Standardisation in paediatric medicine may have the unintended effect of stifling innovation. Thinking outside the box becomes even more important in low-income to middle-income countries like Pakistan, where a large paediatric population requires healthcare. In addition, there is always a lack of funds, making an innovative, low-cost and high impact solution all the more necessary. While regulation and formal research is an integral part of the process, the local synthesis of a solution must start with a creative idea. To address the dearth of avenues promoting lateral thinking relevant to biomedicine and healthcare among students and faculty, the Critical Creative Innovative Thinking forum was formed at the Aga Khan University in Karachi, Pakistan, by a group consisting of students and faculty in 2014. The primary objective of the forum was to provide an arena conducive to lateral thinking and to equip biomedical professionals with the skill set to enable and promote creativity and innovation. This paper seeks to outline those efforts and discuss their potential impact on paediatric care for resource-limited settings.
- Low Middle Income Countries
- Medical Innovation
- Narrative Medicine
- Paediatric Innovation
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- Low Middle Income Countries
- Medical Innovation
- Narrative Medicine
- Paediatric Innovation
Throughout medical training, ‘doing no harm’ is emphasised. All new interventions in medicine undergo (by necessity) a rigorous process before they become acceptable practice as early ideas can fail to yield anticipated benefits or even cause harm.1 However, standardisation, especially if accompanied by the elimination of any variation, runs the risk of stifling innovation.2 There is also evidence to indicate that changing behaviours—especially those of physicians—is challenging.3–5 In low-income to middle-income countries (LMICs), many innovations are the result of work undertaken elsewhere, and many of these ‘imported’ solutions require large amounts of financial and infrastructural funding. Improvisation (or adaptation), paired with sustainable business models, allow for more efficient use of limited resources and pre-existing frameworks.
There are several precedents for the adoption of this philosophy in LMICs. Uganda, for example, is participating in the Millennium Science Initiative, a collaborative effort with the World Bank that aims to build science capacity and encourage innovation by sponsoring partnerships between industry and research. Two universities, Makerere and Mbarara, are at the forefront of this programme, housing several incubators (an incubator being a centre specifically geared towards providing assistance, financial or otherwise, to innovations in their infancy of development).6
With regards to Pakistan, like most LMICs, its healthcare system is rife with problems. Poverty, combined with low healthcare literacy and governmental mismanagement, and a burgeoning population (fertility rate: 3.6 births per woman) contribute to additional strain on the scant resources of this country,7 8 making improvisation and creativity even more important.
Determining whether we have had an impact on promoting paediatric innovation in Pakistan is currently difficult to gauge; therefore, in the following sections, we simply aim to describe our experiences in trying to achieve the abovementioned goal.
Our experience of instilling creativity and innovation into paediatrics and child health in Pakistan
An important tool for innovation in medicine is looking beyond the doctor. It is imperative to involve not only all the stakeholders, ranging from the child and parents to the paediatric nurse, but people from other professions as well.9 While this idea is not new per se (participatory action research has a long history), it is still not being fully used in the academic medicine community of Pakistan. This paper focuses on the use of unconventional means of stakeholder inclusion to promote healthcare innovation.
In this context, a group of individuals (including faculty and students) at the Aga Khan University founded the Critical Creative Innovative Thinking (CCIT) forum to address what they saw as an acute lack of innovation in the Pakistani biomedical community. Funded by the host institution, the Aga Khan University, CCIT aimed to provide a forum for innovation and for adaptation of innovation to benefit and better suit Pakistani society. The forum’s mission is to promote biomedical and healthcare-related creative ideas and innovations in a manner that is non-hierarchical, transgenerational and interdisciplinary. Compared with other innovative arenas in the country such as Elaj Trust, which promotes welfare through social innovations, CCIT is, to our knowledge, the only group that specifically targets biomedical creativity and innovation. So far, the group has propagated its mission through three avenues: Ignite, Hackathon and Narrative Medicine. We discuss each one in turn below.
