Applying anthropology, design, and theory to medical education and medical practice

A version of this post has been published on Medium.

My nightmare experience with the healthcare system several years ago prompted me to commit to playing a role in fixing it. Among the things I’ve done since then are write and publish lots of articles and blogposts and speak at lots of events, telling about my nightmare, sharing similar stories of others, and addressing what designers need to know and do to increase their contribution to such a fix. Most recently, I did these things in the context of teaching a course at the Austin Center for Design, an educational institution focused on applying design and entrepreneurship in the space of large-scale “wicked problems.” Our broken healthcare system is one such wicked problem.

The course I’m referring to is an advanced theory course, but one during which we examined the relevance of theory to design and social entrepreneurial practice today. We addressed healthcare during two parts of the course: one focused on what limits what we can imagine, the other on the opportunities of entrepreneurship.

Some of what limits what can be imagined within the healthcare system is addressed very powerfully in “How Medicine Constructs its Objects,” a chapter in a book written by Dr. Byron Good. The chapter is one of the readings I assigned to students. In it, Good provides an anthropological perspective on Harvard Medical School education, describing how students learn “fundamental practices.” Here is a series of quotes I used in class to guide discussion of this chapter — notice the emphasis on objectifying the patient, the power of the write-up and of presenting patients, and the pressure to fall in line:

"Entry into the world of medicine is accomplished not only by learning the language and knowledge base of medicine, but by learning fundamental practices through which medical practitioners engage and formulate reality in a specifically “medical” way. These include specialized ways of seeing, writing, and speaking."

"Within the lifeworld of medicine, the body is newly constituted as a medical body, quite distinct from the bodies with which we interact in everyday life."

From a student:
"I would occasionally be walking along a street and find myself attending to anatomical features of persons I passed, rather than perceiving them as persons with social characteristics…"

"This reconstruction of the person is essential to a student becoming a competent physician."

"When first learning medical interviewing “I felt that it was a great privilege for me to hear some intimate details of their lives” and she would spend time listening to what patients wanted to talk about. By the fourth year, however, she said “you start to develop this sense of ‘well, I have a job to do here and I’m doing something for you, so I’m going to just do it as efficiently as I can.’"

From a student:
"You’re not there to just talk with people and learn about their lives and nurture them. You’re not there for that."

From a student:
"One thing about medicine I actually admire is [that] there really is an ideal of clarity…and [logical presentation]. The ideal write-up has sort of all the facts that argue in favor, and all the facts that argue against, and conclusions drawn from those… drawn together in sort of a summarizing formulation about what you think is going on and then a plan of attack. I mean, something is very satisfying about that. Of course the real world doesn’t lend itself to that, so you distort the real world a little bit to make it fit that nice pattern."

"Writing both reflects and shapes conversations with patients. It provides the categories and structures of those conversations, and it represents a structure of relevance that justifies the systematic discounting of the patient’s narrative."

"There is an enormous social science literature on doctor-patient communications. In our interviews, however, medical students indicate relatively little concern about this domain of talk. In part this is because it constitutes a surprisingly small amount of time. … But the medical students’ lack of concern about their conversations with patients is also a result of their perception that the central speech acts in medical practice are not interviewing patients but presenting patients."

"Doing case presentations is probably the main thing you concentrate on… for the medical student, their one chance to be in the lime light is when they present, and it’s also probably the area where you’re most likely to either gain the respect or the annoyance of your colleagues, and especially your superiors…"

"Students become quickly aware of the performance dimension. They rehearse presentations, learn to give them without notes, even to make up details if they do not remember them exactly, and are very aware of the response. If the performance is not successful, the team members start fidgeting, rolling their eyes, … And this is the single most important source for criticism or approval which students experience in the early stages of clinical training. “It’s not how much time you spend with your patients or how caring you are with them or how good a rapport you establish with them…”, but your presentation of cases.”"

Little surprise that humanizing the healthcare experience is considered by many to be healthcare’s number 1 need (see, for example, this recent interview of Dr. Bridget Duffy, former Chief Experience Officer at Cleveland Clinic).

A bit more from the Good chapter:

"Students have an awareness of the “conventionality and arbitrariness” of much of what they prescribe, true even of the most dangerous procedures; “They see treatments that have poor outcomes as well as those that provide benefit. They see some residents or attending physicians doing procedures they think should not be done or behaving miserably toward patients. At the same time, they recognize they are not senior enough to judge what should be done, and they feel deeply the pressure to show solidarity, not to question the actions of those up the hierarchy.”"

"The powerful have total control over your self-esteem."

One of the slides I used in class of relevance to all this, referencing Dr. Jay Parkinson’s TEDx talk:

An all-too-common example of how all this gets experienced by patients and their loved ones is powerfully reported in April Starr’s recent “Free ideas from a human-centered designer for hospitals that want to be (or make it seem like they are) patient-centric” (another of the readings I assigned to my students):

I had the recent misfortune of watching my husband in severe pain and as a result stay in the hospital for a week. As a human-centered designer, it’s hard for me to turn off my observational and ideation skills so I figured I’d channel my frustrations and provide some free consulting.

Some of her recommendations:

Fucking introduce yourself already. 

Who are you? You walk into the room and we don’t know your level, specialty, name, or role. Should we listen to you? What questions can we ask you? Who the fuck knows?

If you are too busy/self-important to introduce yourself, hand over a laminated sheet with a picture, name, and specialty like this: 

We will waste your time much less with our annoying, time-consuming questions if we know who you are.

Decouple decision making from communicating. 

