What the fanciest hospital suites forget
In a March 4 Atlantic article, Lindsay Abrams asks how much should be spent beautifying hospitals. She reviews evidence that making the hospital experience more appealing and comfortable can actually improve health outcomes. For example, natural lighting can ease pain and elevate mood. But the issue of how hospitals are designed goes far beyond creature comforts. Most notably, the move from shared to private hospital rooms has major implications for what the hospital experience means to patients. Given the choice, who wouldn't opt for a private room? But on closer analysis, the choice for many turns out not to be quite so clear.
A friend has given birth in two very different places. One birth experience took place in an old-world hospital where she stayed on a ward, a large room housing up to a dozen patients. This hospital boasted a relatively thin staff, a skimpy food service, and relatively few amenities. The other birth took place in a state-of-the-art U.S. women's hospital, replete with private rooms and guest services rivaling a five-star hotel. Had some problem arisen with her labor and delivery, there is little doubt that the U.S. hospital would have been able to provide more sophisticated equipment and personnel to deal with it. However, both births proceeded uneventfully. So which birth experience did she prefer?
Many of my colleagues in medicine naturally assume that she would choose the women's hospital back in the States. It offers second-to-none medical technology, world-class health professionals, and out-of-this world creature comforts that leave many patients feeling more thoroughly pampered than at any other time in their lives. Yet when asked where she would prefer to have her next baby, she replies unhesitatingly that she would opt for the old world hospital. Why? There she felt less alone. She could talk and bond with other patients. She felt like part of a community of mothers. "It just felt so good being with all those other moms," she says with a wistful smile.
Over the past century, the architecture of the American hospital has undergone a dramatic transformation. At one time, patients were generally housed in open wards, where each was aware of what was happening with the others and conversations between patients were common. Then wards were replaced with smaller rooms, generally occupied by two patients. In both situations, privacy could be difficult to sustain, in part because doctors and nurses seeking to preserve privacy could often do little more than pull a curtain. Today, the ward is ancient history and the double room is fast going the way of the dinosaurs. Hospitals being built today feature private rooms.
Nobody wants to lose sleep due to a roommate's television viewing or snoring. Yet sometimes our zeal for privacy gets the better of us, short-circuiting opportunities for compassion and community. It is hard to be ill and in pain, especially seriously so, but such burdens are often magnified when we shoulder them alone. When the poet John Donne famously wrote that "No man is an island," he was not making a purely descriptive statement. He was also highlighting our powerful need for companionship -- someone to talk to, a shoulder to cry on, and a human being to share our experiences with. Typically, the events taking place in hospitals represent experiences when we need one another most.
In some respects, hospitals increasingly resemble high-security prisons, where we go out of our way to preclude patients from interacting. In our haste to control infections, we isolate them. In our zeal to preserve confidentiality, we prevent patients from getting to know each other. They sometimes begin to feel as though they are being kept like specimens in hermetically sealed containers. To spend day after day in a single room, particularly when visits from family and friends are few and far between, can resemble a form of solitary confinement. Yet patients are not only threats to one another. They can also serve as mutual bridges to companionship and healing.
Even though health professionals such as nurses and doctors frequently interact with patients, there is a limit to what we can offer. For one thing, the people in white coats and surgical scrubs are often too busy to allow the development of a deep human connection. Moreover, many of us have never been seriously ill or hospitalized ourselves. By contrast, other patients often know what the world looks like from the vantage point of a hospital bed. They have been through similar travails, and certain kinds of conversations may be possible only with another sick person. While some patients may do well in isolation, others long for more human contact.
Some may object that calls for patient community are both anachronistic and impractical. After all, we live in the era of automated teller machines, pay-at-the-pump fuel stations, and on-line customer service. How many of us actively seek out interactions with neighbors, let alone complete strangers? As Robert Putnam famously observed, many today are bowling alone, relying on television and the Internet to satisfy needs once met by face-to-face conversations and block parties. It is even possible that most patients, given a choice at admission between a ward and a private room, would opt for the latter. But perhaps that they don't know what they are missing out on.
One particularly problematic form of "privacy" is the social stratification of patients by race, ethnicity, and socioeconomic status. Several decades ago, an upper-class white woman lost consciousness as a result of a motor vehicle accident near our county hospital. Unbeknownst to her, the hospital's name had recently been changed from County to Wishard Hospital, in honor of a dedicated physician. When she regained consciousness, her brow furrowed with worry, and she immediately demanded to know where the ambulance had taken her. "You are at Wishard Hospital," the paramedics told her. "Thank God," she responded, the worry lines on her face melting away. "I was worried you had taken me to County!"
A similar situation provided the premise of the 2007 Rob Reiner film, The Bucket List. In it, a white healthcare magnate (Jack Nicholson) finds himself sharing a hospital room with a black mechanic of modest means (Morgan Freeman). The former is estranged from his closest relatives, bouncing from one superficial relationship to another. The latter, though poor in money, is rich in human connections. At first wary of each other, their shared experiences as patients bring them together, showing them how much they really share in common as human beings, and they end up partnering up to do the things they always wanted to do before death. Under normal circumstances, they never would have encountered one another, but shared suffering enables them to forge a common bond.
Whether hospitals are composed of wards, doubles, or single rooms, we need to nurture opportunities for patients to connect and share experiences. Infection control, confidentiality, and privacy are all important, but they alone cannot complete the circle of care we need. We are not just broken down mechanisms that need to be repaired. We are also suffering human beings, who need someone at our side we can talk with and get to know. Sometimes what we need more than anything else is a friend. What a shame it would be if our zeal for privacy prevented us from making a friend at the very moment in life when, perhaps more than any other, a friend is just what we need most.
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