Design research ‘War Story’

Nazima Kadir, Plan’s new Head of Design Research, presented a ‘war story’ during User Research London on 16 June 2017. ‘War Stories,’ a term coined by pioneering design researcher Steve Portigal, refers to the inevitable logistical and emotional hiccups that arise when doing face to face, in-context research with people. Outside of a controlled environment of a facility and dealing with human beings with their complications, war stories enable design researchers to reflect and connect.

Nazima narrated her experience in a medical innovation project. She discovered that the key informant, a surgeon, had staged his use of a product during a live surgery to convince her of his expertise. With sharp anthropological analysis, Nazima put forward cultural implications for healthcare of the surgeon’s lies and his provocative behaviour.

Nazima’s war story

For a recent medical innovation project, I did research (including shadowing, observations, and in-context interviews) with health care professionals who work in operating rooms. This was challenging to arrange because surgeons did not want to risk patient privacy.

A friend of a friend connected me with a surgeon who was keen to chat. I interviewed him informally. I mentioned that I had heard that surgeons disliked the product because they felt that using it reduced their sense of professional craft. The surgeon declared this anecdotal information to be absolutely false.

In contrast, he told me that he was an avid user of the product. He said that using this product was a necessity for surgeons who were concerned with patient outcomes. I followed up the interview with an observation of him doing a surgical procedure, in which he used the product.

Months later, I contacted him again to do a week’s worth of observations and to ask for his help in connecting us with other doctors and nurses.

On the first day of our observation, I realized that everything the surgeon had said during the initial interview (as well as his behavior during the surgical procedure) had been fabricated. When I asked him about his daily routines and his “pick list” (the items always available during the surgery), he admitted that he never used the product in question. When I asked why he had said otherwise during our first meeting, he equivocated and bluffed, saying that he had answered on a general, idealized level, rather than based on his own usage. I realized that despite initially vociferously denying that surgeons preferred not to use this product because it reduced their sense of craftsmanship, he actually shared the same prejudices against the product.

Later, I found out from his assistant that the only time that he had used this product was during the surgical procedure I observed. Essentially, he had staged the use of the product for my benefit.

He also exhibited a drastic shift in attitude. During the first encounter, he was polite and warm. During this second encounter — which lasted 3 days rather than 4 hours — he was incredibly hostile towards me, was physically inappropriate with my female researcher colleague, and was sexist towards both of us by speaking to the cameraman (who knew nothing about the project) while dismissing us.

It was highly unpleasant and difficult to know the reason for this hostility. Was it from my probing questions? Was it his resentment that he had to actually spend time with us in order to get an “in” with the world of private sector consulting? He considered himself entrepreneurial. In addition to his position at a state hospital, he also worked at private hospitals, and had several private side ventures whose financial viability were questionable. Perhaps he saw this as an easy, financially lucrative gig but not as easy as he had anticipated? It’s difficult to say.

Realizing that he had lied during the initial interview and staged the use of the product for our benefit, we decided to make the best of the situation. We continued to work with him to connect us to other health-care professionals and to give us tours of hospitals. However, we disregarded the information we obtained during our interviews with him due to his lack of trustworthiness. I also treated him warily and with more formality to enforce professional distance. When speaking with him, he avoided committing to dates, times, and communicating details. After the unpleasant first day, I only communicated with him via text rather than voice because he couldn’t equivocate and bluff via text. This forced him to commit to dates and times and limited his potential to treat me and my colleague with hostility or inappropriately.

In academic anthropology, working with “unreliable” informants is a hot topic. When I did my doctoral fieldwork, I learned a great deal from those who lied and exaggerated their own importance. I resided in a community of anarchist squatters who rejected hierarchy and authority. When informants emphasized their importance, this signified that they were marginalized from the norms of the community.

In commercial ethnography, “unreliable” informants are just as common, but not as openly discussed because it’s harder to explain their value to both clients and members of project teams who are less familiar with how to interpret information. In this case, what did I learn from this informant’s behavior?

It had been difficult to find surgeons who wanted to participate in the project due to concerns about patient privacy. Yet, he was keen to participate. Did this mean that he did not share the same concerns about his patients? Was he marginalized from the norms of the community of healthcare providers?

His desire to participate was so great that he lied throughout the first interview to give the appearance that he was an avid user of the product. Yet, during the second encounter, his behavior demonstrated hostility and disrespect towards myself and my researcher colleague. It’s possible that his aggression signaled ambivalence towards participation. But it’s also possible that his behavior reflected gender, race, and class privilege rather than outright hostility. As a male surgeon in Europe, he may just treat women who he deems subservient in this matter. In that case, what does that mean for the culture of power within surgical teams in which the surgeons are nearly all white European men and the nurses are Filipina women?

Not being subservient women, in the end, we managed his aggression to connect us to other surgeons and providers and were able to complete the study.

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