Upon asking a simple question: who was in charge of my husband’s care, the head of a certain specialty (in front of all her silent and obedient resident ducklings) told me:

“We are like a five-wheeled car being driven by five drivers”.

I responded:

“Well, cars don’t have five wheels or five drivers for a reason.”

She then responded:

“Well, we all may argue but we come to one conclusion at the end of it.”

That wasn’t what I was asking. I wanted to know WHO we should listen to for the final word, not HOW they make decisions. Before this gaggle of 8 people entered the room without knocking, waking up my husband and sucking all the air out, a DIFFERENT group of 5 doctors do the same thing and give us DIFFERENT information. I simply wanted to know who to listen to. Just trying to understand what the fuck is going to happen with the person I’ve decided to share my life with who is in intense pain that’s all. NO BIG DEAL.

If they don’t want to have a hierarchy for decision making, fine. There should still be a designated point person for communication of next steps. Argue and make your decisions behind the scenes, and then send that decision off to ONE person who can come into the room and explain it clearly to the patient.

Decide which is more important to do in front of the patient: teaching or providing medical service. 

I understand and realize that residents shadowing doctors is an important way that they learn. However, their presence is disruptive. In one day, we had 5 different groups of residents and their arrogant leaders come by and wake my husband up to ask the same set of questions that have been documented in his chart (that 5-wheel car doctor seems to think everyone is reading).

If patients are in pain, had a rough night of sleep (all of this documented, RIGHT?) then give them a fucking break and pick on the other patients who slept better and are more in the 1–5 pain range.

Really understand why you became a doctor & adjust accordingly. 

Do you REALLY want to help people or do you like solving medical problems? If it’s the latter, maybe you should stay behind the scenes and let the people who are good at caregiving and communicating do what they are good at.

Ok, but you are still a control freak and want to stroke your ego by talking with the patient in front of all your resident minions? Fine, but then adjust your comunication style when you cross the threshold. Don’t use acronyms, don’t assume we understand medical terminology, let us speak occasionally…etc.

I also shared some of April’s subsequent tweets in class:

And, sadly, this one:

Three days ago, April published “MORE free ideas from a human-centered designer for hospitals.” It includes:

Humanize the medical case. 

My husband had had a rough night in the hospital. He had been up all night with with a lot of pain. In the morning when I arrived he had finally fallen asleep and I sat quietly in the corner. Unfortunately, it was 9am and rounds had started. I overheard our case being read outside the door “Male, age 42, presented with diarrhea, large mass on the left lobe of the liver…” I felt a knot form in my stomach and my blood start to boil but couldn’t figure out why I was so angry. They kept talking about him and I finally got up, opened the door and stood outside so they would know I could hear them talking about him. They didn’t stop talking when they saw me emerge from the door. I stood there for a few seconds, hoping someone would realize how rude and disruptive they were being. Eventually I blurted out (possibly not my finest moment) “My husband is resting. We can hear everything you are saying and it makes us feel like he’s a piece of meat. Can’t you talk about his case down the hall so we can’t hear you? Can’t you see in the files that it’s been 3 weeks since this started and it’s still very emotionally raw for us? Maybe skip over this one today. Or ask us first.” To his credit, the doctor was very apologetic while the residents just stared at me like I was a crazy person (you try watching a loved one deal with a painful medical condition without going crazy!).

There were obvious indicators in the data that this was a unique and emotionally charged situation. The doctors also didn’t realize or care. I think that if some personal, and not just medical, details had been highlighted in the case (for example: that he was healthy before all this — he had just had a full physical with no problems 2 weeks prior, he has a 6 year old son, loves to bike, and works as an innovation consultant, and that he still didn’t have a diagnosis) maybe the doctors and residents would have seen us as people, not just a medical oddity to be discussed openly in the hallway.

Teaching hospitals need to consider the impact these VERY different objectives (teaching residents and caring for patients) have on one another. There may be situations where it makes sense to blend activities and others that require a clear separation between them. One way to blend the two activities would be to humanize the medical case. Adding personal details can remind the doctors that these are real people, create a bridge between doctor and patient and encourage the doctors to treat people like people. It would also help patients potentially learn more about the medical side of things if they were a part of the conversation. However other times there should also be a clear separation of activities: when teaching residents, talk about the medical cases (especially sensitive ones) BEFORE you walk to the hospital room. Don’t talk about “the case” in front of them like they aren’t there. Duh.

In class, I also shared a handful of the many thousands of stories of patients experiencing medical misdiagnosis. In “Brain on Fire: My Month of Madness,” Susannah Cahalan, whose misdiagnosis was similar to mine, writes: “we live in a time when the rate of misdiagnoses in the United States has shown no improvement since the 1930s.” According to some analyses, misdiagnoses and other “medical errors are the third most common cause of death in the United States.”

How can this be? Dr. Brian Goldman’s powerful TEDx talk, which I showed in class, details an important part of the answer as referenced on this slide:

In the more recent, “A physician experiences a medical error. Here’s her story,” Dr. Maja Castillo writes:

After my experience, several colleagues recounted cases of the same error at their institutions. How can a potentially lethal error happen again and again at different institutions without leading to a systemic change in medical practice? How can we not see the need for a universal system to record and analyze errors?

It will be no easy task to study medical errors. For too long our culture of blame has shrouded the subject in fear, guilt, and shame. Medical professionals are taught early on that they are dealing with people’s lives, and mistakes are unacceptable. Instead of learning how to assess and respond to errors we are taught to suppress and ignore, as happened in my situation. Our laws perpetuate this process by treating malpractice cases as the fault of single individuals instead of systemic failures. There is no safe space for medical professionals to openly discuss errors without fear of repercussions.

