Sunday, November 16, 2014

Disrupting the UX design education space

A version of this post has been published as an interactions magazine blog post.

My teaching partner Mandy and I stood in silence looking around the room one last time in which magic had happened the preceding 10 weeks. We teach the UX Design immersive for General Assembly in San Francisco. 10 weeks, 5 days/week, 8 hours/day of teaching and learning, of intense, hard work, of struggle, of laughter, of transformation, of bonding that will last forever. Educational experiences don’t get any better than this.

The UX Design immersive is intended mostly for people wanting to make a career transition. Students make a huge commitment by signing up for the course, stopping whatever they were doing prior, and in some cases, traveling long distances to do one thing: to become a UX designer.

General Assembly is one of several new educational institutions that are slowly disrupting the higher education space. Jon Kolko has identified the following qualities shared by many of these institutions’ programs:
  1. they are short;
  2. they focus on skill acquisition;
  3. they produce a portfolio as evidence of mastery;
  4. they are taught by practitioners;
  5. they promote employment and career repositioning, rather than emphasizing the benefits of learning as an end in itself;
  6. they typically focus on "Richard Florida" type jobs and careers: the creative disciplines of software engineering, product design, advertising, marketing, and so-on.
As described by Jon:
“Students who graduate from these programs have a body of work that they can point to and say ‘I made those things.’ This makes it very easy to understand and judge the quality of the student, particularly from the standpoint of a recruiter or hiring manager.”
“These educators have a deep and intimate understanding of both the material that is being taught and the relevancy of that material to a job.”
Given the increasingly heard argument that academic programs are not producing the kinds of designers needed most by industry (see, for example, "On Design Education")… And given that 90% of UX Design immersive students secure jobs within 90 days of the end of their cohort... (I might be moderating a panel contrasting different institutional instructional models at the Interaction 15 Education Summit in February.)

What is it like teaching the UX Design immersive at General Assembly? To get a sense of this, read the interactions magazine blog post written earlier this year by our fellow UX Design immersive instructor in Los Angeles, Ashley Karr, entitled, “Why Teaching Tech Matters.” Also, Mandy and I might be conducting a mock classroom at the Interaction 15 Education Summit in February to give attendees a mini-experience of the immersive program.

—— o ——

Tears filled the room on the final day of the course. We all had put everything we had into the preceding 10 weeks, and we could not help but be emotional. We hope the magic will happen again when we teach the course again beginning in December. But it all will happen in a different space (a new campus opens tomorrow), and Mandy and I will be paired with other instructors instead of each other. 

I will miss the magic of Room 202 in the crazy, crowded 580 Howard Lofts with only one bathroom and no air conditioning, situated next to a noisy construction site; I will miss the magic of working closely with the amazing Mandy Messer; and I will miss the magic of getting to know a certain 21 special, fabulous people who are now new UX designers. 

But we will do it again, and we will try to do it even better.

(photo courtesy of Celso Rodrigues)

Thursday, May 22, 2014

Bringing together designers, ePatients, & medical personnel

A version of this post has been published as an interactions magazine blog post.

Back in 1989-1991, I served on the committee that founded BayCHI, the San Francisco Bay Area chapter of ACM SIGCHI. I became its first elected Chair and served as its first appointed Program Chair for 12 years. I also served as SIGCHI’s Local Chapters Chair for 5 years, supporting the founding and development of SIGCHI chapters around the world.

Much has happened since then. Perhaps of greatest significance were my horrific experiences with the U.S. healthcare system. My healthcare nightmare changed my life and has prompted me to focus on what can be done to dramatically redesign the healthcare system and the patient experience. Indeed, several of my interactions blog posts reflect that focus, with a large part of that focus being on changing the roles and relationships of and between patients and medical personnel and designers. You’ll see that in, for example, “Utilizing patients in the experience design process,” “Learning from ePatient( scholar)s,” “Are you trying to solve the right problem?,” “The importance of the social to achieving the personal,” and “No more worshiping at the altar of our cathedrals of business.” 

All this has led me to start a new local chapter, but this one is not of SIGCHI. This one is for a combination of ePatients, medical personnel, and designers. This one is for changing the healthcare system. This one is the first local chapter of Stanford Medicine X.

Topics/issues to be addressed by the chapter should be of interest to many interactions readers. They include the ePatient movement, peer-to-peer healthcare, other uses of social media in healthcare, human-centered healthcare design and innovation, doctors and patients as designers, the quantified self, patient and doctor engagement, empathy, healthcare technology, patient experiences of the healthcare system, and more. When Jon Kolko and I were the Editors-in-Chief of interactions, we published lots of articles that addressed this level of topics/issues. One of those was a cover story entitled, “Reframing health to embrace design of our own well-being.” (Somewhat coincidentally, two of the article’s authors made a presentation about the content of the article at a BayCHI meeting.)

If you reside anywhere in the San Francisco Bay Area and are interested in the topics/issues listed above, I invite you to join this new local chapter. If you know of others in the San Francisco Bay Area who you think might be interested, please let them know about the group as well.

The chapter is just starting. Indeed, our first meeting has not yet been scheduled, as I'm still seeking venue options (and sponsors). If you know of any venue (or sponsor) possibilities, please let me know.

It feels good to be getting back into the local chapter business. I hope you’ll check us out.

Tuesday, March 11, 2014

What serendipity is providing for me to read

A version of this appears as an interactions magazine blog post; a version was expected to appear as a "What are you reading?" article in an issue of interactions magazine, but it was deemed far too long for that.

My use of Twitter and my attending local professional events have had a big impact on what I'm reading. Indeed, both have increased my reading greatly.

Everyday I spend at least a few minutes on Twitter -- time which often surfaces an abundance of online reading riches. You can get a sense of what comprises this reading by taking a look at my tweet stream, since I often tweet or retweet about compelling readings I learn about via Twitter. A few recent examples:
  • The Unexpected Benefits of Rapid Prototyping -- In this Harvard Business Review blog post, Roger Martin (former Dean of the Rotman School of Management at the University of Toronto) describes how the process of rapid prototyping can improve the relationship between designers and their clients. Roger and a colleague wrote about the importance of designing this critical relationship in a piece published in interactions magazine when I was its Co-Editor-in-Chief. This blog post extends that article.
  • some of the blog posts written for interactions magazine -- Too few people know about these posts, as they are somewhat hidden away and don't all receive (individual) promotion via Twitter. But some are excellent. I've been most impressed by those authored by Jonathan Grudin (e.g., Metablog: The Decline of Discussion) and those authored by Aaron Marcus (e.g., My Apple was a Lemon). A guy named Richard Anderson occasionally has a couple of worthwhile things to say here as well. ;-)

             Essential, indeed.
Local events I attend sometimes feature authors of books, and sometimes those books are given away to attendees. I've been fortunate to have attended many events recently when that happened.

Lithium hosts a series of presentations by or conversations with noted authors about their books in San Francisco. Free books I received because of this series:
  • What's the Future of Business? Changing the Way Businesses Create Experiences -- This book by digital media analyst Brian Solis alerts businesses to the importance of designing experiences. I've found the book a bit challenging to read, but its message and words of guidance to businesses are important to experience designers.
  • Your Network is Your Net Worth: Unlock the Hidden Power of Connections for Wealth, Success, and Happiness in the Digital Age -- I think I'm pretty well-connected as it is, but I'm finding this book by Porter Gale to be of value. You might as well.
  • Crossing the Chasm (3rd edition) -- Attending Lithium's conversation with Geoffrey Moore about the updated edition of his classic book was well worth the time, as I suspect will be true of reading the book. I should have read the 1st or 2nd edition; now I can catch up.
I attend numerous events at Stanford University. A recent event there featured Don Norman talking about his new edition of The Design of Everyday Things. I loved the original (when it was entitled The Psychology of Everyday Things), and shortly after this event, Don sent a copy of the new edition to me. It included the kind inscription: "To Richard -- Friend, colleague, and the best moderator ever." (I've interviewed Don on stage several times, once transcribed for an interactions article; see also the partial transcript and video of the most recent interview, with Jon Kolko.) I'm looking forward to reading this new edition and to interviewing him on stage again.

