ER Doctors of the web

My husband has Cystic Fibrosis (CF), a genetic disease that mostly affects the respiratory and digestive systems. It affects about 30,000 people in the United States, which makes it a bit of a rarity.

We live roughly 30 miles from the closest Cystic Fibrosis clinic, which is normally not a problem because my husband’s CF is mild for a 42 year old and we don’t have very many actual emergencies.

Which brings us to Friday night, or more properly Saturday morning at 12:30am, when after two days of intense gut pain we went to the emergency room (ER) of the local hospital.

Samuel L Jackson from Jurassic Park saying “Hold onto your butts”

The only time the local hospital sees someone with CF is when one of the handful of patients who live in my area can’t make it down to Philly for whatever reason — such as a 12:30 am gut emergency. The people at this hospital know about CF the same way they know about a dozen other conditions they read about in med school. They know the disease exists, but they are not in any sense of the words experts.

When my husband said “I have cystic fibrosis and I think I have an intestinal blockage” the ER doctor was skeptical. Intestinal blockages are rare. They usually occur in people who’ve had some kind of abdominal or intestinal surgery in the past, or someone who’s had a hernia. They do not occur in normal-looking 42-year-old males who fit none of that criteria. But it was a puzzle, because even though my husband didn’t have the  conditions that would cause a blockage, he also did have many of the symptoms of a blockage.

Because it takes about four hours to run a cat scan with contrast to check a digestive system, it was about 5:00 am before the doctor returned.

“Well, your blood work was all normal, but the cat scan shows you do have a blockage”, he explained. “So you’ll need to have the fluids pumped out of your stomach and then if it dosn’t clear you’ll probably need surgery. I assume you want to do that down in Philly” — we nodded —“so I’ll go call transfer.”

A picture of a goat with two rifles in a harness slung over its back making it look like an odd kind of double-barreled goat machine gun. The caption reads just just goat serious.

“Before you do that,” we asked, “could you call the on-call specialist at the clinic? Because while intestinal blockages are rare in general, they’re actually pretty common in cystic fibrosis and we just want to make sure we’re all on the same page before the transfer.”

To understand how audacious a request we were making, you have to understand that an ER doctor, especially a senior one like we had, is God. He makes life or death decisions based on his own knowledge and training literally all day every day. He has people he can consult with and protocols to follow, but he counts on his own expertise. He is being paid to be the expert on every condition that walks into his hospital.

To question a doctor’s decisions or suggest they get a second opinion is to question their knowledge, expertise, and reputation, which can make them a bit defensive.  And frankly, most patients don’t know jack-all about how our bodies work or what’s going on, especially in an emergency situation, so a doctor’s low opinion of patient suggestions or feedback is generally well-earned.

The last time we were in this ER I had to call the CF clinic and have them call the local hospital before the ER doc would deign to speak to them. And here we were, again, requesting a second opinion from a bigger hospital in the city when everybody in the ER knows how to treat an intestinal blockage.

The painting named Portrait of a Young Man, by Alessandro Allori, where a young man in portrait pose is pointing at a fire behind him with a bored expression. Captioned shit’s on fire, yo.


Maybe it was because the ER was slow maybe it was because the doc recognized that there was something odd going on that his expertise didn’t cover, but he made the call.

A few minutes later he walked back into the room and said, “Wow,  you’re really smart.”

Nathan Fillion was about to make a comment, then he closed his mouth and set his head on his chin as if to say "you know what, never mind."

He continued, “Turns out this blockage is called DIOS, and it is common in adults with cystic fibrosis, and we treat it the exact opposite way that we’d treat anyone else’s blockage. We’re setting up a bunch of IVs and fluids for you and you’re staying here.”

So the reason why I’m writing this post from a hospital is because an intestinal blockage doesn’t take 10 minutes to clear.

But the reason I’m writing this post is because today’s events have been a stark reminder that, as our web design and development careers progress, more and more often we are called on to be ER docs.

  • We need to “know our stuff” well enough that we don’t need to consult with our peers for the bulk of decisions. (In some cases, we don’t even have peers to consult with.)
  • We’re called on by all levels of our organizations to act and speak as experts, and to sound both authoritative and sure of our decisions.
  • We’re expected to keep up with the latest literature and self-train and attend conferences.
  • We’re expected to train others.
  • We’re expected to be able to tell war stories of the weird shit we have seen and how we successfully resolved it, and oh boy, we have seen some weird shit.