Three more slides I used referencing TEDx talks, referencing the concept of the god-complex:

(I showed the video of Dr. Jeff Benabio’s talk in class, since he describes how and why physicians have needed to reinvent themselves throughout history and how and why new technologies are requiring physicians to reinvent themselves again.)

Some take a wholistic view. As Stacey Chang recently wrote in another assigned reading, “Health Care — A Final Frontier for Design”:

The dysfunction of our modern health care system isn’t about failure of intention, but rather pursuit of siloed and sometimes conflicting priorities. The needs of clinicians haven’t always aligned with the needs of patients, and both are subject to the demands of payers and regulators, and the financial limitations and business strategy of the provider organization. When each party manipulates and adapts to meet its own needs without regard to the needs of the others, it creates the incoherent mess we call our health care “system.” Medical professionals are trapped in the episode-driven fee-for-service revenue machine that defines value by productivity rather than impact on the patient’s health. Patients are trapped in the 10-minute office visit, the formularies and preauthorizations that second-guess their physicians, and arbitrary limits on visits for physical therapy or psychotherapy that ignore their needs and their rate of progress. Patients bypass their doctor for the drugstore clinic, or just don’t bother until they’re really sick. Both clinicians and patients get lost regularly in the systems that surround them, be it EHRs that prioritize accounting or hospital campuses that haphazardly add spaces to accommodate new services or capabilities.

Chang, the Founding and Executive Director of the Design Institute for Health at the University of Texas at Austin, comments on the role design has played thus far in healthcare:

Design interventions in health care have tended to be piecemeal. They address specific aspects of the ecosystem — more friendly clinic experiences, easier-to-use medical devices, improved medication adherence, more effective care protocols — but don’t achieve the large-scale transformation that design has activated in other industries. 

At an Austin Forum I took my students to, Dr. Mini Kahlon of the Dell Medical School and Ed Park of athenahealth were critical of Silicon Valley’s role in this:

More from Chang, this time referencing new opportunities for design in medicine, particularly in the context of medical education:

The Design Institute for Health aspires to establish ways to achieve [large-scale] transformation through a new type of collaboration.

The governing principle is that patient and provider experiences are designed to produce a shared responsibility for the ultimate outcome, in a model that continuously learns and evolves.

To be fluent in these new models, students of medicine and other health professions need different training. At the Dell Medical School, students transition earlier than usual from classroom learning to clinical rotations in order to clear time in their second and third year, when they are taught design skills. (For example, students will learn how to conduct ethnographic inquiries to learn about the needs, pains, and motivations of clinical and social service providers in the community.) They apply those skills by identifying systemic health challenges in the community, conducting unconventional research, and then developing new solutions. The most compelling efforts are then incorporated into the strategic work of the medical school, turning students into allies of change, instead of just recipients of a traditional curriculum.

Underlying the new models is theory, as described in another assigned reading, “The Future of Health Care?”:

[Dean of the Dell Medical School, Clay] Johnston and others point to the theoretical work of Elizabeth Teisberg and Martin Harris, developing the Med School's "value-based" approach to health care systems: finding ways to produce and quantify better outcomes for patients. Teisberg is the author (with Michael Porter) of Redefining Health Care: Creating Value-Based Compe­ti­tion on Results (2006), a seminal work in the field, arguing that the profession and the industry must shift from the fee-for-service model that currently governs medical practice, hospital finances, and health insurance plans, to a value-based structure that measures and rewards health outcomes – and over time, by eliminating unnecessary and repetitive treatments, broadly reduces the cost of care. Teisberg, now a full professor and executive director of Dell's Value Institute for Health and Care, and colleague Scott Wallace summarize their approach in a recent article, "Four Steps Within Your Stride" (www.healthmanagement.org): measure outcomes; document "care paths" to determine best practices; use integrated teams of varied expertise across the patient's full cycle of care; design solutions that incorporate the direct experience of patients. Elsewhere, Teisberg summarizes the value-based goals: "Higher value opens the opportunity to enable better health for more people with the same resources."

Such a theory sets the stage for radical innovation, but some are wary of this theory, including Dr. Jay Parkinson whom I quoted earlier:

Even a faculty member at the Dell Medical School (Dr. Ted Held) expressed some doubts about it in response to a question from me at a recent event at which he was speaking.

But other attempts at shifting to a value-based approach have begun to bear fruit, and when coupled with design, great things are likely to happen.

Actually, lots of great things have started to happen, even in Silicon Valley, where Stanford’s Medicine X initiative, with which I’ve been involved as a design advisor, speaker, workshop facilitator, ePatient scholar, and event organizer, has done much to spearhead co-design with patients and, as Dr. Bryan Vartabedian puts it, “the rise of medicine’s creative class”: “there’s an unexplainable high to seeing 400 years of a stagnant profession turned over like rotting compost.” Last month, Medicine X held its first conference focused on medical education; Clay Johnston was a keynote speaker.

I’ve worked a bit with the Dell Medical School. Stacey Chang provided a design project for some of my User Experience Design Immersive students at General Assembly; I featured Chang at a Medicine X event I organized on the University of Texas campus; and I’ve worked on design (process) strategy with the head of a medical department there. Healthcare has been the focus of quite a bit of the work of my design strategy consultancy, OE Strategy.

For more information about the course referenced repeatedly above that I taught at the Austin Center for Design, see “Teaching Theory at AC4D.” There was more to the sections that addressed healthcare and much much more to the entire course. 

