geomedtric – innovation in healthcare

Guest Bio: Mr. Rodney Mountain – NHS Tayside ENT surgeon, previous associate postgraduate dean with interest in healthcare education, technical skills training and research related to healthcare products and service design. List of question themes and full question: Entry into the design world - Starting chronologically, from your early life, what got you interested in design and other avenues that could help health care apart from just the one path that we are all on? Trigger to enter the design world - Was it something personal that triggered you to go down to DJCAD? Alternative considerations - Before that, were you searching for other industries/approaches as well or were you quite sure that design would be the right approach? Rise of computing - Now we (interviewers) didn't live during the rise of the computing age, but we hear about how, during the 90s for example, there were opinions that computing (more specifically the internet in the 90s) was all a fraud, or a bubble. Could you share some of your thoughts on that? Living through start of the computer age - Some might say that you shouldn't overhype these new technologies, but as someone who's lived through that kind of thing, could you tell that you were living in a period of rapid change? Applications in healthcare - Still, there’s big applications for this in healthcare you feel? Networking and connections - Something I’ve always noticed is your wide connection with people. You tend to go out of your way and reach out to people, you know, doing interesting things within healthcare outside healthcare. Is it something you consciously cultivated? Is it something is just part of your personality? Skills for design work - In some sense this design work is not even a “side thing”. You could say it’s in a way completely out-with the skills normally gained through the medical job. Would you agree? Design and sensory experience - That reminds me of a new book that came out. It's called aesthetic intelligence. it was written by the ex-CEO of LVMH the luxury goods conglomerate that owns Louis Vuitton etc. A point she makes is that the AI revolution, data and stuff is good and all. But the aesthetic side, appealing to human senses and relying on taste/intuition (as opposed to over-reliance on big data) is why luxury brands, although remaining relatively small are able to sustain themselves for far longer and not get commoditized and become one in a crowd. And those kind of brands are the ones that evoke more passion within their customers. Using design with malicious intent - We could just go back to that point about aesthetics. The point of art is to evoke some kind of emotion in the person as opposed to appeal to logic. Do you think that, trying to use art in a “scientific” discipline like medicine could be used maliciously if people try to evoke the wrong emotions. Favourite artists - Going back to art and design. Do you have any artists that you particularly enjoy? In any medium whatsoever, that maybe you draw inspiration from? Medicine & Art - Do you think there's a benefit to that? I mean, do you think those two go hand in hand? Medical students and maybe people who enjoy using their hands to make art. Advice to med student self - Okay, so a hypothetical question. If you could go back to medical student Rodney what would you tell him? Reliving med student life - So another similar question, if you were to wake up as a medical student today, without the contacts that you currently have, but with the same knowledge. What would you be doing? Any regrets choosing medicine - You’ve talked about how long and difficult a medical career is. Have there been times when you've regretted choosing medicine? Message to those wanting to leave - If you had a megaphone what would your advice be to those 70% of students who are thinking of leaving? Noting things down on paper - One of the first things I noticed about you was your habit of noting things and ideas down in a pocket notebook. I was just wondering, are there other habits you've adopted that you find very useful to you? Useful habits - Are there other habits that you can incorporate alongside using visual tools? Book recommendations - What are some books or resources or advice that you think have impacted you the most? I know you’ve mentioned ‘change by design’ before, but I was wondering if there are some others that we haven't managed to talk about. Promising areas apart from service/product design - In medicine, what you’re doing now is spreading awareness of design and trying to contribute to that area by merging the arts and medicine together. Let's say, it started to get universally accepted and has started to plateau (in terms of growth) in an ideal world, what other problem or area of potential value-add would you be working on? Inspiration - Is there anyone you draw inspiration from? Quality of life vs longevity - In some sense, starting to think about quality of life is a different field entirely isn't it. That last bit of life is no longer based on scientific principles of health versus disease but more philosophical or design-oriented thinking of what makes a good life. Implementing change within healthcare - Healthcare seems like it's one of those rigid sectors and in most cases for good reason because mistakes are too expensive. Especially with regards to patients’ health and lives. On the other hand, it also makes it hard for changes of benefit to be applied into systems or how people do things. So have you yourself encountered problems when implementing change? If people who want to change something but just feel too much resistance, how can they cut through those barriers? And what would your advice be for especially younger people who want to make a difference in this sector? Short-termism in healthcare - You said it was challenging to get that kind of thinking in healthcare. Is it a matter of finding a designer from the outside? Advice for younger generation - Any advice for younger up and coming professionals who want to try and change things? Podcast Transcript Entry into the design world Q1: Starting chronologically, from your early life, what got you interested in design and looking at other avenues that could help health care apart from just the one path that we are all on? A1: Really good question. I think we are all on a pathway much like you're on at the moment where you have to focus in on the science and the methodologies that you are taught through med school and how to practice as a doctor. You kind of do that cause it's a safe way of doing things. But then I suppose, later on in my career, I've come to realize that our ways of working through using a pure scientific method work well for certain things, but they definitely don't work in areas of real human complexity. [These methods] work really well in emergencies and in single disease entities, you know, if you take just the management of a single disease, they work quite well, but Earth is far more complex. I just don't think that the science based mindset is the only way to go to try and problem solve and to find new solutions. That's where I sort of asked myself, are there other disciplines that come from completely different sectors that might be able to work together with us and help come up with ideas? And so, I just took myself down to the art college (Duncan of Jordanstone College of Art and Design), and this must be about six or seven years ago, and knocked on the door, met up with some of the staff and said ‘look, I’m a guy up at Ninewells hospital working in healthcare, but I’d be more than happy to help your design students if they've got any projects and things they want to do in health and social care, just get in touch. When that started off I just linked up with some students but that's