A Return To Simplicity

I recently watched the entire 6 episode run of A Chef’s Table (IMDB) on Netflix and I was struck by how much each chef’s passion and drive was for purity, the directness of farm-to-table and a focus on clean and perfect ingredients. Although there is still a place for innovation in high tech, complex and abstract creations in the food world (Achatz, Dufresne, Cantu and of course Adria) where the lines between art, experience, memories, emotion and food blend together in beautiful ways, there are many chefs that are pushing for perfection in going back to traditional methods and presenting the ingredients in the cleanest and purest way.

In short: A return to simplicity.

Dan Barber of Blue Hill is one of these chefs that is leading the innovation of presenting the absolute best ingredients and products with few frills and as direct as possible to the consumer. “You get to taste what a tomato REALLY tastes like,” he says “when the plant is grown in the best conditions and without a focus on how it looks.” His innovation in so many ways is that he is taking us back to a time before complex, mass-produced, bland foods. By keeping things simple, he in fact brings about a new way of looking at what we eat.

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Credit: High50.com

While watching the episode on Barber along with the ones on Magnus Nilsson of Faviken and Francis Mallman, I couldn’t help but think about the concept of Jugaad in the field of medical device innovation. A colloquial Hindi-Urdu word that can mean an innovative fix or a simple workaround (Wikipedia), it has been an idea that has stuck with me ever since I read an article where simple plastic cones had been easily reshaped to become water desalination containers. Such a simple and beautiful design could change the lives of thousands if not millions of people.

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An example of jugaad where the bicycle drives the sharpening stone. Credit: youtube.com

In so many ways, it is easy to make something more complicated and to keep adding features; building on what is already there. To look at a problem (be it mass-produced, mass-farmed foods or an unmet medical need) and think about how to address it in the most pared down and simple manner in many ways is more challenging. At the same time, it does also mean a greater potential for end user adoption, as the usage should be more intuitive and decreasing the slope of the learning curve.

Just this week, IDEO revealed their Antibotics campaign as a refined approach to getting children to take their antibiotic pills. Sticking with the definition of jugaad, this is an innovative solution to the ages-old issue of getting children to take their medicine (and swallowing pills whole no less!). Fundamentally, the medication is no different, but by simply crafting a storyline around the pill, you can increase compliance and medication adherence. This is absolutely elegant in its simplicity.

I will soon be running a clinical trial of an endoscopic device at my home institution that I developed using Teflon heat shrink tubing and ceramic balancing beads used in motorcycle wheels. The device is an endoscopic cap that allows the gastroenterologist/surgeon to now have circumferential directional guidance on the video monitor to increase procedural accuracy and to be precise in reviewing portions of the esophagus/intestine that they may have previously biopsied or want to keep an eye on. Total material cost for each cap? Less than $0.10 and biologically safe.

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When I was looking through the prior art when designing the device, I was struck by how much of the IP that existed to address this issue relied on high tech, complex solutions involving gyros, external hardware for positioning, magnets and other electrical systems. In an age where we are surrounded by technology and with new things coming out every day, it is easy to pile tech on tech. Taking a step back and thinking about a solution to a problem that does not necessarily rely on a complex approach can be refreshing.

Stanford Biodesign’s India branch has recently developed a way to confirm secure cardiac positioning and insertion of the electrical leads for pacemakers. Using some plastic, popsicle sticks and a spring, they prototyped out a functional system that can let the physician know if the leads were inserted securely into the cardiac muscles. A complex and potentially catastrophic problem was addressed with the most basic of materials.

Dan Barber says, “Without great ingredients, there are no good dishes.” Indeed as a creator, inventor, and/or designer, we need to have the right armamentarium, the right skills and the best environment and infrastructure to innovate. We create where we identify a need or see a problem in the world that needs a solution, and there will always be elegance in refining and paring a device down to exactly what is needed.

Forward Thinking With Historical Precedent

This past weekend I watched The Imitation Game and it got me thinking quite a lot, not only about the Ultra project/Bletchley Park, but also about the many parallels drawn between Alan Turing’s work and Google as well as Silicon Valley as a whole.

There is certainly no mistaking the revolutionary work that Turing did during WWII. Deciphering the Enigma through the creation of a machine that would use brute force analyses to churn through all the possibilities led to the advent of the modern day computer. In recognition and respect of his work, Google even sponsored the New York screening of the film and invited people to take part in a code breaking challenge.

In learning about this, along with Turing’s original method for recruiting people onto his team back in 1942 by placing a crossword puzzle in the Daily Telegraph (image credit to Charis Theobald), I couldn’t help but remember back when I first moved to Boston and a mysterious billboard showed up in Harvard Square:

google billboard

Turns out, this was posted by Google as a method of recruitment with the final page of the website inviting you to submit your resume. The parallels between this approach and Turing’s crossword puzzle are undeniable to me, and reflect not only a clever recruitment method to join a creative and innovative institution, but perhaps a homage to Turing himself.