Lastly, consider following me on Twitter as I continually tweet about things happening in design and social entrepreneurship that are likely to impact the badly needed transformation of our system of healthcare.

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.

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With your permission, we might discuss it during our panel session at CHI 2009 in Boston (see "Figuring out the 'one thing' that will move UX into a position of strategic relevance" for more info).

Applying "design thinking" to, um, design

"The Omnibox is really great; thanks for coming up with that" said my friend Pam from Tuesday evening's BayCHI audience. "But what's up with the tabs? I've watched numerous people be confused by and just ignore them. Do people really use them?"

Pam, unknowingly sitting immediately behind the Firefox design team (Firefox also uses the tabs metaphor), was asking this of Google's Glen Murphy, who had just described the process of designing Google Chrome -- Google's new browser -- to a near capacity audience at PARC. Much of his description had been focused on the meticulous process of designing Chrome's tabs. But why tabs? Glen had said that the team had settled on use of the tab metaphor very quickly, emphasizing that it just seemed right to everybody. What other options were explored and considered?

Glen had repeatedly stressed the value of user research during the design process, saying that he couldn't overstate the importance of the many "cognitive walkthroughs, lab usability tests, and longitudinal studies" that were conducted. But did the team generate and seriously explore and test many concepts other than tabs?

Doing so is often an important part of a good design process, certainly one of relevance to the design of Google Chrome. Indeed, it reflects an application of "design thinking," something I've written about in previous posts (e.g., "Crummy innovation") and in interactions magazine (e.g., "On Addressing Wicked Problems..."). Business professionals are hearing lots these days about the importance of applying design thinking to business decision making -- a process typically dominated by analytical thinking.

But another good time to apply design thinking is, um, during product design.

Note that I'm certainly NOT claiming that it wasn't applied during the design of Google Chrome. For all I know, lots of concepts other than tabs were generated and explored. I should have asked. But I do know that the generation and exploration of multiple design concepts happens much too little in many engineering-centric companies.

I did ask a question of Glen. However, my question focused on the role product management played during this project. Glen had stated that the Chrome team was comprised of people from engineering, user experience, and product management (though he was not permitted to reveal how many from each). Glen had also stressed the importance of the close relationship that was maintained among engineers, designers, and users throughout the project (see his slide to the right); for example, the engineers observed every user study conducted by user research personnel -- something which is, indeed, probably still far from the norm. I wanted to know what product management was doing during the project, since it didn't appear to be represented in that important slide (though I would tend to want to see it there).

Glen had also emphasized the importance of the interchangeability of roles at Google, saying this was his first project in the role of designer at Google, having been in the role of engineer on previous projects. According to Glen, this interchangeability facilitated the important closeness of the relationship between designers and engineers.

But one can be in the role of designer without extensively applying "design thinking," which, again, I say WITHOUT implying that was true in this case. But when it is true or is likely to be true, there are things that can be done to increase its application.

At the recent CanUX workshop (which I didn't attend), Jerome Ryckborst presented an approach he developed for use in the company at which he works. Here is what Jerome said about this on the Vancouver User Experience discussion list in September:

"Over a year ago, our CTO decided we would not hire a designer to support our 100 software developers, and declared that the UI was ultimately the responsibility of developers. The problem I saw with this: developers untrained in design believe they're designing their software, but they actually aren't doing things that designers would recognise as design activities. I took this as a challenge because I didn't want Usability to be the mop-and-bucket brigade at the end of the development process. I set out to improve the outcomes of our developers' design efforts. ... With the help of my colleagues and the ideas of various experts, we assembled, tested, and refined an ideation-design process specifically for software developers.

You, too, can learn and use this process."

Jerome's CanUX 2008 slides, which describe his process quite nicely, are presently accessible on the CanUX 2008 homepage. Labeled "Five-Sketches-or-Else," the process consists of a series of activities (some of which are iterated) which facilitate the generation and exploration of design concepts, preventing settling on a single concept much too quickly.

Also at CanUX 2008, Brandon Shauer talked about the sketchboarding technique I referenced recently in "Prototyping for tiny fingers." It, too, facilitates the generation and exploration of design concepts.

And there are other approaches that can be taken, some of which I've described in previous blog entries and where the best choice of an approach can depend on a variety of factors. But common to these approaches is facilitation of the approaches by "UX" personnel. As I've argued often (see, for example, "Soft skills"), UX personnel need to be able to play the role of facilitator of a good research and design process involving non-UX personnel as much as if not more so than doing the research and/or design themselves.

Is "design thinking" being applied during the product (or service) design process where you work? If you need some help with this, give me a holler.

On facilitating a jury's deliberations, and more

As I've described in past blog posts, I love to facilitate group sessions of all sorts of types. Earlier this week, I found myself in the unusual position of facilitating a very important group session in a building designed by none other than Frank Lloyd Wright and in the role of jury foreman.

I've served on a jury before, but never as a jury foreman. And I hesitated a little bit when my fellow jurors quickly asked me to be their foreman (or presiding juror, as they are sometimes called here in the U.S.), because the task before us -- placing monetary value on the plaintiff's past and future medical expenses, past and future loss of income, and past and future "pain and suffering" was going to be challenging, even more challenging than we all knew at the time of making this initial decision. But it was because it was going to be challenging, and because I knew of the importance of a good facilitator to this process, that I agreed to take on the role. And I'm glad I did so. Our work was intense, with lots of differing viewpoints among the jurors, but we finished our job in a single day, much to the surprise of us all.