really snowballed now into a situation where we got a whole lot of us now that have really started a new conversation. There's been quite a lot done through the years in medical art and the benefits of arts and health care, particularly in psychiatry and psychology in terms of benefits and therapies but what hasn't really been tapped into a lot is the value of design thinking and methodologies that could be applied in healthcare. And that's the bit that's really opened up. You know, the design of products, the design of environments in a hospital spaces to work better for people, architecture helping design better buildings. But probably the most valuable component is a whole methodology called service design – how you redesign services to meet the needs of your customers. It's done in industry, it's done in any commercial world where you really need to understand your user well so that you can design a product or service that they'll buy and they'll come back for. We’re very poor at doing that in the health service: we think we go out and create services that we think are right for people, but we very rarely actually spend time with them to find out what their real needs are and what service they would buy into. And that's the difference. That's where service design methodologies are coming in now. We're just finding our feet as it's all a relatively new philosophy. back to question list Trigger to enter the design world Q2: Was it something personal that triggered you to go down to DJCAD? A2: Good question, I think being a surgeon you, by nature use your hands a lot. You know, if you speak to most surgeons, where are they at their happiest? It's when they are actually operating because it's a craft, it's a skill. I've kind of realized that if I look back when I was finishing off school and thinking about what I wanted to become, it was either architecture or medicine – quite different things! But I wanted to do something where I was working with my hands, designing making stuff. I like crafts, I like making things I like art, I’m a reasonable photographer! I'm not a great photographer but I do quite a lot. So I'm always into trying out creativity, trying wacky things. So I suppose it's just a natural inquisitiveness. back to question list Alternative considerations Q3: Before that, had you been searching for other industries as well or were you quite sure that design would be the right industry? A3: That's another really good question and I think once I started working with the art college at the University, I soon came to realize that it's actually the value of the wider creative industries to healthcare. It's not just design, it’s computing, it’s gaming, it’s drama, it’s film. It's about a whole lot of these creative industries and trying to hook them up with healthcare and doing things together with them. So yeah, it's not just art and design, it's creative industries and healthcare, which is massive. In Dundee, the group that we've done a fair amount with is the gaming industry. So we’ve done a lot of interesting stuff with the guys from Abertay University and they’re really good. I've helped one of the ex-Abertay students who now runs a company and he's come up with a wonderful game for Cambridge University, for their laboratories. They wanted to create a game that could teach people how to look after cell cultures because, in a laboratory, you've got different stem cells, and cell lines, and they need different nutrients and you need to be careful about all sorts of thing. They wanted to create a game that they could use for educational purposes and so they put that out to the whole of the UK for people to compete to design the game. The group in Dundee won it and I knew one of the guys so I joined and sort of helped him and now that's a product that's being used in Cambridge laboratories. The value of computing and digital technologies is huge. The more I read, the more I realized that the clever people looking to the future are going to look at digital technologies and healthcare. And where that can be used in AI, augmented reality, all that sort of stuff. I think there's huge opportunities to improve things. back to question list Rise of computing Q4: Now we (interviewers) didn't live during the rise of the computing age, but we hear about how, during the 90s for example, there were opinions that computing was all a fraud, or a bubble. Could you share some of your thoughts on that? A4: Man, it’s funny chatting to an old guy like myself! I feel very privileged to have not grown up with that stuff and then just realizing the massive benefits that we take for granted now. You guys have grown up in this age, you’ve learned to type, you’ve learned IT skills. I'm embarrassed to sit in the clinic, slowly clicking through a keyboard! We didn't even have keyboards back then – those were for typewriters, these big clumsy things. If you look back in my era of growing up, we had landline telephones, we had radio, television was just coming in. The growth in technology of mobile devices and phones is a revolution. I grew up with in South Africa and one of our family members worked for Bell, one of the big telephone companies, and he got moved to Canada where I think they had one of the big bell bases. I remember he was trying to explain to us that they were completely recreating the phone, and that this was a major project that was going to be revolutionary. I suppose the biggest one and the most revolutionary change in technology that comes to my mind is the internet and the access we have to everything nowadays. I can't think of a day that goes by in my life that I don't use the internet in some form or another. One area which I don't quite understand where it's going to go is artificial intelligence (AI) and robotics. That, in my opinion, is going to be the exciting thing in your lifetimes. When you’re in your 60s, looking back, you know, everything's going to be done by more robotic based systems with probably less error occurring. No doubt, there will be some bad guys involved in the misuse of this technology, which is one of the dangers (of AI) but I think it will be a lot different to what it is now and there will be a strong digital and robotic component to healthcare. back to question list Living through start of the computer age Q5: Some might say that you shouldn't overhype these new technologies, but as someone who's lived through that kind of thing, could you tell that you were living in a period of rapid change? A5: Yeah, I wouldn't have known that it was happening at the time. If you managed to see the ‘Hello robot’ exhibition at the V&A Dundee, there was a high number of exhibits there that had a health and social component to them. One brilliant showcase I remember was this little baby robotic seal. It was the same height as a young baby. They made it very soft so you could actually cuddle it, and it didn't feel like a robot, it just felt like a stuffed toy. The value of this robot was in providing company for lonely, mainly elderly, people who may be suffering from dementia, and requiring a little bit of extra input in their lives. When you held the seal and you said something to it, you immediately got a little animal-like response. I could see people in the museum engaging with it, and immediately there was an emotional reaction almost as if it was alive. Then there was another exhibit for robots involved in terminal care – for somebody that was dying and literally just needed contact with, you know, somebody actually stroking them and keeping them calm. Rather than a human being doing that for 24 hours a day, this was a robotic system that just cared for you in a tactile sense. That's phenomenal. I have no doubt this is an exciting area. I don't think there’ll be robots represented in human form. I think