The Academic Life in Emergency Medicine (ALiEM) Faculty Incubator was hard at work during the pandemic to bring you the fifth volume of the Education Theory Made Practical series. This series strives to make theory accessible to educators by distilling the background and key literature of each theory and grounding them in practical education scenarios.

The Faculty Incubator is a year-long professional development course for medical educators centered around a virtual community of practice (a concept we have all started to appreciate during quarantine). Teams of 2-3 participants from around the world authored primers on education theories and different teams offered a first round of peer review on each post. As in prior years, they will be serialized on the ICE Blog for review and comment. You can learn more here.

They have published three e-book compendiums of this blog series (Volume 1, Volume 2, Volume 3) and you can find the Volume 4 posts here (the e-book is in progress!) As with the previous iterations, final versions of each primer will be complied into a free eBook to be shared with the health professions education community. 

Your Mission if you Choose to Accept it:

We would like to invite the ICE Blog community to peer review each post. Your comments will be used to refine each primer prior to publication in the final ebook. No suggestion is too big or small – we want to know what has been missed, misrepresented, or misconstrued. Comments as small as grammatical errors all the way to new scenarios for practical applications or new citations are welcome. (Note: The blog posts themselves will remain unchanged.)

This is the third post of Volume 5! You can find the previous posts here: Banking Theory and, Constructive Alignment.

IDEO’s Design Thinking Framework

Authors: Lauren Falvo, mD(@Sim_Falvo); Mohammed Hagahmed, mD(@hagahmedMD) 

EDITOR: Abra Fant, MD MS (@DRABRACADABRA)

Main Authors or Originators: Tim Brown/David Kelley (CEO of IDEO/company founder of IDEO) and Roger Martin

Other important authors or works: 3 I Model and HCD Model (Tim Brown/IDEO);  Service Design Model (Stickdorn & Schneider); Double Diamond model (British Design Council Institute); Design Thinking model (Hasso-Plattner-Institute)

Part 1: The Hook

Schizophrenia Glasses

Dr. Pneumo is an assistant emergency medicine professor at Academic Hospital School of Medicine (AHSOM) located in Big City, USA. She has recently taken over the medical student clerkship and has been tasked with updating the school’s approach to its core curriculum. Dr. Pneumo is excited to be a part of this change, but is new to curriculum design and still figuring out how to engage her learners.

AHSOM is located in the heart of the city and serves a large homeless population. Many of these people are struggling with mental health illnesses and are forced to use the emergency department to obtain many of their resources. During her shifts in the department, Dr. Pneumo has become increasingly concerned by the behavior of her learners. She has noticed that learners are joking more often about psychiatric patients, using the word “crazy.” Other learners are frustrated with these patients, complaining that the patients are “poor historians” and cannot focus enough to have a history or exam.

Dr. Pneumo would like to update the medical student curriculum to promote awareness of the struggles that mental health patients experience. Her goal is to increase empathy and understanding for this population, so that they may be treated with the respect they deserve. She is also hoping that this improved foundation of knowledge will lead to better history and physical exams, and therefore better care for these patients.

With these goals in mind, how can Dr. Pneumo update the current curriculum?

Part 2: The Meat

Overview

Design Thinking is a problem-solving approach that can transform the way organizations develop products, services, and processes. The benefit of Design Thinking is that it brings together what is desirable from a human point of view to what is feasible from an economic and technological perspective. People who are not trained as designers are given the tools to address a vast range of challenges. As defined by Tim Brown, executive Chair of IDEO, the design company which created the Design Thinking Framework: “ Design Thinking is a human-centered approach to innovation that draws from the designer’s toolkit to integrate the needs of people, the possibilities of technology, and the requirement for business success.” [7]

Rather than convincing people to buy into what businesses are selling, Design Thinking focuses on the actual needs of people (known as “end users”). It revolves around field research and the exchange of ideas that often leads to unexpected results. It can weave together the elements of human psychology, sociology, demographics, environmental factors, and anthropology to generate novel solutions to some of the perplexing problems in business.

Another major feature of Design Thinking is the concept of rapid prototyping rather than thinking about feasibility. By creating and abandoning multiple prototypes (which can range from a sketch, symbol, or text, to a complex 3-dimensional model), idea generation is compounded and boundaries become less and less limiting. [1]

Background

In comparison to the rigorous scientific method of investigation, Design Thinking is a relatively new methodology. The practice originated as a response to the question of what design had to contribute to the modern world. The first person to mention design thinking as a way of thinking is the scholar and cognitive scientist Herbert A. Simon in his 1969 book titled, The Science of the Artificial [6]. He continued to contribute many ideas throughout the ’70s which are now regarded as principles of Design Thinking4.