I learned a lot during this trial, particularly about the spine and spinal surgery and various approaches to pain management. My university human anatomy and physiology instructors of years ago were pitiful in comparison to the lawyers and surgeons and other medical experts we heard from over a two week period.

But there were things that happened during the trial that were very dumb. Perhaps I should say that there were things that should have happened during the trial that didn't, and possibly never would in this type of judicial system.

One of the problems was that we, the jurors, were not permitted to ask questions of the witnesses. Of course, we didn't expect to be able to ask questions of the witnesses. But most of us wanted to be able to do so, as there were questions that needed to be asked that weren't, and questions that were answered in ways that were less than clear. Could a means be devised via which jurors could ask questions in a way that wouldn't create a big mess? I think so, but I won't dwell on this issue, since it is minor compared to others.

A bigger problem was that none of the reports prepared by the medical experts, the economists, and others documenting the process and results of medical exams, extensive and rather complicated present-day-value calculations, and more were made available to us during our deliberations. Those reports contained critical information on which we should have been basing some of our decisions, but our access to them was denied.

We watched as all of the reports were tagged as official exhibits during the trial. This led all of us to believe that we would have full access to these reports during our deliberations. However, as we learned at the start of those deliberations, none of the reports had been submitted as official evidence, and only official evidence was available to us in the jury room.

Now that would have been OK -- well, somewhat OK -- had we known this during the trial. Why did they not tell us this? We all would then have been much more diligent about writing down the contents of those reports, much of which had been fully displayed to us on a large screen or on large boards during the testimony of those who prepared the reports (not that we were given enough time to write down everything of importance, but...).

Some of the contents of those reports -- contents that were read aloud by witnesses -- were indirectly available to us in the jury room. Access to those contents required asking the judge to have a court reporter join us to read aloud from the court transcript as we listened in silence. But we were told that our requests had to be very precise; if a requested portion wasn't what we were looking for, we'd need to submit further requests to the judge, as we were not to be permitted to interact with the court reporter in order to help him or her find the information we saught. Plus, we observed witnesses misstating report contents on some occasions; would we remember when this happened and have access to the accurate information via a juror's notes?

An even bigger problem lied in the inability of certain witnesses to interact about the case either prior to or during the trial. For example, the surgeon testifying for the defense was not permitted to interact with the surgeons testifying for the plaintiff. In my opinion, they were all highly competent and well-intentioned doctors. Interaction among them would have enabled them to discuss some very critical uncertainties that could have clarified the picture considerably; indeed, I would have loved to have facilitated that discussion! Instead, it was argued that we should make our judgments about what kinds and numbers of surgery, pain injections, therapy sessions, and more would be needed by the plaintiff over the course of her life by deciding which doctor's credentials appeared to be superior, or how likely it would be that a doctor brought into the process late in the game could really know enough or be telling the truth, or some other equally poor basis.

And then it was all handed over to be decided by a jury of twelve -- all equally well-intentioned, but probably none of whom really wanted to be there, none of whom was adequately paid for being there (only $15/day plus mileage, compared to, for example, the $9000 one witness was paid for half a day), and none of whom had enough of the expertise that really should have been applied to making these decisions. I'm very proud of what the jury did, the process we used, etc. But might there be a better way?

What might that better way involve? Oh, how about working together more, avoiding hand-offs, enabling decision makers to participate (effectively) in the process, providing access to needed data and rationale, etc. -- all things I would recommend and have recommended to be a part of most companies' "user experience" practice, management, and organizational strategy. Are they no less applicable in the U.S. judicial system?

A major theme reflected in contents of our upcoming January+February 2009 issue of interactions magazine is the need for companies to change their ways. As we grow very close to electing a president of the United States seemingly intent on making fundamental changes to the ways things are done in Washington, D.C., perhaps it is appropriate to consider extending that intent outward to the ways things are done in our courtrooms, by insurance companies, by legal teams, and by those whose lives are changed forever negatively, but unintentionally, by others.

___

A couple of additional notes...

I was intrigued by differences between the two lawyers' use of "technology" during the trial. The defendant's lawyer kept it simple, sticking only with writing on flipchart paper and showing us tables from reports (yes, those reports we were not later permitted to see) printed onto large sheets of foamcore (though still often printed too small to be easily readable by the jury). The plaintiff's lawyer, on the other hand, projected computer displays onto a large screen. He zoomed, and he animated, usually quite effectively (though sometimes he could not get the zoom function to work as he wanted). For awhile, he even got away with displaying claims during witness testimony that were not being made by the witness (I was surprised at how long it took for the defendant's attorney to voice an objection, which the judge quickly sustained).

I was also struck by the extent to which practice and "academic" research appear to be intertwined in the medical profession, at least at the level of those who testified during the trial. Sadly, in the world of "user experience" and HCI, we have a situation where many practitioners belittle "academic" research and researchers, and many "academic" researchers belittle practice and practitioners.

Lastly, on Facebook, Matt Jones said that people would be put in the gaol in the U.K. for blogging about their experiences on a jury. Here, jurors are permitted to say as much or as little as they want to anyone about this stuff. Indeed, the lawyers were anxious to take advantage of this immediately after we were all dismissed. They even asked the judge to tell us they wanted to speak with us all, and they stood out in the hallway via which we would exit to intercept us before we could depart. I told them to look for my blog posting.