An Ignite presentation, much like its brethren the TED talk and PechaKucha, is a presentation format whose main purpose is to educate and inspire the audience by delivering a powerful idea in a very short period. Ignite presentations run for 5 min and are composed of 20 slides that autoforward every 15 s. Ignite is a public benefit corporation that supports Ignite events in more than 350 cities the world over.10 The traditional scientific presentation can be daunting for many, especially when there is a dearth of evidence to support a hypothesis (as is usually the case with an innovation). Thus, a lot of good ideas can be lost.11 Owing to the refreshing change to the detailed medical presentation it provides, it has become a regular fixture at medical conferences in the USA, with the Society of Academic Emergency Medicine holding their inaugural Ignite session in 2014 at their annual conference in Dallas.12
Studies on similar types of presenting have shown that such concise presentations offer many benefits: their social nature promotes quick peer-review, networking and the ability to be heard by professionals outside the field of medicine.13 An event like Ignite at the Aga Khan University Hospital was a natural fit for CCIT’s agenda to allow people from both medical and non-medical fields to present on any topic they were passionate about as long as they could link it to biomedicine. The success of the first event led to a further four Ignites in quick succession. Overall, as expected, students represented the largest cohort of ‘Igniters’—over half were enrolled in different professional training programmes, including medicine and nursing—followed by physicians and non-medical professionals (including an improvisational actor, a creativity specialist, founder of a Down syndrome support group, a model, a journalist and a neuroscientist, among others). Presenters essentially take what they are passionate about and link it to healthcare. For example, the improvisational actor talked about the synergy required in his acting troupe. This ability of knowing your teammates and predicting their moves can prove invaluable in the trauma bay of an emergency room, for example.
Encouraging outcomes were observed as a result of these presentations. Some ideas are discussed in detail below:
Emergency medicine protocol app: one presenter (a medical student at that time) talked about his own brainchild: an app that would use standardised evidence-based guidelines embedded in an interactive interface to guide paramedical staff in the stabilisation and treatment of patients with certain conditions. He conceived the idea first when he saw patients coming to Karachi (where the region’s tertiary care centres are situated) from villages hours away, having no place to stay, only to be asked to come back for a second visit after they were prescribed the necessary diagnostic tests on the first visit. What if a standardised mobile application can be used by the doctors in the villages to prescribe the necessary tests, saving the patients a trip? He later modified the idea to deal specifically with patients visiting the emergency room. The initial testing of the app will be on children presenting with respiratory distress to an emergency department in Pakistan. It will use standardised protocols such as the Clinical Respiratory Score and the WHO Integrated Management of Childhood Illnesses as guides to diagnose and treat respiratory distress in children. The advantage of using this application in Pakistan is that it can be used by general physicians in rural areas lacking paediatricians or emergency specialists. The application is currently under development, and a trial is planned next year.14 The full Ignite is available at https://www.facebook.com/CCITforum/videos/348163808717943/
Children’s books: a paediatric emergency physician talked about his work on a series of children’s’ books to promote health literacy. Whereas there is no shortage of such material in English, his work focused on catering to the Urdu-speaking community, it being the national language of Pakistan. The entire presentation is available for viewing at https://www.facebook.com/asad.i.mian/videos/10152463916191630/
Play therapy: a nursing student talked about using play therapy to make the whole hospital experience in Pakistan (inpatient or outpatient) less traumatic for the child. He talked of various methodologies of implementing this in LMIC paediatric care settings, all supported by recent literature and pertinent examples. The full presentation is available at https://www.facebook.com/CCITforum/videos/500742796793376/
Even though the 5 min Ignite is not enough to put forward a concrete solution, its aim is to do just enough to hone and share a conceptual understanding of the issue.15
Audience response (as gathered via feedback forms with Likert scale questions) was generally very positive. While this feedback is not to be taken as predictive of the presentations’ future impact, this semiquantitative assessment of the audience’s opinion gives us a good idea of the effectiveness of Ignite as a mode of biomedical communication.
Hackathons are integrative events, typically lasting several days, where people collaboratively ‘hack’ towards achieving viable solutions to existing problems. The acute need for hackathons is felt as technology is fast changing the way we see child health. The power of technology is still largely untapped and harnessing it can bring about dramatic changes in the health landscape. Hackathons can yield both disruptive and non-disruptive innovations. A disruptive innovation is one which completely reorders an already established system, such as the introduction of an electronic health record to replace a paper-based system. A non-disruptive innovation improves a process without removing it, such as a novel way to improve current efforts to reduce smoking in a community. The secret to the hackathon’s success lies in the multidisciplinary approach it promotes. Each participant, therefore, brings something new to the table, be it a businessman, medical professional, artist, designer, engineer, researcher, scientist and so on. An ideal hackathon would have equal representation from at least all the major professional disciplines mentioned above.16 In the pre-event phase, participants are advised not to attend the event with preconceived solutions and follow the organic process of problem solving leading to a solution. This results in all team members becoming principle stakeholders in any innovation developed during the hackathon.
