Rapid Ethnography – The Study of Behavior, Communication, and Context in Cosmetic Surgery Consultations and the Design of a New Medical Device Psychologists and Human Factors Specialists, MSc Betina Rangstrup and MA Thomas Koester FORCE Technology, Department of Applied Psychology Design Engineer Malene Nibe, Danish Technological Institute BSc (Psych) Tille Vedel Schøler, Aalborg University Adjusting expectations • This presentation is not about patient safety, human error, failure or risk • But it is about a consumer health care technology in a setting where adjustment of expectations and patient satisfaction is of extreme importance • • • • Work in progress – testing a prototype Drawing the whole picture – not going into detail Presenting examples from our work process A case study in application of rapid ethnography The context Pre-surgery consultation for cosmetic breast augmentation The problem From the perspective of the patient: Many choices to make What hospital or clinic? What surgeon (confidence and trust)? What implant material (silicone or saline)? What shape (round or anatomical)? What projection/profile? What size? How will I look after surgery? Illustrations: www.eurosilicone.com The solution 3D Surgery is a decision support tool based on 3D computer visualization technology Illustrating how the result may look Based on realistic surgery results from database rather than morphing (competing technologies) 3D Surgery The SEPTIGON model applied as framework for understanding pre-surgery consultations for cosmetic breast augmentation Gender, age, personality, social background, etc. Emotional state and behaviour. Pre-consultation decision process and motivation. Opinions, knowledge, expectations and wishes for consultation, surgery and surgical outcome Surgical preferences, competence and values. Previous experiences and plan for consultation process and own role in decision process (Surgeon). Emotional states and behaviour. Opinions, knowledge, expectations and wishes for consultation, surgery and surgical outcome Patient Artifacts within the consultation room Surgeon Friends, relatives, spouse Measuring instruments, computer, implants, mirror, 3D Surgery, etc. Consultation room Society and culture Trends, body image, norms, media, aesthetic surgery culture Space, spacing, light, noise, temperature, electricity provided, also used for, ownership, etc. Time, structure, law and regulations, purpose and content Consultation process Hospital Profile, branding, prices, values, goals, finance, organisational culture, employees, management, etc. Ref.: Koester, T. (2007). Terminology Work in Maritime Human Factors. Situations and Socio-Technical Systems. Copenhagen: Frydenlund Publishers. Our job Understand 3D Surgery Prototype in the context of use Understand how 3D Surgery Prototype is perceived by users (patient and surgeon) Give inputs to the design process (both software and hardware) Give inputs to the future use of 3D Surgery (and to instructions for use) Outline of our work process Data analysis, SEPTIGON model Design recommendations Field study, video stimulated recall interview User tests, participatory observation, verbal selfreporting protocol and heuristic evaluation Data analysis, theater reference frame and decision making theory Design recommendations Design recommendations Ongoing prototype development Field observations, rapid ethnography Methodological approach: Data and results are used both in fine tuning of our instrument and in the design process Our instrument Method Method Our data and results Rapid ethnography Composite methods Insights Data analysis framework Psychological theory Theater reference frame Design observations, comments and recommendations Decision making theory Not rolling out a fixed or standardized method – but continuously adjusting choice and application of method according to the insights we get through the process Rapid Ethnography 1. Rapid ethnography 2. 3. Composite methods Theater reference frame Decision making theory Two observes, discussion of observations Use of key informants Hours or days rather than weeks or months First insights: The rapid ethnography data analysis 1. General understanding of the user context and how it could be investigated further using composite methods 2. Finding that the consultation consisted of an elaborate interactional process between surgeon and patient and with the use of several artifacts 3. Finding that the interactional content of the consultation could mainly be understood as a decision making process (into which the 3D Surgery equipment was to play an important part) First design observations, comments and recommendations Kommen Dato tar No. 1 jun-12 Setup relevans Baggrund Design(Grymer, OUH, Observation (O) område alle) Udsagn læge eller læge testperson (L eller LT) Udsagn patient (P) Teori (T) Bruger Beskrivelse (Læge = L Patient = P) Grymer PL O, L, P Software 2 jun-12 Grymer O Software PL 3 jun-12 Alle O Software PL 4 jun-12 5 jun-12 Grymer Alle O O Hardware P Anvendelse og P instruktion Designanbefaling Kameraet fremstiller kun 3D foto af torsoen, men Det kan eventuelt undersøges, hvorvidt det er muligt at inkludere en patientens vurdering af brystets størrelse i forhold del af hoften, når der fotograferes. Der er dog stor sandsynlighed for, til kroppen er baseret på en helhedsvurdering. at dette vil blive for besværligt, særligt ift. Shape Modellen. Alternative løsninger, hvor billedet af patienten kombineres med billederne i databasen til en samlet fremstilling kan undersøges. Se også kommentar no. 43 Det er usikkert, hvordan og hvor præcist Er der eventuelt brug for optegning ved lav kontrast mellem kameraet registrerer brystvorten. brystvorte og hudfarve? Det ses ved brystløft og brystformindskende operationer, at der ofte sker en reducering af brystvortens størrelse, hvilket har en stor betydning for det visuelle resultat. Der er mulighed for at patienten indtager to helt forskellige kropsholdninger ved fotografering før og efter operationen – og at dette har konsekvenser for 3D billede og databaseindhold. Patienten oplever at modtage en stor mængde information under konsultationen, og der er derfor risiko for ”information overload”. Det kunne være væsentligt at teknologien er gearet til at forventningsafstemme omkring størrelsen på brystvorten, fx kunne man forestille sig mulighed for at justere størrelsen på det genererede billede i Shape Modellen. Betydningen af kropsholdning for billede og volumen skal kortlægges. En mulighed, man kunne overveje, er at lave 3D foto med patienten stående udstrakt op ad en væg i lighed med når man skal måle legemshøjde. Se også kommentar no. 44. Det skal være muligt at give en simpel og letforståelig forklaring til patienten af hvad formålet med 3D-foto er. Prioritet Høj = umiddelbart væsentligt for funktionalitet Trivision kommentar Mellem = væsentligt (dato + tekst) når teknologi funktionel Lav = skal overvejes ift. endeligt produkt Lav Mellem Man kan formentlig sætte en hofte på - på samme måde som vi laver en kunstig ryg Systemet giver et bud på brystvortens omkreds men operatøren har ansvaret for at optegningen går godt. Lav OK - burde være muligt. Høj OK - dette har ikke betydning for softwaren. Men det er oplagt at lægen indfører de rutiner der går mod et bedre resultat. Høj Hvordan? Har I et bud? Composite methods: The field study 1. Rapid ethnography 2. Composite methods 3. 4. Theater reference frame Decision making theory Combined observation and video stimulated recall interview Ecological validity (“almost real” patient and real surgeon) Continuous evaluation of realism by surgeon and patient Regular usability tests with participatory observation, verbal self-reporting protocol and heuristic evaluation Second insights: The field study data analysis 1. Further understanding of the user context 2. Confirmation of relevance for applying a theater reference frame for further analysis in relation to the interactional process 3. Confirmation of relevance for applying psychological decision making theories for further analysis in relation to the decision making process Second design observations, comments and recommendations 26 8.2.13 Alle (Grymer) LT Software L Program 1: LT forstår ikke helt rækkefølgen, da Navngivningen i programmet skal være enslydende anvisningen ikke har samme navn som skærmen - reflektorer/mærker (se billede) Høj 27 8.2.13 Alle (Grymer) LT 28 8.2.13 Grymer (Grymer) LT 29 8.2.13 Grymer (Grymer) LT, O 30 8.2.13 Alle (Grymer) LT, O Software Software Software Software L L PL L Program 1: LT kunne godt ønske sig en knap der Selvom der er to programmer, bør det gøres til en oplevelse af ét hed ”vis målinger” der gik over i program 2 program for brugeren fremfor at det skal åbnes separat Program 1: Begge brugere undrer sig over Hvordan er man kommet frem til det nødvendige antal prikker i antallet af prikker i siden, og synes det er mange. siden? Kan der blive færre? Hvor mange prikker nødvendige i siden (se billede), jo flere markeringer der skal foretages, jo længere tid tager det. Program 2: Påfyldning af volumen: det ser ud Vi regner med dette er en præmatur funktion og ikke bud på den som om brystet kun vokser ud ad – ikke til siden endelige fremstilling og i midten Hjælpeteksten er rettet fra reflektor til mærker (skal muligvis ændres fra mærker til noget helt tredje?). Mellem Der er indført en knap der "hopper" til 3D doctor og indlæser aktuelle patient og model. Mellem Vi arbejder på at indføre en autodetektion af konturen. Dermed burde det ikke gøre noget at antallet af konturpunkter er højt (med mindre auto detektionen fejler ofte). Vi vil dog også reducere antallet af