How architects ruined healthcare

Joshua Landy is a practising critical care physician and the co-founder of Figure 1.

If everyone who stays at a particular hotel gets sick, you don’t need to be an epidemiologist to wonder if the hotel is the problem. So if physicians across the country are reporting record levels of burnout, we might ask if hospitals are the problem. Could the workplace itself somehow be toxic to its workers? If so, it’s probably not due to asbestos in the walls or toxic black mould. It’s because a well-intentioned effort to make things better for patients ended up making them worse for everyone.

If you’ve been to a hospital that was built or renovated in the last decade, you know the aesthetic. Muted pastels, potted plants, and plenty of places for patients and their families to occupy themselves. This is not accidental. The principles of modern hospital design are clearly explained in a fascinating 2012 paper called “Building patient-centeredness: Hospital design as an interpretive act.” In it, Dr. Elizabeth Bromley, a medical anthropologist and psychiatrist at the University of California, interviews a variety of planners, architects, and executives and records their unvarnished opinions on what they’re aiming to create.

“Many people, when they walk in the ground floor, they say they don’t feel like they’re in a hospital,” bragged one planner. “It’s a grand space, the lobbies, the circular openings through the lower levels, nothing says ‘hospital’ there.”

Bromley notes that “architects built few conference rooms and lounges, leaving little room for physicians and nurses to congregate.” The planners who advocated these designs expected healthcare professionals to interact primarily with their patients, considering staff collegiality to be a “threat to hospital performance.” And they got their way: Physician lounges are widely reported to be a thing of the past.

The rise of patient-centred care means that in addition to those open spaces and familiar coffee shops, there’s little sign of the technical aspects of medical care. As a physician, I recall learning how to practice “patient-centred medicine” in medical school. The emphasis was on producing empathetic doctors. We learned acronyms for questions that enhance a patient’s sense of autonomy. But I sense that for architects and planners, a deeper misunderstanding may be afoot. How deep a misunderstanding? This deep: Several of the administrators and architects speak glowingly of “the Disneyland concept,” where all the messy parts are hidden “to generate a seamless fantasy world.” Disney’s experience with obscuring the unappealing parts of theme parks has been appreciated by the media. A well-known example is the pneumatic waste disposal system installed in 1971 whose tubes carry refuse across the nine-acre park to prevent guests from ever seeing it. As Bromley explains, when this strategy is applied in a hospital, the intent is “concealing from the visiting public the techniques that constitute the work that produces or defines the setting.” Translation: If you are a healthcare professional, you are the messy part.

Let’s be clear. Healthcare that does not look like healthcare is not healthcare — it is a sort of theatre created to distract an audience of anxious patients. It doesn’t serve their interests. It’s a funhouse mirror vision of patient-centred care, where it’s more important to pretend you’re not sick than to be properly treated.

For me, finding this paper was like finding the cause of a patient’s disease. Everyone from the American Medical Association to the Mayo Clinic is treating the symptoms. An important tenet of acute care medicine is that finding the source of a problem and fixing it is always preferred to speciously treating side effects.

Business teamwork studies, including one by, ahem, the Disney Institute, recognize that collegiality between colleagues is a necessary ingredient for team success. This has been mirrored in my experience as a medical team leader and co-founder of a medical technology startup company. Teams that talk about their work are better able to accomplish goals. The experience of shared problem solving imbues teams with collegiality, making work easier and more enjoyable. And modern hospitals are specifically designed to eliminate collegiality.

I remember one of my attendings once saying, as he flipped a series of switches in vain seeking a light to illuminate the patient’s bed from above, that people who design hospitals should be punished by being treated in them. And one day, they will be. As will you. So think about this next time you visit a hospital: Is this place built to make us healthy — or to distract us from thinking about our health?