Midnight plane to Doha

Well, it happened – I have arrived in Doha, Qatar. I’ve been here for a couple days now and still trying to figure out how I feel about it. This is my first country transition on the Watson, and it’s as though I’ve started a new trip altogether. I’m looking for the thread that connects Sweden and Qatar, and I know that thread is me and my project, but I still don’t think I’ve found it yet.

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My last evening in Stockholm.

I had a lot of strange, existential thoughts like that as I traveled to Doha via Dubai a few days ago. I traveled through the night, with a layover in the Dubai International Airport from 11pm to 2am. When I got off the plane in Dubai, I walked through the night heat to the airport bus to get to the nearest terminal. The bus took a little more than 20 minutes, and a banking ad covering the outside of the bus made it impossible to see outside.

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Can you see the little red hats of the Emirates crew?

As I stood in the bus, which might as well have been rambling in circles for hours, I was struck with the weirdness of it all. Here I was, totally by myself at midnight in Dubai, my first time in the Middle East and surrounded by families and couples and a high ratio of men to women. That Fight Club quote popped into my head: “If you wake up at a different time, in a different place, could you wake up as a different person?” In a foreign place at a strange time, you lose a sense of who you are and how you got there. Especially if you’re tired and you’re at an airport, you just put one foot ahead of the other and go, and that’s all you know in that moment.

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Leaving Sweden.

It’s hard not to think about identity on the Watson. I feel like I’m scattering bits of myself all over the world, like making a drip castle in the sand – except the bits are much further apart, left in separate countries and with different people I meet.

This is tied to a sense of reinvention that comes with the Watson. It’s as though this grant is breaking me down into simple building blocks to be pieced back together in new ways over the course of the year. I get remade with each leg of the journey, and (hopefully) I’m building towards something better. It feels like, after all the work I did to graduate college, the Watson grant looked at me and said, “Nope. You’re not done yet. Go further, learn more, and keep building.” And so now I’m on this crazy tabula rasa journey.

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I don’t usually do food pictures, but wow – I had never flown Emirates before, and they’re awesome. The regular economy ticket includes a meal and a drink (even wine!).

Well, the good news is that my mini existential crisis has ebbed now that I’m in Qatar. Once I finally got through an hour of passport control at 2:30am in the Doha airport, I traveled to the home of a lovely family who is hosting me for the whole month that I’m here. Watson part 2, here we go!

Sideways to Vasa

I couldn’t leave Stockholm without posting about Vasa. Vasa is an old Swedish warship and the star of the Vasa Museet here in Stockholm. A friend of mine in Malmö told me again and again that I had to go to Vasa, so I promised I would. His other main piece of life advice was to watch Sideways, the film with Paul Giamatti, so I watched it the same day. I’m glad I did both!

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This is what you see when you walk into the museum. The ship has been shielded from the “worldly elements.”
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This is a 1:10 full-color scale model of what the ship looked like when it was built, with the original in the background.
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The Vasa ship was commissioned during the Thirty Years’ War, illustrated by this map.

Vasa was built in 1628, and Vasa sank in 1628. Sadly at the time, but happily for the museum, Vasa set sail in 1628 for a mere 20 minutes before promptly sinking just off the harbor (in view of all the townspeople that had waved goodbye to the ship). Sitting in the water for 333 years before it was lifted in 1961, Vasa was nearly perfectly preserved. Though the colors had worn off, the wood was still strong and the ship had never seen the horrors of war.

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In the one room with natural light in the museum, you can see a small model of Vasa just before it sinks. The ship was too top-heavy and narrow, and a gust of wind easily blew it over. You can see it tilting dangerously here.
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Here you can see why Vasa was ill-designed. The bottom should have been wider with more ballast. Also, the two gun decks on top (rather than just one) made for a center of gravity that was too high and thus too ‘tippable.’
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The “back stern castle” of Vasa was decorated with richly colored statues, all designed to showcase the power of the king.

A beautiful and cannon-filled ship, Vasa was supposed to strike fear into the hearts of Sweden’s enemies. It is covered with religious and political imagery, including Roman Emperors to suggest that the Swedish king was somehow related. The king at the time, Gustavus Adolphus, commissioned Vasa and was partially responsible for its demise, as he insisted on adding a second gun deck (with very heavy cannons!) late in the ship’s construction.

