Description

Taking care of patients has always been the core business of hospitals, but as the ‘Short History of Hospital Architecture’ in this book demonstrates, this does not mean that they were built with the intention to cure people. That only became their primary mission with the advent of the scientific revolution of the 17th and 18th centuries, when the medical profession began to look more toward empirical science for inspiration. This change marks the beginning of an unending struggle against irrational views about illness and healing. There has never been a shortage of rituals, rites and the use of herbs and drugs, the alleged healing qualities of which often depended entirely on religious beliefs, superstition or salesmanship. The medical profession has made the fight against these dubious therapies one of its primary objectives and hospitals as we know them today are the physical manifestation of this fight. Since the late 18th century, they could be called ‘healing machines’ (machine à guérir), that is to say, buildings designed to cure those suffering from medical disorders. A machine is a technological device designed according to rational principles and because hospitals have defined themselves as machines run by medical professionals and technicians, they have always been seen as offering the best possible chance of recovery.

The negative aspect of this outlook is that people were treated as objects of the same order as any other objects studied by the natural sciences. For centuries, medical professionals adhered to the Cartesian distinction between mind and body, seeing the latter as an object which functioned solely according to physical laws (and which was thus divorced from the workings of the mind). Diseases, therefore, had to be dealt with in much the same way as defective machines: by interventions based on the findings of the natural sciences. Medicine considered itself as one of them and thus treated mental illness, too, in the same way, i.e. as a mechanical failure.

René Descartes (1596–1650). Portrait by Jan Baptist Weenix. Descartes is associated with the conviction that mind and body represent separate worlds, implying that people’s state of mind cannot impact on their medical condition in any way.

As long as the Cartesian separation between mind and body prevailed, the idea of taking into account the patients’ personal experiences was believed to be on a par with the superstitious concepts medicine had tried so hard to overcome. Ultimately, the emergence of psychology at the end of the 19th century began to undermine the Cartesian dichotomy, and since then it has become widely accepted that people’s mental states can have an impact on their physical well-being. Psychology, however, did not at first reject the view that mental disorders should be seen as mechanical failures. Moreover, the idea that patients should have a say in what is done to their bodies and minds — something which is now believed to reduce the stress on them — had not yet developed.

In the 1930s, people’s personal experiences were increasingly seen as linked to their social and physical environment. Consequently, health-oriented interventions in the environment, previously focused on hygiene, now incorporated attempts to offer relief from stress. In the 1950s and 1960s, the modern housing estates that were then being built in large numbers came under fire, with experts blaming the living environment they provided for a great increase in psychological diseases associated with stress. Similarly, hospitals themselves began to be seen as stressful environments that hampered their patients’ healing processes. Friendlier, less machine-like architecture was promoted as a way to diminish stress, and patient-centered care became a popular slogan. Moreover, new organizational concepts were developed to alleviate the inevitable tension people experience when they are hospitalized. In the same vein, the evidence-based design movement that emerged in the United States in the 1980s began to explore the ways people react to their physical and social environment with the aim of learning how spatial design can influence medical outcomes. In sum, psychology was perceived as a way of exploring the link between personal experiences and objectively verifiable medical data.

The Bijlmermeer, Amsterdam, the Netherlands, 1968–1975. The ‘Cartesian Dichotomy’ was increasingly challenged in the 20th century. In the 1950s, the phenomenon of stress was discussed at numerous medical conferences and linked to mental and physical health problems. New housing estates like the Bijlmermeer were seen as particularly unhealthy.