there will be the odd robot that looks like vaguely humanoid, but for the most part I think you won't even know they’re there and what they’re doing in the environment. I think robots would greatly change things and improve patient safety, hopefully. The bit that is missing, and the bit that I really don't know where it will go is robots trying to be empathic. That real understanding of another human being’s needs, that's probably a little bit further down the line. So human beings are still going to be needed in a care setting for some of those really complex decisions where empathy and care is needed, like end of life decisions. I'd be a bit cautious as a young person at the moment though, looking at a career that could be digitized. You know, so if you're looking at maybe going into accounting or something like that, that's all just figures and it's already changing quite dramatically. Tasks where you previously needed 10 accountants might only need one in the future. Even law is now starting to experience the creeping in of AI with legal things being digitized. Interestingly, in the V&A exhibition, there was a BBC workstation that you could go to and you could key in your occupation e.g. doctor, nurse, architect etc. and it would tell you the risk of you losing your job as a consequence of these AI and robots. Healthcare professionals (doctors, nurses, allied health professionals), we've still got a chance, and I think that's because of the empathy that’s needed in what we do. back to question list Applications in healthcare Q6: Still, there’s big applications for this in healthcare you feel? A6: Oh yes. Huge. In AI analysis of data and almost pre-empting that somebody's becoming unwell. As an example, they've worked out now that for an individual with maybe a slight risk of getting diabetes, hypertension, a few other things etc., if you were able to monitor their physiology on a daily basis in their homes [and you can do this with body wearable technologies now], and if you pick up on a subtle change in specific variables, it might be an early warning that you need to go see that gentleman because that's an early sign that maybe his blood glucose is going to go off. So it's almost pre-empting problems before the patient or even the doctor realizes that something's starting to happen. Because you can recognize patterns. You can work out patterns of things between different age groups of people, how the physiology changes and when you should step in early and prevent a problem. Yeah, and speaking of AI and data, Chris McCann is someone who’s linking that space with wearable technology. He'd been a med student here and in his second year, saw that there was a real opportunity for wearable technologies to measure physiological variables and then Wi-Fi link it to a nursing station. So you can have 30 people on the ward with one workstation monitoring it more like an ICU and you sit and traffic light things red, amber and green with warning systems that when physiology changes, it picks up a sick person before they become sick. So Chris's idea and technology is taking off now. That's become huge. Mayo Clinic and a whole lot of people are investing in him. And I think the value of that technology may be more in the community than in hospitals. We all tend to think “oh, that'd be great on our wards” but there’s far more value in the transfer phase and after. So if you got a sick elderly person and you've got them stable enough to go home, a dangerous part is in transfer back home with, say, a family member taking them. An even more risky thing is when they’re home where monitoring everything in essence stops and if they could take their wearable device on that journey and have it remotely linked to the GP or district nurses just keeping an eye on them just quietly in the background that could be very useful. Plus the patients wouldn’t even know that it's going on. back to question list Networking and connections Q7: Something I’ve always noticed is your wide connection with people. You tend to go out of your way and reach out to people, you know, doing interesting things within healthcare outside healthcare. Is it something you consciously cultivated? Is it something is just part of your personality? A7: It is probably part of my personality. I'm always open to new ideas. I never say no to anybody, even if they come along with a wacky idea. I like the principles behind collaboration. Any successful society if you look at why they’re successful, you often find that they are very good collaborators. You know, it goes back to simple tribal sort of things. If you work together and collaborate, you've got a chance amidst the threats in the wild. If you act as individuals you stand less of a chance. In say, a football team, if all the players collaborate then you're going have different talents within the team. So at this point I like helping other people take ideas forward. That's what we do a lot with the art and design students and with quite a lot of med students that are interested in this line of work. “So they’ve got an idea how can I help facilitate that for them?” You'll find as you get older, if you work in one place, you get to know the place, you get to know the people and you know where you can steer them for collaborations. So 9 times out of 10 when students come to me with a big idea or project it’s not something that I can personally supervise and advise them on but I'll say, “ah I know somebody” and would set them up; an email link or some introduction and then let them go. Let them run. So collaboration is what I enjoy. And I think you'll find in your careers as you get older, you're going into a line of medicine and you’d become good at it. But then you need something extra to do and to keep up an interest otherwise you get bored and I'd definitely keep looking for something new. But this, the design, it's something that is going to keep me occupied. It's so interesting and so fascinating. back to question list Skills for design work Q8: In some sense this design work is not even a “side thing”. You could say it’s in a way completely out-with the skills normally gained through the medical job. Would you agree? A8: Very much and often very much out of your own depth, you know… I had to learn a lot. I've had to ask a lot of questions. I’ve embarrassed myself by getting things wrong. I mean, to my mind, if you don't go out and try new things, things won't move on. You've got to be a little bit creative. A new idea could collapse and not become anything or could suddenly open up a lot of interest. And it also involves challenging the designers that people come out of art college and are trying to be architects or interior designers or graphic designers to say, "what is human experience?" Because I always talk about user experience. It's what a designer does. We're UX designers and we create great human experiences. But what is experience? I posed that question to a group of masters product design students last week, and I'm sure if you looked at their individual portfolios, they'll have that word in there the whole time. You know, finding out the user experience then designing a great experience and something that is delightful, all that sort of stuff. What do you mean by experience? I suppose my hypothesis being a science sort of guy is that all human experience is sensory. You know, when you actually sit back our experience of the world (something good or bad) is what we see, what we hear, what we feel, taste, touch; the human senses. If you take the senses away we are absolutely nothing. We’re having a really interesting discussion at the moment with the design world and they get it. If you're going to create something really with a wonderful experience for somebody bring on as many senses. It’s like when you