Design and Medicine: Melding Two Worlds
Steven McGaughey, MD, is a pediatric emergency medicine fellow at Oregon Health and Sciences University in Portland. He studied architecture at Dartmouth before beginning medical school at the University of Iowa, where he developed his passion for design with a series of illustrations and medical infographics. Always seeking to meld design and medicine, he looks for creative opportunities within his everyday work. As someone who also studied architecture before medical school, I was eager to compare our experience. In this interview, Steve talks about what it’s like to move between two worlds, his current interest in the design of electronic medical records, medical informatics, and how to keep your passion alive through the well-defined pathway of medicine.
A: What has your journey in medicine been like?
My dad is a cardiologist, so I always had some concept of going into medicine. As a byproduct, I always thought I’d end up outside of medicine—pursuing my own independent path. I’ve long had an interest in art and design though I’ve struggled to rectify how medicine and art would work out in my life. During my undergradate years I persued premed and, since I had already been interested in art and architecture, an architecture major. As I was getting to the final years of my undergraduate degree, I felt the pathway towards being a physician was too much. It felt like the premed system just kept pushing you towards the next steps. I’d look at my peers and feel the pressure of applying for the next phase. With that I failed to evaluate what I truly wanted. So, I took a step back, decided that I would take a year and work and I worked for an architecture firm in Boston. Looking back, it was helpful for me to get out of the medical bubble and see what what architecture was like. In the end architecture didn’t quite fit. I made the decision to pursue medicine with the hopes I’d find avenues for art later. I returned home for medical school, then I did my pediatrics residency in Washington in St. Louis. I’m currently in the early stage of a pediatric ER fellowship.
A: Rewinding a little bit, I did an architecture program for undergrad. What was that like for you, balancing the premed vs. the design?
I found it worked as a nice mental balance for me. I had hopes that I would meld the two worlds nicely into a contiguous, medical-architecture whole, but I found through undergrad that keeping them separate allowed my different personalities to play out. I could study organic chemistry, and then I could stop and go to studio to paint or do sculpture. It was energizing to turn off one part of your brain and reengage another. But there was no one else who was interested in those two worlds. While I really enjoyed the process, it was a bit isolating where pre-meds would be like “I have no idea what your life is like,” and vice versa.
A: You mentioned this melding of the two worlds, where do you feel like you are along that?
I’m still struggling with it. In medical school I melded them a little bit better. I got interested in illustration, and I had a project that I called daily doodle where I would draw everyday as a push to continue artistic pursuits. But honestly it continues to be difficult for me to understand where I best fit in. I think ER clinically is a good fit for me, especially in pediatrics, where it is a challenge to accomplish things that are straightforward in the adult world, say putting in an IV or get a CT. In a way there is always a design problem to solve that is unique for every kid. At the extreme end you could sedate a child to do a minor procedure, yet on the other you can use distraction and play to accomplish the same task. There are so many factors—changing the room, re-positioning the parent and child, dimming the lighting, changing your body language—that greatly affects how a child will react. It’s constantly a mental game to accomplish tasks in the ED.
Outside of my clinical work, I’m pursuing my interest in how medical professionals interact with computer systems. I’m currently in the Masters of Clinical Informatics program. Its taught me to think broadly about how information systems help us provide care. As you know, these electronic medical records are not really designed from a physician forward perspective, nor are they designed with efficiency in mind. Part of that is the billing aspect – it’s a large part how hospital structure works – but I think there is a lot of work to be done on how we make medical information systems work better for us, symbiotically, rather than to feel like we are fighting against a very rigid system.
A: I’m interested in this tension between the possibilities that these two fields can come together, one the one hand you have particular problems that come out of the lived experience and that is one way to think through this hybrid world/sensibility. How, as you are thinking about your future trajectory, is this project that you are focusing on right now, or is it something more amorphous? How would that relate to the strictly clinical dimensions?
