The dilemma of empathy in design

A version of this post has been published on Medium.

Can you be or get too close to a situation or group of people to design effectively for it or them? Or is being fully in that situation or group of people beneficial, perhaps even essential?

Don Norman and Roberto Verganti are among those who have argued that “the more that design researchers immerse themselves in the existing context, the more they ... are trapped within the current paradigms,” making it difficult to imagine, let alone design, a paradigm change when such might be needed.

Dan Saffer tells a relevant story:

About 10 years ago, I worked on a project for a new system for people with diabetes. We talked with many people who had diabetes or who helped educate diabetics. I even wore an insulin pump around for several days. In short, we were building up subject matter knowledge and empathy for the people we were designing for. During this user research phase many of us (myself included) started to have actual nightmares that we had diabetes. I remember once looking at my toes, wondering if the tingling I was feeling was the onset of diabetes. (It wasn’t — probably just my foot was asleep.) We’d empathized to the point where we really identified with diabetics and their problems, which are considerable. We had so much empathy for them, in fact, that for several weeks, we couldn’t solve the problem. It seemed intractable, given what we knew about the condition and the state of technology at the time.

But Emily Pilloton, in an article entitled, Depth Over Breadth: Designing For Impact Locally, and For The Long Haul, wrote:

For design within communities, we must genuinely identify with the community and consider ourselves part of it in order to produce solutions that are informed and long lasting in their impact. Through such empathy, our actions become inherently collective, making more permanent impact. This power of collective action was beautifully described in a 1994 white paper published by the South African Government’s Rural Development Program committee: “…The people must together shape their own future. Development is not about the delivery of goods to a passive citizenry. It is about active involvement and growing empowerment.” 

I am entirely convinced that our greatest successes have and will come from work that is local, deeply entrenched, long-term, and in our own backyards. I firmly believe that lasting impact requires all three of the following: proximity (simply being there, in the place you seek to design with and for), empathic investment (a personal and emotional stake in collective prosperity), and pervasiveness (…involvement that has impact at multiple scales).

On what was this view based?

(After more than a year) bouncing between projects, constantly having to shift gears between cities, user groups, research sets, prototypes, and team dynamics… we began working closely with a single school district: the Bertie County Schools in Eastern North Carolina. Bertie County is the poorest county in the state, with close to 80 percent of its school district’s students living in poverty. Since the partnership’s start (a year ago, we) have spent nearly half our time in Bertie, building educational playgrounds, designing new computer labs, rewriting entire curricula, and implementing countywide education campaigns. 

What we quickly discovered was that being there, as citizens, rather than just designers, was 80 percent of the battle. By becoming immersed in the community, cheering at high school basketball games, and weighing in at board meetings, we have earned the trust and partnership of the school district’s teachers, parents, and students, making our work more personal, appropriate, responsive, and meaningful. Gathering feedback from the community happens more smoothly, the ability to prototype and experiment with new ideas is more fluid, and a public understanding of our process has become more common. All the capacities required by the design process have become more natural through face-to-face engagement and open communication with the community, which of course, requires us to be there. 

Where wide-scale endeavors fall flat is in their cursory understanding and lack of long-lasting commitment to the communities they serve. It is only by becoming a member of a community… that we can truly understand the issues and produce sustainable and effective solutions.

Jon Kolko addresses part of this when he states in, Wicked Problems: Problems Worth Solving, “It may take weeks of observation to become aware of the intricacies of tacit knowledge in other people, which a short-term project-based approach to design doesn’t provide.”

And contributing to this is, as George Aye stated recently, the role of an imbalance of power between designers — who, when they “work on complex social sector issues, …often enter situations with power inherently given to them (even if they don’t realize it)” — and the “communities being served”:

For all the talk about being human-centered, one very human factor often gets overlooked — a basic understanding of how power operates in relationships between people. This lack of understanding by design(ers) results in wasted funding, poorly prioritized projects, and broken promises to the very communities that are being served.

