One evening in 1933, the Hungarian biochemist Albert Szent-Györgyi was served a paprika dish for dinner. At the time, he was investigating natural sources of ascorbic acid for his research on vitamin C and scurvy. Although he did not enjoy the dish, he also did not want it to go to waste—so he brought it to his laboratory. To his surprise, Szent-Györgyi was quickly able to purify a substantial amount of ascorbic acid from paprika, leading to major advancements in the field of nutrition.1 The finding is best summarized in his own words: “Discovery consists of seeing what everybody has seen and thinking what nobody else has thought.” It takes a keen eye to make a unique connection between an observed phenomenon and a completely novel idea. Such astute thinking is crucial for plastic surgeons, with great potential to promote creativity and innovation. The process of innovation can be broadly defined using the five steps displayed in Figure 1.2 As the figure illustrates, simply observing a phenomenon will not lead to innovation. The observed information must be interpreted to lay the foundation for the proposal of an innovative idea. The proposal can then be reflected on and further refined before implementation. Note that the process is cyclical; observations of implemented ideas may lead to new ideas for improvements. For example, achievement of the first microvascular anastomosis in 1966 completely changed the field of plastic surgery. Since then, innovators have relied on the technology to make substantial progress in replantation and free tissue transfer procedures. Thus, the aim of this article is to discuss how observation can lead to innovation.Fig. 1.: Process of innovation.Observation and creative thought can arise at the individual level and at the group level. The first section of this article discusses factors that facilitate observation and creative thought at the individual level. The popular image of the lone scientist having a sudden “lightbulb moment” omits much of the work and thought that lead to such breakthroughs. Innovation is also not limited to solo endeavors, and thus in the second section, innovation at the group level is discussed. By examining how successful businesses approach observation systematically, we will demonstrate how teamwork can be leveraged to facilitate creative thinking. OBSERVATION FROM THE INDIVIDUAL’S PERSPECTIVE Innovations are often described as the result of serendipitous, fortuitous occurrences. For example, Alexander Fleming famously developed penicillin after observing unusual mold on a contaminated petri dish, and Sir Isaac Newton established the theory of gravitation when he saw an apple fall from a tree. Such simple stories suggest that successful innovators are inherently better at type 1 thinking, which describe the automatic, effortless, and associative ways in which a stimulus may elicit a creative thought. However, a closer look reveals that innovation also depends on type 2 thinking processes, which describe the controlled, conscious, and purposeful effort to think creatively.3 In reality, the achievements of individuals such as Fleming and Newton were a culmination of determination, experience, and opportunity. Storytellers often leave out the fact that Fleming’s inability to treat infected soldiers during World War I was what motivated him to pursue antibiotic research for years before his discovery. Furthermore, the full potential of penicillin was not recognized until 10 years later. Thus, it is important to discern the characteristics of excellent observers that facilitate meaningful inquiry and the fervor to persist when the use of novel realizations is not imminently apparent. Pursuit of Diverse Interests Innovators are known for being curious about many topics—not only their specific craft. Often, curiosities lead to well-established hobbies, from cooking to painting or repairing vintage cars. Hobbies can foster creativity through two mechanisms. First, they may relieve stress, which primes the brain for more divergent thinking and idea generation, falling under the category of type 1 thinking processes.4 For instance, George de Mestral was a Swiss engineer who grew up with a fascination in technology and received formal training from prestigious institutions. When he was not at work, he spent his time hunting in the mountains and, as the story goes, he was pestered by the burs that stuck to his clothes.5 Rather than endure the problem, he began investigating the fastening mechanism (step 1 in Fig. 1) and made a connection between what he observed and a potential future use (step 2 in Fig. 1). Although it took several years, de Mestral was eventually able to turn his examination of an annoyance into a useful invention: Velcro. De Mestral portrayed many qualities of an astute observer and innovator. While keeping his mind open to identify problems and new ideas in his day-to-day life, de Mestral relied on his technical expertise, experiences, and persistence to bring those ideas to fruition. In addition to priming the mind for more creative thinking, hobbies can lead to innovation by enabling connections between seemingly unrelated ideas in what is known as “associating.”6 Apple founder Steve Jobs famously claimed that “creativity is connecting things.” He exemplified this himself, as he leveraged his fascinations with the simplicity of Zen Buddhism or the fine details of a Mercedes-Benz to make his products sleeker and more functional. In addition, observing analogies between problems can lead to parallel solutions. Biomimicry is a specific form of design that relies on biological analogies. For example, a German glass manufacturer observed that millions of birds were dying per year because they flew into glass windows. Although window