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While museum-goers can no longer walk inside the original ship, there are museum workers that work inside, below, and around the ship to maintain it.
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This is part of the back stern castle on the top floor of the museum. The ship is huge, requiring a four-floor museum just to see all levels of it!
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I really liked this little model display of “tacking,” a technique of turning into the wind – something that might have kept Vasa going for a bit longer than 20 minutes, though not much longer.

As I said in a recent post, I think that museums that have one main focus (something more specific than a region or a time period) are the best, and Vasa Museet is no exception. It was great to hear all the little details about the ship – how it was built, who worked on it, the errors leading to its instability, the crew that sailed with it that day, the dramatic inquest afterwards, and more. I feel like I retained much more from that museum than I did from the Medieval Museum, for example, or the currency museum. Those topics are just too big and broad to delve into over the course of an afternoon.

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I think my favorite part of the museum was this “design-your-own-ship” game, in which you could adjust the ballast and width and so on to build a ship sturdier than Vasa. I managed 100% stability, but “lost my job” with the king because I brought the speed down to 20%!

Another cool part of the museum was the complete replica of the upper gun deck. Even though people can’t go into the real deal anymore, it was great to see the deck as it used to be and walk by some cannons.

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Life in Vasa (at least, what it would have looked like).
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Apparently people played backgammon on ships in the 17th century!
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Lastly, there was an exhibit about the 15 people whose remains were found with the ship. Using new facial reconstruction technology, the museum was able to display what they looked like.
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Leaving Vasa Museet, which is specially built to house Vasa and protect it from the world outside.

I’m glad I saw the Vasa Museet and the movie Sideways – I do recommend both. There’s still so much more for me to write about Sweden. There are more museums, many more cinnamon buns, more trips to IKEA (via the very-Swedish free IKEA bus), and, of course, more project meetings (including a conference!). But these memories, notes, photos, and recordings will have to wait, as I think about packing and online check-in and various other flight preparations.

Tomorrow will be a full day of travel, and I won’t arrive in Doha until early Friday morning. So, wish me luck! And a big thanks to Sweden for being the nicest, most welcoming first Watson country I could ever imagine. I already know I have to come back.

 

Health post: Let’s get into it

In my last health post, I described the CTMH Fellowship program, which follows a problem- and need-based approach to developing medical technology solutions. Though the idea for the fellowship was conceived by Stanford University in the U.S., the focus on finding a real need ahead of developing a solution seems well-aligned with the Swedish tradition of human-centered design (ergonomics). Sjoerd and I discussed what factors influence the success of a medical device based on what he’s learned from the CTMH fellowship program, the Stanford program, and eHealth companies in general.

These are factors that are important to consider when designing a medical device anywhere. However, we also talked about what specifically makes Sweden so “healthy” – that is, what cultural and political factors affect its healthcare system and eHealth innovation. I’ve talked about this with many other Swedes, including doctors and researchers; for example, I first visited Karolinska Institute to meet with Gösta, a professor of medical engineering there. He’s the one who first suggested that I contact Sjoerd at CTMH, and I’ll include some of his thoughts in this post.

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The closest train station to Karolinska Institute is Flemingsberg. As you exit the train station, you’re greeted with this sign. “Flemingsberg: From Brains to Business.”

One of my favorite questions to ask is, “What is the main reason that Sweden has such a high health standard?” Sjoerd’s answer was that the public system provides access for all. I would say about three-quarters of the Swedes I’ve interviewed share this sentiment that the free (or nearly free) healthcare is #1 reason why Sweden is one of the healthiest countries in the world. Sjoerd showed me a slide with the actual numbers, which I’m not sure I’ve ever shared in detail:

  • Healthcare and dental care are separate.
  • Each visit to a doctor costs 150kr, about $18. The maximum you would pay in doctor visits per year is 1,100kr, about $150. After that the government pays for everything.
  • Dental care is entirely free until the age of 20. After that, each dentist visit costs 150kr for a total of 1,100kr per year.

So even if you go to the doctor and the dentist many times, you won’t pay more than $300 in medical fees in one year (unless you seek special, non-mainstream treatment).

Nationwide access to public health is a political (or perhaps economic) factor contributing to the country’s high health standard. Another political factor is the country’s functioning infrastructure, which allows it to support and maintain hospitals and new technologies. Also, the government makes a concerted effort to invest in medical technology. The Stockholm city government established the SLL Innovation Fund two years ago to help medical device companies address the needs of the country’s growing and aging population (http://sllinnovation.se/). While this is a good step, Gösta said that the money in the fund is “not enough” yet.