Chelsea Hostetter, in an article with the title that I stole for this post, reveals that already being a part of the community to be served isn’t enough:

Alex and I were embedded into the trans and queer community of Austin, and it’s really hard when you’re part of the LGNTQ community and also talking with members of that community about their needs to not feel like you want to take action right then and there. There were a lot of emotions I felt around the research that was just difficult to process as a queer person myself. 

The Transgender Day of Remembrance is an event held for the community to remember the lives of the transgender victims of homicide with that year and to communally grieve. So throughout all of our interaction with the trans and queer community, the underlying ribbon we found is that somebody usually knows someone who has died whether through murder or through suicide. It’s tragic, and it’s awful, but that is the day to day of our community. As I was listening to the many names called out of lives lost that year, I started sobbing. Watching one person grieve is harrowing, but watching an entire community grieve, and feel connected to people you haven’t even met, is something that is completely, deeply, and soulfully impactful. At the time we dove really deep into the research but it struck a very deep, dear, personal chord with me. I previously considered myself a member of the queer community but through that research, I realized that I hadn’t been a good ally of the trans community like I previously thought. I didn’t have enough information or empathy to properly support our trans community then. 

I don’t think that (the app we designed for the queer community when we were students at the Austin Center for Design) would have worked in the state it was in (then) because I wasn’t as embedded in the queer community as I am today. I am now a regular member of several queer community meet-ups and work with an internal group at frog that promotes diversity and inclusion. I realize in my specific case, in order to be helpful and beneficial and really design for that community, you have to be embedded in it. In my current position within the community, I feel far more able to help people.

The following recent tweet and the top of the article it points to is of relevance…

…as is April Starr’s tweet which she composed shortly after she and her husband endured a terribly designed process of rounds by doctors and residents during her husband’s hospital stay:

[See her “Free ideas from a human-centered designer for hospitals that want to be (or make it seem like they are) patient-centric” and her “MORE free ideas from a human-centered designer for hospitals” for more.]

I’ve been marginalized professionally and through a health crisis and a healthcare nightmare (and as a result, a long stretch of homelessness). Does this make me better suited to design for diversity and for healthcare (and for the homeless) than designers without that experience? I think so; in fact, I think it even makes me better suited to work on other social issues of great complexity. [But does this mean I wouldn’t need to further connect with people in non-diverse, the healthcare, or the homelessness ecosystems and engage in or otherwise tap (additional) design research when designing for healthcare and for the homeless? Not at all.]

If one hasn’t had such experiences, is one ill-suited to work on such issues? I don’t think so. As Tina Seelig writes, everyone experiences “challenging character building opportunities” during one’s life that facilitate one’s ability to develop empathy for those whose character building opportunities are more challenging. And by embedding oneself in the community to be served as much as possible, as described by Emily Pilloton and Dan Saffer and Chelsea Hostetter…

Is all of this only of relevance when addressing “wicked problems” (i.e., social issues of great complexity)? 

And what of Norman and Verganti’s caution about becoming trapped by the current paradigms the more one immerses oneself within them? What can one do to not become trapped? Dan Saffer’s continuation of his story of developing too much empathy for diabetics:

It wasn’t until we were able to step away from the diabetics’ perspective and become less empathetic that we were able to come up with a product concept. We needed distance — a psychic removal — in order to really assess the problem and take action to change it. In other words, we had to act like designers, which meant we had to be more objective, to sit outside and to the left of the problem space. As this experience taught me, too much empathy can be as crippling as too little. 

Empathy will get you to see the problems from the users’ perspective, but not the solutions.

Do you think Emily Pilloton and Chelsea Hostetter would agree? Would George Aye find this imbalance of power to be unacceptable?

Questions, questions… (Indeed, I addressed the content of this blog post — and much more — during a session entitled, “Question Everything: Workshop to Help You More Effectively Design for Social Impact” which I led with Susan Wolfe last month during San Francisco Design Week. Should you be interested in such a workshop, give us a holler.)

Go ahead — ask people what they want

A version of this post has been published on Medium...