walk into a really nice restaurant. Lighting’s right. You might also smell food as you walk in and think to yourself “This is good.” You sit down on a comfortable chair. There's music or something in the background that is just perfect, not too loud etc. If that's orchestrated well, human beings would have a great experience. back to question list Design and sensory experience Q9: That reminds me of a new book that came out. It's called aesthetic intelligence. it was written by the ex-CEO of LVMH the luxury goods conglomerate that owns Louis Vuitton etc. A point she makes is that the AI revolution, data and stuff is good and all. But the aesthetic side, appealing to human senses and relying on taste/intuition (as opposed to over-reliance on big data) is why luxury brands, although remaining relatively small are able to sustain themselves for far longer and not get commoditized and become one in a crowd. And those kind of brands are the ones that evoke more passion within their customers. A9: Yeah, they are. They're just really lovely. It's getting back to basics. And sensation is pretty fundamental. It's also so fundamental in what we do in healthcare. I was actually just writing something last night for a design journal and I was analyzing what we do in healthcare. We take a history, there’re examinations, special investigations, differential diagnoses, treatments, and that's our sort of routine. But think about it, how do you take a history? You have to have a conversation. To listen. To listen properly. And to me, empathy is just proper listening, deep listening, understanding, by having to visualize that person and get an understanding of the emotion, and everything so, history-taking is very much auditory and visual. Majority of it. Once you've taken your history, you move on to physical examination when you actually descend onto somebody else's personal space. And you listen to their heart. You listen to their lungs. You feel a lump. You’re suddenly bringing in in your hands, your ears and everything to actually documenting physiological changes. But again, that's sensory. Special investigations? Radiology is very sensory. You go into the scanner, what comes up? It's an image that you look at. Blood tests? Even though the inputs go into a machine the output gets given to you as a visual bit of information. So I guess in a way that’s visual as well. Even all the steps in healthcare when you break them down. They’re sensory. I think some of the clever robotics in the future is going to involve all the senses. Perhaps it might pick up even the tone of voice. Those subtleties. I think that'll come. back to question list Using design with malicious intent Q10: We could just go back to that point about aesthetics. The point of art is to evoke some kind of emotion in the person as opposed to appeal to logic. Do you think that, trying to use art in a “scientific” discipline like medicine could be used maliciously if people try to evoke the wrong emotions. A10: Definitely. We fortunately don't have much of that in, in healthcare. You know, deliberate, malicious stuff. But I mean, just thinking on the hoof, I can think of many adverts for drugs, in the drug world. It makes you go “Dear me, this is all just about money. Probably a lie.” But it's the way it's been put across to try and increase sales. And although in the US there is a lot more than we see here, I occasionally see the odd thing here too. And I think “ooh that's a lie, but it's some clever wording and somebody is going to go and buy that and try it out.” I think there's quite a lot of malicious stuff on the internet too. You know, people use Google a lot for their symptoms and they immediately get directed to quite a lot of sites that are there just to make money. And again, I'm not blaming the Americans because that's not just them. It’s just that there's such a hyper-capitalist sort of system, and that's just the way things work there. But if you enter an American website with symptoms of a lump or a sore throat, there'd be an immediate thing saying you need to see your specialist. “You might have cancer” and so on. This scaremongering happens, which adds to anxiety. Patient has a neck lump… and the GP might have a look and say that might just be a sebaceous cyst, or some completely innocuous thing. But they've already gone in and googled “neck lump” and were told they've got lymphoma or some nasty cancer. And they wait for two…three weeks to see us (ENT team) and by the time they come in, they’re petrified. So it's often not in right context. I also think there's deceit in the drug world. Side effects of drugs are enormous, but they tend to just get pushed under the carpet a little bit. back to question list Favourite artists Q11: Going back to art and design. Do you have any artists that you particularly enjoy? In any medium whatsoever, that maybe you draw inspiration from? A11: Mr. Mountain: Yeah, that’s a really good question. Art’s a funny thing you know, it’s often in the eye of the beholder because we’re all also different. I'm unnaturally attracted to surreal and impressionist art forms. If I were to wander around an art gallery with limited time then I would probably go into the wing with those art forms. I love good photography as well. I don't know what I mean by good photography but you just know when you've seen something that connects. That is really good photography. As for favourite artists, I like supporting local artists. I live in Fife so there are open days where artists can open up their houses for people to come around. I enjoy that since you’re actually meeting the person that's created the artwork along with seeing their stuff. I've got quite a few artworks that I bought from real people that I know and who live in the area because there’re so many talented artists around and it's a tough career to make money as an artist. Ferenc: You only really hear of the ones at the top. Mr. Mountain: And yet there's so much talent around. A lot of talented healthcare workers as well. I know quite a few med students who are really good. Not only artists but sculptors doing a whole lot of work. back to question list Medicine & Art Q12: Do you think there's a benefit to that? I mean, do you think those two go hand in hand? Medical students and maybe people who enjoy using their hands to make art. A12: I really don't know how close that link is. But I do know that getting into med school is tough. There is usually a lot you have done to build a wonderful CV to make yourself competitive. Among those are often sporting and artistic talents. There're a lot of great musicians amongst medics. A student with me last week is a brilliant violinist who also plays the cello etc. So they quite often have these talents that add up to this bigger thing; getting into med school. Sadly a lot of it gets lost when you’re just in the routine of med school etc. It kind of takes second place. I think as you get older once you've established and you're into things, go back to those activities that you really love doing, because it keeps up an enjoyment of life. Otherwise you’d become too narrow. You become cynical. I look around and a lot of my colleagues just come in and do their job. But they're unhappy and it’s because they're not doing things they love doing. back to question list Advice to med student self Q13: Okay, so a hypothetical question. If you could go back to medical student Rodney what would you tell him? A13: I probably wouldn't do it any differently. I'll explain. It’s that when you're a med student, often your peers and the medical school and the people around you will try and keep you on a straight and narrow path of a standard career progression. In other words, you have to go into med school, do your foundation, straight after foundation go into your next bits. And that you mustn’t take any time out. Honestly take time out. Go do something you really love. Travel. Get experiences from elsewhere. It's a long, long career now. When will all you guys likely retire? 