|FLOWER POWER: Images of nature, like those at this Duke University cancer clinic, can ease patient stress.|
Slideshow: "Wellness by Design"
A series of innovative hospital designs narrated by Jain Malkin, an interior decorator whose work is discussed in this piece.
I’m sitting in a mauve vinyl recliner facing a mauve laminate counter and cabinets. On the countertop are a couple of candy jars, five peacock feathers leaning around a black wall phone, a small plant that may or may not be real, three boxes of medical-exam gloves, and a radio tuned to smooth jazz. A curling five-by-seven-inch photo of the participants in a 2000 fund-raising walk hangs below a sign warning guests not to use cell phones. Someone has pinned three teddy bears to a small strip of cork on the grayish-white wall. “I’m gonna be Okay,” says the slogan on the orange bear’s chest. The yellow bear wears a blue scrub outfit with an 800 number and the slogan for a cancer organization. On the white bear, hot-pink embroidery declares, “Cancer sucks.”
Thank God for intravenous Benadryl, which knocks me out in just a few minutes. The cancer treatment is state-of-the-art, but the decor is decidedly behind the times.
Over the past decade, most public places have gotten noticeably better looking. We’ve gone from a world in which Starbucks set a cutting-edge standard for mass-market design to a world in which Starbucks establishes the bare minimum. If your establishment can’t come up with an original look, customers expect at least some sleek wood fixtures, nicely upholstered chairs, and faux–Murano glass pendant lights.
Unless, that is, your establishment is a doctor’s office, medical clinic, or hospital. Mounting clinical evidence suggests that better design can improve patients’ health—not to mention their morale. But the one-sixth of the American economy devoted to health care hasn’t kept up with the rest of the economy’s aesthetic imperative, leaving patients to wonder, as a diabetes blogger puts it, “why hospital clinic interiors have to feel so much like a Motel 6 from the ’70s.”
A Hyatt from the early ’80s might be more accurate. The United States is in the midst of a hospital-building boom, with some $200 billion expected to be spent on new facilities between 2004 and 2014. Although more spacious and sunlit than the 50-year-old boxes they often replace, even new medical centers tend to concentrate their amenities in public areas, the way hotels used to feature lavish atriums but furnish guest rooms with dirt-hiding floral bedspreads and fake-wood desks. Hospital lobbies may now have gardens, waterfalls, and piano music, but that doesn’t mean their patient rooms, emergency departments, or imaging suites are also well designed. “Except for the computers you see, it’s like a 1980s hospital,” says Jain Malkin, a San Diego–based interior designer and the author of several reference books on health-care design. “The place where patients spend their time 24/7 is treated as if it’s back-of-the-house.”
Consider diagnostic imaging departments. MRIs and CT scans can frighten many patients, and research shows that simple elements such as nature photos can ease their stress. Yet the typical scanner room still looks “as if it’s a workshop for cars,” says Malkin, with bare walls and big machines. One of the bleakest rooms at the UCLA Medical Plaza, where I spend my time, is a waiting room in the imaging center. Small and beige, it epitomizes aesthetic neglect, with stained chairs, mismatched tiles, and tattered copies of U.S. News & World Report. The only wall art is a drug-company poster on myocardial perfusion imaging—just the thing to comfort anxious patients.
Cost is of course an issue. Malkin estimates that enhanced design amenities can add about 3 percent to the cost of a large project. The big shortage, though, is not money but attention. When hospital boards and executives talk with architects and designers, it’s rarely about the imaging department.
Also, unlike a hotel, a medical center rarely trains its staff to pay attention to how the place looks to guests. Hence the often-torn drug posters, teddy bears, and countertop clutter. If you work somewhere every day, after a while you don’t notice eight-year-old snapshots and peacock feathers too tall for the space. The ad hoc, staff-oriented decorating that fills an aesthetic vacuum can be worse than bare walls. Lee Mequet, a Southern California real-estate agent, recalls a chemotherapy visit with her husband, who was so ravaged by lung cancer that his skull and bones showed under his skin. The treatment room, she says, was “decorated for Halloween, with pumpkins and paper skeletons, and the tragicomic horribleness of the images made me want to rip the fucking things from the wall.” Alas, cable TV has yet to create a makeover show called Designed to Heal.
When I started thinking about health-care design, I assumed that insurance price controls and third-party payments were the source of the problem. But hotels upgrade their rooms to please business travelers whose expense accounts impose budget limits. When airfares were set by law, airlines competed by offering better food and prettier stewardesses. Patients generally do decide where to take their business, even if rates are fixed and someone else is paying. They may not know what their health care costs, but they certainly know what the hospital looks like. In academic surveys, patients in better-decorated, hotel-like rooms rate not just the environment but their medical care more highly than do patients in rooms with standard hospital beds and no artwork. That customer-satisfaction result would tell any smart hotelier to redecorate. But hospitals feel less competitive pressure and are more resistant to change.
