Yea, but what’s the problem? A simple lesson learned from a current fellow

As a current Biodesign fellow, now one-third of the way through the program, I am confident in saying that the most useful lesson learned so far happens to be the simplest of them all…

Now three weeks removed from the program’s flagship clinical immersion and needs finding phase, my team has just finalized a list of 16 clinically observed needs—filtered down from a less manageable 260—which we will use as a medium for learning the rest of the Biodesign process. Around here, this method for systematically identifying, validating, and putting forth a strategy for solving some of today’s unmet clinical needs is simply referred to as “The Process.”  The two fellowship teams of four are composed of engineers, physicians, PhD’s and business people. We have all spent the beginnings of our young careers attempting to solve some very difficult problems. Now as fellows, we are given the privilege of trying to do something much tougher, something completely foreign…we are asked to find them.

As an engineer with little prior clinical experience, I found myself on the third day of the fellowship biting my lip during a lecture on cardiac electrophysiology so as not to say out loud: “wait, so the heart is on the left side right?” Weeks later, I was standing on tip-toes trying to get a glimpse over a surgeon’s shoulder during an open surgery for an abdominal aortic aneurysm. Equipped with my notecards and pen, and nothing but an occasional glimpse into the patient’s gut, I was frantically trying to figure out what on earth the surgeons were doing. Then I realized: ‘oh yea, I am not here to learn how to repair an aneurysm. I am here to figure out what the surgeons are not doing, or what they could be doing less invasively, or more effectively, or in a less expensive clinical setting.’ With this new mindset, I felt as if I had strolled into the kitchen of a nice restaurant and was watching the head chef preparing a soufflé. I was racking my brain trying to figure out what this culinary expert might need so that the people sitting out in the dining room might leave happier and more satisfied. Please keep in mind though: personally, I can hardly prepare a decent bowl of pasta.

Luckily this program provides the fellows with access to tremendously successful mentors and advisers that help us learn how to find problems. During a sit down with Mir Imran (a man at the heart of the invention of the Implantable Cardiac Defibrillator) we were told: “It is only a problem if somebody will care that you have solved it.”  As simple as this sounds, our team has realized how easy it is to fall into the trap of perceiving something as a problem just because we can envision a better way of doing it.  This solution based thinking is the ultimate Biodesign faux pas and comes free with the beloved faculty retort: “Don’t be a hammer looking for a nail.”

As an engineer, it is unnatural to abstain from thinking about solutions. During that AAA surgery I noted, “it is taking too long for the surgeon to suture the vessel closed.” What I was actually thinking was, “I bet I could make a miniature sewing machine for that”. Since I often make this mistake, my team often auto-responds to one of my clinical observations with: “Yea, but what’s the problem?” This question is repeated relentlessly until someone can identify a real negative down-stream effect of the observation. For example, it simply isn’t good enough to say that something is taking too long.  We are taught to put methodical work into answering questions like, “What is gained by the system as a whole by incrementally speeding up this procedural step? How might this affect the flow of the hospital? How will the patient be affected?”

Often we are reminded of the risks involved in attempting to change practice patterns. Sure, we are in the business of trying to change things, but we have to address a significant, quantifiable problem or nobody is going to buy it, no matter how perfect the solution. This is one of those rare pieces of advice upon which all our advisers agree.