Moving on from government, Sjoerd and Gösta also identified some of the cultural and historical factors that relate to Sweden’s health and medical technology. First, history. Sweden was not a part of World War II and thus came out of the war completely unharmed, leading to a period of thriving industry in the 1950s and 60s. I was happy that Gösta, along with a couple other Swedes I’ve met in the past week, mentioned history as a reason that Sweden is so healthy and technologically advanced. I hadn’t been thinking about Sweden’s recent history, at least not in relation to my project. I had been thinking of medical technology as a here-and-now thing, a view supported by my meetings with young start-up companies. Also, despite Sweden’s small size, it has produced many inventors over time. People always point to Ericsson, Spotify, and Tetra Pak as classic examples of Swedish invention; furthermore, the first implantable pacemaker was invented in Sweden, at Karolinska Institute. This strong engineering background and history of innovation (especially considering the importance of the Nobel Prize to Sweden, as I mentioned yesterday) might be why so many Swedish innovators are inspired today.

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The student library at Karolinska Institute.

Next, culture. In Sweden, there is a prevailing attitude of trust in the government. Gösta, Sjoerd, and many other Swedes have expressed this. I’ve also noticed it myself, not just in healthcare but in taxation, transportation, childcare, education, and more. There is a trust that the government does good, plus the corollary that government workers want to do good. Swedish people often seem passive and obedient due to this trust, accepting what the government offers since they know, truly, that their government has their best interests at heart. I’m not sure how this relates to attitudes towards medical tech, though, except to say that attitudes might be filtered by the government’s opinion. If the government recommends some medical device, the public will be inclined to use it.

However, it’s not as though people are wary of tech that doesn’t get government recognition; rather, I have heard from many that there is an openness to new technology in Sweden. This is a cultural trend that is important for creating an environment in which medical devices are successful and adopted. In fact, Sjoerd described the Swedish as “early adopters,” often the first to try out a new device or system. Gösta put it more broadly, saying that the acceptance of technology is due to Swedish people being tolerant and flexible overall. Today, I spoke with a Swedish Swarthmore alumna, who said that not only is it the norm for people of all ages to pick up new tech, but it’s considered strange for elderly people not to text or have smartphones or want to learn new technologies (for example).

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Inside Karolinska’s new main building.

Early adoption has its pros and cons, however. It leads to instances of “legacy tech” or “legacy software,” meaning that older or original versions of a technology are used even if newer versions have become available (https://www.techopedia.com/definition/635/legacy-system). For example, Sjoerd told me about EHR systems in Sweden. As I’ve mentioned earlier, EHR systems allow hospitals to keep electronic records of all their patients. In each of the 21 counties of Sweden, the county government is responsible for managing the hospitals in that county and deciding what software they use (http://salusdigital.net/ehr-records-sweden-future-brings/). Back in the 1980s, these counties started adopting EHR systems one by one. Now, the 21 counties have different EHR systems, some far older than others (the so-called legacy tech). Unfortunately, it isn’t so easy to upgrade legacy technology, as I alluded to in my last health post; for a hospital to change EHR platforms, for example, they would have to hire a large engineering team, successfully transfer massive amounts of sensitive information, get the government’s support, and find a time that works for the hospital. This isn’t a problem in countries that are “late adopters,” who adopt technologies after they’ve been available for quite some time. Then these countries can pick one up-to-date system to deploy nationwide.

There is a second problem with being an early adopter: what if you adopt something really bad? What if you sign onto a technology too early, before it has been tested? It’s finally time to tell you about Paolo Macchiarini. Originally from Italy, Macchiarini is a throat surgeon who just lost his job as professor of regenerative medicine at Karolinska Institute here in Stockholm. He rose to fame for his trachea transplants, replacing patients’ tracheas with synthetic tracheas built from their own stem cells – a completely new and innovative approach. However, the idea was too bold; six of Macchiarini’s eight transplant patients are now dead, and he has been charged with research fraud,scientific misconduct, and even falsifying credentials on his résumé. Karolinska Institute seems to be thoroughly embarrassed to have hired him, and they fired him as soon as the scandal came to light. Sjoerd mentioned Macchiarini – though I’ve heard of him many times now – to illustrate that “bending the rules usually goes well…until it doesn’t.” Macchiarini is an example of the Swedish drive to try new things can come at the expense of trying them too quickly, overlooking various rules and regulations.