“Do not ask people what they want.”

This is a mantra in the field of design research. It is said over and over and over again.

It was said years ago by the likes of Steve Jobs, Jared Spool, and Jakob Nielsen (and many others); it was said more recently by the likes of Erika Hall and Don Norman (and many others); it was said perhaps most recently — earlier this week — by designer Jason Li:

Karen Holtzblatt has written: "Don't ask your customer what they need or want or like. People focus on doing their life not watching their life. So if you ask the customer, people can't tell you what they do or what they want, because it’s not part of their consciousness to understand their own life activities."

Don Norman said: “Don’t ask them what they want, because people don’t know what they want. Seriously, you don’t know what you want; I don’t know what I want.”

And, of course, there is the famous quote attributed to Henry Ford: “If I’d asked people what they wanted, they’d have said faster horses.”

But, doesn’t the answer about faster horses reveal important information? And do you really think that Don Norman never knows what he wants?

Do you never know what you want? Does what you think you want never reveal something of importance about what you really want, something which can be fruitfully expanded via additional questioning or other types of research? And is it never a part of your consciousness to understand your own life activities?

In an earlier post, I referenced a medical conference in which patients in the audience — patients who had invested tons of time in understanding their health(care) experience and in identifying what they wanted — were seriously offended when a speaker — a designer of wearable sensor products — proclaimed with pride that he never asks users what they need or want, but only observes user behavior. 

Is it advisable to observe user behavior? Of course. But is it good practice to offend the people for whom you are designing by refusing to ask them what they want?

The mantra of “do not ask people what they want” seems to partly be a reaction to over-simplistic practices of “requirements gathering.” But it also seems left over from the days of designer pomposity — when the approach of “designing for” dominated over the approach of “designing with.” This is not a claim that “designing with” only means you need to ask users what want; far from it. But users actually do often know what they want and need, and when they don’t (completely) know, answers to such questions often contain important clues.

Go ahead — ask people what they want. Just don’t ONLY do so.

___

Thanks to attendees of the May meeting of the ATX UX Book Club (Article Month) for their feedback to a draft of this post.

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:

Similarly:

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.

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 d.school, 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 d.school:

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.

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...

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.

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."

Laugero argues:

"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.

Out with the Old, In with the New: A Conversation with Don Norman & Jon Kolko

I've interviewed many people -- individuals and pairs -- on stage, including Doug Engelbart (with Tim Lenoir), Alan Kay, Bill Buxton (once with Cliff Nass, once with Mitch Kapor), Sara Little Turnbull (three times, once with Stephanie Yost Cameron), Clement Mok & Jakob Nielsen, Joy Mountford, Paul Saffo & Jaron Lanier, Alan Cooper, Don Norman (four times, once with Janice Rohn), Bill Gaver & Wayne Gray, and Bill Moggridge. (Transcripts of the only three interviews that were recorded have been published in interactions magazine.) I've also moderated several panels of three or more people.

However, the best of these, for multiple reasons (some very personal), might have been the most recent: a "conversation" with Don Norman and Jon Kolko, which took place at the Academy of Art University (AAU) in San Francisco the evening of September 30, 2011. The ~2-hour exchange with and between Don and Jon and the audience (comprised mostly of AAU students) was particularly engaging, thoughtful, rich, and delightful.

The title I gave to the event was, "Out with the Old, In with the New: A Conversation with Don Norman and Jon Kolko on Trends in the Overlap between Art, Business, and Design."

Topics addressed included the nature of and the difference between art and design, whether design should be taught in art schools (such as AAU), Abraham Maslow, usability, what design (or all) education should be like, the problem with "design thinking" courses, the destiny of printed magazines and printed books, aging and ageism, the relationship between HCI and interaction design, Arduino, simplicity, social media, Google, privacy, design research, the context in which design occurs, the Austin Center for Design, solving wicked problems, whether designers make good entreprenuers, politics, Herb Simon & cybernetics, the strengths & weaknesses of interconnected systems, and how designers should position themselves.

