How to be anti-disciplinary [the pinnacle]
In the previous post, I talked about my path integrating disparate experiences to create a diverse and cohesive perspective. Now, this is all about using that perspective to find a purpose.
Let's start with a video I made last year. I think it sets the stage nicely for the rest of this post. It's also just inspiring and fun to watch!
To be something - do it.
I knew I wanted to be known for creativity as much as I wanted to be known as a great doctor.
Starting my emergency medicine residency, I had a nagging feeling that I needed to push my creative identity. I hadn't really called myself creative or assumed the role of "a creative." No one asked me about anything classically considered a creative pursuit. Some people close to me knew I loved making photos, but other than that, it wasn't really something people knew me for. I received comments about a few presentations I had given during medical school and received great feedback on the video we had created for my MPH capstone (in the last post). As I thought about what I wanted to make out of my medical training, I knew I wanted to be known for creativity as much as I wanted to be known as a great doctor. To start our training, each of the residents filled out a packet to help us brainstorm and uncover what our goals, priorities, strengths, weaknesses, fears, and excitements were coming into training. Among my goals was to be "known for giving great presentations." So I got to work improving my writing, visual design, and presentation skills.
That was maybe the first and most important lesson I learned; if you want to become a particular person or do something, start telling people you are that type of person or do that type of thing. Don't let imposter syndrome stop you from assuming an identity. Some things require a specific proficiency to tell others you do; you can't be a physician unless you go to medical school and pass board exams. You don't have to have any sort of proficiency to tell people you're a writer or photographer, or baker. You just have to do those things over and over again. As you start to convince yourself of the identity, other people will begin to believe you too.
The ideas I had floating around in my head had yet to coalesce into anything tangible. The lessons hadn't yet started to shape any cohesive understanding of my formula or purpose. I could sense a deeper connection between my life experiences; I just couldn't yet tie them with a common thread.
Finding connections in new places
As I neared the end of the first year of my residency, the dots started to connect.
The first was stumbling across another emergency medicine physician who ran the Health Design Lab at Jefferson University. Dr. Bon Ku, an emergency physician, uses "design thinking" to help develop new medical technology, improve food deserts in Philadelphia, promote physical activity among kids, use 3D printers to help surgeons plan complex operations, and teach medical students skills in creative problem-solving.
Design, or design thinking, is often misunderstood. Most people think it means something about making stuff look pretty. People typically think about interior designers or graphic designers, or fashion designers. They think of the end products of those professions, commonly aesthetic goods. What people miss is the process used to arrive at those products. Design thinking is the process of producing a good or service that not only solves the end user's problem but is enjoyable to use along the way, making it more likely to be used at all. At its core is the idea of creating from a place of empathy for people. Health design thinking is the adaptation of that process to solve problems in health care. Imagine that, creating something in our health care system from a place of empathy for the patient. The idea immediately resonated with me. I dove into the core books on the topic and searched for it in the medical literature. I realized that was pretty much nothing. Well, there were a handful of papers that introduce the idea of "design thinking." Mostly the search led me to organizations like IDEO and the Standford d.school. I learned about the entire section at Mayo Clinic dedicated to using design thinking for innovating.
The more I explored the concept of design thinking, the more it started to feel familiar. Not because I was learning the skills of design, per se, but because what I read and watched felt remarkably similar to what I had learned through my training in public health. Similarly to realizing that the emergency department was directly at the cross-section of medicine and public health, I started to see public health as a degree in design - health design. So much of what I had done and learned fit within the model of design thinking. Any public health problem is first tackled with some type of needs assessment. It varies in its form but is not dissimilar from the process of needs-based problem solving seen through a design thinking approach. Prototypes are built via pilot studies, role-playing and other lower fidelity, lower-cost ways of testing an idea. I was taught various brainstorming activities to generate ideas among a large group of people and ways to converge on the best ideas. I had an entire semester course entitled "Program Evaluation". I learned how to elicit, distill, understand, and incorporate the feedback of an intervention - the bedrock of the "build and learn" cycle of design thinking. It all resonated so strongly with me because it made tangible so many of the ideas I had uncovered through my education in public health but didn't know how to necessarily introduce into my clinical and professional role as an emergency medicine doctor.
empathize/define/ideation : interviews, needs assessment, observational studies
ideate : pilot studies, think tanks, literature review
prototype : intervention, simulation models
feedback : program evaluation
Krebs Cycle of Creativity
None of these things exist in isolation - there is no boundary between my role as an emergency and public health physician.