punkter nu. Lav Korrekt Høj På OUH anvendes et program der "låser" musen til en desktop, så den ikke kan komme ud på projektorene. Dette program installeres på Grymer-maskinen. Se dog også punkt 18. Program 2: Musen kan forsvinde ud af skærmen, Musen bør ikke kunne forsvinde ud af skærmen. så den ikke er til at finde. Dette er tidskrævende og et irritationsmoment Theater reference frame • Rapid ethnography • Composite methods • • Theater reference frame Decision making theory Idea derived from the rapid ethnography analysis Idea further refined in the composite method analysis Theoretical background inspired by Goffman Chosen for its explanatory power Theater reference frame • • • • • • • • • • Scene Props and scenography Actors and spectators Roles and shift of roles Lines Manuscript Improvisation Dramaturgy Choreography Frontstage, backstage Theater Reference Frame Insights: Dramaturgy 1. Introduction "Setting the scene" a. From waiting room to consultation room b. Patient’s background for wanting surgery c. Patient health status questionaire 2. Surgical information "Presenting the product" a. The implants - type and material b. Surgical techniques and implant choices c. Surgical results (before-after pictures) d. Before, during and after the operation 3. Collecting data "Measuring the patient’s body" a. 3D Surgery picture and measurements b. Cardio rhythm and blood pressure 4. Shared decision making "Making the right choice" a. Trying out implants in front of mirror b. Viewing 3D Surgery Shape Models 5. Outroduction"Contracting" a. Taking implants and 3D pictures home b. Booking operation e. Complications Theater reference frame results Waiting time at picture processing: • Traditional usability pathway: Reduce waiting time through optimization of manual picture processing • Theater approach: Adjust dramaturgy and choreography, use time slot to introduce a welcome break for trying implants in sports bra • Adjust focus in SW development: From usability of interface to development of other features Theater reference frame results Props: • Use of simple props e.g. implants, bra and mirror for visual appearance with clothes on • Use of high fidelity props (3D Surgery) for visual appearance without clothes • Adjust focus in SW development: No need to put effort into a “with clothes feature” • Statement from CM about visual appearance with/without clothes Decision making theory • Inspired by the distributed cognition paradigm (Hutchins), shared decision making and distributed decision making (Chapman et al.) • Inspired by the naturalistic decision making paradigm (Klein): Decision under time pressure • Multiple participants • High-stake consequences • Unclear goals • Incomplete information (to be solved by 3D Surgery) • Uncertainty • Time pressure Rapid ethnography Composite methods Theater reference frame Decision making theory Decision making theory results Example of outcome from decision making approach Design recommendation: Create option for patient to bring selected pictures home on USB memory stick Effect: Increasing likelihood of long-term patient satisfaction with surgical choice Background: • Important decision / time pressure (consultations often shorter than 1 hour, time to make decision 10-20 minutes) • Avoiding use of short-cuts and biases in decision making • Possibility to include spouse, friend etc. • Facilitating emotional bond with product choice (consumer perspective) Validation of insights and results Rapid ethnography Composite methods • • Theater reference frame Decision making theory Follow-up interview with patient and surgeon Retrieving comments from development team Summary Our instrument Method Method Our data and results Rapid ethnography Composite methods Insights Data analysis framework Psychological theory Theater reference frame Decision making theory Design observations, comments and recommendations Conclusions and lessons learned 1. We find that rapid ethnography with limited time and resources can generate valuable in-depth contextual enquiries 2. Results are used not only for input to the design process as observations, comments and recommendations, but also as input to the continuous fine tuning of our repertoire and application of methods, frameworks and theories in our analysis (method and data triangulation) 3. When employed as part of the design process, a rapid ethnography approach can save otherwise wasted time and resources for development of superfluous system features 4. Thus, applying a rapid ethnographic approach ensures that even with limited time and resources, the medical device is designed to create not only a perfect fit for the user, but also for the context of use. Contact information Betina [email protected] Thomas [email protected] FORCE Technology Department of Applied Psychology Copenhagen, Denmark www.forcetechnology.com