The video of this event appears at bottom of this posting. I encourage you grab a cup of coffee (or a beer), start the video, sit back, and enjoy. For those interested in reading some of what Don and Jon said, here are just a few of the highlights (not necessarily in the sequence in which they occurred during the session):

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Regarding the user experience:

Jon:

"Most people attach the experience in which they have received a thing to the thing, which makes it much more important."

"...enjoyable and pleasurable ... and magical and sexual and sensual and poetic -- these are the words I use; ... if you can encourage the more ethereal and fleeting qualities, the rest comes with it."

"Design that is discursive and has a personality -- that is intended to evoke reflection of an end user -- that is the stuff that is succeeding in the market right now, and it doesn't even have to be well-done. That is what consumers are responding to."

Don:

"Usability is important, but it is not the most important thing. There are lots of parts of (the iPhone) that are completely unusable, and you know what? It doesn't matter."

"You can have negative components, and you can have things that are difficult or aren't yet well-finished or well-developed. As long as the total experience is wonderful and your memory is wonderful -- that is what matters."

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Regarding the "design thinking unicorn" (as Jon called it):

Don:

"Engineers and MBAs are fantastic at solving problems, but they aren't any good at making sure it is the right problem... The difference between that and designers:" (designers explore and learn and watch people and try things, Don said, via a detailed example regarding the task of designing an automobile)

Jon:

"Now, if you get an MBA, you might take a class called "design thinking," where you will learn a bunch of design methods. You'll learn a method called, "empathy." For 4 days, you learn about empathy, and then you are now certified to be empathetic. Clearly, it can't be that reductive. The problem is not that it is being taught that way; the problem is that the MBA comes out armed with this knowledge and is managing YOU, and making more money than YOU, is YOUR boss, and is telling YOU how to do your job when they don't know how to do it themselves. I've seen that happen a lot."

Don:

"If you really want to be in control of your own destiny, go get an MBA in addition to your design (degree)."

Jon:

"Something that might make more sense is getting a public policy degree, particularly if you want to cash in on whatever this design thinking thing is and applying it in a way that is really impactful."

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On Google:

Don:

"Google doesn't understand people -- doesn't understand consumer products; they're all about technologies... They believe in algorithms. They don't care about people. Larry and Serge are brilliant technologists, and they believe they can solve everything with an algorithm... They don't believe in designers -- they believe in testing: we'll see what people like best. What that does is give you design by committee. What is Google's product? The product is not search; the product is not advertising. The product is you. ... They are selling you to their advertisers. Their customers are the advertisers, and their product is you. So they don't care if their products work very well."

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On design research, the context in which design operates, and solving wicked problems:

Don:

"You have to figure out what it is that people need, how people function, how do I put this technology so that it effortlessly fits their needs and functions well, and ideally is also really pleasurable and enjoyable."

"The problem I've discovered -- even though it makes great logical sense: how can you build something unless you really understand the population you are building it for and what people are doing and their needs? -- is there is never time. ...in thinking about that, I decided it was a bad idea to teach people to do design research first, because in reality, you never were allowed to do it."

Jon:

"A couple of things have changed or represent an alternative point of view. I worked at frog for about 4 1/2 years, and when I started, we had a design research practice that was small. When I left, companies were hiring us to do design research engagements -- 4 or 5 hundred thousand dollar engagements -- where all we did was do design research. ...what changed was the relationship between empathizing with end users and building something which resonates on the market, which is different than understanding the problem you are trying to solve. I think there is a subtlety there of 'I conduct design research to understand how a coffee maker works' versus 'I conduct design research to understand what it means for this person to brew coffee,' one of which is more touchy-feely, fuzzy, subjective, and interpretive. ...all of the concerns shared by Don are true, and the anecdote of the product manager saying, 'Yeah, yeah, yeah, next time you can do your great process; this time... you know what to build, just go build it' embraces the corporate structure of quarterly profits, time to market, the artificial race to get product out, build it and iterate on it, fail fast and fail frequently, ... Increasingly, I think those are all wrong, and I think they are really wrong and harmful as well, because you can take design out of the context of business and stick it in other contexts ...such as public policy and social problems... You can stick it in a lot of contexts, because it is a discipline. It is artificially embedded in the context of business, and when it is, you have to embrace the rules of business... You don't have to buy into that, though. And what I've seen is that most of the students that I run into ... don't want anything to do with that, but they don't know any other route. They are told to go corporate or go consultancy, (as if) there is no other choice. But there are a lot of other choices. All those things (Don said) are true, and that is usually the reason the right process is cut. But you don't have to buy that."