70, I would gamble on. It is probably 68 at the moment but you can be guaranteed it would move up because that's just what they do. So it's a long time between now and then. And yet it’s a rush to have to progress, along a career to particularly keep up with your peers and “those guys who’re ahead of me” etc. Forget it, that's just a waste of time. You can do other things. Even if you take a year off, do another degree or something and then come back, that's certainly an option. We’re setting up a healthcare design masters, which will be open either end of this year or next year. So it'll be a year out for medics, nurses, or for art & design students to do a master's in healthcare design. If somebody is interested in the creative industry, that would be an opportunity. So don't be scared of taking time out and trying unconventional things. back to question list Reliving med student life Q14: So another similar question, if you were to wake up as a medical student today, without the contacts that you currently have, but with the same knowledge. What would you be doing? Mr. Mountain: So finishing off or starting med school? Sushil: Just in the middle of med school. What would you be doing? A14: Good question. Trying to pass exams. In all seriousness though I would try to keep up the other things that I enjoy doing. What I used to do when I was a med student was to keep up my sports. Yes it made life pretty hectic. But then it gets tougher anyway when you go into your specialist training. Because then you’re doing a job as well as studying and often having a family to look after etc. So keep doing the things you are passionate about, whatever those are, and don't forget about them. That’s what I would do. Secondly, careers in medicine could be digitized, and that might be something that impacts my decision-making in medical school. In radiology for example, a lot has already been digitized. Interventional radiology you’d still need human beings. But I’m referring to actually analysing x-rays, CT scans, all that sort of thing. Diagnostics. I think a lot of that will be done through AI. My wife's a pathologist so she sifts through images for a living. And I keep saying that to her. But she firmly believes that you would still need human beings. And she's probably going to be right for a while, but I can almost guarantee that even for pathology, AI is going to kick in and take that over. But I guess you can't really predict the future too closely too. You’ll get it wrong if you try too hard. back to question list Any regrets choosing medicine Q15: You’ve talked about how long and difficult a medical career is. Have there been times when you've regretted choosing medicine? A15: No, I’ve been lucky. I've always enjoyed it. And yeah that's a really good question because I've been worried when I look at the statistics of where medical students are, five years or so post-med school. Do you know how many are actually working in the UK? Among Scottish graduates I think five to eight years on, it's only about 30%. Tiny. I thought it would be 70%. With 30% having children or gone abroad, to work in Australia, New Zealand, Canada or wherever they've gone, but the statistics are scary. And there must be something wrong. I think people are trying to find what it is that’s not working out. Why it is that people are going from a fantastic career and packing it in. back to question list Message to those wanting to leave Q16: If you had a megaphone what would your advice be to those 70% of students who are thinking of leaving? A16: Yeah, I don't know. I really don't know. I mean, I probably wouldn't use a megaphone. I would probably try and gather them all together and listen to their reasons why and then try and work back to how we’re supporting people in careers. I think we often don't support people well enough. I can think of two family friends that have been trained here, gone to work in England and then ran into a lot of the politics of what was going on and the BMA fought for them for a long time trying to work on junior doctors’ hours of work and all these sort of things. And Jeremy hunt basically, destroyed a whole lot of goodwill in England, amongst the junior doctors, and those two family members of mine just got fed up with stuff and went to Australia and New Zealand just to try things out initially. They’re loving it. They've been looked after. I mean, the one guy was just saying, “Listen, I'm there with my girlfriend. She's a doctor as well. In our first week of work, they sat us down and said, How can we try and work your rotas out so that you guys can be off on weekends together?” Is that ever done here? No. So yeah, looking after people. Medicine’s a tough and stressful career and you need to have a supportive, nurturing work environment. I think that often doesn't occur here. It's funny when you asked me about what things were like in the past. My era of growing up, med school and then postgraduate training there involved a completely unacceptable level of bullying and harassment. You won’t believe the stories that my generation could tell, of the way we were bullied and harassed and that you just nodded your head and got on with it. Otherwise, you lost your job. Simple as that. That's much better now. We've still got a few senior people where their behaviour is not appropriate, but there're not that many of them. But it used to be the norm. It was like going into an army and being shouted at and having things thrown at you and it's scary stuff. That's a whole lot better. But there's still something that's not right. And that's why people are leaving. back to question list Noting things down on paper Q17: One of the first things I noticed about you was your habit of noting things and ideas down in a pocket notebook. I was just wondering, are there other habits you've adopted that you find very useful to you? A17: That's a really good question. And I think you picked up on that habit of actually having an old fashioned pen and paper when you go to meetings, or have a conversation. I don't know if you've noticed, I often doodle down key points and sketch little diagrams. I also teach our surgical trainees that when they've done an operation they should go back and write an operation note or draw the operation. Initially the reactions is, “I can't draw”. But I tell them that I can’t draw well either. But if you actually visualize something through an image, when you come back to that you immediately think “oh yeah, that’s that person”. So in our clinics now we've got loads of patients who've had operations. And they come into the room, I open it up, and there's a picture and I go “Oh, yeah, that's the parotid that was the difficult one”. And it's because it's an image and not a whole lot of text. So it’s about using visual tools and simple mind tools that can immediately help you steer into conversation. Most of the way we work in healthcare is that we’re problem solvers. So we go out and develop and deliver new products and services. That's the way we train, we continue to be problem solvers. We're not problem finders however. We don't do that much. We don't take the time to go and actually spend some time with real people, listen to their lived experience, and then distil down the important things that matter to them and then develop the product and service. So I use visual tools quite often to facilitate this problem-finding and solving process. Realistic medicine’s a good example of a visual tool that you guys might know. If you asked me what's my understanding of realistic medicine, this (*points to realistic medicine