In the film, Keira Knightley’s character Joan Clarke is portrayed as a lowly secretary that was able to complete the crossword puzzle (and subsequent testing) well under the time that Turing had set as the goal. In reality, Joan Clarke was well educated and was independently brought on board as part of the code breaking team. Even so, the movie portrayal of Clarke again echoed to me some of the more recent interviews with top Google[X] team members where they talk about shifting focus away from hiring a specialized individual for a specific position to hiring talented (and “T-Shaped”) individuals. The logic is that like the movie version of Joan Clarke, if you possess a certain level of ability, then you’ll be able to adapt and excel at the task at hand.

This is one of the most fascinating things to me about how many of these major institutions in the Bay Area function. To have a goal of bringing together multi-talented individuals that each have a breadth of experience and capability paired with deep understanding of one (or more) fields to solve a problem is quite unconventional in the rest of the nation and the world. We are more used to filling position Y with someone that went to school/has experience in/got a degree in Y, rather than filling the position with someone that has the capability and acumen based on their CV, experience and innate ability to fulfill the requirements of position Y.

Google is certainly not alone in this approach. IDEO, Facebook, Apple and Microsoft all recognize and identify T-Shaped individuals, and build teams, facilities and initiatives with such people.

The apparent innate ability of Keira Knightley’s (fictionalized) character in the movie also speaks to the individuals that were responsible for the genesis of what we know today as Silicon Valley. Wozniak, Jobs, Gates, and Allen among others (Zuckerberg for one) all dropped out of college to pursue their passions and ultimate success. There is constant discussion in the startup/innovation realm about how formal degrees do not necessarily equate ability. Although the subject is parodied in Mike Judge’s show Silicon Valley (clip here) and demonstrated by Knightley’s character, there is truth in this as well.

To me, the movie comes at a pivotal time in this age of innovation, startups and tech. Clearly, we have gained inspiration directly and indirectly from the concepts and work of Dr. Turing, while at the same time the fictionalized components of the movie reflect modern day ideas (and perhaps ideals) injected into the storyline.

The Intersection of Medicine and Design

With the release of the Apple Watch this week for public purchase, we are now seeing the implementation of wearables that have the ability to pick up potentially clinically applicable data from the user. Google’s Fit and Apple’s HealthKit are further blurring the lines of performance tracking and relevant health information. All the while, the packaging is slick with clean interfaces and cutting edge hardware integration.

More than ever, design is playing a big role in medicine and health care. In everything from medical device designs, where the end user is the physician, on through publicly accessible technology such as the Apple Watch, design clearly matters. A significant amount of effort (and funding) is going towards ergonomics, form, interactivity and ease of use. Companies such as IDEO have been working in this space for decades with their innovative methodology regarding human-centric design, and even the upcoming Dell School of Medicine in Austin recently announced the collaborative creation of the Design Institute for Health (helmed by IDEO alums Stacey Chang and Beto Lopez) where the focus will be design thinking and creative solutions in the health care field.

This past week while working with other surgeons performing laparoscopic colon resections, I was struck by the sharp contrast of decades-old instrument designs and the recent device additions to the operating room. Coviden’s Ligasure energy device we use now is distinctly ergonomic, intuitive and a well thought out blend of form and function. Down to the UI of the power source LCD screen, and even the audible tones to indicate stage of cauterization, it’s a device that is a great example of how device companies have a major focus on ease of use and aesthetics. In contrast, we are still using stainless steel forceps and needle drivers who have correct methods and techniques of holding and using that are not immediately obvious.

The field of medicine and especially the field of surgery is one of legacy and history. Instruments and procedures are named after pioneering individuals whose names are always spoken in a reverent tone. As such, these instruments shouldn’t be immediately rendered obsolete as they are a critical and fundamental part of the surgeon’s armamentarium, but perhaps there is a way to improve upon them.

Aesthetics, design, UI/UX are factoring heavily into products in every field and medicine is no exception. If anything, it is now a requirement. Cumbersome, overly complex or clunky designs are no longer acceptable in new products entering the market.

When I design my devices for the OR, ease of use and intuitive-ness are high on the list of importance. With more recent studies on the IDEO methodology and through conversations with the wonderful individuals at IDEO, I feel that they have helped me refine this process and approach in an intangible, but fundamental way. Once the intended function of the device is established, build it so that form IS function has become the goal. This is where human-factors engineering comes in to play, as designing with the end-user in mind and thinking about when and where the device will be used is what will ensure its (hopefully) ultimate success in implementation.

Wearable Tech: Here To Stay?


With the rapid advancement of technology, and an ever-growing list of companies producing wearable devices, discussions involving not only the concept of Quantified Self, but what direction the world is going with the adoption of these products are becoming commonplace.

Even so, the abandonment rate in regards to the usage of wearable tech is surprisingly high. Endeavour Partners recently published their findings (http://endeavourpartners.net/assets/Wearables-and-the-Science-of-Human-Behavior-Change-EP4.pdf) on this subject. Although 1 in 10 individuals older than 18 own some type of activity tracking device, they found that 1/3 of owners stopped using the device within 6 months and less than half of all owners of these devices still use it at all.