Alice from Alice in Wonderland sitting next to Dorothy from The Wizard of Oz says “I’ve seen some weird shit.”

It’s not enough to be the ER doc of web design.

We have to be the compassionate ER doc of web design. We have to put our egos behind our attention.

When our users tell us what they know and what they experience, we must assume that they’re giving us their truth. We can’t assume that our users are wrong, or stupid, or making bad decisions. If a user is doing something “the wrong way”, we have to ask why, and really listen. The user may have developed this as a workaround to plug the holes in our expert decisions. We may have missed something in the research phase (if we had a research phase). Sometimes a user’s odd experience means we missed a valid and important use case.

If our mental model doesn’t match the mental model of the user we’re speaking to, either we failed to educate them, or we failed to be educated by them.

A sign that says "Do not question authority! They don't know either."

No matter how long we’ve been designers, we have not, in fact, seen all the weird shit the world has to offer. We have to keep an eye out for the oddities because those cases are both meaningful for the users and meaningful for the product.

We can’t automatically discount edge cases and odd user experiences because they’re rare. Cystic fibrosis only affects one in ten thousand Americans, but many of them know each other, through networks or hospital interactions. They’re a community. When we’re observers, we need to recognize that what we may see only once or twice in a career might be someone else’s every day lived experience and their culture.

Improving a product for small sub-population of users  may not affect every user, but it may affect the thousands in that population, and to those thousands, that’s meaningful change.

And most of all, we need to listen when our users say “have you talked to this person about this weird case? Because they may be able to tell you more about it than you know now.” It takes guts on the part of the user to tell an expert they aren’t an expert, and it takes guts on the part of the designer to swallow or egos and be willing to listen. We should greet their courage with our own.

Web design doesn’t always mean the difference between life and death, (and sometimes they do). Regardless, our decisions have lasting meaningful impact. We need to design like our users know what they’re talking about, and like our decisions will have a lasting impact on their success. To accomplish that, we must function as both experts and learners, and we’ll be better designers as a result.

It turns out the people we’re serving are really smart.

Owning It

In a perfect world, web-based projects are the making of a project is something like a Venn diagram of responsibilities and actions. Product [1]sometimes called Business, represented by the Product manager or Project Manager helps IT [2]represented by the  Tech Lead and UX [3]represented by the UX Lead understand the business goals of the project, UX helps Business and IT understand the best flows and uses of the product and how to reach the business goals and IT helps Business and UX understand the technical constraints and how best to build it.

A venn diagram showing the equal weighting of Product, User Experience, and Information Technology for completing a project. Summed up in the paragraph before it. And I take it so seriously I set it in my very best werewolf font.

In the real world, I’ve found, the circles of influence aren’t equally weighted. Product owns the purse strings, so generally they get what they need or the project is cancelled. If IT decides it’s not going to build what Product or UX request, well, nothing gets built[4]or the wrong thing gets built, or in desperate cases the whole thing gets built in an Excel spreadsheet with a thousand macros by a Product person who could be doing something better with their time.

But if UX is the one out of alignment with the others, well, it doesn’t take much for Product and Business to build and ship without UX input—it happens all the time in our tiny corner of the universe.

We have to own and harness our ability to influence others. We have to show that while we may not necessarily have been granted the authority to make decisions, we are the authorities in making those decisions.

There are two ways to gain authority:

  1. Gain the trust of the other circles and build a positive reputation, so that people want your influence on the things you’re good at
  2. Get someone who already has authority over the other circles to grant you the authority to influence things.

In general, you can do them in either order but it helps to do both.