The second connection came while I was watching a series on Netflix called Abstract. It's a show that showcases the work of various creative professionals across a wide range of fields like illustration, photography, shoe design, and in this case, material design. The particular episode that forged the connection in my mind highlighted the work of architect and designer Neri Oxman. She's an Israeli-born architect who had initially studied medicine until taking up architecture and got a Ph.D. in design computation from MIT. She became an Associate Professor at the MIT Media Lab studying material ecology - literally, 3D printing the built environment using silkworms and other organisms.
Mid-way through the episode, this diagram flashed on the screen:
This illustration was initially published in an article Oxman wrote in the Journal of Design and Science entitled Age of Entanglement. It shows how (creative) energy is passed through the four areas of human creativity; Art, Science, Engineering, and Design. In the episode, she explains how information is processed through the scientific method to become human knowledge. Knowledge informs building and constructing the physical world. The physical world is refined through design to alter human behavior, which changes people's perception of the world through art. I paused the episode and sat in amazement. It's a visual representation of the exact thing I've always felt but never knew how to express.
Joi Ito, an original founder of the MIT media lab explains in the article Design and Science what makes anti-disciplinary work unique:
"Interdisciplinary work is when people from different disciplines work together. But antidisciplinary work is something very different. It's about working in spaces that simply do not fit into any existing academic discipline-a specific field of study with its own particular words, frameworks, and methods."
As an emergency physician, I exist somewhere between art and science. As a public health physician, I live somewhere between engineering and design. The practice of medicine is an art grounded in science. Public health is a practice that engineers "the architecture of choice" through design and policy to help people live healthy lives. In reality, though, I don't exist in any of these quadrants. None of these things exist in isolation - there is no boundary between my role as an emergency and public health physician. On any given shift, I perform life-saving procedures, counsel patients on misinformation of COVID vaccines, perform HIV screening, provide housing resources for the homeless, provide antibiotics for infections, and any number of things that may walk through the emergency department doors.
Innovation & Biodesign
More broadly, in emergency medicine or medicine, we've widely accepted our roles as scientists and understand the clinical aspect of our jobs to be a certain amount of art. A finesse of both gestalt and interpersonal dynamics helps us arrive at a diagnosis. It's easy to extrapolate our experiences to that of engineers - we help build new systems and pathways for managing sick patients, help construct new facilities to accept the ill, and develop new tools to help us do our jobs. The area most overlooked is the area of design. Because "design" is often thought of as simply making things look pretty, it's de-emphasized in health care. We're quick to offer solutions but slow to find ways to listen to patients and one another to understand problems at their roots. New technology is often developed before identifying a problem to solve.
We need to create spaces - literal and symbolic - where experimentation can occur safely, where failure won't cause harm, and is encouraged because that's when we learn the most.
In many ways, innovation in medicine requires the same approach used in traditional research; experimentation and failure, prototyping and reiteration. The problem with health care is that the stakes are so much higher than conventional lab bench research. How can you allow for failure if you're working with people's lives? Instead of a system established for quick pivots and failing fast, we're forced to move slowly without much room for error, much less failure. It leads to slow changes over decades, not the rapid changes needed to fix our current system. There are downsides when pushing rapid innovation, to be sure. We've seen the adverse effects when scientific papers are published ahead of formal peer-review during COVID-19 (see hydroxychloroquine and ivermectin). Papers that would have previously never been published for the general public were disseminated through mainstream media. Leaving the responsibility of interpretation to the general public led to confusion around treatments we now know to be of no benefit and possibly harmful. To quickly build medical knowledge of COVID-19, we created an atmosphere where shoddy medical research quickly propagated through mainstream channels without the usual review process and created misinformed public opinions on what is safe and effective treatment for COVID-19. Anecdotes like this shouldn't dissuade us from searching for new ways to make change within health care, though. It should guide us on best practices. We need to create spaces - literal and symbolic - where experimentation can occur safely, where failure won't cause harm, and is encouraged because that's when we learn the most. To incorporate effective design, we must find safe ways to promote deploying solutions to problems before going through all traditional healthcare testing and regulation.