Carbon Five hosts public events every so often in San Francisco. Authors of three books were featured recently (two of which were given away):
  • The Lean Entrepreneur: How Visionaries Create Products, Innovate with New Ventures, and Disrupt Markets -- Authors Brant Cooper and Patrick Vlaskovits join the many now touting lean in this book about starting or evolving businesses. This is a valuable read, given that designers are increasingly playing key roles in these activities.
  • Loyalty 3.0: How to Revolutionize Customer and Employee Engagement with Big Data and Gamification -- Here, Rajat Paharia, founder of Bunchball, offers a book that should be of great interest to experience designers. I've found the book to be too formulaic in structure and presentation, but...
  • Rise of the DEO: Leadership by Design -- The enjoyment of the on-stage interview of authors Maria Giudice and Christopher Ireland prompted me to purchase this book, which proved to also be too formulaic for my tastes. Yet, given the increasing importance of the presence of design-oriented leaders in executive offices...
At a recent event launching GfK's new UX San Francisco labs, Aga Bojko talked a bit about her new book, Eye Tracking the User Experience: A Practical Guide to Research. In addition to offering complementary copies of the book, this event offered some of the best port I've ever tasted, from three different vintners! Plus Arnie Lund spoke about user-centered innovation. An excellent event it was, plus the book looks excellent as well.

Always an excellent event is the (near) weekly local live broadcast of the radio show West Coast Live. Early during the show, audience volunteers operate an ancient maritime device known as the biospherical digital optical aquaphone, after which the volunteers receive a gift. Recently, that gift was a copy of the book, How to Fail at Almost Everything and Still Win Big: Kind of the Story of My Life -- a book by Scott Adams, who was once a guest on the show and is the creator of the Dilbert comic strip. I wasn't sure I'd read the book, but I've found it to be thoughtful, entertaining, and compelling. And given the current mantra in our business regarding the importance of failing often and quickly...

Neo, the employer of Jeff Gothelf, author of Lean UX: Applying Lean Principles to Improve User Experience, hosts a series of events on lean UX in San Francisco. I heard Jeff speak about lean UX just before the publication of his book last year, and at a recent event, Neo was handing out a few copies. I'm finding the book to be concise and a quick read -- an excellent supplement to Jeff's talk and the many articles and presentations I've seen on the topic.

Kim Erwin spoke about her new book, Communicating the New: Methods to Shape and Accelerate Innovation, at another recent event in San Francisco. Unfortunately (and surprisingly, given the tendency revealed above), she was not giving away copies of her book, but since her talk was terrific, I made the purchase. I'm glad I did -- an excellent book touting collaboration and participation.

One of the final two books I'll mention -- and I could mention more! -- was sent to me by UX designer Katie McCurdy, whom I first met at Stanford Medicine X 2012. Katie and I were both there as ePatient scholars, so she knew of my health(care) nightmare story and knew that I would want to read a similar story told by Susannah Cahalan in the gripping book, Brain on Fire: My Month of Madness. This book and a similar book entitled Brain Wreck: A patient's unrelenting journey to save her mind and restore her spirit by Becky Dennis say much about why and how the U.S. healthcare system needs to be redesigned. All experience designers working in healthcare need to read these books and the many patient stories like them that are available on the internet.

Is this a typical collection of reading material for someone working in the experience design (strategy) field? Probably not, but I kinda think it should be. Is this typically how people working in this field learn about and acquire their reading material? Again, probably not, particularly for those who don't live in a place like the San Francisco Bay Area. But I'm delighted with the mix of reading material I learn about and consume due to serendipity. Thank you to those I follow on Twitter, and thank you to those responsible for local professional events.

Friday, November 15, 2013

Utilizing patients in the experience design process

A version of this post has been published as an interactions magazine blog post.

Dave deBronkart (a.k.a. e-Patient Dave) is quite well-known for his assertion during a TED talk and at other times that patients are the most underutilized resource in healthcare. I think that underutilization extends to the healthcare and patient experience (re)design process. Part of the reason for this lies in some of the views of the roles patients can effectively play.

At Medicine X 2013, Sonny Vu ruffled some feathers when he said that, in his company's design process for wearable sensor products and services, they don't ask users what they need or want, but rather observe user behavior. Attending the conference was a large contingent of ePatients who have done a lot of work identifying what they need and want and then doing something about it [see my Learning from ePatient( scholar)s blog post]. In no time, Sonny was challenged by ePatients in the audience, and the controversy became a point of significant discussion among the ePatients after that session.

This is an issue that comes up often, and in my UX teaching, I share and contrast views that you do ask users what they need and want with views that you observe user behavior instead.

Can users know what they need? Can users know what will solve the problems they encounter? Many have argued that the answer is "no" and consequently choose to conduct no design research at all. However, others argue:


But what can you learn from spending time with users? User experience design researcher Catalina NaranjoBock tweeted a partial answer, echoing an assertion made by Sonny Vu:

Karen Holtzblatt has written often about this, but she goes further:
"Don't ask your customer what they need or want or like. People focus on doing their life. So if you ask them outright, people can't tell you what they do or what they want. It's not part of their consciousness to understand their own life activities."
Yet, in the world of patient experience, views such as Ann Becker-Schutte's are being expressed:

And in the experience design world, co-design -- the involvement of the user or customer in the design process as designers -- is increasing in popularity.

So how should one proceed?

IDEO's Dennis Boyle is among those who argue for the need to focus design research on edge cases:

John Hagel, co-chair of the Deloitte Center for Edge Innovation, makes a similar argument, stating that one should explore emerging innovations on the edge that are rising up to challenge the core. In a presentation I made at HxD 2013, I pointed out that those on the edge in the world of healthcare include participants in the quantified self movement, participants in peer-to-peer healthcare, and ePatients, three groups which overlap. Quantified self participants continually document aspects of their health and experience, peer-to-peer healthcare participants actively engage with other patients about their health and experience, and as stated by Leslie Kernisan, "...e-patients aren't like most patients. They're more motivated, more medically sophisticated, ..." One can argue that such behaviors and qualities make such people better able to know what they do or what they want or need.

But there is much to be learned from typical patients as well, and observational research might be particularly favored in such cases, though even typical patients have important insights to share. Fortunately, a trend is developing to both ask and observe, and to co-design. However, it is still the case that, whether you are talking about ePatients or most patients, patients continue to be the most underutilized resource in the badly needed redesign of healthcare and the patient experience.

Thursday, September 19, 2013

Learning from ePatient( scholar)s

A version of this post has been published as an interactions magazine blog post.

Increasingly, patients are making invaluable contributions to the redesign of our broken healthcare system and the patient experience. Designers working in healthcare should be aware of and leverage these contributions.

Among the facilitators of this is Medicine X, a fabulous conference held annually in September at Stanford University. As stated by the conference organizers:
"Medicine X aims to bring together the best and brightest doctors, patients, academics, and industry leaders to talk about emerging technologies and how best to improve healthcare." 
"We seek to empower patients and give them a louder voice in healthcare discussions." 
"...patients are a core set of stakeholders. Yet they typically haven't been meaningfully represented and engaged at academic medical conferences. We want to change that."
To fulfill this goal, Medicine X invites select ePatient scholar applicants to attend the conference and some ePatient scholars to participate in the conference organizational and planning process. What is an ePatient scholar?
"ePatient scholar: 1. A specialist and expert who is highly educated in his or her own medical conditions and who uses information technologies (e.g., Internet tools, social networks, self-tracking tools) in managing their health, learning from and teaching others. 2. (Stanford Medicine X ePatient scholar) An educator and role model for other patients and health care stakeholders."
A valuable contribution provided by all of the ePatient scholars (and many, many other patients) is the story of their patient experience. Many of these stories are gripping, documenting much of what is wrong with healthcare and suggesting fixes. Some stories can be found in blogs; some stories can be found in online patient communities. During Medicine X, some stories are shared on stage. An example is that provided by Britt Johnson (pictured nearby) at last year's conference; the video of Britt's talk is essential viewing.

EPatient scholars' patient experiences form the basis of and provide the motivation for many of their additional contributions.

Two misdiagnoses and the urgent implant of a cardiac defibrillator made Hugo Campos realize how crucial it is for patients to engage in healthcare decision making with clinicians. This has prompted Hugo to tirelessly advocate for the rights of patients with pacemakers and implantable defibrillators to gain electronic access to the data collected by their electronic devices. Difficulty obtaining all sorts of medical records has led many to join Hugo in the call of "Give us our damn data." 