For quite some time, a paradigm shift has been underway that takes this evolution one step further, inviting patients to take an active role in treatment, something that in the United States is already considered a matter of ‘conventional wisdom’.[1] ‘The elevation of the patient to partner’, the American Joint Commission concluded, ‘is not a ceremonial title bestowed for a “feel good” moment, but has significant implications for the quality and safety of patient care’.[2] From the traditional, medical point of view, this turns the world upside down, offering people who obviously lack professional knowledge and expertise — and are likely to be burdened with numerous unsubstantiated notions — the opportunity to interfere with medical procedures they know nothing about. Giving patients a say in the way they are treated clearly touches upon the very essence of medical practice and remains quite difficult to achieve. ‘In ideal circumstances, hospitals would be highly responsive to the needs of their patients. In reality, this is rarely so. Patients are in a weak position. They are in an unfamiliar setting, vulnerable because of their illness and their lack of information and dependent on others’, Martin McKee and Judith Healy conclude in a report of the Joint Commission, a not-for-profit organization that assesses health programs and organizations in the United States.[3] ‘Although it is self-evident that care should be focused on the needs of the patient, in reality many hospitals are run more for the convenience of the staff.’[4] Obviously, it is very difficult to reconcile the hospital as an impersonal ‘healing machine’ with the hospital as a caring institution that not only offers treatment, comfort and support, but also invites patients to take responsibility.

This paradigm shift coincides with a new definition on health, one that is widely promoted by the World Health Organization: people can consider themselves healthy if they can do anything they want without being hampered by their physical or mental conditions. Clearly, this approach puts personal experiences at the center and breaks away from the view that people are ill, and therefore in need of medical treatment, if from an objective, scientific point of view one or more ‘mechanical’ failures and dysfunctional parts can be identified (which is almost always the case).

Political and economic trends, not public pressure, are decisive for this paradigm shift. In an effort to control public health expenditures, many countries in Western Europe are moving away from healthcare systems in which the volume and the costs of medical treatment are determined by state bureaucracies. The trend toward transferring responsibility to the ‘end user’ is affecting all aspects of the economy, and there is little doubt that it will also transform medicine. Ideally, the individual customers should have a say in the cost and the quality of the services they are being offered; patients should use their purchasing power to force providers to adjust their services to the needs of the patients. The paradigm change obliges patients to better understand the options open to them; they have to be free to select the hospital or medical specialist of their preference, and they need to understand that they share responsibility for all decisions concerning their health and treatment. In order for patients to make rational choices, data such as the effectiveness, quality and costs of different therapies, the track record of medical specialists and the performance of hospitals have to be transparent and freely available. However, most countries still have a long way to go before this is the case.

The Unfallkrankenhaus, Berlin, Germany, Karl Schmücker und Partner, 1997, is the result of the reconstruction and extension of a historical pavilion hospital. It fits into its surroundings rather than dwarfing it, adding a friendly dimension often lacking in older facilities.

Technology, especially the Internet, plays a fundamental role in this paradigm shift. If the unprecedented abundance of information now readily available can be properly managed, information technology may help to create the ‘expert’ patient. ‘By increasing the likelihood of preventions over cure’, Sunand Prasad, a British hospital expert, believes, ‘such a patient will reduce expenditure in the health system’. In his words: ‘The costs of creating the expert patient must be far less than the costs of treatment of preventable diseases.’[5] The way the Internet facilitates communication between the medical establishment and the patients helps to further reduce the gap between the two groups. Instead of obliging patients to visit the doctor, certain procedures — from diagnosis to monitoring and follow-up — can be organized through websites or apps.

Why, then, is it taking so long for this paradigm change to take hold more broadly than it has to date? Obviously, resistance from the medical world continues to a certain degree. Many patients are reluctant to take on any responsibility for their treatment and prefer to surrender all initiative to the medical authorities. The substantial costs involved in public health also tend to foster conservatism: ‘The great expense of hospitals, together with their complexity and user requirements, militates against change. Should something that is untried be planned and built?’, Lawrence Nield wonders.[6]

Despite all this, the momentum for change appears to be irreversible. If the necessary conditions are met — if the patient is well-informed, if the effectiveness of treatments and performance of providers is transparent and, ideally, if a network of medical and non-medical facilities is in place — the shift of responsibility to the patient is bound to enhance rather than diminish the quality of healthcare. This empowerment will transform the medical machine into a service provider that takes its clients seriously.

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Originally published in: Cor Wagenaar, Noor Mens, Guru Manja, Colette Niemeijer, Tom Guthknecht, Hospitals: A Design Manual, Birkhäuser, 2018.