings from surgical patients’ perspectives (e.g. during diagnosis explanation and consenting for surgery), to see how their experiences match professional opinions of drawing utility.

The author suggests the following take home points from this discussion:

Take-home messages

  • The vast majority of surgeons surveyed draw in their routine practice.

  • Drawing allows information to be filtered to create audience-tailored, simplified representations of reality.

  • Utility was reported across the domains of patient consent, peer communication, post-operative and follow-up care, medico-legal, education, and planning operations.

  • Drawing can be an efficient, convenient way to communicate with both patients and peers.

  • Images are efficient tools for communicating visuospatial information like shape, size, position, and orientation.

  • Template ‘base drawings’ may save time, improve consistency, and help less artistic surgeons.

  • When drawing, surgeons should orientate the viewer with relevant, legible labels.

  • Surgeons were enthusiastic to improve their drawing skills with formal training.

Limitations

One surgeon found some colleagues relied too heavily on drawing and inappropriately replaced verbal description with these. Poor drawing skills could make this practice dangerous if solely relied upon to communicate the relevant clinical detail. Others felt illegible handwriting (e.g. labels) could make documentation dangerous through misinterpretation. A Consultant Plastic surgeon cautioned that drawings could be inaccurate or falsified more easily than photography or video if used in a medico-legal context. Despite widespread use, it is interesting that there is currently no formal drawing training or assessment in surgical curricula to ensure information documented in this form adequately communicates the intended information.

The author acknowledges that the method of data collection by an online survey was open to potential self-selection bias from surgeons who are interested in drawing. Arguably however, those with strong opinions against the practice of drawing could also self-select into the survey. All scaled questions had equally weighted positive, neutral, and negative response options, and both positive and negative critique of the practice was requested in free-text questions. The author also recognises that as some specialities were less represented, the generalisability of this data will be lessened for them. With these caveats in mind, this paper remains the first to establish data on the prevalence, purpose, and perceived value of drawing for surgeons. It offers a waypoint for further study of this common practice.

Conclusions

This paper establishes the collective professional opinion of 100 surgeons regarding the value of drawing, which plays a thriving role in current surgical practice. This is interesting, as it is not a skill that is taught or tested in formal surgical curricula. The utility of drawing transcends merely documenting visual information, allowing surgeons to quickly visualise simplified, dynamic representations of reality. This facilitates communication between professionals, and with their patients. The efficiency and availability of this medium allows drawing to maintain a distinct role in medical communication despite the evolution of other imaging modalities such as photography and radiography. This paper is the first to document the prevalence of drawing amongst surgeons, substantiates an informed professional opinion supporting this practice, and demonstrates widespread enthusiasm for further training in these skills.

Acknowledgements

The author would like to acknowledge the contributions of Dr Nethmi Kearns (Medical Research Fellow), and Dr Cónail Kearns (Psychiatry Speciality Registrar) for their review and feedback on the papers content. Also thanks go to Mr Donald Sammut (Consultant Hand Surgeon), Mr Dimitris Damaskos, (Consultant General Surgeon), and an anonymous Plastic Surgeon, for providing example drawings. Lastly, thanks are given to the 100 surgeons who gave up their time to participate in surveys and give engaged feedback which shaped this publication.

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