Unable to get a satisfactory response from doctors to her multi-year digestive problems, Katie McCurdy (pictured nearby) applied her design skills to the construction of a visual timeline of her symptoms and medical history. Katie's hope was that this timeline would communicate much more and more effectively than medical records or her usually rushed oral description in a doctor's office, and she has had some success with it. Wouldn't it be nice if such visual timelines could be created by or for other patients?

Important input to such a timeline might come from Symple, an app developed by ePatient scholar Natasha Gajewski for tracking symptoms. Natasha built this app because of the difficulty she had tracking the symptoms of her rare autoimmune disease between doctor's office visits. Symple is now used by tens of thousands of patients around the world.

Sean Ahrens (pictured nearby) is among the ePatient scholars who have made valuable contributions to what is increasingly referred to as peer-to-peer healthcare. Because of his and others' similar health needs, Sean designed and developed, a social health network for patients with Crohn's, colitis, and other inflammatory bowel conditions. lets patients share and learn what treatments work for others, track their health, and meet others near them. As stated in a recent MIT Technology Review article:
"The site is at the vanguard of the growing 'e-patient' movement that is letting patients take control over their health decisions -- and behavior -- in ways that could fundamentally change the economics of health care."
Many ePatient scholars help patients connect in other ways. Tweetchats are particularly popular. Three-time cancer survivor Alicia Staley's weekly tweetchat for the breast cancer community (#BCSM) is perhaps the best known of these. Alicia started this tweetchat to combat the extreme isolation she experienced. (To get a better sense of the importance of such connecting, see Katie McCurdy's blog post, "On Speaking Up.")

ePatient scholars share their insights in multiple ways. The contributions of the most well-known ePatient, Dave deBronkart -- a.k.a. e-Patient Dave -- have included a TEDx talk and an ebook entitled, "Let Patients Help."

Many share their insights via blogs. Katie McCurdy's blog, referenced above, is filled with gems. See her recent analysis of the use of the term "patient engagement" for another great post. Carolyn Thomas's great blog includes a related post. Sarah Kucharski, founder of FMD (FirbroMuscular Dysplasia) Chat (and pictured nearby), is another excellent blog writer; her recent post on patient engagement provides important advice to designers of health apps.

Advice to designers is among the contributions I have made. As you might know from my interactions magazine blog posts alone, my writing and speaking on healthcare system and patient experience redesign have been focused, in part, on identifying what designers need to do in order to have maximum impact on that redesign. See, for example, "Are You Trying to Solve the Right Problem?," "What Designers Need to Know/Do to Help Transform Healthcare," "The Importance of the Social to Achieving the Personal," and the blog post you are now reading.

In short, there is much to learn from ePatient scholars, and you can learn more from and about most of those highlighted above as well as the other ePatient scholars attending Medicine X this year by accessing the 2013 ePatient ebook put together by the conference organizers. Use this ebook (and this blog post) as starting points to include the oft missing voice in the redesign of healthcare and the patient experience: that of the patient. Better yet: come meet us all at the conference September 27-29; we'll be happy to talk to you.

Monday, May 27, 2013

Are you trying to solve the right problem?

A version of this post appears as a blog post for interactions magazine.

I just looked through the variety of graphical depictions of the human-centered design process that I show to and discuss with my masters degree students during the first class of the semester. Sure enough, none of them includes a step often called reframing or a step that obviously includes reframing. Hmm... Does the design process followed by many fail to include that activity?

I think it does. Hence, I think many designers spend a lot of their time trying to solve the wrong problem.

This is not a good thing.

Fortunately, I've been increasingly running into references to the importance of reframing. At the recent Healthcare: Refactored conference, Aza Raskin argued that we are still solving the wrong problem in healthcare; a part of the solution: "reask the problem; reframe it." At the recent Healthcare Technology Forum Innovation conference, Gavin Newsom argued, "If you don't like the answer, ask a different question," and Dennis Boyle argued similarly but went further, "Ask whether you are solving the right problem; understand those whose problems you are trying to solve."

In a recent Fast Company Design post entitled, "How Reframing a Problem Unlocks Innovation," Tina Seelig describes different ways to accomplish reframing, including the way referenced by Dennis Boyle:
"At the Stanford, students are taught how to empathize with very different types of people, so that they can design products and experiences that match their specific needs. When you empathize, you are, essentially, changing your frame of reference by shifting your perspective to that of the other person. Instead of looking at a problem from your own point of view, you look at it from the point of view of your user. For example, if you are designing anything, from a lunch box to a lunar landing module, you soon discover that different people have very diverse desires and requirements. Students are taught how to uncover these needs by observing, listening, and interviewing and then pulling their insights together to paint a detailed picture from each user's point of view."
In his new book, "Interviewing Users: How to Uncover Compelling Insights," Steve Portigal extends Tina's words:
"interviewing customers is tremendous for driving reframes, which are crucial shifts in perspective that flip an initial problem on its head. These new frameworks (which come from rigorous analysis and synthesis of your data) are critical. They can point the way to significant, previously unrealized possibilities for design and innovation. Even if innovation isn't your goal, these frames also help you understand where (and why) your solutions will likely fail and where they will hopefully succeed."
When trying to solve "wicked" problems, (transformational) innovation often needs to be your goal. Hence, reframing is essential, as argued by Hugh Dubberly and others in an interactions magazine article entitled, "Reframing Health to Embrace Design of Our Own Well-being." In a BayCHI presentation of some of this material, Rajiv Mehta and Hugh argued that failure to reframe is why most healthcare apps developed to date have had only a modest impact.

Who is responsible for design might partly explain the frequent failure to reframe. Aza Raskin (see earlier reference) says "the problem in healthcare is that design is now mostly in the hands of medical gurus." Don Norman has argued that "engineers and MBAs are fantastic at solving problems, but they aren't any good at making sure it is the right problem."

Regardless, if "reframing the question" is "one of the most important principles in design" (as Tim Brown argued recently), then we should do a particularly good job of teaching it and making sure it is done. This includes including it in our graphical descriptions of the human-centered design process.

I know of at least two such graphics that include it. It is present -- if not called out explicitly -- in "Define" in the following process taught by the Stanford

And it appears explicitly on a poster I stumbled across recently at an event held at the Institute for Creative Integration:

Clearly, I need to add these two depictions to the collection that I share with my students.

Tuesday, May 21, 2013

The Final Class of the Semester

This post has been published as a cowbird story.

Midway through the class I was teaching -- the final class of the semester, I announced that it was time to take a break. Unexpectedly, no one moved. One student eventually left the room for a couple of minutes, but for the most part, the students remained engaged with each other, talking about their masters degree projects, the masters program, and their future plans. Some of us selected more to munch on of the treats students brought to the class. Students had brought treats to most every class of the semester, but this day, the treats were extra special, including those pictured (shh! don't tell any university officials!).

My teaching of this group had been evaluated by a university observer a few weeks earlier. Recorded observations included: "Class feels 'together.' Everyone on the same page. Students seem genuinely interested in helping each other. Activity was very group oriented. Class almost feels like a family." Today, the family didn't want to separate.

A bit more than an hour later, I wrapped up the class and announced that we were done. Again, no one moved. Ten minutes passed; twenty minutes passed; thirty minutes passed. The interaction continued, and some expressed how greatly they had enjoyed meeting and working together throughout the semester. The starting time of the next class that was to meet in the same room crept closer, but no one in the room wanted this class to end.

Eventually, after additional assurances that we would all remain connected, the students began to disengage. The semester may have finally reached its end, but the bonds of this academic family might very well endure.

Saturday, April 27, 2013

What designers need to know/do to help transform healthcare

A version of this post has been published as an interactions magazine blog post.

I've been immersing myself in all things focused in some way on dramatically changing the U.S. healthcare system and the patient experience. This has included attending lots of events. Last week, I attended the Health Technology Forum Innovation Conference. Two weeks ago, I attended the Second Annual Great Silicon Valley Oxford Union Debate focused on whether Silicon Valley innovation will solve the healthcare crisis. Near the end of March, I attended both a panel discussion about "Improving the Ethics and Practice of Medicine" and hxd (Healthcare Experience Design) 2013. ... (The list goes on and on.)