One of my first project posts for Sweden was entitled “Barriers to Business.” It was about how the strict medical regulations in Sweden can make it difficult for new medtech companies to succeed and can even kill innovation. The Macchiarini story – which I’ve now heard many times – put that in perspective. Yes, it is very difficult to break into the health technology market. While this was initially presented to me as a disadvantage of the system, I have since heard from many Swedes that it is an advantage. Sjoerd said that the system might need to make it more difficult, in fact, if such a change would have prevented the Macchiarini disaster.

Oh museum, my museum

There are so many wonderful museums in Stockholm, most of which I thought I wouldn’t see. My Lonely Planet guide listed most of them as having entrance fees of about $10-15 each, which is definitely too much money for me to spend on a simple afternoon visit (especially after visiting so many free museums in Malmö and Gothenburg). I was never much of a museum person, but now that I’m traveling alone, I’ve begun to seek them out. Museums, both the good and bad ones, provide an easy way to spend time between project meetings, visit different areas of a city, and learn more about a country’s culture and history. And the more museums I see, the more I’m impressed by the good ones.

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First up: the Medieval Museum.

So I was quite disappointed to read that Stockholm, already so expensive compared to the rest of Sweden, charged for its museums as well. Luckily, my Lonely Planet guide is just a little out-of-date. It doesn’t incorporate the results of a February 2016 law that removed the entrance fee for many of these state-owned museums (https://www.thelocal.se/20160202/now-its-free-to-go-to-swedish-museums). Good news for me! This post covers five of the free museums I’ve visited in the past week (with more to come).

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Stockholm in medieval times covered little more than the area of today’s Gamla Stan (“Old Town”).

The Medieval Museum was fun because it focused on day-to-day life in a medieval Swedish village, using life-size wax people and prop houses. The museum is housed in a fairly small space and doesn’t require much reading, teaching visitors more about feeling and attitude than strict facts (which is appropriate, since we’re discussing a time period that ended 600 years ago).

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The “craftsman” in his home, which is large enough to walk through (I even went up to the second floor!).
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According to this wax figure, medieval gardeners were quite sad.
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This corner of the museum, with its shifting background colors, was clearly meant to emit an eerie vibe about death punishments in the Middle Ages (see the gallows in the back?).

Moving on, I visited the much larger Natural History museum next. This is where I got a sense of Stockholm’s importance and size as the capital of Sweden; the natural history museum here is admittedly much better than the one in Göteborg (which consisted mostly of overly lit 1940s-esque taxidermy cabinets – instructive but creepy). The Stockholm Naturhistoriska Riksmuseet makes an effort to place its stuffed subjects in more “natural” poses and environments. I also appreciated the more focused and relevant exhibits such as one about Sweden’s waters and another about climate change.

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This is as much of the museum’s exterior as I could fit in one photo without jumping onto the highway!
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The ceiling of the dome in the center of the museum.
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Emission sources in the climate change exhibit. I probably would have spent a lot more time there if there had been descriptions in English, but I got a general sense of the topic.

Remember when I told you that Sweden is home to the world’s largest scale model of the solar system? I visited the “Sun” my first day here in Stockholm. It’s represented by the Ericsson Globe (“Globen”), and it’s huge. I was happy to find both the moon and the Earth in the Natural History Museum, placing the “Earth” 7.6km from the “Sun” (exactly 1/20000000th of the actual distance).

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Earth is close to the gift shop, while the moon is close to the IMAX theater.
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As I said, the museum placed its animals in a “natural” environment: here you have a stuffed fox ready to play!
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Let’s be honest: the Göteborg Natural History museum didn’t even have a dinosaur hall.

Next, I decided to visit the Royal Coin Cabinet (“Kungliga Myntkabinettet”), the city’s currency museum right next to the Royal Palace. I’m not so interested in currency, but it’s one of the few museums in Stockholm – really, in all of Sweden – that’s open on Mondays, so last Monday I thought, why not?

Well, honestly, I don’t have many positive things to say about this museum. It’s difficult to retain any information after staring at a thousand years’ worth of coins.