decals were effective to steer away the birds, they were an annoyance to building occupants who wanted clear views. Thus, the glass manufacturer borrowed an idea from nature: orb-weaving spiders spin ultraviolet light–reflective webs that are visible to birds, but not humans. He used the same technology to develop a clear window coating to drive away the birds.5 Although nature cannot provide answers to all problems in surgery, identifying solutions in other industries or areas of medicine can prove useful. For instance, our team at the Michigan Center for Hand Outcomes and Innovation Research frequently surveys journals in other specialties to identify potential project ideas. Cultivating interests in diverse topics can enhance our ability to observe unique insights that may be applicable to our work. Avid Note-Taking The curiosity of renowned inventors is also reflected in their extensive recordings of diverse observations. For example, Thomas Edison and his associates, inventors of the light bulb, recorded 5 million pages of ideas, drawings, and experiment results on an array of topics. Research indicates that note-taking serves a “storage” function by facilitating retention of lessons and facts. In addition, note-taking serves an “encoding” function that improves understanding, especially when notes are reviewed.7 This facilitates step 1 in the innovation process (Fig. 1), which consists of interpreting the meaning of an observation. Traditional note-taking in the research laboratory or classroom relies heavily on type 2 thinking processes, given the need to focus on facts and problem-solving. However, the unconscious mind continues to ruminate even when one is not actively thinking about a problem. Therefore, notes can also serve as permanent reminders of otherwise fleeting observations that more closely align with type 1 thinking. This explains why big ideas often start small—on a napkin or note card. For instance, renowned screenwriter Aaron Sorkin came up with the plot for his first play (and subsequent screenplay), A Few Good Men, while working at a theater and jotting down his ideas on cocktail napkins over a period of several months. When Sorkin pieced them all together, he was able to write the entire movie plot. Note-taking provided a tangible way to build on prior thoughts and arrive at a novel idea. Although innovations are largely the result of individual work and willpower, whether they are useful depends on environmental factors. For instance, Rosalind Franklin was the first person to observe that DNA has a double-helix structure. However, a combination of institutional issues and illness prevented her from receiving credit until after her death. Nevertheless, her fastidious note-taking and photographs revealed that she was a keen observer and deserving of recognition for her discovery. Since then, technology has started to evolve more rapidly. Thus, ideas that seem like a fantasy now could be feasible soon. For example, Twitter founder Jack Dorsey first came up with the idea for his social media application while starting a company to dispatch taxis and emergency services online.8 He observed a gap in the market—he wanted people to be able to share not only their transportation status, but also their social status and instant messages by means of the Web. Although he did not have the skills, experience, or connections to develop and market his idea at the time, he wrote it down and returned to the idea years later when he was working at a different startup. With the support of investors and his team, he was able to build a platform that now has more than 145 million daily users. Nevertheless, it is important to note that Dorsey explored other entrepreneurial endeavors before the success of Twitter. Although he never abandoned his original idea, he was also willing to evaluate the potential of other innovations in the meantime. Willingness to Be Wrong Finally, a common trait of all astute observers is their willingness to consider alternative explanations or solutions. As humans are repeatedly exposed to environmental stimuli, they become cognitively habituated and establish expectations and assumptions. These expectations and assumptions are “frames.”9 For example, we expect birds to have two legs and wings—this is a frame that helps us avoid information overload whenever we see a bird. However, frames can prove constraining for innovators seeking novel approaches to a problem. If the physician John Snow had not challenged the widespread belief in nineteenth-century England that disease was spread by “miasma,” or bad air, he would not have discovered the waterborne nature of cholera.10 His willingness to accept alternative explanations for the spread of the disease led him to identify the Broad Street pump as the source of London’s cholera outbreak in 1854. All successful innovators participate in experimentation, which means that some ideas are destined to fail. As Edison famously claimed, “I have not failed. I’ve just found 10,000 ways that won’t work.” With each experimental failure, he observed phenomena that could lead him closer to a solution. OBSERVATION FROM A COLLECTIVE PERSPECTIVE The previous section discussed how observation at the individual level relies on the specific characteristics that distinguish excellent observers. At the collective level, the impact of observation is determined by scale and scope. For example, businesses benefit from observations conducted by teams, which provide comprehensive evaluations of consumer needs that can then be used to develop products. Private companies have also leveraged the power of group efforts by forming close relationships with research universities. Doing so broadens their knowledge base, increasing the ability to