I haven’t been a person who takes a prescribed pathway. I tend to take a kind of shift based on my current surroundings and opportunities. It’s mainly putting myself in scenarios where I’m meeting interesting people. I didn’t know clinical informatics existed until late in my residency, nor did I understand the manpower/infrastructure that existed behind EMR and all the processing of the data that we create. It was born out of something that I interact with day to day. It was interesting to me because I love graphical interface design that links a human with a computer system. When your day to day life is controlled so much by these systems, I just start to think of the design characteristics and design problems. It’s an interest created as a byproduct of my training,. I am molded by what is around me and where I work in the day to day. I’m not quite sure how that’s going to play out yet, and it might not have anything to do with EMR or clinical informatics. So, we’ll see.
A: So what thoughts have you given to a concrete design of the EMR?
The history of present illness is the crux of what we do in medicine—it’s taking that narrative, pulling the data out of it, and thinking about what we want to do as the next step. I don’t think EMR follows that kind of logic. It says, “OK. Type a long narrative into a box with a note.” We create this note, but within that note it’s a kind of black box. Anyone can read the note, but the computer doesn’t intelligently take my narrative and break that down into useful characteristics. It would be useful to think about, say, this is how long the fever has been going on, or when certain symptoms come up, and then intelligently pulling in relevant immunization or family history. In the future I hope that EMRs can intelligently take the History of present illness, and do something useful with that. It’s a technological barrier of having to parse a narrative and put it into discrete data boxes. It’s not an easy process. But it’s unfortunate that this wealth of information is stuck a black box. I wish the computer would intelligently take bits of that information to help us move forward. I think that’s coming from the consumer world, but the lag time between the medical world and the consumer world is pretty large. We just have such a wealth of information in this systems—we could possibly answer questions that are unanswered since conducting large randomized study often not financially feasible.
A: You mean some conditions get more research attention and funding?
Yeah, you know that’s somewhat of a financial decision. It’s not surprising to go across the country and see cancer institute’s popping up and they seem to be well funded, and that’s wonderful. But there are also rare genetic conditions that affect kids, but these are orphan projects. If we could utilize this EHR data, we might be able to bypass the currently expensive large scale trials that are needed.
A: Where do you think designers can play a role in this?
I see designers helping with gaining the trust of medical professions with more human centered design. We need to feel like EMR makes our job better and easier. There is also the issue of how we speak to a patient but still document on the computer. This will continue to be a problem as we become engulfed by all this data we need to enter into the computer. That’s where you see scribes in the ER, people whose job it is to be the computer. That’s a good solution on a small scale, but if people can figure out how to decrease the barrier between the computer and the patient, it could really help.
A: Speaking of the ER, how did you decide on a specialty, and do you think your design background played a role in that?
I think subconsciously it did. It wasn’t a prescribed move to think, “Hey this is a field with opportunities for design,” but I think wanting to have both hands-on experiences with the more intellectual aspect of medicine made pediatric ER a nice fit. We see a combination of things— physical things that we need to fix like lacerations, and then there’s the more intellectual aspect of diagnosis, and the design problem of figuring out how to get the participation of the patient. I think my interest in tinkering with and doing things played a large aspect. You just have to think a lot about doing relatively straight forward things in a unique way—its fun.
A: What do you think your next five years will look like?
It’s a good question, there are things that defined, like finishing up my fellowship. Hopefully I am able to fulfill this master’s in clinical informatics. After that process I hope I can be engaged with the system that I am in. I know I want to do clinical medicine, I love working with kids, I love what I do, I just need to find other ways to fit design into it. I started to work medical design companies, thinking about solutions to medical problems. I think it’s fun to work with those who have engineering backgrounds – to be able to give our medical perspective to help design medical devices. Honestly, I would love to change how we interact with EMRs. I think it’s a really large problem. And I think it’s hard because the systems that are dominant now are pretty insular. There are a couple of companies that essentially own the entire market and currently they are not very open. So, I think part of what I’m able to do depends on the direction of the market.
A: What would you say to people trying to decide what their future career will be?
I hope that people who are interested in medicine are aware of their varied passions and feel empowered to take their passions into medicine. Even though we have a pretty concrete structure of how we teach medicine and how we think of the process of medicine, there needs to be change. Even though there might not be a lot of role models, we need to start bringing in other fields. I think that’s really important, and I hope the new generation can help us do that.