Range and emergency medicine
The emergency physician is the person best suited to handle this type of problem-solving. The breadth of knowledge of emergency physicians gives them a unique understanding of problems from multiple viewpoints. Problem-solving happens when knowledge from one area or domain can be extrapolated and applied to a new context. As we learn and gain experience in life, we develop mental models of the world around us. We make sense of how the world works by creating schemas in our minds that represent patterns we then use to understand new problems and situations. It allows us to be flexible and adaptable and conversely makes us prone to errors and causes failure in logic when mental models aren't applied appropriately.
Heuristics are a mental model that we all use every day to help simplify our lives and navigate our way through them. For example, when you buy a new red car, you may notice that everyone else seems to have purchased a new red car while you're driving home from the car lot. You conclude, erroneously, that the majority of people in your city drive red cars. It's improbable that more people have started to drive red cars today than yesterday. Instead, because your brain is primed to recognize the red cars around you, you notice them more easily. As your attention is drawn to the other red cars around you, your brain can more easily recall having seen them. Cognitively, you confuse the ease with which you remember seeing red cars with the overall proportion of red cars around you. This is called an "availability bias." It's an oversimplification, but it happens all the time, and it's no different in medicine.
To protect against this type of flawed logic, decision-makers should have a wide breadth of experience to draw from and a systematic way of applying their knowledge. Consider the idea of the "hedgehog vs. fox." In the book Range: Why Generalist Triumph in a Specialized World, David Epstein tells the story of how cognitive psychologist Philip Tetlock came to understand foxes and hedgehogs. A fox is someone who thinks broadly and has a broad domain of knowledge. They're not considered the "expert" of anyone domain but instead are skilled in asking the right question. They can turn to experts in a particular area when they need to dig deep into something. Hedgehogs are narrow in scope but dive deep into one area or domain. They are the person who can answer the nuanced questions about that domain. Hedgehogs are apt to failures in logic, though, as they tend to fit problems into their more narrow scope of understanding. Because they understand a domain so deeply, the heuristics they've developed to understand their particular domain are more rigidly applied to new problems leading to similar errors in logic described in the red car scenario above. When the solution is a hammer, every problem looks like a nail.
Thomas Edison was among the most productive inventors of our time. At the time of his death, he held 1093 patents spanning numerous domains; electricity, sound, batteries, and light. We know him for the lightbulb, but many don't realize he is among the first to ever create a motion picture camera. He developed new ways of extracting rubber for tires. He was one of the original audiophiles and produced what was, at the time, the gold standard in quality for consumer recorded audio - the phonograph. Not bad for someone with no formal education beyond the lessons learned working on railroads early in life. He became an expert on developing mental models for the world around him. In the autobiography, Edison, Edmund Morris describes the wide net Edison cast when consuming knowledge. "He now claimed to study twenty-seven periodicals, ranging from the Police Gazette and 'the liberal weeklies' to the Journal of Experimental Medicine, plus five papers a day and "about forty pounds of books a month." Later Morris writes, "The breadth of his erudition in other sciences was extraordinary...a common force - electricity - had linked his experiments in telegraphy, telephony, sound and light technology, magnetic mining, movies and battery design." Edison's natural curiosity and penchant for exploring new areas of human knowledge meant he could form unique analogies and mental models of how the world worked. While he wasn't necessarily the world's expert on material science, he could extrapolate what he knew from electricity and apply it to rubber production. He was an anti-disciplinary thinker.
Purpose
This is where I find myself currently. The challenge we're all tasked with is the search for the purpose along life's journey. What felt like a meandering path without understanding who or what I am has developed breadth and creative problem-solving. My purpose is to antagonize traditional silos and ask good questions. My vision is to push beyond what's already been done to help others live healthy, meaningful lives. My role is to be an anti-disciplinary academic emergency physician, to use principles of design to move between the domains of human creativity in pursuit of one leaving medicine better than how I found it.
Next time, we'll talk about some ways I've found helpful to hold wild-sounding ideas and how to introduce them to others without sounding like you're just pitching pipe dreams. I'll share some resources I've gathered over the past few years while exploring the health design space.