We can all relate to this. Either on a personal experience level or a friend that bought a FitBit and initially would wear it nonstop, but then all of a sudden did not. As an early adopter of Glass and firsthand experience with multiple wearable devices, I found myself no longer wearing Glass on a regular basis after about 5 months of daily use.

So why, with so many companies offering new devices, touting new technology, are we spending our money on the products but not using them?

This is a complex question that has a multifactorial answer.

There are three major factors that play a role  in why users haven’t fully adopted wearable tech:

1. Friction
2. Societal Reception
3. Delivered Value


This is the most fascinating aspect of wearable technology abandonment to me because the bar is set extremely low. Friction is defined as difficulty in use/interaction with the device not only on the mechanical level (buttons, plugs etc.), but also on the way the device integrates into daily activities and life in general.

All companies are acutely aware of this and spend incredible amounts of manpower and funds on making the most user friendly UI/UX possible along with creating the most aesthetically pleasing (though this is always in the eye of the beholder) form that they can. Even so, even motivated individuals that are willing to sit down and learn how to use a device can become frustrated with it very quickly leading either to improper usage (and further frustrations resulting in abandonment) or immediate abandonment due to unsuccessful use.

Although we all believe that the addition of a device in our lives will be easy and that doing something as nominal as plugging an activity tracker into the computer every evening is not a lot to ask for, our actions (or inaction in this case) speak volumes. We are just not self-motivated enough to add another piece of technology into our lives for personal use in the long-term setting.

Societal Reception

New devices and technology always takes some time for society to accept it. We live in an age where a conference, show, or convention showcasing new electronic devices happens almost every month. Technology is reaching us faster than we as a whole can process it, and allow for its natural integration into our lives.

With more disruptive devices such as Glass, it is quite literally in your face not only for the wearer, but also for those that the wearer interacts with. As much as we want to accept and integrate it, public acceptance of Glass in the everyday setting has just not caught on. Although I never had a negative experience while wearing Glass, I was acutely aware that others might view it with suspicion or curiosity. I found myself taking it off, turning it around, or at least pushing it up on my head regularly as I moved from one social setting to another.

FitBit, the Nike Fuelband and other activity trackers are certainly more accepted due to their small size and more traditional location-of-wear. At the same time, others easily notice them due to bright colors, distinct shape and design. There is an undeniable “techni-ness” to them that does not blend naturally with clothing, wristwatches and makes them almost immediately noticeable even when they are neutral colors.

Delivered Value

This is what a device “gives” you. Activity trackers tell you the number of steps taken, approximate calories burned, and so on. Glass lets you interface and access your e-mail, messaging, (limited) web, listen to music, take photos and video along with the ability to share them and more.

On the surface, these seem to be high value and desired features and information by the end user. Abandonment rates speak otherwise. Without outside incentives (such as institutional rewards programs for wearing FitBit), people cease to focus on what information the devices give them. As the information is not even clinically relevant, beyond some level of personal knowledge, the devices provide little else.

In the case of heads-up displays such as Glass, nearly all functions are already easily available (and socially accepted) in smart phone form. Looking to the upper right corner of your field of view instead of looking down at your phone is not a big enough advantage to ensure long term adoption of a device that needs to be worn on the face, needs to be recharged, and also still needs to be paired to a phone (or linked to wifi) to use most of the features.

So what does this all mean?

Wearable tech is here to stay. The field is relatively new, especially in the public market and as a whole, companies are still trying to feel out and test what will result in long-term adoption. Apple’s upcoming watch is a big step into addressing all three issues with device abandonment. Aesthetically it looks almost exactly like a classic watch, has (what appears to be) an intuitive UI, and has built in sensors and programs that collect potentially clinically relevant health data. As we get closer to the release date, it will be interesting to see how it is received.

Companies such as Google have also recognized that device value and long term adoption rely (at least for now) on making usage specialized, mandatory, or indispensable. With their recent announcement of the end of the Glass Explorer program and a new focus on business use cases, Google has clearly seen that the device has a place as a tool in a business/work setting (as a telepresence troubleshooting device, as a telementoring platform, and as a hands free communication device) in contrast to generalized public use. By focusing in on specific industries and situations-for-use, Google (and more specifically Tony Fadell of Nest) is pivoting their focus with the understanding that they have a great concept and need to put their time, energy and resources into fields of highest yield.

Coming from the medical and surgical field, I still believe that Glass has value in the hospital. Although adoption has been slow (part of the friction of new technology use), there is immediate understanding of the potential value of a heads up display system like Glass with application towards patient care and physician training.

What the future holds for wearables, where they will ultimately settle out in terms of use cases, and how they will enter our daily lives is going to be fascinating to follow. As technology continues to improve and shrink, long term adoption and acceptance may very well increase as the hardware becomes more and more integrated into already-worn or carried accessories such as glasses, watches, wallets and the like.

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