Patients like me are part of the problem. When I was diagnosed with breast cancer, I didn’t shop around for the most attractive chemotherapy clinic. I went to the best oncologist I could find and got the room that came with him. “Most people would take the most-competent clinicians even if they were in the worst possible environment,” says Malkin.
But why assume good medicine must come with bad design? Most hotel guests care more about reliable reservations than about crisp duvet covers. That doesn’t mean they want ugly rooms, though. Given the choice, they’ll go for the hotel that offers the best of both. When Starwood Hotels, which owns the Westin, Sheraton, and W brands, upgraded its rooms in the late 1990s, the rest of the hotel industry followed.
Under similar competitive pressure, medical facilities react the same way. When Baby Boomer women started choosing hotel-like birthing centers over hospital delivery rooms, hospitals quickly wised up. Now even rural hospitals offer well-designed labor-delivery-recovery suites. “People do shop, and they will actually sometimes change an obstetrician because they want a certain hospital experience,” says Malkin.
Much of the time, however, patients don’t know they can do better. Take semiprivate rooms. Like hotel guests, sick people aren’t eager to share their rooms with strangers. But most patients assume they don’t have a choice. “You grow up thinking that is how hospitals are, that there’s always two people in a room,” says Malkin. As of 2006, however, the American Institute of Architects’ guidelines, which many states use for their regulatory codes, specify single rooms in new medical- surgical and postpartum units. Medical centers may not care what makes patients happy—such a subjective, unscientific concept!—but they can no longer ignore the research demonstrating that single rooms lead to better outcomes: lower infection rates, shorter stays, less noise and hence better sleep, fewer expensive patient transfers and subsequent medical errors, and much less stress for patients.
Such “evidence-based design,” which draws its principles from controlled studies, is the great hope of professionals who want to upgrade the look and feel of medical centers. Much of this research follows a seminal 1984 Science article by Roger S. Ulrich, now at the Center for Health Systems and Design at Texas A&M. He looked at patients recovering from gallbladder surgery in a hospital that had some rooms overlooking a grove of trees and identical rooms facing a brick wall. The patients were matched to control for characteristics, such as age or obesity, that might influence their recovery. The results were striking. Patients with a view of the trees had shorter hospital stays (7.96 days versus 8.70 days) and required significantly less high-powered, expensive pain medication.
Along similar lines, a 2005 study compared patients recovering from elective spinal surgery whose rooms were on the sunny side of a ward with those on the dimmer side. Those in the sunnier rooms rated their stress and pain lower and took 22 percent less pain medication each hour, incurring only 80 percent of the pain-medication costs of the patients in gloomier rooms. Other studies, with subjects ranging from the severely burned to cancer patients to those receiving painful bronchoscopies, have found that looking at nature images significantly reduces anxiety and increases pain tolerance. Not all distractions are good, however. Ulrich and others have found that inescapable TV broadcasts and “chaotic abstract art” can increase patients’ stress.
Of course, Starbucks and Starwood didn’t wait for decades of peer-reviewed research to prove that customers would respond to better aesthetics. Their CEOs were willing to bet that subjective quality improvements would translate into higher sales. Patients like the diabetes blogger who are tired of “dreary, dull and dare I say, a bit depressing” medical environments need similar visionaries.
Meet Joanna Cain, an oncologist and the director of the Center for Women’s Health at the Oregon Health & Science University in Portland. When the center hired interior designers for its new facility, Cain told them she wanted the place to feel like a day spa filled with artwork. She got her wish, with cherrywood finishes, curving fixtures and ceilings, warm colors, chair groupings that encourage conversation, and slate accent walls. The mission and design inspired philanthropy—gifts not only of money but also of glass-art tiles, a “grandmother’s garden” of rosemary and lavender, and, above all, lots of art. “Going to the doctor now has a bit of the feeling of also going to see a very special, almost private, art collection at the same time,” says one patient. “I can’t tell you how nice that has been, especially when you are going for a less-than-pleasant procedure or discussion, or are simply in pain.”
Cain acknowledges that “it does cost more to build this, but not that much more”—perhaps 10 percent to 15 percent. Asked how she measures the design’s success, Cain points to her patients undergoing chemotherapy: “It’s a place that makes them happy.” She acknowledges that a beautiful environment should never trump excellent care. “But take it from the other side,” she says. “If you have a choice and you can be in a place full of light, where there’s beautiful art that your eyes can rove over and feel comfort from—which would be a better experience, assuming they both are the same [medically]? And why don’t we think people deserve that?”