That’s where responsibility and ownership come in. For the purposes of this post we’re going to use “responsibility” and “ownership” interchangeably. Showing responsibility is a surprisingly powerful force when it comes to communication and getting things done. Responsibility means:

  • Owning your design skills. Consistently look for ways you can improve, through feedback from peers and co-workers, conferences, classes, articles, whatever sources you trust. Once you find ways to improve, implement them.
  • Owning your communication skills. If you’ve created the best design in the world but you can’t explain why it’s the best design, or positively respond to criticism, or work with others, you haven’t created the best design in the world. A design is only as good as its explanation.
  • Owning your mistakes. Whether it’s not keeping up with your calendar, overcommitting yourself, or dropping a ball, we all do it. Ownership is clearly saying “I make this mistake, I’m sorry, and here are the things I’m doing to make sure it doesn’t happen again”…. and then actually doing them.
  • Sharing your victories. Make it clear that the work you are credited for couldn’t have been done alone. Recognize the people who helped you (even if they didn’t want to or made it difficult).
  • Being compassionate toward the other members of your team[5]This doesn’t mean being a doormat—you are not personally responsible for the actions of others. It does mean that unfortunate disasters and personal mistakes happen to everyone, and holding a … Continue reading. Say “That sounds awful, how can I help?” more than you point fingers.
  • Being available for questions[6]Be available within reason. If you have higher priorities, it’s best to communicate that. And remember that you don’t have to take on every project that someone else dreams up. even well after a project has launched. A five minute phone call to answer a question about something you worked on years ago may be enough to save someone else dozens of hours of time researching, even if you’re not delivering the news they want. They’ll remember that you helped them.
  • Documenting your work. Good documentation, in whatever form you choose, makes the difference between future-you or your future counterpart thinking you’re a genius and thinking you’re a slacker.

Not one of these skills is easy. But that’s what ownership is about: holding on to the hard things as tightly and reliably as holding on to the easy things.

And none of these skills are going to make us rockstar designers. There’s no guarantee that they’ll confer extra creativity, speed, or talent. They won’t make us famous and they probably won’t make us stinking rich. They will make us sturdy, reliable designers.

When we work on the skills above, we show that we’re consistently putting in the effort to make the team successful. We prove that we know what we’re talking about—and we prove that when we do make mistakes, we’re transparent about them. We gain trust from our teammates and our management team, and we gain authority through that trust. We clearly communicate our value and we lead others, not through coercion but through effort, to recognize that value.

While there are a few places where where Design is so baked into the culture that a UX Designer has the authority to stop a project in its tracks, they are still rare, and chances are most of us don’t work there.

For the rest of us, our authority and our influence grows when we increase our peers’ respect for us both as Designers and as people. That growth is driven directly from our own actions. We must transparently and consistently not only prove that we know what we’re talking about, but also that we are willing to do the hard work of clear communication, keeping our word, and making it easy for others to work with us.

When faced with a problem that can be solved by taking the easy route, or by owning our role, we should own it.


1 sometimes called Business, represented by the Product manager or Project Manager
2 represented by the  Tech Lead
3 represented by the UX Lead
4 or the wrong thing gets built, or in desperate cases the whole thing gets built in an Excel spreadsheet with a thousand macros by a Product person who could be doing something better with their time
5 This doesn’t mean being a doormat—you are not personally responsible for the actions of others. It does mean that unfortunate disasters and personal mistakes happen to everyone, and holding a grudge is rarely useful
6 Be available within reason. If you have higher priorities, it’s best to communicate that. And remember that you don’t have to take on every project that someone else dreams up.

The persistence of point-of-sale chip readers

A point of sale terminal with the new chip reader.

Saturday afternoon at Target. I swear that my extended family is singly responsible for 10% of the company’s lifetime gross earnings.

In line in front of me is a gentleman who looked to be in his late 70s or early 80s. Next to him is whom I presume to be his daughter, looking to be in her 50s. He’s buying staples: Cereal, milk, some canned food.

It’s time to pay, so with trembling, slow hands, he pulls out his debit card. And he stares at the credit card reader.

Now, for those of you who haven’t had to endure the last two years of American credit card chaos, let me introduce our point-of-sale terminals. They all have a slot into which you carefully, with one motion, insert your chip-equipped credit or debit card.

This gentleman, with trembling hands and a slowness that comes with age, inserted the card in not quite one absolutely perfect motion.

As a result, the card reader returned an error.

Well, now he’s confused. I mean, he’s probably 80 years old and knows exactly how much money is in his account.

His daughter pipes up. “Dad, swipe it! Put it in here and swipe it.”

American point-of-sale terminals also have a magnetic stripe reader. There are still a lot of cards out there with magnetic stripes and no chips, though they are dying out now that the liability for fraud falls on the least secure of the bank and the store. Thus, the terminals let you swipe your card, just as we have since the original POS terminals replaced the credit card imprint machine a generation ago.

