Sense of Direction

These fieldnotes describe a doctor’s method for providing physician referral names and directions to his patient after completing a final checkup, and his staff’s procedures for providing more information about the referrals. This study occurred in the Winter of 2005. It was the last of three visits for the patient. The doctor is a fertility specialist in Central Texas, and the patient’s name is Tanya (my wife). I accompanied her to all three visits and used it as an opportunity to observe and document a referral process. Because of my relationship to the patient, it was one of the few instances where I had full access to the procedures that a physician and his staff use to provide a referral, and the emotions associated with the process. During this time I was working for an environment design and wayfinding consultant that specialized in designing wayfinding systems for a variety of health care institutions in the United States.

Getting referrals and directions from our doctor
After completing Tanya’s checkup in the examination room, our doctor asked her if she had a gynecologist in town (he used the term “Gyney”) to which she replied, “no.” He recommended four doctors by name and described how he knew them, where he met them, and where and when they worked together. He also commented on their qualities and personalities. Then, still standing in the patient checkup room, he provided Tanya with directions by giving general street addresses for all four doctors and used his body and arms to geographically indicate their office location and the direction of travel from the exam room within the building (he assumed Tanya was familiar with Austin based on her reactions to his verbal description of the street addresses which consisted of head-nodding and multiple utterances of the phrase, “uh-huh”). He offered to have his staff provide her with the doctors’ names and their contact information. He was very kind and courteous, but his charade of directions did not make Tanya feel at ease.

Observations:
– Our doctor didn’t ask us if we were familiar with Austin prior to gesturing his directions, nor did he use specific geographic language (North, East, South, West) when describing office locations.
– When we were done talking with our doctor we had a sense of the districts that some of the other doctor’s offices were located in, but couldn’t associate the locations with their names.

Getting directions from our doctor’s staff
When the checkup was done, our doctor walked us down the hallway to an administrative staff desk to complete insurance paperwork. He wrote down the names of the four physician referrals on a small Post-it note, and asked his staff member to provide us with contact information; he didn’t tell her to give us directions to the physicians’ offices. (Note: three other doctors shared the same office suite, and there were no signs or placards near or on the administrative desks to indicate which staff member served each doctor. During previous visits, we were often confused about who to approach during the check-in and check-out process.) After receiving the Post-it note from our doctor, the staff member gave the note to her colleague, who commented that she couldn’t read his handwriting. Both staff members huddled together to interpolate the handwriting, then one referenced a health care network-sponsored medical directory which contained the names, pictures, contact information, and addresses for a wide range of local physicians. The directory itself was dog-eared and seemed old; one staff member explained that physicians pay a subscription to be listed in the directory. The administrative staff member responsible for our paperwork and files wrote down the names of the referred physicians on the back of one of our doctor’s appointment cards in our file. She didn’t ask us if we needed directions or if we knew where they were located. Finally, we walked down the hall to another desk to fulfill the financial transactions and received congratulations from an administrator. In an ironic moment, she also asked us if we needed to know the names of any good doctors.

Observations:
– How do we know that the administrative staff members correctly interpreted our doctor’s handwriting? This was an anxious moment for Tanya and I and we questioned their judgement.
– Why wasn’t the medical directory online? Approximately six administrative staff members sat behind one long desk that serviced three different physicians. After some questioning, I learned that all of them spend time searching for the dog-eared directory when patients and caregivers, who are short on time, need additional information about other doctors or network services. If the medical directory were online, then Google Maps to each physician office would only be a click away.
– During our visits, I noticed that many other couples were also getting referrals to other specialists. The doctor and his staff seemed to lack a formal, or, at the very least, an agreed-upon process and set of tools for providing physician referral information and directions to visitors.

Some ideas for improving this experience
Use plain language, common visuals, and be redundant. If maps and directions are good then they are true, simple, memorable, portable, and describe what visitors will see and hear when they arrive to the site and begin to interact with staff, other visitors, and the environment. If directions are bad (and, they usually are), then there are inaccuracies about location, and discrepancies between written or printed information, spoken directions, and the place itself. These discrepancies often take the form of unique language, shortcuts, and unofficial hand-drawn maps that are inconsistently used or applied by staff members at all levels of an institution.

Synchronize and share data. Creating and managing accurate logistical information is often overlooked by physicians, health care networks, and institutions. Web-based solutions such as Google Enterprise which includes both Google Docs (shareable, online documents), and the Google Maps API (interactive mapping technology) can assist staff members in keeping contact and directional information up-to-date.

Create a palpable sense of place. Why does every doctor's office feel like the one that I went to when I was a kid in the 70s and 80s? Why do so many private-practice health care environments look, feel, and operate in an antiquated way? Environments speak to visitors in very literal ways: front doors plastered with cautionary messages can make visitors feel unwanted; drab walls, floors, and lighting can dim their mood and affect their physical state; chaotic administrative offices filled with cluttered desks convey disorganization and confusion. Many of us would not tolerate such poor qualities in the retail establishments or restaurants that we patronize. Bad environments are bad business. “Placemaking” is a design method that can turn a place around and make it delightful, useful, and usable for visitors.

Coordinate and orchestrate every interaction you can imagine. Big health care experiences start in small ways. Brief interactions with small, private-physician practices put us on a path to more complex interactions with larger staffs, and more complex systems, procedures, tools, and places. Physicians and health care institutions that have working relationships should coordinate their methods for obtaining, accessing, and sharing accurate information about each other to make it easy for patients and caregivers to use their services. A visit to the doctor is stressful enough; confusing procedures and logistics only add to a visitor’s anxiety. The relationship between the information a visitor receives and her interactions with staff and the environment must be synchronized.

Finally
With some help from Google Maps, we found our way to the referred physician, then got lost once we were inside the building – victims of a “shortcut”. But, there is a happy ending:

 — Jon Freach, Principal Designer, frogTexas