Eliminating noise and confusion

With lots to do -- often much too much to do and not always what would be most beneficial for them to do (as referenced in prior blog entries, including "Realities, dilemmas, framings, ..."), user experience personnel aren't always able to do their best work, which can make them and those with or for whom they are doing the work less than fully satisfied. Past blog entries have referred to some of the ways of dealing with this; recent blog entry suggestions include saying "no," improving soft skills, and offloading certain types or parts of the work to others.

But there are additional possibilities.

One of them -- which can come in all sorts of variations -- was described by Craig Peters during the User Experience Managers and Executives Speak course I offered this past spring. Craig founded and oversees the work at Awasu Design and was co-founder of Bolt | Peters.

Craig has discovered that even some of the best user experience organizations and personnel, and the organizations and personnel with or for whom they work, are continually experiencing a considerable amount of noise and confusion, which gets in the way of doing the best or most appropriate work.

User experience personnel have long expressed frustration with others' lack of understanding of and appreciation for them and their work, (potential) users, and/or the impact user experience can have on business success. This has prompted many to develop materials to be used as part of ongoing "evangelizing" efforts.

However, such efforts, while important, are usually not all that is needed. Noise and confusion often persist, in part because there are additional sources of noise and confusion, many of which are experienced by user experience personnel themselves.

Among these additional sources of noise and confusion:

• an inadequate understanding of the organizations for or with which you do your work;
• an inadequate understanding of the organization you are in;
• an inadequate understanding of the processes used by the organizations for or with which you do your work;
• lack of certainty regarding who is responsible for what;
• and lack of certainty regarding how to negotiate with and explain the work you'll be doing to those for or with whom you'll be working.

As explained by Craig, such noise and confusion leads to all sorts of problems, including:

• others' inconsistent experiences of user experience personnel and their work from project to project;
• work activity selections that are not the best for the situation;
• things falling through the cracks;
• scheduling and timing difficulties;
• unwanted creeping project scope;
• management needing to step in much too frequently to solve problems;
• designs that are not as good as they could be;
• and missed opportunities to do work that is particularly needed or particularly strategic.

All of these kinds of problems hinder critical working relationships and leave personnel feeling overwhelmed and unhappy.

Craig described the process followed to discover the nature and characteristics of such problems and to design their solutions in work done for Wells Fargo. And he described the nature of part of the solution developed for and with Wells Fargo personnel. At Wells Fargo, the core of the solution was a Customer Experience Lead program, complete with a guide and a collection of materials and tools to be used by whomever plays the role of Customer Experience Lead on a project. (Those materials and tools included organizational explanations, forms for a customer experience brief, numerous checklists, and numerous one-page explanations of customer experience work activities.) Additionally, a new stage was added to their user-centered design process, training was developed for Customer Experience Leads, and various personnel were designated owners of different components of the program, providing a mechanism for making improvements to the program going forward.

The program developed for Wells Fargo is receiving rave reviews. Wells Fargo's Secil Watson, SVP of Channel Strategy -- the organization which includes the Customer Experience group -- even recommended Craig and this type of work during her presentation at MX (Managing Experience) 2008.

What I think makes this kind of effort especially valuable is that it puts organizations in a much stronger position to address many other critical issues (see past blog entries for discussions of many examples of these) that the noise and confusion can cloud. And if done correctly, the process for identifying the nature and characteristics of such noise and confusion will begin to reveal the nature and characteristics of other critical issues, providing guidance for subsequent improvement efforts.

It is important to emphasize that the program developed for Wells Fargo will not be the solution for noise and confusion experienced elsewhere, whether involving an "internal" organization (akin to the organization in Wells Fargo) or an "external" agency. Certain components might be similar, but the program developed for Wells Fargo is working because it fits the way things work at Wells Fargo and addresses their specific needs. Things work very differently in different companies.

It is also important to emphasize the high quality of the customer experience (and related) personnel at Wells Fargo. For example, I've referenced and quoted Secil Watson repeatedly in this blog (see, for example, "Breaking silos"), and I invited her to write an article for my first issue of interactions magazine as Co-Editor-in-Chief (which she did -- see "The Business of Customer Experience: Lessons Learned at Wells Fargo"), because I think so highly of her approach. I've also referenced the excellent work done by other Wells Fargo management personnel in this blog (see, for example, "Developing user-centered tools for strategic business planning"). Highly capable and successful personnel are not immune from such noise and confusion or from the benefits of outside assistance regarding it or other important issues. And they recognize that.

Craig and I are now teaming up to offer such assistance. Give us a holler to learn more.

Roles and Relationships

In two of my most recent three blog entries, I argued that too much of the work done by user experience professionals ends up not being beneficial.

A good example of this was described last evening by TiVo's Margret Schmidt (VP of User Experience Design and Research, and pictured nearby) and Elissa Lee (Sr. Director of Research) during a presentation entitled, "Bringing the Spirit of the DVR to the Web: TiVo Launches a New tivo.com."

The abstract of that presentation:

"TiVo is often noted for its friendly TV experience. We recently launched a new version of tivo.com designed to bring that same simplicity and ease-of-use to our web presence. It took a close partnership between User Experience and Marketing, the right balance of internal and external design leadership, and a strong internal research team dedicated to continuous feedback in order to make the design a success. We'll discuss how we structured the project, the research techniques we used, and what we learned along the way."

The third sentence of that abstract -- italics added by me -- stands in sharp contrast to what happened during a redesign of tivo.com a year earlier -- a redesign that, even though built, was never launched. The slide to the left outlines some of the key reasons for that failure. In short, roles and relationships were all messed up, and TiVo executives, helped by results of post-design usability testing conducted by the internal research team, recognized that a launch of the redesigned site would be highly inadvisable.

