Cards on the Table:
Building trusting relationships between providers and patients
The University of Chicago's Center for Interdisciplinary Inquiry and Innovation in Sexual and Reproductive Health (Ci3)
There’s a disconnect
between sexual and
reproductive healthcare —
and young people.
How might we bridge the gap and facilitate open, non-judgmental conversations between young people and the providers who care for them?
Ci3 is a faculty-led initiative to advance sexual and reproductive health, rights and justice locally, nationally, and globally. With a particular focus on adolescents, women, and communities of color, the goal is to develop new research methodologies, evidence, intervention strategies, and novel solutions to advance human health and well-being.
During the summer of 2019, I worked in the Design Thinking Lab at Ci3 with the concept "Cards On The Table" (CoT), generated as an idea for provider curricula. It was highly favored among young people and providers.
Literature and anecdotes tell us that young people do not feel comfortable raising topics about sexual health with a provider verbally. In the exam room, providers may intuitively sense that there is a question the young person wants to ask, but chooses not to.
The length of time a provider generally has with a patient is about 15 minutes. This includes addressing whatever the young person came to the clinic for, not including addressing other topics. Building enough rapport with a young person to have an open conversation about other sensitive topics in 15 minutes is not always a realistic scenario.
Lastly, while intake forms can capture useful information for a provider, they are also challenging to change. Intake forms require approvals from many layers of the clinical institution, including legal. They are also often based on risk assessments, which can feel shaming for the patient completing them.
Cards On The Table
“Card on the Table” started as a set of cards with sexual health topics on them. A young patient would pick these up at registration or in the exam room and select topics that they would want answered during their consultation. When the healthcare provider enters the room, the provider would ask them what questions they are interested in. Throughout the project, the concept evolved in different ways in which will be described below:
“We have an assumption that young people don't have questions or want to ask providers about them if they do.”
“I feel iffy towards doctors because – I don’t know, it feels weird to me. I never know how they would tell me some type of information or if they would be judgmental about me asking questions. Or they might tell my parents about what I said.”
—Female patient, 15
Throughout the 11 weeks, we conducted more than 40 interviews and prototype testing sessions with different kinds of providers (Pedeatricians, OB/GYNs, Psychologists, APNs, medical assistants, etc) and patients (in clinic and mock consultations). The project was driven by rigorous PARTICIPATORY DESIGN methods. See below for more details about the design process timeline.
During research we addressed questions of content and form. Here are a few of the questions explored:
1/ What selection of content will speak to young people’s most common SRH concerns, while embracing a wide range of topics?
2/ How can we balance using language that resonates with young people and medically accurate terminology?
3/ Is there an ideal number of cards? How many is too many? Or too few?
4/ What different ways might young people use CoT? Can it both support existing questions and provoke new ones?
5/ What age groups and contexts of use is CoT appropriate for?
6/ What advantages does CoT offer providers? Why is it beneficial rather than a burden?
An array of processes and tools were used to understand the system in which the problem space was embedded in. Througout this phase we were able to analyze and understand patterns and themes emerging from all data we collected, generated insights, and established new perspectives for higher fidelity interventions for young people and the providers who care for them.
1/ There is a wide variety in providers’ approaches to ASRH care depending on knowledge, comfort, and training.
• Providers across all levels can benefit from ASRH-specific training
• ASRH delivery is informed by individual priorities and biases
2/ Our mental models of medical care can limit how SRH care is provided and to whom.
• SRH is commonly scoped as “women’s health” or contraception
• Healthcare is framed as a solution to disease rather than as an approach to wellness
3/ Current SRH education efforts are inadequate and young people know it.
• Young people are interested in detailed SRH beyond their immediate situation
• Current SRH education doesn’t reflect the lived experience of young people
4/ Young people are interested in taking ownership of their own healthcare.
• Young people experience healthcare interactions as “at” rather than “with” them
• Young people fear judgment from providers + parents
Designing Cards on the Table
In a clinic setting, it is critical to go into the field with designed pieces for interviewees—clinicians, patients, and family members—to easily react to on the spot without too much abstraction. As such, we developed early “provotypes” based on hypotheses generated from our literature review and initial conversations with clinicians and patients. These were then iterated upon over the span of several weeks.
In order to get the CoT goals delivered to best optimize open and non-judgemental conversations between young patients and providers, different form factors were developed to address the gap among stakeholders. Bearing in mind the clinic flow, privacy, production cost, information structure, approachability, etc, we designed 3 forms of the concept.
ANATOMY OF A CARD
The refined high fidelity prototype includes several key advances in design to improve communication of ASRH between patients and providers, empowering young people and revealing as a key for quality of care.
PROTOTYPE TEST FINDINGS
1/ CoT v.s. CoW: Young people preferred a wall installation over a card deck, citing scannability, while providers find a wall installation infeasible in clinic.
2/ Normalizing v.s. reinforcing stigma: Natural tension emerged between normalizing and reinforcing stigma about SRH topics, particularly when we considered how how visible/discreet to make the intervention.
3/ Disrupting a mental model: The passive presence of a tool encouraging SRH conversations can help expand mental models about where SRH care belongs.
4/ Increasing effectiveness: While CoT is flexible enough to be delivered in any clinic flow, it seems to be particularly effective when coupled with an open and conversational approach from the provider.
Possible clinic flows using CoT
1/ Develop a strong point of view for content on the backs of cards: workshop with multiple stakeholders, parent and young people focus groups.
2/ Prototype and test a “how to use” guide for providers
3/ Identify and source ideal materials
4/ Spanish translation with parents and young people
5/ Explore alternative contexts of use: sex ed tool for schools; conversation starter with adults; inpatient use.
6/ Test all form factors: in mobile health units, school-based health clinics and PEDS clinic.
SPECIAL THANKS TO THE WHOLE TEAM
Co-leads: Julia Rochlin and McKinley Sherrod
Ci3 / DTL Team: Amanda Geppert, Emily Moss, Sierra Ribero, and all our colleagues at Ci3.
Institute of Design Faculty/Advisor: Ruth Schmidt
© Copyright Julia Rochlin