I've also been writing and speaking about this topic as well. Recent examples include the blog post I wrote for interactions in December entitled, "The Importance of the Social to Achieving the Personal" (in healthcare) and my presentation at hxd 2013 entitled, "Preventing Nightmare Patient Experiences Like Mine" (subtitled, "Avoiding 'Putting Lipstick on a Pig'").

As most agree, the U.S. healthcare system and patient experience are badly in need of disruptive innovation, a transformation, and/or a revolution. Hence, the subtitle of my hxd 2013 presentation implies that there are things (UX) designers need to be aware of or do (or not do) so that they can do more than only contribute to modest improvement of the status quo.

What are those things? The things I addressed in that presentation:
  1. too many designers are too enthralled with technology and too focused on digital user interfaces to have a great impact on transforming healthcare;
  2. human-centered design as often practiced is better suited for achieving incremental innovation instead of the disruptive innovation most needed -- Don Norman and Roberto Verganti have written a great essay about this;
  3. design research too often falls short of revealing the nature and dynamics of the socio-cultural models at play that need to change;
  4. design research too often focuses on common cases instead of the "edge" cases which can more identify or reveal emergent and needed innovation;
  5. essential to solving the "wicked problem" of healthcare is reframing it, something not all designers do adequately -- Hugh Dubberly and others addressed this particularly well in an interactions magazine cover story;
  6. designers need to get picky about the kinds of healthcare projects they work on.
(See the presentation for more on each item in the list.)

What would you add to this list? Is there anything in the list you question? Let's have a conversation. Please comment below or contact me via email at riander(at)well(dot)com.

And if you hear of any events you think I might be interested in attending...

Monday, January 28, 2013

On what holds UX back or propels UX forward in the workplace

A version of this post has been published as a blog post for interactions magazine.

Among the teaching that I've done: UX management courses and workshops via the University of California Extension, during conferences, and in companies. And a topic I have always addressed therein: what holds UX back and propels UX forward in the workplace -- or to put it another way, what increases and what decreases the influence of UX on the business.

Last month, Dan Rosenberg authored an interactions blog post in which he states that a root cause for a lack of UX leadership in business decisions relates to "how the typical types and methods of user research data we collect and communicate today have failed our most important leadership customer/partner/funding source, the corporate CEO." (Dan will be elaborating on this in the March+April 2013 issue of interactions.) In my courses and workshops, we identify all sorts of reasons UX isn't as influential as it might or should be, and we often do so in part via use of a simple "speedboat exercise" as I described in a UX Magazine article entitled, "What is Holding User Experience Back Where You Work?". (A variation of the exercise can be used to help identify what has propelled UX forward in workplaces.)

I've also often addressed this topic in my blog, sometimes referring to discussions that occurred during my management courses or during conference sessions. For example, course guest speaker John Armitage made the following point:
"There is only so much air in the room -- only so much budget, head-count, attention, and future potential in an organization. And people within the organization are struggling to acquire it -- struggling for power, influence, promotion, etc. whether because of ego or as a competitive move against threats of rivals. People will turn a blind eye to good ideas if they don't support their career and personal objectives. Hence, if user experience is perceived as a threat, and if they think they can stop it, they will, even if it hurts the company."
Guest speaker Jim Nieters addressed the role that the positioning of UX personnel in an organization plays:
"You want to work for an executive who buys-in to what you do. If that executive is in marketing, then that is where you should be positioned. If that executive is in engineering, then that is where you should be positioned. Specifically where you sit matters less than finding the executive who supports you the most. If the executive you work for has reservations about what you do and wants proof of its value, that is a sign that you might be working for the wrong person."
Organizational positioning and the type of user research conducted were two of the factors debated by a stellar panel of UX executives and managers I assembled for a CHI conference session entitled, "Moving User Experience into a Position of Corporate Influence: Whose Advice Really Works?".

We also addressed this topic in interactions articles published when I was the magazine's Co-Editor-in-Chief. For example, in "The Business of Customer Experience," Secil Watson described work done by her teams at Wells Fargo Bank:
"We championed customer experience broadly. We knew that product managers, engineers, and servicing staff were equally important partners in the success of each of our customer-experience efforts. Instead of owning and controlling the goal of creating positive customer experience, we shared our vision and our methods across the group. This was a grassroots effort that took a long time. We didn't do formal training across the group, nor did we mandate a new process. Instead, we created converts in every project we touched using our UCD methods. Having a flexible set of well-designed, easy-to-use UCD tools ... made the experience teams more credible and put us in the position of guiding the process of concept definition and design for our business partners."
Forming the centerpiece of their UCD toolkit: an extensive user research-based user task model. The influence of the use of these tools extended to project identification, project prioritization, business case development, and more.

I encourage managers to employ the speedboat exercise to prompt diagnosis and discussion in their own place of work. Also, peruse my blog posts and past issues of interactions for more on factors that impact the influence of UX. And give particular thought to the role user research might play; along these lines, look forward, with me, to what further Dan Rosenberg has to say in the March+April issue of interactions.

Friday, December 21, 2012

The importance of the social to achieving the personal

A version of this post has been published as a blog post for interactions magazine.

During a recent Sunday evening, I participated in the popular healthcare communications and social media (#hcsm) tweetchat. This weekly chat, started nearly 4 years ago, was the first regular hashtag healthcare chat on Twitter, but it is now only one of many. And many of this many bring together patients seeking help and support.

Twitter conversations are just one of an increasing number of patient uses of social media in healthcare. Some of these uses are described in The Multidimensional Role of Social Media in Healthcare published in the July+August 2011 issue of interactions. Among them are online patient communities such as and Such communities comprise a growing system of peer-to-peer healthcare which empowers patients in ways essential to a fully-functional healthcare system.

Earlier this month, Jane Sarasohn-Kahn referenced some of the benefits of health-focused communities:
"Social networking holds significant promise for engaging people in health and changing health behaviors. Two thirds of people try to change their health behavior each year; 50% do not sustain those behavior changes... When people connect with a social network of peers, though, commitment to behavior change is bolstered and supported..."
This would be key to the success of, for example, the American Heart Association's recently proposed use of social media as a weight-management tool for children.

This importance of the social to achieving the personal was one of the recurring themes of the Stanford Medicine X 2012 conference in September. Some examples: Pew Research Center's Susannah Fox referenced the integration of apps and a website with in-person support groups as the secret to the success of Weight Watchers; founder Sean Ahrens argued that the key motivator of use is that users' entries are status updates for all -- that users self-track for others, for sharing; IDEO's Dennis Boyle echoed this, stating that the quantified "us" is more motivating that the quantified "self"; and Ernesto Ramirez, a leading facilitator of the Quantified Self movement, argued that the "ourness" of data is what matters most -- that a word better than the word "empower" would be "emp-our-r." At a subsequent "The Future of Health" event in Palo Alto, Keas's Adam Bosworth spoke about the increasing importance of gamification to individuals' achieving healthy behavior, arguing that if you're not a part of a team, you won't sustain in the game.

Note that the social influences more than motivation. As pointed out by Stanford's BJ Fogg:

In short, people can often learn a great deal from others in social networks that is of direct relevance to achieving their personal goals and to triggering advisable behavior. Indeed, much of importance can often be learned. As Roni Zeiger puts it, "a well-functioning online patient community is a network of microexperts."

However, not all applaud such uses of social media. As Elizabeth Mynatt put it subtly in IT in Healthcare which appeared in the May+June 2011 issue of interactions, "online sites such as are causing a stir in the medical community."

Yet, things keep moving forward. Reports of the benefits of peer-to-peer healthcare are accumulating. Without a doubt, achieving the personal is often much too hard without the social.

Monday, April 30, 2012

A(nother) call to action regarding healthcare

A version of this article was published in UX Magazine earlier this month.

For years, I have been addressing how UX can move upstream to play a more substantive, stategic role in business. An example of this was my CHI 2007 panel entitled, "Moving UX into a position of corporate influence: Whose advice really works?" Another example was my Mx 2008 presentation emphasizing the challenges UX personnel face when attempting to move their work upstream.