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Of course, American currency was part of the permanent world currency exhibit! I was glad to see something familiar here.
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A bit of entertainment in an otherwise less-than-thrilling array of objects: a dragon guards its treasure.

Next up is the Sjöhistoriska Museet, the Maritime History Museum of Stockholm. It’s situated in a beautiful building just by the water. While I can’t say it’s particularly instructive, it’s still fun to walk through (a bit like the medieval museum). One gets to see many model ships and develop a bit of a sense for life as a sailor, especially with the mock bunks built in shipping containers in one section of the museum.

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The Maritime Museum.
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The stern of the Amphion, the specially-commissioned “personal pleasure craft” of an old Swedish king. This is the real thing, with the king’s cabin still preserved and visible through the windows.
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My favorite room in the maritime museum: “Old Globes for Young Explorers.”
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View from the back of the museum. The fall colors are lovely in Stockholm!

Finally – at least for this post – I visited The Nobel Museum in Gamla Stan. You might already know that most of the Nobel Prizes (all except for the Peace Prize) are awarded in Stockholm each year. The museum has information about all the winners, in all the categories, since the Prizes began in 1895. It showcases various award winners and their projects, and it also covers the life of Alfred Nobel himself. I was really impressed with the Nobel Museum. I didn’t have any expectations about it and I never really planned to go, but I’m so glad I did. It’s well-organized, and I think that the best museums are those with a specific topic – I find it easier to learn from such focused museums.

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Schrödinger’s Nobel Prize diploma! I learned that every Nobel Prize, in addition to the award money and medal, includes a uniquely customized diploma like the one shown here. That means there are over 500 different Nobel Prize diploma designs from the past 100+ years.

This is going to sound really cheesy, but I found the Nobel Museum incredibly inspiring. The museum’s main message is that anyone has the ability to be a Nobel Prize winner, and it really feels true when you see the huge diversity of past winners. Also, the museum stresses that experimentation, failure, and persistence are key to developing something prize-worthy – not sheer genius or resources or luck.

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Of course, I looked at some of the medical prize-winners. This is the first example of packaged insulin for diabetes patients (1923).

Sweden deserves to be proud of Alfred Nobel and his Prizes. Based on the snippets of his life that I saw at the museum, he seemed to be an interesting man (with a dry wit) who clearly saw the value in celebrating great achievements and inspiring future generations.

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Showcased projects, color-coded by the type of prize they won (chemistry, physics, literature, peace, or medicine). I was glad to see an assistive device – the wheelchair – as a prize-winner on display.

Health post: Intro to CTMH

This past week I met with Sjoerd of CTMH, the Centre for Technology in Medicine and Health here in Stockholm. CTMH is the result of a joint effort by the KTH Royal Institute of Technology (research university), the Karolinska Institute (medical university), and SLL, the Stockholm County Council. I was interested by CTMH’s clinical innovation fellowship program, in which fellows are put in teams of 4 to identify a problem or a need in the healthcare industry and then come up with a solution. It’s almost like a startup accelerator for startups that don’t exist yet, and it’s entirely problem-based. The CTMH program is based on a similar program at Stanford University called the Biodesign Innovation Fellowship.

According to Sjoerd, Stanford found that a huge success factor for start-ups – that is, what distinguished the winners from the losers in business – was whether or not the proposed solution actually met a real need. With that in mind, the idea of both the Stanford and CTMH “biodesign” fellowships is to identify medical problems long before solutions are discussed. The CTMH fellowship mentors a few teams every year, each team consisting of one medical fellow (a doctor); one technical fellow (an engineer); one fellow in management (an economist or businessperson); and one fellow in design. Each team spends the first two months in a hospital context, simply observing. They are tasked with identifying 250 needs in the first 6 weeks without thinking of any solutions or letting their own ideas cloud their judgment. Sjoerd told me that while 250 needs sounds like a large number at first, no team has ever found fewer than 300 needs or issues in a hospital context in the given amount of time.

The next few months of the fellowship are spent refining and validating the needs, removing those that are not real or recurring, as well as figuring out what is a feasible need to tackle. For example, one need that is absolutely real and recurring is the need to standardize electronic health record systems, EHRs, across the country. If a patient moves from Stockholm to Gothenburg, for example, it will be surprisingly difficult for their health records to transfer from one hospital to another if the two hospitals use different software systems to manage their EHRs. However, this is not a problem for CTMH fellows to solve; it’s a large scale problem that requires the influence and resources of the government.