Since 2010, when the US government held the first medical hackathon, their popularity has spread and numerous such hackathons have been held on five continents.17 There are several success stories that have come from such hackathons. Smart Scheduling and Pill Pack are two such examples. The former uses decision trees to predict patient appointment behaviour, which could prevent no-shows or double-bookings. Pill Pack offers drug delivery to the doorstep and helps in organising medications by dose and time. Both ventures are now successful commercial enterprises. In another example, a paediatrician from Uganda built an Augmented Infant Resuscitator in 2012 at a hackathon to improve infant resuscitation in resource-limited regions.18
However, most innovations at hackathons never make it to production and usually die with the hackathon. It is important to keep in mind that despite the promise and excitement surrounding the innovations, the journey from the hackathon to a fully marketable solution is a long one. Only so much can be done in a few days. To get the product to the market requires testing, traditional research, ethical review, market analysis and so on. That in no way undermines the value of these events, as failures and repetitions are part of the creative process. These failures can then be modified and built on by other innovators until a successful product is created. Such crowdsourcing initiatives hold many other advantages over traditional research methods as well. They lower the legal barriers that often ruin collaborations between institutions, innovators and companies; what usually takes months of legal back-and-forth can be accomplished in the span of a few days. This is because during the event, participants are not limited by job descriptions, processes or funding requirements.19 This in turn promotes open access to data. Researchers often sit on unpublished data for long periods of time. With hackathons, these databases become open to other innovators in the field.20
Hackathons are gaining a foothold as models for innovation in LMICs themselves. They have become annual features in India and Uganda and have proved so popular that they have attracted interest from outside the hosting institution as well. For example, at a hackathon in Bangalore, participants came from other cities in India and a hackathon at Makerere University in Uganda registered participants from neighbouring Nigeria as well. Over time, the applicant pool has increased, requiring organisers to have robust selection criteria. Promising ’hacks' from Uganda include a digital infusion monitor and control device, a wireless physiological monitor and an automatic surgical suction pump controller.9
In Pakistan, the first medical hackathon was held in March 2016 in Karachi by an organisation called the Elaj Trust. It was during this hackathon that an application called ‘Ambusolve’ was pitched to decrease the time required to dispatch an ambulance. This is vital in one of the world’s largest cities where traffic conditions are a huge hurdle to ambulances reaching anywhere on time.21 Another idea pitched at a different (non-medical) hackathon about the same time was DoctHers.22 In Pakistan, while 80% of medical graduates are female, only 25% end up practising due to sociocultural limitations.23 This solution harnesses the power of these ‘stay-at-home’ doctors by linking them to patients via video conferencing.
As detailed above, medical hackathons can be particularly beneficial for Pakistan and hence the first-ever medical hackathon at Aga Khan University (henceforth, referred to as Hack V.1.0) was a natural fit for CCIT to plan and execute.24 The goal of the two-and-a-half-day event was to bring together an interdisciplinary group of people to discuss shortcomings of emergency rooms, including but not restricted to paediatric emergency medical centres throughout Pakistan, and come up with sustainable and practical solutions. Of the participating body (‘hackers’), over half were students and female. Around two-thirds of the participants belonged to the 21- to 30-years age bracket. Participants came together from 19 different universities/companies, ensuring great diversity. Almost half of the participants were medical professionals, followed by 8% nurses. Businessmen, IT professionals and engineers weighed in at 4% representation each.
The hackathon brought forward a wide array of useful and interesting ideas to help paediatricians tackle day-to-day issues they might face in the emergency rooms. The winning ideas are listed below:
Breath Hacks Automated Bagger: In resource-limited settings, ventilators are a rare commodity. Patients who require urgent intubation to maintain their airway are manually bagged for hours on end waiting for a ventilator to become available. Furthermore, due to resource limitations and low staff count in paediatric medicine, not enough health professionals are available to bag the child. The parents of the child are the usual volunteers in such circumstances. Team Breath Hacks wished to change this by creating an artificial, cost-efficient, but sturdy automated ‘bagger’. By the end of the event, this team had made a working prototype of their idea, shown in figure 1, and their business model was deemed sustainable enough to be implemented in most hospital setups in Pakistan.
HistorER Card: Team HistorER wanted to improve on and automate the history-taking process of patients presenting to the emergency room, paediatric or otherwise. Their cost-effective idea: a Quick Response (QR) code on the medical health card of the patient. This card could immediately be scanned at any emergency department in Pakistan to give a concise proper history with just enough information needed to satisfy the medical professionals responsible and to dictate healthcare.
The JackED: ECGs of infants and children are usually compromised, owing to their restless nature. Team JackED introduced a new gown that aims to replace current hospital wear. It contains a removable flap on the front that can be customised in many ways. The ECG electrodes can be sewn into the flap, allowing for a tight fit and, consequently, accurate recordings. The final product was highlighted as being only minimally more expensive than the current gowns, allowing for sustainable mass production.