infographic*) is in my head. Visual ways to remember stuff is also useful as you get older. back to question list Useful habits Q18: Are there other habits that you can incorporate alongside using visual tools? A18: Mr. Mountain: Yeah another really good habit that I've learned from the design world is concerning presentations. Say, you are asked to do a talk on a subject, the healthcare habit or way of doing things is to create a PowerPoint presentation often with a heading and a few bullet points. Have you been to a lot of those? It's so boring. And I think human beings naturally don't engage with that. A good way of engaging with an audience and getting them on board is to start with a real human story. Tell a story about somebody who's been diagnosed with so and so disease and here is how they first discovered they might have a problem etc. A real human story. And then start weaving your facts and everything in around it. It's a really good way to capture people's imagination if you're doing a presentation. So try it out. It really does work. The second thing is when you put together a talk, try and take away as much of the text as you can, and put up images instead. You can maybe put a heading as the only text. Have you been to any of my talks? Sushil: I have seen one of the TEDx talks, where you started off asking everyone to imagine they feel a neck lump. Mr. Mountain: Exactly. Get your audience to do something. I did another talk in Dundee a few years ago where the lady said, “Look, create 20 slides and then send them to me and I'll just give you a bit of feedback as to what I think.” And I did an old fashioned thing of including way too much text in it. She said “Stop, stop, stop. Try and take all the text off. That's your challenge. And come back.” I asked, “But can I keep a little bit?” And you know I did manage to keep a little bit in, but now I think she's right. Her advice was absolutely spot on. Even explaining complex scientific things, I’d rather use an image than text if you can and I’d always try to bring in a story. A story is key to capture and keep people's attention. So yeah, those would just be little tips. back to question list Book recommendations Q19: What are some books or resources or advice that you think have impacted you the most? I know you’ve mentioned ‘change by design’ before, but I was wondering if there are some others that we haven't managed to talk about. A19: Yes I’d suggest ‘change by design’. If any of your audience are interested in design and what's called ‘design thinking’ then change by design is a very readable and simple book. You can understand it and I think good books make complex things simple. Thinking of other books that are really good in a healthcare context, there's a book on disability by Graham Pullin and I don't know if I've shown you that. It’s called design meets disability and Graham Pullin is an academic designer that works at Duncan of Jordanstone here in Dundee and he's a very humble guy. But he's probably in my mind a world authority on design for disability. And it's a book where he goes through the history of the disabilities that we take for granted now. You know, regarding spectacles-wearing, if you went to the 1950s NHS all your glasses came out with these horrible black rims, quite fashionable now, but standard issue things. People were given hearing aids in much the same way. They were big clunky things and nobody wanted to wear them. And if you look at specs now, something like 40% of Americans that wear specs don't have a visual disorder. It’s a fashion statement now as well. And Graham takes you through all the disabilities, physical disabilities and all that sort of thing. It's a wonderful book. As a healthcare worker, other books that I think are worth reading are just about everything written by Atul Gawande. Atul Gawande is just fantastic at really standing back and looking at the bigger picture of healthcare. His stuff I really like. Yeah, those are just a few that are fairly high up on my list. back to question list Promising areas apart from service/product design Q20: In medicine, what you’re doing now is spreading awareness of design and trying to contribute to that area by merging the arts and medicine together. Let's say, it started to get universally accepted and has started to plateau (in terms of growth) in an ideal world, what other problem or area of potential value-add would you be working on? A20: Yes, I always like doing something new. I would probably go and get a better understanding of computing. Because I don't have a clue. I use computers, but that whole AI, robotics and that type of stuff. I'd channel my energy into that. I know I'll never be able to achieve much in my lifetime in that space. But I think that's where I would go in and get a deeper understanding and see who I could work with in that world. I’d like to understand AI better. How it actually works, how these algorithms work, and how they could work more effectively. That's probably where I’d take my energies to. back to question list Inspiration Q21: Is there anyone you draw inspiration from? A21: Mr. Mountain: Yeah, quite a few people. I've been hugely inspired by Catherine Calderwood as our Chief Medical Officer for Scotland, and realistic medicine. She, to my mind, has been a breath of fresh air. Your group of med students have probably not covered realistic medicine much at all. Am I right? Ferenc: There hasn't been much mention of it in the curriculum. Mr. Mountain: It's a key, almost philosophical rethink of what we should be doing. The style, culture and the way of working. And, you know, she's a Scottish chief medical officer. She's not political. It's not a political appointment. But she's been a visionary in challenging us as healthcare professionals to just sort of pause and ask “Let's reflect on what we’re trying to do. Shouldn't we just completely rethink the method of the way we work?” , I think proper shared decision-making, getting away from paternalism is a very key thing. Your generation are much better communicators than my generation were. But there's still a lot of people that are very paternalistic in the way they practice. And there are patients that like that, you know, especially among the older generation, where they want the doctor to tell them what to do. But I think that bit of realistic medicine of saying, “Look, we need to empower people to have a bunch of decent information before making big decisions” is important. Her whole concept of personalized care is crucial as well. To my mind when I think about personalizing, I think about journeys, that you think, “Oh, I've seen you today with your sore throats and had a look at you and I'm worried that you might have cancer. I'll do your scan and I'll see you next week or the week after to get the results. I’ll do your operation, I'll follow you up.” And really personalizing something and once you reach a stage where you can't do that anymore, personally handing it on to another responsible person to do that. We don't do enough of that in healthcare. We move people around “I’ll refer you to orthopaedics, I will refer you somewhere else.” We used to have GPs doing that. GPs are under such stress now. But I think that old fashioned thing of your GP really knowing you and you go back to see your same GP has unfortunately been lost. The other reason why I really look up to Catherine for her idea generation is that she's challenged (and I think she's quite right) in saying “Do we over-investigate and over-treat people particularly towards the end stages of their lives?”