Once each fellow team has a recurring, real, and solvable problem, they are finally allowed to brainstorm solutions. At this point, the business plan becomes important. How will they fund their idea? Sjoerd said that there must be an alignment between who experiences the need and who pays for it. He told me about the company Ortivus, which created an electronic patient service for ambulances. The system allows paramedics in an ambulance to gather a patient’s diagnostic and medical information and transmit it to a hospital emergency team before the patient arrives. This addresses a need of the hospital workers: they save time and money when they are fully prepared for the arrival of a new patient. However, the Ortivus system must be paid for by the ambulances where it is installed, rather than the hospitals.

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Inside an ambulance, a paramedic gathers basic data about a new patient using the Ortivus system (taken from http://www.ortivus.com).

Unfortunately, many ambulance services work independently of hospitals, delivering their “clients” to the hospital that is nearest at any given moment. Since Ortivus’s solution would directly benefit a hospital rather than an ambulance, ambulances were not motivated to invest in it. In short, while Ortivius’s e-health solution perfectly addressed the existing need, no one was willing to pay for it. The company finally made money by marketing to hospitals with proprietary ambulance services (where the ER workers in the hospitals would have the same boss as the paramedics in the ambulances).

The ZIO Patch is another example that illustrates the importance of a business plan. The patch is a heart monitor that is less invasive than traditional ECG techniques. Patients wear the patch for two weeks as it collects data. After two weeks, the patient’s general physician receives a ZIO Report based on an algorithmic analysis of the collected data. It’s easy to see why the ZIO Patch is a great idea as it is more comfortable for patients and collects longer-term data than the typical approach of an ECG, during which a patient might wear up to 12 leads and a cardiologist is needed to analyze the results.

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A typical scenario for a patient undergoing cardiac monitoring. (Photo from NY Times: http://www.nytimes.com/health/guides/disease/heart-attack/diagnosis.html).
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A patient wearing the ZIO Patch for continuous cardiac monitoring. (Photo from ACEP Now medical journal).

However, the company had trouble selling the ZIO Patch to cardiologists, as it threatens their jobs. Sjoerd said that the typical cardiologist’s response to the ZIO Path was similar to, “Well, that does seem like a good idea. But what I do now works well, and it requires my presence. Why would I invest in a tool that takes away my role?” So, the makers of the ZIO Patch thought about who benefited most from their solution and therefore who would be motivated to pay for it. They realized that they should market their product directly to the general practitioners who would receive the final analysis of the patient’s data, and this way the GP would interact directly with the patient without the need of a cardiologist.

The ZIO Patch example shows that finding the motivation to pay is a key tool for success, as well as recognizing and bypassing the competition (in this case, cardiologists). Sjoerd summarized that there are 3 important considerations when addressing a need: the solution needs to be feasible; there must be a monetary benefit; and finally, the overall impact must be big (that is, the solution must affect many people rather than just addressing one person’s need or solving a very rare problem). Finding the motivation to pay is wrapped up both in the feasibility of the solution (will someone be willing to pay for it?) and the monetary benefit (will the cost of the product be worth the amount that it saves the payer?).

There’s another aspect to all this, though, that relates to both the monetary benefit of a device and its overall impact: the value of human life. Sjoerd stressed that good tech must have a large positive impact on human life not in terms of duration of life, but quality of life. Such a discussion requires monetizing the value of life. Sjoerd suggested that, while other cultures might consider this to be a “taboo” topic, Swedes are surprisingly pragmatic and understand the need to determine the monetary value of human lives. (As it is the case that Swedes are the people who invented IKEA and created the highly functional society I’ve been living in these past few months, I definitely agree that “pragmatic” is a good way to describe Swedish attitudes towards, well, everything).

To be more technical, budding companies must do a cost-benefit analysis based on QALY and DALY figures. I hadn’t heard these terms before, but they make sense. QALY stands for “quality-adjusted life year,” and it is a monetary measure of the health outcome associated with prolonging a patient’s life. Adding life years with a poor quality of life is worth far less than adding life years with a high quality of life. A similar measure is the DALY, the disability-adjusted life year, which essentially counts as “one lost year of ‘healthy’ life,” or a negative life year (World Health Organization; http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/). So finally, this is another factor that contributes to whether or not a medical device is successful; it must save or improve enough lives, while maintaining a high quality of life, to justify its costs of production.