So, the elderly man with deliberate movements oscillating from a tremor swipes his card.

The machine tells him, “USE THE CARD READER.”

See, it’s that liability question again. If the store takes the magnetic swipe when it could have taken the chip, they are exposed should the transaction be fraudulent.

But the old man is more confused than before. And we’re now up to five minutes of wading through the machine’s weird demands.

He knows it’s the card reader now, so once the machine resets (and that takes time) he is able to insert it deliberately in the exact way the machine likes, and it finally accepts his offering.

It asks for his PIN number.

He enters his PIN number.

Then he pulls out the card.

Uh oh. The machine didn’t like that. You have to leave the card in because, well, I’m not really sure. My guess is it’s because everywhere else in the world your PIN is stored, encrypted, on your card, but America has to be weird, so it calls your bank to ask for your PIN. Or it’s because it just likes cards. Whatever.

Seven minutes now. Daughter and checker are getting flustered. The poor gentleman is suffering from this constant cognitive kick in the privates.

Still, once more into the card slot, my friends. This time, he gets the card in right, slowly punches in his PIN, and waits while the machine tells him to NOT pull his card out.



PULL YOUR CARD OUT NOW NOW NOW NOW NOW, screams the alarm. To POS terminal designers’ credit, they changed the signal based on merchant and consumer feedback. Originally, the sound of removing your card was a loud klaxon that suggested you are a horrible person for deigning to leave that card in one microsecond than necessary, and that you should feel SHAME. Target’s vendor rolled out a patch that reduced the air raid siren to a slightly urgent but more pleasant three note tune.

At long last, our honored elder has completed his purchase of milk and cereal. It’s only taken 10 minutes for all this to happen. Everyone in line behind me long ago abandoned this crisis for one of the other 24 lines.

I’m still here. Not because I’m mad at the gentleman or even laughing at him. I’m mad at the people who let this experience get this bad.

With point-of-sale, you’re trying hard to balance two problems:
1. Consumers want to buy stuff with as little friction as possible.
2. Merchants don’t want to get fucked over by fraud.

Mind you, merchants want low friction sales and people don’t want to be fucked over by fraud, but for a moment let’s focus on just these two use cases.

In the first case, you want to make it as easy as possible for consumers to provide proof of payment.

In the second case, you want to make it as hard as possible for people to commit fraud.

Now, who’s buying the machines? The consumers, or the merchants? Yep, the merchants. So they’re going to focus on a system that will limit their liability in the new world where the least secure part of the product-to-cash chain is liable for fraud.

The end result is a secure system that requires genuflections, magical thinking, and a lot of signage to help consumers buy stuff.

But here’s my ultimate question: Is this really the zero-sum game I just made it out to be?

The heart of good, user-centered design is a solid empathy for the people who use the products we design. That empathy is not either-or; it’s both-and. It understands we cannot be everything to everyone and compromises must happen to deliver a cohesive and grokkable experience. But it also knows that to help one user, you don’t (and shouldn’t) hurt another.

This is already a daunting design challenge given the dense regulation that comes with merchant banking and finance. And yet… we have Square and Stripe handling billions of dollars in transactions for small businesses (e.g. the coffee shop I’m currently sitting in). These systems provide a better experience than the current POS terminals because they are focused on lowering sales friction first. They still suffer from the genuflection of inserting the chip into the reader, but as POS systems they are remarkably low in friction.

The chip reader isn’t the final destination, however. We have contactless cards in Europe; you can even use them in lieu of Oyster cards to ride the Underground. And, of course, there’s Apple Pay. The friction falls without compromising safety and fraud prevention.

In the meantime, though, I wish I could have made the point-of-sale designers — and their leadership — watch that 10 minutes of suffering that poor man went through in front of me. It left me irate that we can’t design for everyone, that we still create systems that foment magical thinking, that instead of treating design as a zero-sum game they could have done the hard, hard work of making a system that empowered consumers AND protected merchants.

This shouldn’t happen. Not in modern design. Not in a world where we’re demanding ethical, empathetic design as the cornerstone of our entire “user experience” movement. That it does suggests that maybe, instead of focusing on arguing over “what is UX” and “should we call it UX” at every turn, we should be asking how we can get better at designing for the actual people who use the things we design.