Musings of a Cancer Doctor

Wide-ranging views and perspective from George W. Sledge, Jr., MD

Tuesday, April 30, 2013

On Design Flaws


During the course of a recent trip I became aware -- if ever I needed reminding -- of the world’s many design failures. Mostly these are trivial. For example, every time I go to an airport and use one of the bathroom stalls, I am always amazed that the stall doors open inwardly. This would be fine anywhere else, but with carry-on luggage and a computer bag, navigating the stall is more complicated than it should be.


And then, in the same stall, the designers had thoughtfully put in a shelf above the toilet. What a nice touch, I thought -- some place to set things other than the floor. I continued thinking that right up until I leaned forward to flush the toilet and banged my head, the shelf strategically situated to maximize concussion. Not for nothing was my high school nickname “Clumsy George,” but that doesn’t mean you have to design airports to give me contrecoup lesions in my occipital lobes.


And the airplane? Well, whoever designed airplane seating has a small, eternally claustrophobic place awaiting them in Hell. I have long legs, and my knees always bump up against the seat in front of me, and the seat itself is hard and uncomfortable and narrower than it should be. Getting to the seat itself is always something of an obstacle course, given the width of the aisle. And the overhead compartments often aren’t big enough to take standard roll-ons. The design of Coach Class practically screams “WE DON”T CARE ABOUT YOUR COMFORT” at every step.


And then I went to my hotel. By and large I like Westins. During my year as ASCO President the Alexandria Westin was my second home. The rooms are comfortable and quiet, and the staff professional and courteous.  But the showers have soap dishes that aren’t dishes, but rather stylish parallel metal bars. The soap is a pretty green thing made to look like a leaf. I’m sure some soap designer (this has to be a design specialty, right?) devoted a significant potion of his career to getting the soap just right from an aesthetic standpoint. But every time I put the soap in the soap tray, it falls between the metal bars and to the bottom of the tub. I lean over and -- you guessed it -- bang my head.  


I brought along a new dress shirt. I’ve never understood new shirts, with their many pins, plastic cuffs, cardboard innards, and whatever. What is the point of all that stuff, anyway? Does it date from before Permanent Press was invented? Is it there to impress me that the shirt makers are legit? Is it to provide employment for armies of pin-inserters? All I know is that, by design, I always get pricked whenever I put on a new shirt. I always miss a pin, and it always finds my skin. This time was no exception.


That’s human design. At a more basic level, Mother Nature is full of design flaws. Indeed, in contrast to the idea of “Intelligent Design” much beloved by creationists, it is fairly clear that our bodies are chock-full of poor designs: the human appendix, which appears to exist primarily for the benefit of general surgeons; our poorly engineered spines, our lousy feet, our defective vitamin C-metabolizing gene, our ability to have ectopic pregnancies (who would design a fallopian tube for implantation by a fertilized egg?), and other examples one could name.


Engineers (and surgeons) spend large amounts of their life engineering design flaws out of everyday things. The best writer on this subject is Henry Petroski, a civil engineer at Duke and the author of To Engineer is Human: the Role of Failure in Successful Design and To Forgive Design: Understanding Failure, among many others. I lack Petroski’s erudition and elegance on this subject, so his work is highly recommended.


Some of what I might consider flawed design (the airplane seat is the best example) may be considered great design by others. The airplane seat is rugged, durable, safe, and -- this is the important criterion -- maximizes the number of paying customers one can stuff into a small space. The different goals of end-users and designers make what one calls a design flaw a matter of contention. I still hate airplane seats. If they aren’t flawed design then the alternative is that the designers are sadists.


Some design flaws result from the belief that style may be more important than substance. That style and substance need be separate if a false dichotomy, of course. Apple became the most successful present-day industrial enterprise based on it ability to marry style with substance, but all too often the two are viewed as separate rather than unitary goals.


Simple lack of field-testing has to be part of flawed design. Did no Westin executive ever stay overnight and use the soap in the shower? Did no American Airlines boss ever fly in coach class from San Francisco to New York? Well, the answer is probably “no,” given the increasing chasm separating business CEO’s and their customers.


Why didn’t the CEO’s insist on hearing about field-testing? And was no junior person willing to say, “This design stinks?” Field-testing highlights bad design, and it always amazes me that so few companies put their work to the test before exposing their designs to the public. Or perhaps, they ignore the field tests for bean-counting exercises.


Even when the potential for mishap is recognized, design flaws are ignored in the interest of expediency. The famous Challenger space shuttle disaster occurred because senior management ignored the engineers’ concerns, and something similar (if not so catastrophic) occurs regularly in all sorts of organizations.


Sometimes the right designs are used in the wrong places: the toilet stalls I mentioned above are an example. Sometimes original designs (Petroski is quite good on this) are altered, piece-by-piece, by others until the original quite functional design is rendered unrecognizable and dysfunctional. Our evolutionary design flaws parallel this common engineering problem.


How about in Medicine?

All right, I’ve had my fun at the expense of others, but are we in the medical business any less prone to design flaws? Hospitals and clinics routinely irritate patients and staff, and the irritation often stems from avoidable design mistakes, bad patient flow, inept organization, and incompetent information management.


And simple irritation is the least of it; our design errors can kill. How many patients suffered unnecessary complications because (as happened horrifically in several cases) two heparin vials of hugely different dosage were designed to look identical? How many patients went to the OR with their physician being dyslexic as to lesion location, with tragic results?


All of these, in my experience, are either avoidable or amenable to improvement. Not that life will ever be perfect. Clinics would still move slowly: some patients show up late, and some show up sicker than you expected, and small delays concatenate through the complex hospital ecosystem. Even the most foolproof of systems can be out-fooled by master-level incompetence and sheer bad luck. But we can do better, eliminating much of the waste that is legion in the American healthcare system.


Process engineering was late to enter the healthcare system, but now is beginning to have an effect, at least in some places. I visited an oncology practice in Huntsville, Alabama that had undergone process engineering, with impressive savings and improved patient satisfaction. Elsewhere, new hospital designs have broken down some of the old silos that lead to fragmented and inefficient care after process engineers examined old practices.


Not that anyone will enjoy a visit to the hospital, any more than they enjoy flying cattle class: ultimately, we are not resorts. But we can make things less miserable. Maybe I’ll stop banging my head against the wall in time to preserve some brain function for my old age.