discover new inventions and recognize the potential of existing ones. Both examples use groups to overcome cognitive barriers and frames that are especially limiting for individuals. This section discusses the challenge posed by frames and the approaches companies have taken to overcome them. Although collective observation efforts are certainly not the only solution, they are powerful in addressing the issue of cognitive habituation. Empathic Design “Empathic design” is an innovative method that entails the observation of customers using products and services in their natural environment (Fig. 2).11 This direct observation enables designers to better understand consumer needs, including those of which the consumers themselves may be unaware.12 For example, consumers might articulate their desire for additional features through product customization. In contrast, an unarticulated detail might be the factor that triggers use of the product. Empathic design, however, is not simply limited to designers observing consumers. Designers are also encouraged to use products themselves. For example, Gillette women’s razors were developed by a female designer frustrated with using products designed for men. From a male perspective, the razor may have been perfectly functional, but a razor designed for facial hair did not necessarily meet female needs. This case illustrated the advantage of having diverse perspectives when working in groups.Fig. 2.: Empathic design process.To maximize the amount of information that can be observed, businesses using empathic design often use small teams of observers from a variety of different backgrounds.11 By introducing different perspectives, the constraints imposed by the frame of any individual observer can be overcome. It is important to note that varying perspectives are advantageous not only for gathering diverse observations, but also for reflection and analysis phases of empathic design. Once the important data have been collected, design teams share their findings with colleagues who did not participate in the observation phase. This provides even more perspectives on how to interpret the observed information. Studies have shown that groups serving as networks for the dissemination of information from diverse sources facilitate complex problem solving that would otherwise be difficult for innovators to accomplish on their own.13 Empathic design teams are such groups. Collaboration to Diversify Perspectives On a broader scale, collaborative relationships between university investigators and research and development groups at pharmaceutical companies have been demonstrated to increase both the speed at which inventions are discovered and the significance of these discoveries.14 The improvement in knowledge acquisition can be traced to the broader knowledge base that forms as a result of collaborative efforts. Ready access to scientific knowledge external to the firm may guide internal research processes, for example. The overall ability of companies to advantageously gather and use knowledge is defined by the concept of “absorptive capacity.”15 External relationships and other diverse sources of knowledge have the most positive effect on absorptive capacity when they are complementary,14 and joint research efforts between surgeons and medical device companies are examples of how establishing networks for complementary information exchange leads to innovation. Although surgeons and medical device designers may be constrained by their respective frames, collaborative efforts provide useful insights and help overcome the limitations to innovation. Much like empathic design teams rely on diverse member make up to expand their potential scope of observation, innovation in surgery may be encouraged by increasing diversity in areas such as gender and educational background.16 Furthermore, collaborating with external groups on joint research efforts will expand the knowledge base, both refining the innovative search and increasing the likelihood of discoveries. For both these avenues of improvement, it is important to note that exchange of knowledge and ideas is best accomplished when there is adequate cooperation and trust.17 At the Michigan Center for Hand Outcomes and Innovation Research, for example, the team is composed of members at various stages of their educational and professional careers. By giving due consideration to the observations and opinions of all members, a wider range of research and problems can be addressed. Cooperation and trust are also necessary when seeking opportunities for cross-disciplinary research. Experts in the direct observation of behavior, such as human-factors specialists and psychologists, have been involved in efforts assessing team performance and safety in the operating room.18,19 Although nonmedical professionals may initially be perceived as “outsiders,” establishing trust is vital for surgeons to take full advantage of the valuable observations they may provide.19 Actions to Enhance Observation Observation sets the foundation for creativity. Although environmental factors and opportunity are key ingredients in the pursuit of producing impactful innovations, individuals can actively improve their observation skills and steer the trajectory of their ideas. Specifically, innovators can hone their observation skills by cultivating diverse interests that enhance their ability to make analogies between disparate problems. In addition, individuals can leverage the power of writing things down to clarify their understanding and reiterate their goals. Innovators are also encouraged to consider alternative ideas and explanations for their observations. Finally, leaders can leverage the insights of their teams to foster more inclusive innovation.