To sum up, according to the Swedish Centre for Technology in Medicine and Health, successful medical devices are borne out of a true need; are paid for by the people that benefit most from having that technology; address a need that is recurring and real, experienced by multiple people; and make a significant impact on improving the quality of life for patients, meaning that they are worth their cost in quality life years saved.

#sthlm

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Kungsträdgården, the “King’s Garden.”
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S:ta Clara kyrka (St. Clara’s church), in the middle of Stockholm.
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A kardamummabulle, the cardamom-spiced version of Sweden’s famous cinnamon buns. 

Today, I found myself overwhelmed with gratitude as I left the second of the two project meetings I had today. I’m not sure what I’m so grateful for – the fact that both meetings went so well, or the kindness and openness of strangers, or the amazing opportunity of the Watson overall. Probably a healthy mix of everything.

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S:t Jacobs kyrka at the end of the garden.
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Across the water is the Riksdagshuset, or the Parliament House.
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I’m pretty sure this is the back side of Riksdagshuset.

I forget how amazing this all is sometimes, like this morning as I struggled for a place on the elevator on my way out of the subway and into the pouring rain. But then I remember that I wasn’t going to work, but that I was going to a meeting I set up all by myself and that turned out to be super interesting, and also, I’m in Sweden!

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A quiet street in Gamla Stan, the old town.
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“St. George and the Dragon.”
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My new friend in Gamla Stan.

Throughout the Watson application process, there were many times when I thought I wasn’t right for a Watson Fellow. I thought I’d be better suited to life at a tech company, or that I was too much of a homebody…but then I’d think of those high school days when I Googled flights to Perth because it was the furthest place away and I’d know it was right. And I don’t think, anymore, that we should always do what were “better suited” to do.

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This is the Stockholms stadsbibliotek, the main library in the city.
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This is inside the library’s rotunda. I wish I could show you all sides at once – it’s wonderful to be in there and spin around to look at all the books!
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Walking through the large park on the island of Djurgården.

Last fall, I expressed my worries to one of the Swarthmore professors who interviewed me during the internal selection process. I didn’t think I had been doing well. He told me that it should be okay because the Watson Foundation looks for people that have the ability to grow. (In other words, “You’re right that you’re far from perfect. But that’s a good thing.”). So I suppose it’s important to question yourself a bit. There’s so much to learn and so many ways to grow. It’s certainly a humbling experience to work like crazy in the U.S. to get this fellowship and then realize that most of the world has never heard of it, as you try to explain what you’re doing to each new person that you meet.

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Someone’s fancy summer home on Djurgården.
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Leaving Djurgården.

Wanderlust level of the day: happily satisfied and still in wonder.

Health post: Veryday

My first project meeting here in Stockholm was with Veryday, a design consultancy firm that does ergonomic, or user-centered, design for client companies (similar to IDEO). I talked to Tara, who is a Designer/Design Researcher on Veryday’s Healthcare team and has done her PhD in human-centered research on the cancer patient experience of radiotherapy.

Veryday, which was called Ergonomidesign until 2012, has focused on “user-driven innovation” for over 40 years, working on products to improve people’s lives day to day. In 1969, Veryday’s first year, the company consulted with Permobil to design a battery-powered wheelchair. Healthcare has always been an important sector for Veryday’s work; they have since designed operating rooms, clothing for disabled people, ambulance stretchers, crutches, asthma monitors, and more (http://veryday.com/history/).

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Veryday’s super-cute headquarters in Bromma, Stockholm.

Tara is from the U.S. and moved to Sweden about 6 years ago, so I had a unique opportunity to ask her to compare the two countries’ approaches to human-centered design. “There is a human-centeredness that is embedded within almost every aspect of Scandinavian culture,” she said. “You don’t have to fight for it.” She said that everyone in Sweden wants to improve patient experience; in the U.S., while companies would certainly be open to having that discussion, nothing would move forward without monetary incentives.

Tara said that when hospitals in the U.S. do focus on patient experience, they usually do it to differentiate themselves from other hospitals, competing to be the best. However, Sweden’s nationalized healthcare system makes competition between the hospitals unnecessary. The result is not nationalized mediocrity but rather a nationwide discussion of how all the hospitals can be better for all Swedish citizens. If a patient experience is improved in one hospital, how can that be extended to the whole nation? Tara was speaking from her experience working on the Swedish Testbed for Innovative Radiotherapy, a joint effort by university hospitals, companies, and regional cancer clinics to improve the radiotherapy experience for all cancer patients.