Related challenges (and warnings) were emphasized more recently by Samantha Starmer and Greg Laugero.  Starmer argues:
"Given the current power of CX at the C-level, UX practitioners must step up our game, otherwise we will lose progress we have made to be more deeply involved in strategy beyond just performing usability services. We need to act now to be part of the broader CX solution. If we don't proactively collaborate across divisions and organizational structures, we will be stuck playing in the corner by ourselves. If we don't figure out how to manage partnerships with other departments in a collaborative, creative, customer focused way, the discipline of UX as we know it is at risk. CX management will take over."
"UX design has done a great job in the last decade of redefining (for the better) how we define requirements for products with digital UIs. There is no doubt about this. But this has come at a cost of upward mobility in our organizations. We're functional players that make tactical work more efficient. We're not strategic players that help our organizations transform themselves. The closer we look at UIs, the more pigeonholed we're likely to be.
...stepping up [to strategic challenges] may mean stepping out of our comfort zones. ...we can't go in waving deliverables -- our standard bulwark. We have to step out from behind our wireframes and prototypes and think strategically."
However, will such a strategic focus actually satisfy UX personnel who have so often complained of corporate marginalization? Jon Kolko argues that the answer will often be "no" since most are actually interested in doing work that is usually much more meaningful and socially impactful than found in most corporations and consultancies. Consequently, Kolko calls on designers to reject the confines of the short-term focused, often marketing-driven corporate world to become social entreprenuers so to get the opportunity to tackle some of the world's many "wicked problems."

One of those wicked problems: a U.S. healthcare system declared "broken" by speaker after speaker at Stanford's Medicine 2.0'11 conference. This declaration has been echoed by many, including Donald Berwick M.D., who oversaw Medicare and Medicaid until this past December:
"Health care is broken. ... We have set up a delivery system that is fragmented, unsafe, not patient-centered, full of waste, and unreliable. Despite the best efforts of the workforce, we built it wrong. It isn't built for modern times."
UX personnel have worked in the world of healthcare at the level of the UI for years. Yet, many medical UIs haven't benefited from the input of UX personnel and most of the thousands of healthcare apps available today are considered to have been designed for the wrong people, and it is not clear how many of them really work. Even if more apps were well-designed and did work, would that fix what is broken with healthcare? Jeff Benabio M.D. tweeted his opinion:

To put the problem in UX/CX terms, what is really needed is transformation of the healthcare customer experience -- i.e., what is often referred to as the "patient" experience. And what is truly needed is not "improvement," but "transformation" as captured by this graph from Forrester Research's Kerry Bodine.

Can UX personnel contribute to this transformation? As argued by Laugero (see above), not so long as UX personnel have an excessive UI focus.

A recent paper by Don Norman and Roberto Verganti is relevant. According to Norman and Verganti, human-centered design as practiced by most UX professionals can contribute to only incremental innovation -- "improvements" to existing products or services. Radical innovation (a.k.a. "transformation," to use the terminology used above), on the other hand (see the nearby figure), requires technology or meaning change, the second of which can be achieved only via the comprehension and change of the dynamics -- often subtle and unspoken -- of socio-cultural models at play. According to Norman and Verganti as well as Jon Kolko, the design research that is often a part of the human-centered design process typically doesn't reveal such dynamics. According to Norman and Verganti, the focus of design research is usually not on such meanings; according to Kolko, the amount of time typically alotted to design research is too short to allow for their discovery.

Kolko argues that participatory design -- the practice of designing with rather than designing for -- can provide the time via which adequate empathy can be built to reveal the deep, tacit knowledge holding "critical truths and assumptions about behavior, policies, norms, and values." But there are sometimes other sources of this information as well. Interestingly, in the field of healthcare, I've found TED talks to be a great source, and I've written about them (and other sources) in "In need of transformation: the patient experience." For example, four powerful TED talks disclose the great extent to which medicine is conducted in a culture of physician superiority (USC's Dave Logan), anti-creativity (Jay Parkinson M.D.), denial of mistakes (Brian Goldman M.D.), and treatment of diseases rather than of people (Abraham Verghese M.D.).

Some of these cultural characteristics are reflected subtly in the language of today's healthcare system, as pointed out by a group of designers led by Hugh Dubberly
"We call individuals 'patients.' We call physicians healthcare 'professionals' (HCPs). Professionals 'care for' patients -- by observing symptoms, diagnosing diseases, and proposing therapies. Their proposals are not just suggestions: they are prescriptions or literally 'physician orders.' Patients who don't take their medicine are not 'in compliance.'
In the relationship between HCPs and patients, HCPs dominate. HCPs do whatever is necessary, with patients playing a relatively passive role. In some ways, the system reduces patients to the status of children -- simply receiving treatment."
Dubberly et al., focusing on the level of meaning as described by Norman and Verganti, describe an alternative healthcare model of self-management that is contrasted with today's model in the nearby chart. (Such an alternative model is consistent with a growing "e-patient" movement supported by the new Society for Participatory Medicine working to achieve a time "in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners.")

Much more work along these lines is needed. As stated by rebel Jay Parkinson M.D.:
"Going to the doctor, having routine surgery, buying bulk medications online -- all could be radically reinvented with the application of one type of medicine: designed disruptive innovation. Combining the principles of disruptive innovation with design thinking is exactly what health care in America needs. We need to disrupt the current business model of health-care delivery. And we need these disruptions to be designed experiences that are consumer-focused."
Recently, Valerie Casey issued a call to action in a short article entitled, "Healthcare Innovation: Time for Design(ers)." Her call to action was largely one of encouraging designers to respond to four innovation challenges issued by large pharma companies and healthcare organizations.

In my view, UX designers can do more. Learn about the problematic healthcare cultural characteristics that dominate and that need to change. Alter how you do design research. Don't limit yourself to incremental innovation and work that is narrowly focused on UIs. Question the advisability of doing projects that, in essence, only amount to putting lipstick on the very large healthcare pig. Escape your comfort zones in order to have the kind of impact on the world that you desire.

If only it were a matter of the following:

Indeed, designers need to care.

Wednesday, March 21, 2012

An abundance of learning opportunities

Recently, a local friend asked me if I knew of someone I could recommend who would be a good mentor for her. After thinking a bit about who I might recommend, I came up with an answer she didn't expect: instead of seeking a conventional mentor, become active on Twitter and in LinkedIn groups. Via Twitter and LinkedIn, one can learn a great deal, including information about upcoming webinars, tweetchats, and in-person events -- often low cost or even free -- in which one can participate.

Before Twitter and LinkedIn existed, I contributed to the rise in number of in-person events as BayCHI's Program Chair for twelve years and as SIGCHI's Local Chaper Chair for five years. Today, BayCHI and other SIGCHI chapters around the world have lots of competition. Here in the San Francisco Bay Area, there is something going on of relevance to the fields I care about nearly every day.

I try to take advantage of this fact as much as possible. During the seven day period I'm in the middle of as I write this, I've got an evening design charrette (sponsored by the CCA MBA in Design Strategy), two daytime webinars, two evening talks (one via TEDxBayArea), a Creative Mornings San Francisco talk, and an afternoon design research "whiteboard" on my calendar. And then there are the many new blog entries and a couple of LinkedIn discussions that I'll be trying to keep up with...

Yes, I have other things going on in my life. Hence, I'll probably not make it to everything I have on my calendar (indeed, I've already missed one webinar), and I know for sure I'll fall further behind on the reading I'd like to do, but in today's quickly changing world, ongoing learning (and sharing) are vital activities.

I particularly value the longer participatory activities. The design charrette mentioned above focused on healthcare redesign, a topic of particular importance to me. Last month's two-day SF global service (design) jam and January's one-day Stanford bootcamp enabled me to work with people I wouldn't otherwise, rekindle old relationships and develop new ones, refresh and reenergize, and learn (and try out) a few approaches new to me.

And I'm even continuing to contribute to the list of local events, though less frequently than years ago. An example of this was my 2-hour interview of Don Norman and Jon Kolko on stage this past September at the Academy of Art University in San Francisco; a video of this event is available via YouTube.

During a time when our system of education is considered outdated and otherwise broken, taking and giving advantage of new learning opportunities is important. For a good book on this topic, see A New Culture of Learning: Cultivating the Imagination for a World of Constant Change by Douglas Thomas and John Seeley Brown; I received a copy of this book for free at a local presentation by the second author.