Tim Brown and David Kelley are among the founders and originators of IDEO Design Thinking. Brown implemented three core steps for his method: Inspiration, Ideation, and Implementation. This 3 I’s model was developed in the context of social innovation. The first Design Thinking space, Inspiration, involves identifying the idea or opportunity, creating a framework for the design team, and observing the habits and behavior of the target group in their environment. Then, Ideation creates a space for an interdisciplinary team to work together and share their insights into what was observed in order to provide solutions or design new models. Complex ideas or difficult problems can be broken down into less complicated concepts by utilizing visual representations or concept maps. Finally comes Implementation which is a Design Thinking space that is heavily focused on creating a Prototype of the action plan. Through prototyping, newly developed ideas are transformed to a final product delivered to its target audience. Contrary to one might think, innovation through the 3I’s phases does not need to be linear. The process can start or end at any phase as deemed necessary by the design team and until the final product is created.[2]

According to Brown, there are some important characteristics that the design thinker needs to have in order to be successful in his model. They include the following:

• Empathy
• Experimentalism
• Optimism
• Collaboration and teamwork
• Ability to balance feasibility, viability, and desirability

Some of the success factors that are necessary for Brown’s model include:

• Fail earlier to succeed sooner” requires simple prototypes to receive early feedback
• Focus on human needs, behavior, and empathy
• Go beyond the status quo
• Collective ownership of ideas
• Team learning
• Heterogeneity of team members
• Complementing specialization and subject matter expertise of team members
• Noticing what users do or say, and even more importantly what users don’t do and don’t say. The design team then develops an effective communication strategy before the final product is released
• Divergent and convergent thinking
• Optimism through confidence and trust
• Trying by building physical prototypes

Modern takes or advances

As an example of how design thinking found its way to Medicine, students in a two-day course offered by the Hasso Plattner Institute of Design at Stanford looked for ways to improve the patient experience in the Emergency Department. Participants in the course were given roles as patients and family members to get a sense of what it actually feels like to be in the often chaotic and highly stressful environment of the Emergency Department. Before conducting the exercise, the course participants were asked to interview patients and family members who were being seen about their experiences with medical care. By connecting and empathizing with patients and their family members, students were then able to feel what was like to be in their shoes. The first day produced an abundance of material to guide the class’ second day of ‘prototyping’. It became evident that certain themes were occurring frequently. Patients and their loved ones wanted a regular flow of information to help them understand what was going on with their care. They also wanted to know that their providers were communicating with one another. By ensuring clear communication and regular updates, patients would feel relieved which in return reduced the anxiety and fear experienced by their loved ones. The participants concluded the class by presenting their research results and ideas to the administrative staff who decided to implement them to their ED design.[3]

Design thinking has also been used in curricular design to expand data utilized in the course evaluation stage, as well as through the idea of prototyping.[5]

Other examples of where this theory might apply in both the classroom & clinical setting

Design thinking serves as a unique opportunity to pair students’ developing critical-thinking skills with a creative outlet. This level of brainstorming works well in earlier levels of training, before learners’ creativity is limited by “rules” or tradition. Students can create needs assessments within their own class regarding aspects of the curriculum they feel need to be better addressed. They then have the opportunity to brainstorm with their colleagues and other schools (Public Health, Pharmacy, Nursing, Dietetics, Design, Engineering, etc.) and develop prototypes in a “flipped classroom” format.

Design thinking is also well-suited for problem-solving gaps in the curriculum. As an example, medical education is currently limited on its ability to encourage empathy in students, but advances in virtual reality (medical professionals working with engineers and humanities expertise) have allowed for students to simulate brief moments of time in their patients’ days. Design thinking can also help address resource limitations by pooling supplies across multiple departments and developing more simplistic products or models to meet educational needs (ex. designing an intravenous pacer task trainer). Products created through design thinking can help adjust inconsistencies in training experiences. Collaboration with other schools of thought can enrich learning experiences, improve networking, and instill a deeper appreciation of other people’s employment and passions.

Annotated Bibliography of Key Papers

McLaughlin J, Wolcott M, Hubbard D, Umstead K, Rider T. A qualitative review of the design thinking framework in health professions education. BMC Med Educ. 2019;19(1). doi:10.1186/s12909-019-1528-8.

This reference serves as a qualitative review of design thinking in health profession education starting in 2009 (the presumed advent of DT in the health profession). The fifteen articles selected are a blend of peer-reviewed research and commentary on the education framework that explore the possible role of design thinking in problem-solving, curriculum development, and quality improvement for patient care. The authors suggest that design theory is a unique approach to uncover novel solutions to current problems in both health education and the act of health care, while acknowledging that this framework’s use in medical education is contemporary with limited data.

Henriksen D, Richardson C, Mehta R. Design thinking: a creative approach to educational problems of practice. Think Skills Creat, 26 (2017), pp. 140-153.

While this paper focuses more on classroom teaching, the application is equally important in clinical teaching. It emphasizes that problems are becoming more complex and that to solve to them, students must be taught to foster creativity. The paper notes that creativity is not inherent and can be developed in students by educators through careful curricular design that is grounded in experience. It describes an online course called “Learning by Design” and the qualitative analysis of the experience of participants of this course. The results are that design thinking provides a different lens for curriculum development which allows for systematic and creative approaches to problems.

