What do cerumen impaction, hemolysis, sternal dehiscence, and glomerular biopsies have in common?

The opportunity to innovate.

As I’ve plodded through entering data into my hospital’s electronic medical records (EMR) system, I’ve wondered: What would happen if a savvy physician were writing the code?  When I am putting on those contact precaution gowns outside my patient’s room for the 10th time of the day, I’ve asked myself: What would a Google engineer do?

We physicians are smart, resourceful, caring, and diligent — but intractable problems should be solved with innovation, and physicians have not historically been known for their creative engineering skills.  We land on the right side of the curve on organic chemistry exams.  We can memorize the Krebs cycle.  We know the differential diagnosis of a ring-enhancing mass on a head CT, but can we innovate?

I think we can innovate — and I believe that teaching creative thinking will be the next chapter in medical education. Collaborative, creative problem-solving skills —“design thinking” — can help doctors solve what ails health care today.

Teaching Design Thinking in Health Care — A First Step

My introduction to teaching design thinking to health care professionals in training came this past academic year, when I was invited as the Med-Peds program director along with my residents to participate in a class on designing and engineering medical devices.

In this Yale undergraduate class, MENG/BENG404: Medical Device Design and Innovation, Dr. Joseph Zinter and Dr. Alyssa Siefert guide students in the design of practical, real-world, medical devices.  Here is the trick: Dr. Zinter solicits ideas from the medical school faculty.  As a first step, he asked me to recount common, nagging problems that make our lives as physicians difficult.  Intrigued by this, and instead of just coming up with a list of my own pet peeves, I decided to mobilize my residents.  We brainstormed more than 10 problems – everything from those paper gowns patients hate to challenges with the EMR.

One of our gang said, “I just came back from clinic and I had the hardest time scooping ear wax out of this kid’s ear.”  We chuckled a bit.  Of all the great scourges of the world, cerumen impaction was hardly the worst.  And yet, Dr. Zinter was intrigued.  “Tell me more about the consistency of ear wax,” he asked.  “Do you need to scoop or suction?”

Another resident described how difficult it was to extract blood from premature newborns in the Intensive Care Unit.  “The nurses make a nick in the infant’s foot,” one resident explained.  “Then we have to squeeze the foot and collect the drops of blood in these little tubes.  Many times, the blood hemolyzes….  Then we have to do it all over again.”  We agreed that this was not too different than how it was done in the middle ages.

Dr. Zinter asked more probing questions.  “Why can’t you draw blood from the vein?  Is it a problem with the needle?  The collecting tube?”

And so, it came to be that several of our residents became medical device consultants.  Along with the students, we searched for answers among our collective experience. We began to ask: How can we apply design theory to more of the challenges that nag us?

The Elements of Design Thinking in Health Care

Teamwork. An essential component of design thinking is collaborating as a team. Dr. Zinter’s class divided into several groups, each team devoted to a problem that would lead to a product launch. My residents and I met regularly with the two teams of students we were partnered with over the semester. The students asked a ton of questions, played with otoscopes and vacuum tubes, met with nurses, and toured the lab and the newborn ICU — and though they never prototyped with actual patients, they got a chance to observe and really understand what we were up against. There was no room for grandstanding or ego.  The team was in it together.

The iterative design process. Background research and defining the problem is the first step. Second, the students began generating ideas and designing and building prototypes. Then test, revise, test, revise. Failure was part of the story. But with every iteration, the prototypes got better. There were even the “ah-ha!” moments, like when the endoscope’s image was synched successfully to the iphone.

A variety of thinkers. Although you might think that design thinking in health care might be well-suited to only engineering types, what I saw in Dr. Zinter’s class (and what works in industry as well) is that it’s important to bring in the humanities, too. In fact, a wide array of intelligences and abilities makes for the most forward innovations.  (Maybe I shouldn’t have been surprised to learn that one member of the hemolysis team was going to Los Angeles to work in the music industry after graduation.)

Persistence and playfulness. The willingness to prototype, to fail, only to try again is a key element of design thinking.  Innovation takes time and persistence. (Many of the students told me how they scaled back on their course load knowing of the time demand for MENG/BENG404.) There are pressures of deadlines and performance, but there is also an element of playfulness.  The gang played with 3D printers, studied how leeches extract blood, and figured out how to beam the image of a tympanic membrane to my iphone.

A sense of purpose. At the end of the semester, there was an Apple-style product launch.  More than 150 people showed up – friends of the students who hadn’t seen them all semester, several deans and administrators, a few members of the press, and even a few curious entrepreneurial types.  Who draws a standing-room-only crowd to a class final exam?

Real-world medical application of design thinking is what attracted these students — and our two projects were terrific.  “Team Blood Draw” designed a device that could be used with one hand, used existing standardized tubes, and leech orifice technology to more smoothly draw blood from an infant’s foot.  “Team Ear Wax” designed a pen-like endoscope that beamed the image to any computer, along with very unique scooper devices printed from the 3-D printer.  They made it kid-friendly.  The endoscope was shaped like a banana, which “docked” in a monkey’s mouth.

The other projects were amazing.  One group designed a decision-making app that incorporated current data.  Another group designed a titanium device to better hold a sternum together after open-heart surgery to prevent dehiscence.  The project that stunned me the most (besides ours) was the team that designed a virtual reality program for tissue biopsy.  You could put on the virtual reality glasses and “fly” through a glomerulus in 3-D.  It felt like one-part Disney, one-part “Honey I shrunk the kids.”  Even a novice could see the diseased area of the nephron.

The class ended.  The students went off to medical school, research labs, and the LA music scene.  And yet, there is an afterglow – for me personally and I believe for many of my residents.

Design Thinking Can Be Applied Anywhere

As a novice to design theory, all of this captivated me.  Some of it felt very similar to medicine: the curiosity, the persistence, the teamwork.  Some of it felt very different: the willingness to prototype, to fail, only to try again.

We might groan about PDSA cycles, root-cause analysis, and patient panel data.

We speak of interprofessional teams in patient care — I wonder if designers could be invited to the table to help us make medicine better.  More than that, I wonder if we could learn to think more like designers.  We physicians are trained to nail down a diagnosis and prescribe a specific treatment.  Our minds categorize and organize.  A designer’s mind brainstorms and prototypes.  We put symptoms and signs in boxes.  A designer thinks outside of the box.

Applying design thinking to intractable problems in health care — not just the design process but the curious, collaborative culture — is the next chapter in medical education.  We could learn a lot from the department across campus with the 3D printers and cool electronics.

MENG/BENG404 was not only about ridding the world of earwax and decreasing hemolysis.  It was an exercise in collaborative, creative problem solving.  What we learned can be applied anywhere.

Benjamin R. Doolittle, MD, is an expert in burnout and wellness in residents and physicians. He is an associate professor and program director of internal medicine and pediatrics at the Yale University School of Medicine and the medical director of the Yale Medicine-Pediatrics Practice.