All of this might not completely supplant the guidance of a good mentor, but...

Wednesday, February 15, 2012

In need of transformation: the patient experience

Brenda Laurel, a highly-respected designer, researcher, writer, and currently chair of the Graduate Program in Design at California College of the Arts, had surgery last fall at the Stanford Medical Center. Brenda tweets infrequently, but here is what she tweeted following the surgery:

If you've read my "nightmare" blog, you know that Brenda's tweet would pale in comparison to the tweets I would author about my patient experience.

Were our experiences unusual? Sadly, no. After spending two days in the hospital last year with his young daughter who was undergoing some diagnostic tests, Alder Yarrow, a former colleague of mine, recounted his experience and concluded:

"Of all the industries we interact with regularly as consumers, the medical industry definitely defines the low point in quality and consistency of customer experience. Most of us emerge from interactions with the medical establishment feeling more like victims than paying customers."

Speaking of this lack of patient experience consistency, Dave deBronkart, a.k.a. e-Patient Dave (a full-time, empowered patient advocate), detailed "physicians' unwarranted variation in practice" which "has been shown to cause immense unnecessary surgery, with the resulting costs and inevitable percentage of errors and deaths after surgery that wasn't necessary in the first place."

Unnecessary deaths were addressed in a U.K. researcher's tweet in December:

According to leadership guru Steve Denning, "medical errors cause in the order of 100,000 deaths per year."

In a commencement address at Harvard Medical School last year, Atul Gawande M.D. said:

"Two million patients pick up infections in American hospitals, most because someone didn't follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge."

A recent study by the Department of Health & Human Services revealed that:

"One in four hospital patients are harmed by medical errors and infections, which translates to about 9 million people (in the U.S.) each year. ... Hospitals are doing a poor job of tracking preventable infections and medical errors and making the changes necessary to keep patients safe."

The author added, "...hospitals don't seem to give a damn about fixing things."

Jay Parkinson M.D., viewed as a rebel in the medical community, wrote about the experience of getting his dog properly diagnosed and treated when his dog was on death's door. He contrasted that experience, which he raved about, with the experience that most humans receive in the U.S.:

"the dominant experience for most unsafe and inhumane."

Donald Berwick M.D., who oversaw Medicare and Medicaid until this past December,went further:

"Health care is broken. ... We have set up a delivery system that is fragmented, unsafe, not patient-centered, full of waste, and unreliable. Despite the best efforts of the workforce, we built it wrong. It isn't built for modern times."

My patient experience was plagued from the get-go by a major misdiagnosis. So-called rare diseases -- diseases, including mine, that have been diagnosed in fewer than 200,000 people in the U.S. -- often take a long time to diagnose: greater than 5 years in many cases, according to the National Institutes of Health's Office of Rare Diseases Research (ORDR). Almost two decades were required to correctly diagnose the rare disease of a nurse I've met online who now devotes a lot of her time to educating the public about her particular disease which caused her to suffer multiple brain aneurysms.

Delayed and inaccurate diagnoses are two of several problems that tend to plague all victims of rare diseases. According to the Presdient & CEO of the National Office of Rare Disorders (NORD), other problems include difficulty finding an appropriate medical expert, few treatment options, lack of awareness and understanding of the patient's needs, and a sense of isolation. All of these were among the problems I experienced and to some extent continue to experience.

Should anyone ever need to experience those kinds of problems? My answer is, "no." Nor should anyone with any disease have to experience a healthcare system that is as broken as ours. The patient experience in the U.S. (and in many other countries) needs to be transformed. Not just improved, but transformed, as reflected in this graph from Kerry Bodine of Forrester Research. And fast -- as fast as possible.

What all contributes to such poor patient experiences?

Here is a subset of the contributors -- some of the systemic contributors, some of which overlap with others, and all of which contributed to my terrible patient experience.

Doctor arrogance

This contributor has been receiving a lot of attention in recent months. An article in The New York TImes last year started with these words:

"Doctors save lives, but they can sometimes be insufferable know-it-alls who bully nurses and do not listen to patients."

Jay Parkinson M.D. weighs in a lot on the topic of doctors being "insufferable know-it-alls." For example:

"Doctors have such a preoccupation with being right, they can't tolerate being wrong."

And the title of a report published a couple of days ago by the LA Times alone says a great deal: "Many doctors hide the truth about medical errors, study finds."

Because nurses are bullied so often by doctors, nurses more often than not do not have the courage to speak up when doctors make errors. A recent occurrence that got a lot attention in the press and on Twitter involved a doctor in Arizona who exploded with anger because a nurse corrected a patient's misunderstanding -- a misunderstanding caused by the doctor -- about treatment options. The doctor threatened to have the nurse fired and to have her license to practice revoked, and he successfully followed through on both threats. A report written by a nurse about this case stated the following:

"[the nurse's] story is one of an archaic medical model in which the doctor's word is supreme and we are all just nurse maids here to do their bidding. ... I'm really disgusted that a healthcare organization would bow to the tantrum of one very arrogant and immature physician. If there was one example of a surgeon with a God-Complex, this is one."

Not only are nurses afraid of doctors, so are patients. They often don't know when to talk and often fail to ask questions. According to Stanford's Abraham Verghese M.D., patients are interrupted when they do talk on an average of every 14 seconds. Verghese argues that the physical exam is a sacred ritual, one that doctors violate on almost every occasion.

Often, a patient's experience of his or her illness is critical information for an accurate diagnosis. As Paula Thornton put it in a recent discussion about patient experience in the Design Thinking LinkedIn group, "in the absence of a patient's story of the illness, you are practicing veterinary medicine."

Sadly, things don't always go well when patients insist on being heard. An example of such a case was when a doctor, in effect, fired a patient -- i.e., told her that she was no longer permitted to return -- when she asked to get a second medical opinion. It turned out that she was right to do so, as her first doctor's conclusions were wrong.

According to Stephen Wilkens M.P.H., an estimated two-thirds of physicians treat patients in a paternalistic way.

Lucien Engelen M.D., who heads an innovation center focused on the quest for participatory healthcare, put it this way:

"there is something very wrong with healthcare. At present it is mainly one-directional traffic. Doctors say that they talk to patients; perhaps so, but there isn't real negotiation with the patient. For a doctor, the patient too often is simply a disease that generated data on which they base their medical decisions. There is no real co-decision."

In a TED talk of last year, Jeff Benabio M.D. described the series of reinventions doctors underwent throughout history. Relatively recently, Jeff claimed, "we let our arrogance reinvent us ... we thought we were gods again."

USC's Dave Logan, in one of his TED talks, described the five stages that tribes -- groups of people -- go through:

  1. Life Sucks
  2. My Life Sucks
  3. I'm Great
  4. We're Great
  5. Life's Great

According to Dave, the problem with healthcare is that doctors are a stage 3 tribe -- people who most often talk in the terms of "I," "me," and "my." Stage 3 tribes are comprised of people who think that others should just shut up and do what they say.

Atul Gawande M.D., whom I referenced earlier, says that "We train, hire, and pay doctors to be cowboys."

In a TED talk, Dr. Brian Goldman M.D. argued that physicians live in a culture of denial, unwilling to admit to or talk about their mistakes.

"If I were to walk into a room filled with my colleagues and ask for their support right now and start to tell [stories of all the mistakes I've made], I probably wouldn't get through two of those stories before they would start to get really uncomfortable, somebody would crack a joke, they'd change the subject, and we would move on. ... That is the system that we have -- it is a complete denial of mistakes. ... [However,] errors [in medicine] are absolutely ubiquitous."

Wendy Levinson M.D. references yet another culprit in stating that "perverse incentives have contributed to physicians developing 'efficient styles' that squeeze out time to listen [to patients]..." However, perverse incentives are probably not alone responsible for this, as scores of empathy levels of young physicians correlate with patient outcomes better than any of medicine's traditional metrics.

I've tweeted very little about my patient experience, but one day I couldn't hold back:

This neurologist totally dismissed my recollection of what happened to me (to the extent that she permitted me to tell my story), claiming, for example, that the seizures that had me flopping all over the floor in a semi-consicous state must not have been seizures at all. According to her, they must have only been "muscle twitches."

As a doctor who tweets and blogs anonymously recently wrote:

"One of the worse maladies plaguing the medical field is piss-poor communication, and [my own] orthopedist has about the communication skills of a mentally-retarded clam."