Sanders, J and Goh, P. Design Thinking in Medical Education: The Key Features and Practical Application. J Med Educ Curric Dev. 2020 Jan-Dec; 7: 2382120520926518.

This paper reviews the basic concept of design thinking and offers two basic applications for its utilization in medical education: the creation of a new product or curriculum and a way to teach students how to tackle “21st-century problems” which are highly complex in nature. It concludes that design thinking should continue to be explored in medical education to develop design thinking skills in learners to prepare them to tackle future healthcare problems, design curricula, develop faculty and to inform future research and scholarship.

Thakur A, Soklaridis S, Crawford A, Mulsant B, Sockalingam S. Using Rapid Design Thinking to Overcome COVID-19 Challenges in Medical Education. Acad Med. 2021 Jan 1;96(1):56-61.

While not necessarily a key paper, this manuscript details the very relevant utilization of design thinking within the context of the complex challenges of the COVID-19 pandemic and its disruption of medical education. They highlight the key features of prototyping and rapid redesign to remain agile during the changing phases of the pandemic. Finally the paper offers a list of tips for utilizing design thinking to redesign education sessions during a crisis and maintain meaningful change rather than reverting to old ways when it is over.

Limitations

While design thinking can be praised for its innovative approach and interprofessional culture, it is not without its limitations. For design thinking to function at its best, teams need to have adequate time to devote to brainstorming, and project design needs to take place in an environment that encourages and values creativity. Participants should understand that design thinking requires the mentality that it is not only okay but also expected, to fail before one can improve upon something. This theory is most valuable when applied by a team with a diverse background, so projects taking this approach should be reaching out to additional collaborators from other schools of thought (engineering, design, etc.). The team should be open, interested, and actively engaged. It may be challenging to network with other departments and will take time to build working relationships with these new members of the team. Additionally, design thinking is still relatively new in its application to the medical field. There is a paucity of research on its efficacy in resolving obstacles in healthcare. As more schools adopt design thinking theory in their curriculum, we will have a better idea of its best role in our learners’ education.

Part 3: The Denouement

Dr. Pneumo understands that collaboration across professions is important in design theory, so she reaches out to neighboring engineering, design, and social work schools. She also networks with the hospital’s psychiatry department and the local mental health clinic to interview patients with schizophrenia, their caretakers and family members, and their healthcare providers. By doing this groundwork, Dr. Pneumo is able to get a better understanding of the obstacles these patients encounter daily, in their own words. Dr. Pneumo shares these interviews with the engineers and designers who have joined her team. Together, they design a prototype for a virtual reality headset that mimics some of the consistent auditory and visual hallucinations the patients are experiencing in their daily lives.
She shares this prototype with the patients and their families to assess its realism and incorporates their feedback into the scenario and software designs with her team.

Once all team members are satisfied with the prototype, Dr. Pneumo introduces the hallucination glasses into a pilot curriculum for students. The glasses are well-received, with many students comments on how poorly they understood what their patients were going through. Over time, enough data is collected to support making the glasses a permanent fixture of the clerkship curriculum.

On a recent shift, Dr. Pneumo overhears a new rotator in the department venting about a “crazy” patient. “I tried asking him the same question, like, five times, and all he would do was stare at the wall right behind me! Clearly he doesn’t want my help that badly if he can’t take the time to talk to me.” Before Dr. Pneumo can intervene, another learner pulls the new rotator aside. “Hold on,” he says, “I know that you’re frustrated and just want to help. I bet your patient is going through a lot right now, let’s see how we can work together to get him the care he needs.”

Don’t miss the fourth post in the series, coming out Tuesday, July 27, 2021!

PLEASE ADD YOUR PEER REVIEW IN THE COMMENTS SECTION BELOW

References 

1.Efeoglu A, Møller C, Sérié M, Boer H. Design thinking: characteristics and promises. In: Proceedings of 14th International CINet Conference on Business Development and Co-Creation; 2013:241–256.

2. Tschimmel K. Design Thinking as an effective Toolkit for Innovation. In: ISPIM Conference Proceedings. The International Society for Professional Innovation Management (ISPIM); 2012:1.

3. Wykes S. Design thinking as a way to improve patient experience. News Center. Accessed August 23, 2020. http://med.stanford.edu/news/all-news/2016/06/design-thinking-as-a-way-to-improve-patient-experience.html

4. Plattner, Meinel, Leiffer eds. Design Thinking: Understand – Improve – Apply. Springer-Verlag Berlin Heidleberg, 2011.

5. Gottlieb M, Wagner E, Wagner A, Chan T. Applying Design Thinking Principles to Curricular Design in Medical Education. AEM Education and Training. 2017; 1: 21– 26.

6. Simon HA. The Sciences of the Artificial. Cambridge, MA: MIT Press, 1969.

7. Brown T. Change by Design: How Design Thinking Transforms Organizations and Inspires Innovation. Harper Business, 2009.

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