To watch the abovementioned winning presentations, please visit https://www.aku.edu/news/Pages/News_Details.aspx?nid=NEWS-000212
Feedback from the participants, through validated response forms, showed highly positive responses. For the vast majority, this was their first hackathon, and by the end of the event almost all of the participants stated they would recommend this event and would like to be part of the next hackathon.
Reflective writing through Narrative Medicine
Every healthcare professional has, at some point in time, had a clinical experience or an observation that has shaped the way they deal with their future patients. Many a time, this change is not for the best and holds potential to negatively affect the patient-doctor rapport. Due to the sheer number of patients that physicians see in a day, their empathic self runs its natural course and soon dies out. One of the better ways to facilitate physicians getting in touch with their humane side is through reading and writing.25 26
Keeping this background in mind, CCIT started a narrative medicine programme. Narrative medicine involves, but is not limited to, using narrations of experiences of illness.27 There is no limit to what one can write: events as they happened, opinions on them, feelings associated with certain incidents and so on. Reading and writing about patient encounters can serve to bridge the gap between the physician and the child’s attendants. It reminds healthcare givers that the child is a human being and deserves the same respect and care one would give to someone outside the clinical setting.28
Ever since the start of the narrative medicine programme, CCIT has blogged 26 narratives. More than two-thirds of the articles received through this initiative were paediatric oriented. Thirteen of those narratives were from faculty members currently involved in clinical work and three articles were from non-medical professionals, all wanting to discuss key aspects of healthcare and to vent their pain, anger or whichever emotion they wished to express through their writing (see box 1). Notably, 10 of those 26 blogs were written by medical students or fresh medical graduates; possibly due to recent and new exposure to the clinical setting, their writing expressed and portrayed the difficulties/experiences of transitioning from a medical student to a medical professional.
Quoted from ‘letting Ali Die’ available at http://anitinerantobserver.blogspot.com/
The tube came out without any resistance.
‘What resistance were you really expecting?’ I thought to myself. It wasn’t like the tube, though Ali’s lifeline, was tied to his trachea.
I then stopped his cardiac support medications and just observed him and his breathing. But then there was no breathing as there was no bagging. Yet his heart rate chugged along in the 70s (beats per minute), slow for a 10-month-old baby, but expected, given his critical condition. His oxygen saturation remained in the 90s initially, but then started dropping: 80s, 70s and then hung around there, as if providing company to the heart.
‘Give him a chance; he might live through this and what happens later is not really for you to worry about’, said one inner voice.
But I stood my ground and I quelled the urge to ‘re-tube’ him.
One of the most tangible outcomes of these narratives being ‘published’ was the involvement of the readers. With every shared story, readers and authors would engage in a discussion regarding the narrative and the feelings it planned to stir in its audience. This allowed for capacity building in budding medical and nursing students and potentially aided them in their identity formation, by enabling and inculcating empathy and improving the effectiveness of their care29 (see box 2).
Quoted from ‘Is he in the Emergency Room to sleep?’ available at http://anitinerantobserver.blogspot.com/
‘Is he in the Emergency Room to sleep?’ These words still resonate in my head. These words still affect me. They still cut deep into me and make me question the very basis of why I chose my profession. Times like these are when you understand the bitter truth of reality; of what medicine is. When I took the Hippocratic Oath 5 years ago, I had no idea. I had no idea of the position I was going to hold; of how many lives I was going to touch; of the power my white lab coat inherently held. I now understand.
Due to the hugely positive responses the narratives gathered on social media, team CCIT also held a narrative medicine workshop. Participants interacted with staunch advocates of narrative medicine and were mentored and, eventually, asked to do some expressive writing of their own to get in touch with their creative self. The feedback from this workshop was highly satisfactory.
Our experience as summarised in figure 2 shows that it can be quite a journey from a creative or an innovative thought to a working, sustainable solution. It is unlikely that ‘the next big thing’ will be invented/discovered at a CCIT event. Accepting this, CCIT only expects the initiatives to promote a zeitgeist of creativity and innovation. It intends to continue its efforts by expanding to Aga Khan University’s campuses and paediatric programmes in East Africa, by supporting ideas that are pitched at hackathons and by acting as consultant to hospital projects by providing creative/innovative input.
The authors acknowledge team Breath Hacks for graciously providing a photograph of the prototype. We would like to thank the Aga Khan University and Aga Khan University Hospital for sponsoring the endeavours mentioned in this article.
Contributors All authors equally contributed to this paper.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.