A report from The Onion that weighs in on this topic is entitled, "Patient Referred to Physician Who Specializes in Giving A Shit":

"NORTH PLATTE, NE -- After visiting his primary care physician Tuesday with complaints of intense pain in his left leg, computer programmer Dan Fields was referred to a specialist who focuses on giving a shit. "I want to send you to someone who specializes in not dismissing you brusquely after three minutes," Dr. Paul Niles said as he hastily scrawled out a referral and pushed Fields to the door. "Dr. Lewis is really one of the best out there at regarding patients as actual human beings. If anyone's going to listen closely without resenting you for taking too much of his time, it's him."

Doctors do not think creatively

Jay Parkinson M.D. has written:

"Medical education and residency is pretty militaristic. You fall in line or you're out. Trust me, I've been there. If you are an 'outside the box' thinker, this doesn't last long in medical school or residency. The egos of your superiors are too threatened. This is an important fact. Doctors have such a preoccupation with being right, they can't tolerate being wrong. This is of course needed because who wants to go to a doctor known for being wrong all the time?"

And in both his TED talk and his Medicine 2.0'11 talk, Jay said:

"the medical culture is not only uncreative, it is anti-creative. ... Why should doctors be creative? ... Doctors only have pills and scalpels. ... Our reality is very different from an innovative, creative culture. ... We fall into line. ... Whenever we treat patients we treat them with algorithms. We regurgitate; we don't think creatively. We also have this thing called a god-complex... And we're just so frickin tired... And we're terrified of the law."

And they are terrified to fail board exams, as suggested by a recent news report about extensive cheating by doctors around the country taking an exam to become board certified in radiology. I mention this particular report because of the huge role radiologists played in my misdiagnosis.

As the representative of NORD tweeted during a tweetchat last summer:

According to James Howenstine M..D., "conventional medical practice in the United States largely ignores the possibility of parasitic disease" -- which is the disease that nailed me. He wrote that in 2004 but reiterated it in email to me last year. Parasitic disease is most associated with third-world countries where it isn't classified as "rare."

Doctors' dismissal of things patients learn via the internet

"You can't believe what you read on the internet," remains a common refrain among doctors -- a tribe of people who don't much care for their knowledge to be challenged. I've experienced this refrain repeatedly from multiple doctors, many making claims about my disease that my very careful research using the internet reveal to be completely false. "You simply must have not understood what you read," is the followup reaction when I present printouts of my research findings. This reaction is so common that even the few doctors who do use and know how to rely on the internet are afraid to say so:

High prevalence of medical personnel handoffs

Extending my earlier quote of Atul Gawande M.D.:

"We train, hire, and pay doctors to be cowboys. But it's pit crews people need."

However in healthcare, those pit crew members are usually separated by organizational boundaries:

"Patients experience healthcare horizontally -- with many individuals from many teams. Most breakdowns happen in the handoffs."

Some of the supportive data:

"In the past year, 42 percent of Americans reported coordination gaps related to medical records or tests, or communication failures between providers. A fourth said that their medical records or test results were not available during a scheduled visit or that tests were duplicated."

And this results in more than mistakes:

"Frequent handoffs in transitions of care, increasingly common today, make time to connect with patients even more challenging."

Other contributors exist, including difficulty finding and getting access to doctors with the needed expertise, which, as I mentioned earlier, is particularly hard for people suffering from a rare disease. And I've made only a veiled reference to the huge role played by insurance companies. However, I now turn from consideration of contributors to poor patient experiences to (potential) solutions.

What might be done to transform the patient experience given such contributors to poor patient experiences?

Here are some of the efforts that are in progress or that have been proposed.

Screening medical school applicants for people skills

Some medical schools have begun to use what is called a multiple mini interview, or M.M.I., as part of their admissions process to determine whether candidates have the social skills and the perspective needed by a good doctor. During the M.M.I. at one school, candidates are given eight minutes to discuss an ethical conundrum which they were presented with only two minutes earlier; this happens 26 times for each candidate, once for each of 26 ethical conundrums.

"Candidates who jump to improper conclusions, fail to listen or are overly opinionated fare poorly because such behavior undermines teams. Those who respond appropriately to the emotional tenor of the interviewer or ask for more information do well... because such tendencies are helpful not only with colleagues but also with patients.

Candidate scores on [the M.M.I.] have proved highly predictive of scores on medical licensing exams three to five years later that test doctors' decision-making, patient interactions and cultural competency."

At the time this article was published (July 2011), eight schools in the U.S. and 13 schools in Canada were using the M.M.I.

Teaching soft skills to medical students

Instead of or in addition to screening medical school applicants for social skills, how about training those who get into medical school? As Wendy Levinson M.D. stated in the Journal of the American Medical Association:

"medical schools and residency programs provide relatively little education about effective communication skills compared with the educational time devoted to teaching science and technology. Furthermore, medical students and residents are rarely observed during their interactions with patients or given specific feedback to improve their communication."

Here is one example of something that will be done along these lines as reported by CBS in Chicago this past October:

"A Chicago couple thinks a doctor's bedside manner is so important, they're giving the University of Chicago $42 million dollars to teach it. Matthew and Carolyn Bucksbaum are backing the Bucksbaum Institute for Clinical Excellence at the University of Chicago. It will be led by Dr. Mark Siegler -- who's been the couple's physician. They say he's the kind of doctor students should emulate. Carolyn Bucksbaum said the couple was motivated to make the donation after she once had a bad experience with an arrogant doctor who dismissed her illness."

Systems for patient rating of doctors & hospitals

Several efforts are underway beyond the use of Yelp to enable patients to rate doctors and hospitals. For example, there is a business in the U.K. called Patient Opinion which collects patient stories -- good or bad -- about experiences of U.K. health services and then passes those stories on to the right people so the stories can make a difference. Patients also have access to stories others have submitted.

There have been multiple calls for more systems of this nature (e.g., "Choosing a doctor should be like the Amazon shopping experience"). And several articles have been written arguing that patient complaints and poor ratings provide an opportunity for doctors and hospitals to improve (e.g., "Great hospitals permit patients to rip them to shreads").

Organizations devoted to achieving change

Two organizations of particular significance have been formed. One is the Society for Participatory Medicine (a.k.a. S4PM), a society that claims to be "bringing together e-patients and health care professionals," though it appears to have become mostly a voice for or of the patient community; S4PM says it is part of "a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners." The other organization, aimed more strongly at the medical community, is The Beryl Institute, billed as "the global community of practice and premier thought leader on improving the patient experience in healthcare." Oddly and unfortunately, neither organization appears to communicate with or know very much about the other.

There are a handful of other organizations with related missions, including the Center for Health Transformation, the Group Health Cooperative, and the Radboud Reshape & Innovation Center. And there are a few design consultancies focused largely if not entirely on healthcare; of these, "the future well" warrants special note, as it was co-founded by none other than Jay Parkinson, the rebel M.D. whom I've referenced above a couple of times and will reference yet again below.

Online patient communities

A major development has been an increase in the number and sophistication of online communities designed to provide support to patients and to enable patients to help each other. Notable examples include:, which spans a wide range of diseases;, developed by a patient with Crohn's disease; and Online communities have helped many to get the care they need to the point, in some cases, of saving people's lives; interestingly, one of the most publicized examples of this happened via the use of Facebook.

An article published this month in Forbes identifies and describes a few more of these online offerings. A comprehensive list is badly needed.

Convincing patients to change their ways via articles, blog postings, white papers, videos, webinars, workshops, tweetchats, talks, conferences, ... from enlightened/empowered/engaged patients

Several of the online communities just referenced provide this kind of help, along with the Society for Participatory Medicine. A large number of individuals are providing this kind of help as well.

Some of the articles and other forms of communication or interaction provide guidance for becoming e-patients; Tom Ferguson's 2007 seminal white paper entitled, "e-patients: how they can help us heal healthcare," and Fred Trotter's January 2012 blog posting entitled, "Epatients: The hacker of the healthcare world" are two examples.

e-Patient Dave's contributions, including his TED talk, are particularly well-known. Dave has recently begun to offer a series of e-Patient Boot Camps around the world. Additional patients, including myself, are also speaking out in various ways. A patient experience speakers bureau was launched just last month.