Frustrated by this and related experiences, Margret went to Marketing and asked what she could do so that this kind of thing would not happen again. To her delight (and probable surprise), she was asked to lead the next attempt. More of what was new about the next attempt is outlined in the slide to the right. The timelines were still unrealistic, resulting in long hours locked away in a "war room" to get things done -- see those same two recent blog entries of mine about how user experience professionals are too often overwhelmed with work. And the nature of the involvement of and relationship with the external agency was still not ideal -- a problem so many companies experience. But this time, everyone bought into the vision and the approach, and the redesign was not a waste of time and effort.

One can argue that the failure of last year was necessary to enable the success of this year. Indeed, failures of such magnitude often create golden opportunities to make needed adjustments to roles and responsibilities (and process and ...). However, though often hard if not impossible (see, for example, "'There is only so much air in the room'"), do whatever you can to get the roles and relationships right from the start.

Audio and slides for "Moving UX into a position of corporate influence: Whose advice really works?"

Here are the slides from and the audio of my CHI 2007 conference session entitled, "Moving UX into a position of corporate influence: Whose advice really works?" Start the audio, then flip through the slides. (This is not ideal, but the SlideShare's synchronization tool defeated my attempt at synchronizing the audio with the slides).

For a sense of how the members of the panel repositioned themselves on stage during the session (which you'll be able to hear but not see), read "So, whose advice really works?"

View more presentations from Richard Anderson.

Participants (other than me):

• Jeremy Ashley, Vice President of Applications User Experience, Oracle
• Secil Tabli Watson, Senior Vice President Internet Channel Strategy, Wells Fargo
• Manfred Tscheligi, Director of the Center for Usability Research & Engineering, Wein Austria (representing Tobias Herrmann, Head of Team User Experience, mobilkom austria)
• Shauna Sampson Eves, Director of User Experience, Blue Shield of California
• Jim Nieters, Senior Manager User Experience Design, Cisco
• Justin Miller, Senior Director of Product for Europe, eBay
• a large audience in a large, spacious auditorium

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Photo by Pabini Gabriel-Petit.

"User Experience Managers and Executives Speak" update

I've been lining up some of the best San Francisco Bay Area managers and executives -- approximately 14 in total -- to appear during the unique course I'll soon be offering entitled, "User Experience Managers and Executives Speak." The course is being offered in Silicon Valley and will meet 7 consecutive Wednesday evenings from 13 February -- two weeks from today -- through 26 March, 2008.

Want to compare your challenges and approaches with those of managers and executives from a diverse collection of companies including well-known companies such as Google, Wells Fargo, Yahoo!, SAP, Autodesk, Kaiser Permanente, eBay, and Oracle, and several smaller and/or younger and/or less-known companies?

Come hear from and ask your questions of people such as:

• Secil Watson, SVP Internet Channel Strategy at Wells Fargo and author of a fabulous article in the January+February 2008 issue of interactions magazine entitled, "The Business of Customer Experience: Lessons Learned at Wells Fargo" (see also several of my blog entries, including "Breaking silos")

• Irene Au, Director User Experience at Google and former VP User Experience and Design at Yahoo!

• Christi Zuber, Director Innovation Consultancy at Kaiser Permanente's Sidney R. Garfield Healthcare Innovation Center

• Jeff Herman, Senior Director User Experience Design at eBay, author of "A Process for Creating the Business Case for User Experience Projects" and "Creating a System to Share User Experience Best Practices," and former designer at Apple

...and many others.

And share your own challenges and approaches as well.

Can you bypass such an opportunity?

The enrollment fee goes up tomorrow: $495 through January 30, but only $550 after that date.

More information, including a link to the registration site, is available on my website.

User Experience Managers and Executives Speak

I'll soon be offering a unique and exciting course via UCSC Extension in Silicon Valley entitled, "User Experience Managers and Executives Speak." The course is scheduled to meet 7 consecutive Wednesday evenings from 13 February through 26 March, 2008.

From the course description:

"How do user-experience managers and executives achieve success? What are their strategies? How do they approach the multitude of organizational challenges they face? What approaches do they recommend or avoid?

Receive answers to these questions from a wide range of user experience managers and executives from fields such as financial services, consumer electronics, health services, internet services, enterprise software, telecommunications, design services, and insurance, and who are or have been in such roles in companies of a wide range of sizes and at different stages of "user experience maturity." Ask your own questions of the weekly special guests (usually two guests each evening), share your answers, and begin to formulate or make adjustments to your own strategies and approaches.

Among the many guests slated to appear:

• Irene Au, Director User Experience at Google;
• Secil Watson, SVP Internet Channel Strategy at Wells Fargo;
• Klaus Kaasguard, VP Customer Insights at Yahoo!;
• Jeremy Ashley, VP Applications User Experience at Oracle;
• Jim Leftwich, Chief Experience Officer at SeeqPod;
• Mark Plakias, VP Strategy & Design at France Telecom Orange Labs.

This course is intended for those who presently are, or may in the future become, a user experience manager or executive. The course is also intended for other types of managers and executives who (will) work with user experience managers and executives and/or can impact how user experience is addressed and positioned in their companies.

After completing this course, participants will be able to more effectively:

• position user experience in their own companies;
• address their own organizational challenges;
• increase the influence user experience has in their companies;
• lead their own user experience groups or organizations, or work with such groups or organizations led by others."

Please pass on this information to any of your friends, colleagues, bosses, ... in the San Francisco Bay Area who you think might want to take advantage of this special offering.

The enrollment fee is only $495 through January 30; $550 after that date. You can register via the UCSC Extension website.