. And we do. I have no doubt we do. I do a lot of talks on realistic medicine and if you got an audience you’re talking to, I'd like to sometimes get a feel for what kind of experience in the healthcare world they really get. I ask the question to anybody in the audience who either have a personal experience of or had a loved one who has been over-investigated, overtreated and were actually harmed by the drugs or operations. You can actually see a whole lot with their hands up in the audience. And, you know, I see that in cancer stuff too. I'm a cancer surgeon and we definitely do too much to people particularly towards the end stages of their life. It’s just a habit. You’re a doctor and you feel the need to be doing a little bit more. Trying to cure this trying to do that, when it's obvious that you should maybe look at quality of life and allow people to die a dignified death. That's what you should be prioritizing. But we struggle as doctors to do that properly. back to question list Quality of life vs longevity Q22: In some sense, starting to think about quality of life is a different field entirely isn't it. That last bit of life is no longer based on scientific principles of health versus disease but more philosophical or design-oriented thinking of what makes a good life. A22: It's true. Just about every day I have one or, some days unfortunately more people where I have to have some conversations involving breaking bad news. And what I've learned is that people want authentic honesty. Looking them in the eye and being honest with them. That's what they want. But you have this real fear. Have you ever had to tell someone they’ve got cancer yet? It's a scary word. It's scary because you don't know what the human being’s reaction is going to be. Are they going to break down into tears? Are they going to start wailing or are they going to get angry? And anger is quite often the response. So it is going to be an emotional reaction. And we often try and protect ourselves from that. The reality is that if you are really honest with people, they really thank you. You can see it in their eyes quite often. “Thank you so much for being honest with me. I knew that this was bad.” I had a guy last week who came into the coronary care unit acutely with chest pain, shortness of breath. 50 years old. Looked cardiac and that's why he’d gone to the coronary care unit. They soon realized that it wasn't cardiac so they got a CT scan of his chest and everything. Big mediastinal mass, lymph glands in his neck. So they called us to say, "Well this guy is short of breath, his airway’s compressed, he’s hypoxic. Can you help us?" I quickly took a look at him, looked at his scan and lymph nodes in the neck. This can only be one thing. It's gonna be cancer of some sort. Probably gonna be a really bad form of cancer. My first interactions with him on the coronary care unit were ones of an honest conversation. "Hi, I'm from ENT and I’ve looked at your scans and I'm unfortunately concerned that this might be a serious disease. It might be cancer” I actually brought that word into the conversation. You could see him immediately say “Yeah that's what I thought this was. Thanks for being honest with me.” We diagnosed his problem and quickly realised it was widespread small cell carcinoma of the lungs. I don’t know if you've done much on lung cancer, but that is really, really bad news. Struggling to breathe, no chance of any cure with chemotherapy, radiotherapy or anything else. So I had to come back and have an honest conversation, that we couldn't carry out any intervention that would cure the disease and that we were going to just change the focus, to allow a dignified death. Again, a very difficult conversation. “I'm going to help you die in a comfortable way. Pain-free, stress-free.” And he completely understood that. People do get us and we're fortunate to be able to do that. He died within 24 hours. But those bits, you can be trained to do in med school with actors and things, but doing them in the real world is a different thing. Those components of what we do are very much part of realistic medicine. And Catherine is a real star. The other person that I really look up to is a fellow designer in Dundee called Mike Chris. Mike’s a service designer. He used to be a professor at Duncan of Jordanstone and he now runs his own service design company. I've learned everything I know about service design and design thinking from Mike because I've actually gone up and watched him in practice. One of the nice things about design is that, it’s not theoretical. Design is always people doing things. That's why I'm attracted to design. People aren't sitting around and doing theoretical stuff on computers. They’re actually making things, they’re prototyping, they're trying out something. Mike Chris is a wonderful guy in Dundee and if you were looking for another interesting person to talk to, a person who really knows what service design is, how to engage with human beings, find out how to prototype and make things, Mike’s great. back to question list Implementing change within healthcare Q23: Healthcare seems like it's one of those rigid sectors and in most cases for good reason because mistakes are too expensive. Especially with regards to patients’ health and lives. On the other hand, it also makes it hard for changes of benefit to be applied into systems or how people do things. So have you yourself encountered problems when implementing change? If people who want to change something but just feel too much resistance, how can they cut through those barriers? And what would your advice be for especially younger people who want to make a difference in this sector? A23: Mr. Mountain: I think you're spot on to what is a big cultural problem in a big organization like the NHS and I think it's not just the NHS. It probably goes for a lot of healthcare systems. It sort of taps into the sixth component of realistic medicine. That innovation and improvement can occur from a bottom-up fashion, rather than top-down. And we don't do that well. I've had quite a few examples of a good idea that could be taken on but the NHS is just too scared about the risks attached to it. They're very risk averse. Whereas if you work in the private sector, that's not a problem. You take risks. That's the only way you differentiate yourself and get people to buy your product. So we’re too risk averse, I would suggest. We don't have enough people that are angel investors sitting around the healthcare arena, ready to pick up great ideas that are coming up. We don't have a mechanism to link people with good ideas. Not enough angel investors saying ” I'll give you 10 grand to take that idea” knowing that they might lose the 10 grand, or they might make millions out of the investment in you. What we’re trying to do on the local level in Tayside now is that we've got the academic health science partnership with a component linked to innovation and looking at where ideas from students, doctors, staff, patients, could be taken up and looked at closely and seriously. And then really looking at how they could be supported in trying to move things on to become commercially viable. So we try, but we've got a long, long way to go. If I take myself as an example, I've been quite innovative in designing new retractor systems. I came up with new ideas probably five years ago. And I took it to the NHS first and they said “No, that's too risky, we won't do that”. Took it to a company who said “They don't like creating reusable devices.” I eventually found a company in Sheffield, that really got the idea. And we're now going through the CE marking, patenting and all that sort of thing. And that takes years. Way, way longer than you think, because of bureaucracy after bureaucracy. The big problem, and I can almost see this coming my way, is it's something that I've invented and is really useful for use but still has to come through procurement from the NHS to actually put it in theatre for me to use. It may also not