Convincing doctors to change their ways via articles, blog postings, white papers, videos, webinars, workshops, tweetchats, talks, conferences, ... from enlightened medical personnel

Doctors and other medical personnel are beginning to make contributions of this nature, some of which I've referenced above and some via the The Beryl Institute also referenced earlier. A popular blog offered by Kevin Pho M.D. features postings from a large number of medical personnel; many postings there are duplicates of postings that can be found elsewhere on the internet. Of course, since doctors aren't, on the whole, big users or fans of the internet, the reach of many of these offerings are somewhat limited.

Recent conferences of relevance include Medicine 2.0'11 held at the Stanford Medical Center, the Patient Experience: Empathy and Innovation Summit held at Cleveland Clinic, Transform 2011 held at the Mayo Clinic, and the ECRI Institute's 2011 Conference focused on Patient-Centeredness in Policy and Practice held in the offices of the U.S. Food & Drug Administration. The first three have 2012 versions upcoming. A conference that looks promising is Stanford Medicine X which will convene for the first time in September.

Some medical conferences have been criticized for failing to feature e-patient speakers or for not catering to potential e-patient attendees. A symbol was recently developed for use by conferences if patients have been adequately and appropriately considered and represented.

An interesting approach taken by NORD was the publication of an insert for a July 2011 issue of the Washington Post. NORD also sponsors an annual Rare Disease Day. However, potentially more helpful with respect to select rare diseases, including mine, was the 2011 publication of a book entitled, "Wicked Bugs: The Louse that Conquered Napoleon's Army and Other Diabolical Insects"; the author was interviewed on many television and radio programs including NPR's Fresh Air and KALW's West Coast Live. These publications, events, and programs were targeted at the public in addition to the medical community.

Employing alternative healthcare models

The most relevant change advocated is one in which healthcare becomes patient-centered. Such a model changes the role of the patient to, as referenced earlier, that of a driver rather than a passenger -- to that of someone medical personnel do things "for" rather than "to." As put by one M.D., "we need to treat our patients as people and not as disease states."

Jain and Rother have contrasted the views of patients as knights, knaves, and pawns:

"If a society conceived of patients as well-intentioned knights, it assumes that the will and values of patients should drive the structure and organization of health care... The role of policy and payment is mainly to empower patients and physicians working together toward shared aims; insurance coverage should make these interactions as facile as possible.

If a society conceives of patients as knaves, policy, management, and education efforts are designed to work against patients, not with them. Waste and even fraud are the behaviors that come most naturally to the knave -- and it is the role of physicians and health insurance companies to monitor for this behavior...

If societies conceive of patients as pawns, efforts are applied to building systems that ensure patients do what is right for themselves and for the health care system, because patients cannot be trusted to do so on their own accord.

...the patient in the United States today is seen either as a knave or a pawn and is seldom viewed as the knight. Patient-centeredness is lost in a tangle of insurance arrangements."

In spite of this dominant, negative perspective of the patient in the U.S. today, Jay Parkinson leveraged technology to develop a patient-centered practice:

"'...decades ago doctors served their neighborhoods, took cash, and didn't charge a lot because there was so little overhead. So I designed a process that went back to this model, looking at it from the patient's perspective, and just injected a little technology.'

With $1,500, he set up a house-call-only practice in his Brooklyn, New York, neighborhood, serving only two zip codes. He created a website through Applie's iWeb that featured his resume, and posted his schedule on a Google Calendar so patients could enter in an appointment time online.

He also opened a PayPal account for payments, and used Formstack to create forms for gathering patient medical histories and to create specific questionnaires for particular ailments.

Whereas most practices deal with significant costs in office management, Parkinson's start-up costs went to getting his license and buying tools, such as an otoscope and doctor's bag."

Though Parkinson's practice was solo, he used technology to consult with other experts if he needed additional insight. Indeed, a trend still in its infancy is to move medicine "from an individual to a team sport. Solo medical practices are disappearing. in their place, large health systems -- encouraged by new govenment policies -- are creating teams to provide care coordinated across disciplines. The strength of such teams often has more to do with communication that the technical competence of any one member."

The authors of The Innovator's Prescription contrasted a serial, solo approach with a team approach via the following story:

"A friend of ours has suffered from asthma for much of his life. Each specialist he saw seemed to have another possible remedy. It got to the point where he was taking multiple medications with multiple side effects, whose combined cost at one point exceeded $1,000 a month. Then he visited the National Jewish Medical and Research Center in Denver Colorado... a solution shop focused on pulmonary disease, particularly asthma... When our friend arrived, they administered a unique battery of tests, then assembled an allergist, a pulmonologist, and an ear, nose and throat specialist -- to meet together with him. They integrated their perspectives on his long medical history together with the test results, told him what was causing his symptoms, and prescribed a straightforward course of therapy that finally solved his problems."

Delightfully, designers have begun to address healthcare on this level. A team of designers headed by Hugh Dubberly wrote in interactions magazine about a healthcare model of self-management that is considerably patient-centered. The nearby table -- click to enlarge -- contrasts this model with the traditional model. The section at the bottom of the table reveals how the traditional focus for the designer changes as well.

And Jay Parkinson advocates the use of design to transform:

"Going to the doctor, having routine surgery, buying bulk medications online -- all could be radically reinvented with the application of one type of medicine: designed disruptive innovation. Combining the principles of disruptive innovation with design thinking is exactly what health care in America needs. We need to disrupt the current business model of health-care delivery. And we need these disruptions to be designed experiences that are consumer-focused."

Additional models have been proposed by designers, including a model described by Matthew Diamonti, UX Director at the Mayo Clinic -- a model based on the behavior of spiders rather than the current model that is based on the behavior of bees; I'll leave it to the reader to investigate the intriguing details of that proposal further.

Other efforts are underway or have been proposed, but I consider many of them -- such as improving the design of waiting rooms and billing doctors for time patients are forced to spend sitting in them beyond appointed meeting times -- too much about "putting lipstick on the pig." One additional significant effort underway is the replacement of paper patient records with electronic records; that huge effort has been plagued with all sorts of problems due in no minor part to designs that take into consideration the behavior and needs of neither the doctor nor the patient.

I've also made no reference to the growing number of medical apps and devices that have been developed to help people monitor their bodies and their behaviors. Though such apps and devices have received an enormous amount of attention and funding, I tend to agree with Jeff Benabio M.D. who has said:

A few days ago, David Shaywitz reported that a FutureMed extravaganza put on in Silicon Valley last week was not much more than "a celebration of technology for its own sake." And Jay Parkinson, focusing on body data tracking devices, has stated:

"I personally believe that body data tracking is just hype for many reasons. The amount of money these companies are raising is way out of proportion to actual benefit to society."

But controversy isn't new to Jay. When he began his web-facilitated, house call practice described above, Jay was investigated by the New York State Office of Professional Conduct.

"I knew I had plenty of haters given the heated debate in the medical blogs and news stories about my practice. I need to point out that I never once received any criticism from patients or the general public. The only criticism I've ever received came from within the medical community. So someone, somewhere called the state and complained...and given the online discussion I can only assume the complaint was made by a doctor."

The stage 3 tribe known as medical doctors has attempted to undercut other efforts as well. For example, some doctors now ask patients to sign "mutual privacy agreements" that transfer ownership of any public commentary the patients might write so that the doctors can censor their patient reviews if so desired. Of course, taking steps to have a nurse fired and lose her license to practice for educating a patient, as mentioned above, is another example of behavior against patient education and empowerment.

As I've written in my "nightmare" blog, I've made the committment to doing what I can so that others will not have to experience the kind of hell that I was forced to experience when dealing with the U.S. healthcare system. I appeal to all readers to get involved at least to the point of becoming an e-patient. I also ask you to share with me your ideas as to what else can be done -- what all I might do -- in the effort to meet that committment.

As an attendee of Health 2.0 San Francisco 2011 tweeted:

The time is ripe for a healthcare revolution -- an Occupy Healthcare movement -- a patient experience transformation. As Saul Kaplan stated in a Harvard Business Review blog:

"We need a new health care system that ... is designed for patients to champion their own pathways to wellness."

Everyone can play a role in achieving that change.


A duplicate of this posting appears in my "nightmare" blog.