"Not all problems are equally worth solving. It seems like we've taken it for granted that every activity within the context of design is worth doing, whether it is a drinking bottle or a microphone or a website for your band. I don't know if that is true, and I'd like to challenge it and would like more people to challenge it more regularly. That is the focus of the Austin Center for Design: problems that are socially worth doing, and broadly speaking, that means dealing with issues of poverty, nuitrition, access to clean drinking water, the quality of education, ... These are big, gnarly problems, sometimes called 'wicked' problems, and it seems incredibly idealistic to think that designers can solve them -- I agree, I don't think designers can solve them. In fact, I'm not sure anyone can solve them, but I think designers can play a role in mitigating them -- a really important role because of all of the design thinking stuff that we've already talked about: the power of that can drive innovations that are making millions of dollars for companies; it seems that that same power can be directed in other ways."

Don:

"I've seen too many designers who think they know the answers to the problems of education or the problems of health or poverty or drinking water in Africa -- it is amazing how many times design students in America are solving the problems of Africa or southern Asia as opposed to the real problems we have in the United States. If you a trying to solve problems in far-away places, you are fooling yourselves if you think you understand the problems."

Jon:

"That is the easy part. The hard part is that you are exporting your value structure, and people don't want it or understand it. We talk about empathy and how it can't be taught in 40 minutes -- empathy is a long-term thing... Right now, I'm on a tear against project-based learning, because every time you have a project, the project ends, and then you go to the next one. That is true in a consultancy, too. But that can't be true if you are talking about affecting the homeless population in San Francisco, because once you form a repoire with someone, if the project ends, you still have that repoire with someone, because they are a real person."

Don:

"My favorite quote is from (H. L.) Mencken, a journalist from the 1930s: 'Every complex problem has a simple answer, and it is wrong.'"

And related:

Jon:

"The research that is done in the (HCI) academic world is focused on appropriating technology in new ways, in clever ways, in new wild and fancy ways... There's a lot of masturbation, for lack of a better word -- gratuitous use of technology just for technology's sake. If you could reign in that intellectual powerhouse, it could actually solve some problems that are worth solving -- it would be pretty incredible."

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More advice for designers and design students:

Don:

"You have to be true to yourself. Whether you are working as a lone designer designing chairs, or whether you're working as one of several hundred people on a team trying to (solve) some complex sustainability problem..., you have to be true to yourself. Even if you're one voice of many. If everyone had this view, your one voice gets amplified."

Jon:

"It is the best time in history to be a (good) designer, by any metric..."

Don:

"It is a great time to be a designer, because the technology world is changing rapidly in exciting ways which gives all sorts of wonderful potential. ...it is quite often that when there are economic difficulties, the exciting ideas get started."

"Don't try to be the great name designer. The total number of great name designers will always be just a handful. We need a great many designers; we don't need star designers. A star designer is a nuisance rather than a virtue."

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The full ~2-hour video:

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Thanks much to Kathleen Watson, Associate Online Director of AAU's School of Web Design & New Media, who asked me to put together a session of this nature for AAU, and to Lourdes Livingston, Graduate Director of the same school. Thanks also to Susan Wolfe for the first photo appearing in this blog entry; all other still images were taken from the video.

We are planning to do more sessions of this nature at AAU during 2012. To learn of these sessions, follow me on Twitter.