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The Veryday website has the company’s entire portfolio of projects. I was interested by their design of a digital platform to correspond with the blood test kit developed by OneLab.

The tough aspect of this is that, while designing for the patient is an obviously good thing, it’s hard to measure the effect on the patient’s medical outcome. A few days ago, the UK medical journal The Lancet published a study ranking nearly all the world’s countries according to 33 health indicators such as under-5 mortality rates, death rates due to disaster, rate of HIV infections, and alcohol use. It’s a hugely comprehensive study funded by the Bill & Melinda Gates Foundation, and it’s far better than the “10 Healthiest Countries” list from USA Today that I was perusing when I formed my Watson itinerary. I’ll probably reference this study, called “Measuring the health-related Sustainable Development Goals in 188 countries,” many more times, but today I want to say it ranks Sweden as the third-healthiest country in the world, and none of the 33 factors that put Sweden so high on the list relate to human-centered design or a patient-focused approach (as I said, these things are hard to put into numbers).

I asked Tara about this, who replied, “All I can say is that healthcare in Scandinavia is top in the world, but I don’t know if that specifically has to do with them putting patients first, or if it just has to do with some of the interesting dynamics that happen with nationalized healthcare where everyone has access. There’s no disparity of rich and poor.” I think she’s right: from my experience in the past couple months, I would say that the two most important factors contributing to Sweden’s high health standard – both in practice and in the eyes of the Swedish – are 1) the nationalized, nearly-free healthcare for everyone, and 2) the user-centered approach to design and patient care. I think only the latter factor affects success and adoption of medical devices, though (to tie it back to the main focus of my project).

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Veryday’s office lobby and stairwells are filled with examples of previous projects. Many of these projects are focused on developing healthcare products to “enable better care, for the good of both patients and caregivers” as it says here.

Also, the concept of eHealth (electronic health) simply seems more widespread in Sweden. Tara showed me the 1177.se website, which is Sweden’s national online healthcare service. I couldn’t believe I hadn’t heard of it before. It has lots of healthcare information for many different diseases, illnesses, and conditions, as well as personalized advice based on various symptoms. Users can also log onto the site and book appointments or call the number “1177” to get advice about your symptoms and book from there.

This way of booking appointments contributes to one of the differences between the Swedish and American healthcare systems. If you have a medical issue in Sweden, you book an appointment via 1177 and end up with a doctor you’ve never seen before and will probably never see again. In the U.S., you call the office of your family doctor or general practitioner to book an appointment. There’s a greater emphasis in the U.S. on staying “in the system” and meeting with someone who knows your family history. In Sweden, Tara said that it is considered to be beneficial to see a doctor with whom you have no previous relationship. I thought she would say that it is for a medical reason, so that the doctor isn’t biased when making a decision, but she said that it is a privacy issue. The Swedish “want that separation between the patient and the doctor,” she said, “with no blurring.”

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Screenshot of the 1177.se website homepage (Google-translated from Swedish to English).

Finally, I asked Tara what the biggest medical issue in Sweden is, or what disease Veryday seems to be working with the most. Since Veryday’s work is project- and client-based, however, their portfolio doesn’t necessarily form a comprehensive picture of Sweden’s most pressing diseases. Tara said that she has noticed a demand not for solutions tailored to a specific condition, but rather for connecting physical devices with digital cloud-based services. For example, pairing an insulin pump with a cellphone app is a specific solution for diabetes patients, but it’s an example of an overall trend of merging platforms to make daily life easier for someone with a chronic illness. It’s about supporting individual patients more fully in their conditions and integrating the services around those individuals, rather than focusing on one specific disease.

I really liked talking to Tara, and there’s far more I could add from our conversation, but I’ll leave it here for now. Tara helped me think about my project, noting that designers like her would have a hard time answering my questions about the medical outcome resulting from user-centered design. Also, since Veryday is a design consultancy, companies come to them for help with projects and ideas. So while Veryday is all about working closely with users to develop the right device for the right problem, I can’t strictly say that all companies in Sweden care about patient-focused design of medical products. Companies still have to make their own effort, whether that’s conducting user research themselves or deciding to work with a company like Veryday.