I'll be providing updates on the course in this blog as the course nears.

On the advisibility of estimating ROI

Much has been written about analyzing return on investment (ROI) in order for user experience to have influence in a corporate context. And as I detailed in "Calculating return on investment," some have argued that such analyses are and have been essential, while others have argued that dependence on ROI calculations can be and has been excessive and detrimental.

One of the examples I referenced in that blog entry was the major role estimating ROI had played at eBay for several years. Their process for creating the business case for user experience projects was described by Jeff Herman in a paper presented at CHI 2004 and again by Christian Rohrer in a presentation made in January 2007.

However, things have been changing at eBay.

You might have seen some hint of this in how President and CEO Meg Whitman recently described user experience as one of eBay's main strategic priorities.

What has been happening behind the scenes?

One of the changes made has been to how they address ROI.

eBay's Justin Miller talked about this during the session I led at CHI 2007 entitled, "Moving UX into a Position of Corporate Influence: Whose Advice Really Works?":

"At eBay, as Richard mentioned, we have changed significantly, but (not only regarding) user experience. As a company, we had much more demand than we had supply in terms of executing on projects, so we developed ROI calculations for every project that we wanted to do, whether it was user experience related or some other thing. We discussed not doing it for the user experience pieces, but we would have been the only ones not doing it and trying to make the case that we shouldn't need to do it. The fact is, the reason we are at the company -- the reason we've been hired and have grown our group significantly is to drive ROI -- to drive revenue, to drive value. So, we should be able to show that. We've had a lot of success, and we've presented and talked about it. I don't hold it against my company for saying you guys need to do it, because we were doing that for everyone.

Recently, however, we looked at those calculations -- we looked at what everyone had been presenting over the past years. After someone would present their ROI estimates, they would come back a year later and say "here is how we did..." We looked at the results and found that at least 90% of us came back and said, "we did great." But when we looked at the return that we should have gotten if every one of those projects actually delivered what they predicted, we learned that we would have 10 times the revenue of what we have today. We realized that looking at ROI on a project by project basis was not the right approach, whether it was the user experience or otherwise. We needed to be looking at the user experience and other things at a higher level.

So, now we are focused on the initiatives. We are not focused on the individual projects. What are we trying to go after? We are, for example, trying to increase conversion rate, so when a buyer looks at a listing when they come to a site, what percentage actually bid on an item? That is the kind of thing we are looking at -- at whether we able to move those metrics, not at whether a particular project moved the needle by some percentage. And that has had a huge impact and changed the morale of employees, focusing less on the details and the tactics, and focusing more on the big picture, because you can really understand that if you can generate a change at the high level, that has a big impact."

Hence, is estimating ROI advisable? Again, many respond with a blanket, "yes."

However...

So, whose advice really works?

Two weeks ago, I led a session during the CHI 2007 conference entitled, "Moving User Experience into a Position of Corporate Influence: Whose Advice Really Works?"

As I described in a preview, a major focus of the session was five means of -- according to many -- moving user experience into a position of corporate influence: documenting and evangelizing user experience work, owning the user experience, proper organizational positioning, calculating return on investment, and conducting "ethnographic" research. Indeed, according to many, each of these five means is critical to moving user experience into a position of corporate influence. However, one can find arguments against the use or importance of each means. Hence, of interest was which means played critical roles in moving user experience into a position of influence in the diverse mix of workplaces of six panelists, all in or having been in senior management positions via which they have moved user experience into a position of corporate influence.

During the session, I introduced each means, referencing arguments and evidence in support of the means, and referencing arguments and evidence to the contrary. Then, after the audience members proclaimed whether or not they believed that particular means was critical to moving user experience into a position of corporate influence, the six panelists moved to a location on stage reflecting whether or not the means played a critical role in their workplaces (see sample slide).

Note the dissimilarity of the configuration of the panelists in the two nearby photos showing their configuration for two of the five means. Indeed, there was a lot of movement on stage during the session. All six panelists were never together behind the same table, and different combinations of panelists were behind different tables (or "sitting on the fence" in the center) for all five means.

After moving into position for a means, panelists addressed how and/or why the means played or didn't play a critical role where they work.

So, what did the panelists say? Why is it that important words of advice regarding moving user experience into a position of corporate influence should be followed in some cases but not necessarily in all? When should one follow what advice?

The session, which received rave reviews, was recorded for addition to ACM's Digital Library, so you'll all have an opportunity to learn answers to those questions as provided by the panelists via that recording. I'll let you know when the recording becomes available.

However, you can find partial answers to these questions in previous entries in my blog, and I'll address the panelists' answers and the session further in upcoming entries. (I hear that a couple of other people might also be preparing online reports about the session.)

Justin Miller's final words during the panel provide some good overarching guidance. After referring to Jakob Nielsen's stages of corporate usability maturity as providing some good guidance regarding when to do what, Justin said:

"But the really important thing is referenced in the very last sentence of Jakob's article: 'Once you learn how to tickle the organization sufficiently to make it move, you can start planning for your next upgrade...' You have to know how to influence your own organization, because that is what is going to make you successful. And that is going to be different from organization to organization, and within the same organization, it is going to vary over time. So, you've got to be plugged into how to change and influence things where you work, ... and you've got to be sure that you have the right capability (to do that)."

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Justin Miller is Senior Director of Product -- Europe, eBay.

For a couple of my thoughts on Nielsen's stages of corporate usability maturity, see Changing the course or pace of a large ship.

Photos courtesy of Nancy Frishberg.