Can Design Thinking Improve Health Care for Patients, Physicians?
Originally published in the AAFP Fresh Perspectives Blog on February 5, 2019
There we were, after hours -- me, an overzealous physician, and Paula, an extremely supportive medical assistant -- sitting in an empty office on a cold, sunlit Friday afternoon trying to "redesign gift giving." Our objective was to understand and improve the personal nature of giving and receiving gifts, which was the example used in a crash course on "design thinking"(dschool.stanford.edu) (a free online resource from Stanford's design school(dschool.stanford.edu)).
About six months after starting my first job out of residency, I was at the peak of adjusting to full-time physicianhood. Years of monthly rotations with ever-changing challenges meant that, for a while, I struggled to find creative and intellectual stimulus in the repetition of seeing patients every day.
During those six months, I experienced the learning curve of practicing medicine in the real world. I started to understand barriers to care, became frustrated with insurance and the limitations it imposed on my patients, and better understood how the medical system contributes to physician burnout. I read numerous articles about our broken health care system and the policies, regulations and innovations meant to alleviate symptoms of an increasingly complicated medical industrial complex.
After weeks of feeling boxed in by the vastness of the challenges my patients face, compounded by the inadequacy I felt in my own limitations as a physician, I came across a TEDx talk(www.youtube.com) by Joyce Lee, M.D., M.P.H.,(www.doctorasdesigner.com) where, as the mother of two children with severe allergies, she discussed her frustration with EpiPen's poorly designed caregiver instructions. Inspired by her Silicon Valley sabbatical, she and her 6-year-old son designed an informational video(www.youtube.com) to simplify complicated allergy action plans. In her talk, Dr. Lee also described the importance of patients as experts in their own experience of health, and how the innovation process in medicine is limited by a health care culture that prevents those without "appropriate credentials" from collaborating and creating solutions for systems-level issues.
As family physicians, we are all too aware of the detriments of siloed specialty care, or what happens when decision-making power is retained by administrators without medical training and experience. We're also suffering the consequences from a lack of input from physicians in the development of electronic health records. Similarly, developing health care solutions without establishing patient narratives and experiences as the cornerstone for the creative process seems dangerously inefficient.
There are a number of examples of poorly designed experiences in the primary care setting, the most damaging of which is the 15-minute patient visit, which often gives an insufficient amount of time to effect positive, health-focused behavioral change. Other examples include the design of the vaginal speculum,(www.wired.com) clinics that aren't designed for team-based care, and process-based problems such as long wait times(www.healthcaredesignmagazine.com) and missed medical appointments.(hbr.org)
In health care, we've realized the need for improvement. Residents are trained in quality improvement (QI),(www.stfm.org) many larger practices now give bonuses based on quality improvement projects, and we have programs,(www.ahrq.gov) conferences,(www.ihi.org) and curricula dedicated to QI.
However, unlike the QI paradigm of "Plan, Do, Study, Act,"(www.ihi.org) (the PDSA cycle), the design thinking process, as advocated by Dr. Lee, explicitly values empathy as the vehicle to define problems. The human narrative, therefore, is as important to the design process as are data and numbers. Additionally, design thinking is marketed as an egalitarian problem-solving approach, meaning that regardless of workplace hierarchy (rampant in medicine), anyone can design, prototype and test ways to improve products and processes.
The model is as follows:
Empathize: Understand what and for whom you are designing. In this phase of the process, it is important to listen openly and understand where problems lie.
Define: This can take a while to accomplish, as it is the crux of the design process. What exactly is the problem that you are trying to solve? Have you identified it correctly?
Ideate: Think outside the box; come up with all possible and impossible answers for your defined problem.
Prototype: Create an actual 3D representation of your solution. Use whatever materials you have and get creative!
Test: Go back to the users and the stakeholders to see if this is actually the solution to their problem. It may not be, or you may have defined the problem incorrectly. If so, start the cycle over.
In an attempt to learn the design thinking process through Stanford's crash course, Paula and I engaged in active listening and shared meaningful parts of our own individual experience of giving and receiving gifts, sometimes delving into our interpersonal relationships with others.
It reminded me of my own work with a diabetic patient whose A1c was at 11.0 percent for months. After many unsuccessful visits, we finally realized his barrier to short-acting insulin administration was a lack of consistent meal times. After more unsuccessful visits, we brainstormed a solution: I helped him create alarms on his phone to remind him when to eat and, subsequently, when to take his insulin. In three months, his A1c improved to 8.5 percent.
Admittedly, the design process is not always so easy, especially at the systems level. Even with this single patient, it took months of establishing empathy and mutual understanding to finally define a problem that lent itself to an easy solution. For larger-scale solutions, therefore, patience is a key factor in the design process. However, this example shows that design thinking is simply an extrapolation of the behavior change we already elicit from our patients on a daily basis.
So, does the design thinking process work when applied to health care? For the most part, yes, but as stated in the CDC's systematic review(www.cdc.gov) of 24 studies that used design thinking, there are understandable tensions between the needs and conveniences of the user (patient) and carrying out appropriate lifesaving and non-error-prone medical interventions.
Even so, a basic understanding of design thinking has shown me how to identify good vs. bad design. Now, when I look at bad design and inefficient systems, I see challenges that need to be detangled via empathy and understanding, instead of limitations to which I am confined. I find this optimism refreshing. After viscerally feeling overwhelmed by the nature of our health care system, that optimism alone is worth permanently keeping design thinking in my problem-solving toolbox.