get distributed and you might never see it in your own world. So if I were a doctor working purely in the private sector and designed a device that has made it straight from the shop, I'd use it because I invented it. But I can almost predict that this product’s going to be on the market later this year. It is then that we're going to go through a hefty procurement phase where they'll say there's probably bias because I'm going to be biased towards my own product coming in against our competitors. So there are a lot of barriers. It's not easy. Ferenc: What you're saying reminds me of early orthopaedic surgeons and how they would mould their own things they were going to use in theatres. And it's kind of a pity that the practice has disappeared. The idea of surgeons trying to put their own hard work into that aspect. Mr. Mountain: Yeah, we do. I mean, we’re still lucky in surgery in the sense that we do learn new techniques from colleagues. And I don't have to go through a whole lot of bureaucracy to bring in that new technique. It needs safe training on how to do properly. But you can actually do that. And that's why I think surgery is quite fun because new ideas can happen. The technologies we now have are also fantastic in surgical disciplines. The next big technology is robotics and robotically-assisted stuff. So we’re constantly in a field where the devices get better. But the actual “taking an innovative idea forward” making it a success within an organization or making it commercially successful is quite difficult. You've got to be quite determined. I am trying to get design-thinking into our local organization here. And that's quite a challenge because rightly all healthcare systems have quality improvement as a key method for patient safety etc. But then the methods that are used in quality improvement are very often based on measurement of tangible things. They are very rarely involved in patients’ emotions, responses and those things that are more in a design field. So, what I've done locally to bring design thinking into our world is to marry it up with quality improvement. A lot of quality improvement methodologies start here. “I've got an idea on how to solve some issue, I'll go and solve it”, but we are not good at asking “who’re we doing this for?” It’s usually patients, so we need to really sit down with them and then find out what their day to day needs are and then go on and do it. A lot of people think that design is just fashion. But that's only a tiny bit of what design is all about. Just about everything designed was made by man. Think about it. You can look around this room. Everything that is man-made, you can often go back and say that the design process has taken place. And I use a three stage process: It starts with imagination. But it’s not yet a tangible thing. You have an imaginary idea of a future. You then go into sketching, mapping it out, drawing it, and then actually prototyping it. Making it into a physical thing or digital technology, trying it out, failing, and then eventually ending up with something that creates that future that you have in your mind. Its design that’s in the middle of making imagination a real thing. It’s also very much sketching, visualizing and making. But those are the practical things. back to question list Short-termism in healthcare Q24: You said it was challenging to get that kind of thinking in healthcare. Is it a matter of finding a designer from the outside? A24: It’s a mix. There’s this cookbook idea that we brought in, and I've been lucky enough to get the ex-dean of Glasgow School of Art, Tom Inns. So Tom has been paid to actually come in and work with the quality improvement team for about six months, get an understanding of what they do, and then bring design ideas into that world. So I've been lucky enough to do that in Tayside. So yes, it involves bringing in experts. I’m no expert. I'm still learning all the ways. I can work as a service designer to a certain degree. But it's about bringing in people who really know what they're doing, to do it. And it’s about changing a culture, which is very difficult. And if you took an organization like NHS Tayside, our leadership, chief executives or whoever's the chairman of the Health Board, it’s that they are under such tight scrutiny by the politicians that they have to spend most of their working lives looking at money and that resource and how to use it as effectively as possible. So in other words, waiting times and similar types of targets. That's what they’re measured on. Whether they’re in deficit etc. And they're always in deficit. That's one thing that happens in the health service. But that's their day to day life. They very rarely have the luxury of being able to actually stand back and do long-term planning. And that's one of the big problems that goes on. It's all short-termism. To tackle the obesity crisis and diabetes, clever money should be spent on looking at long-term strategies on food, exercise and what's going on in society. Otherwise, we've just got a tidal wave of stuff coming our way and getting bigger. But who's going to do that? Nobody. They'll invest a little bit. It's that they're having to invest all the time and money in the now. But design is very long-term. With a lot of service design methodologies we want to change things in a span of five or 10 years. Realistic medicine is a long term strategy as well because Catherine is a long-term thinker. The other great long term thinker was the chief medical officer just before her. He was fantastic as a chief medical officer because he realized that the first few years of life (seven years or so) as a human being is key to your future health. And there's a lot of research that clearly states that and has worked out that investing time and effort and money into looking after young kids in society will pay huge dividends, both physically and psychologically later on. But that takes time. It doesn't happen overnight. Ferenc: Wow, that must be politically hard to justify as well because there's such a lag time in any benefit you might see if it's even measurable. Mr. Mountain: Yeah. But interestingly enough, outcomes related to his work, is very measurable. And a lot of it has got to do with cortisol levels. You and I have a cortisol rhythm and you get a little boost in the early hours of the morning. In kids that are constantly stressed, that cortisol level goes up, and it doesn't fluctuate as much but just stays up, and stays up for the rest of their lives. And that's why you die of heart attacks, strokes, diabetes, all these sort of things later on. You’re programmed wrongly in those early years and you can measure those things. And that's where his stuff has really taken off. Because there were some tangible things where you could say, “yeah, this is for real.” So yeah, we've been lucky in Scotland to have some really future thinking leads. But yes running a health organisation is a thankless job because of the money and politics. back to question list Advice for younger generation Q25: Any advice for younger up and coming professionals who want to try and change things? A25: It’s to constantly be inquisitive. Always challenge what you see around you and challenge the literature. Really there's a lot of rubbish out there. Okay rubbish is the wrong term. But you know, I look at a lot of published stuff. And I think “that just doesn't fit the real world” because quite often publications are dealing with a single disease entity, a drug and an outcome. Life's not like that. Life’s way more complex, physically, psychologically, socially. So they've very rarely painted true pictures of people's life. So be very critical but also be imaginative at the same time. back to question list

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