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Architecture and Medicine: Podcast with Diana Anderson and Emi Kyota



Before we get into this week's topic, would you please take 1 MINUTE to complete this GeriPal survey!  It will really help us out.  We swear, only 1 minute!  Click here to complete!  Thank you!  Now on to this week's topic.


Alex: What do you get when you mix a doctor and an architect?

Eric: An Archidoc?

Alex: No a Dochitect.  What do you get when you mix a gerontologist with an architect?

Eric: A gerontolitect?

Alex: No an environmental gerontologist.

OK, so we didn't have that EXACT conversation on this podcast, but something close to it.  There is a growing recognition that many of the settings where older adults receive healthcare are not designed to meet the needs of older adults.  The early part of this movement resulted in the Americans with Disabilities Act, which mandated such things as accessibility for persons with wheelchairs.  But it so much more than that.  The architecture of health care buildings can actually impair the health of older adults or people living with serious illness - think lack of windows, rooms designed around beds, and placement close to noisy workspaces.  Can you say delirium???

Re-designed spaces also have the potential to improve outcomes for older adults and people with serious illness.  Further, redesigned spaces can improve quality of life for healthcare providers, and those benefits may be passed on to our patients.

To discuss these fascinating issues we talked with Dochitect Diana Anderson, MD, M. Arch (UCSF geriatrics fellow) and Emi Kiyota, PhD, environmental gerontologist.  Click here to learn more about Diana and links to her publications, and here to learn more about Emi and her website Ibasho, Japanese for "a place where one can feel at home and be oneself."

Enjoy!

by: @AlexSmithMD




  


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TRANSCRIPT

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, there are two people in our studio audience with us today.

Alex: We have two people in our studio with us. We have two architects with us today, we have Diana Anderson, who is a Dochitect, she is a physician and architect, a Dochitect -- I think you actually trademarked that.

Eric: You coined the term Dochitect, right?

Diana: I did. It was a toss up between dochitect and archidoc.

Alex: I think you chose the better one.

Eric: Archidoc.

Alex: Archidoc [laughing]

Eric: It does sound like a children's show, Archidoc. The Archidocs.

Alex: Dochitect, and she's a fellow in our geriatrics fellowship, welcome to the GeriPal Podcast, Diana.

Diana: Thanks Alex, good to be here.

Alex: And we have Emi Kiyota who is an Environmental Gerontologist, and she could tell us what that is. She finished the GBHI fellowship, Global Brain Health Institute, UCSF fellowship this past year. Welcome to the GeriPal Podcast Emi.

Emi: Thank you for the invite.

Alex: What is Environmental Gerontologist?

Emi: Good question.

Alex: Wait, is that a long story?

Emi: A little bit.

Alex: Oh, wait then, we should do that later.

Eric: Before we go into the long story, so we're going to be talking about architecture and the impact it has on medicine and what role should we be thinking about design and all of the things that we do, but before we do, we always ask for a song recommendation. Do you have a song recommendation for Alex?

Diana: We do, there's actually surprisingly quite a few songs that talk about architecture and engineering, we picked one by Simon and Garfunkel, and talks a little bit about Frank Lloyd Wright, who was a very famous architect.

Eric: Yeah, there's a nice building where both Alex and I live (in Marin), the Marin Civic Center, the Frank Lloyd Wright building...

Alex: Yeah, Frank Lloyd Wright sprinkled throughout. So long, Frank Lloyd Wright by Simon and Garfunkel turns out it was... there's a story behind this, Garfunkel asked Simon to write a song about Frank Lloyd Wright, and this is towards the end of Simon and Garfunkel time together. Paul Simon didn't actually know Frank Lloyd Wright, so he wrote this song, and you'll hear it's like, your song is gone too soon, I barely got to know the tune. Frank Lloyd Wright died at age 89 I believe, so he had a long time to live.

Eric: Was he still alive when the song was-

Alex: So, Simon, Garfunkel later said that he actually wrote it about Garfunkel and their impending breakup. So it's like when he said so long, Frank Lloyd Wright, he's singing so long, Garfunkel, I barely got to know you, I loved harmonizing with you, I barely got to know the tune, so long, bye. Yeah.

Eric: Let's hear a little bit of it.

Eric: (singing).

Alex: All right so maybe we can start off with the stories. How did both of you get interested in architectural design and how it impacts older adults and medicine? Starting with Diana.

Diana: So I guess I'll start. It's a bit of a long story but I'll summarize it, I started out in architecture, which many people who know me know about that. In architecture school, I went on to my master's thesis and as part of that tour to hospital in Europe, that was a life changing afternoon for me and one of those aha moments, where I felt actually quite comfortable and encouraged being in this healthcare space that had never happened to me before, I always felt pretty anxious and icky when I walked into a healthcare building from what I'd seen. This was the tuberculosis sanatorium by the famous architect Alvar Aalto in Finland and it completely changed my career. I went back to Canada and said, "I want to design a hospital that has some of those healing elements that the architect thought so carefully about."

Eric: What were some of those healing elements?

Diana: So the setting back then, when Tuberculosis Sanatoriums were being built, they were located in supportive environments, lots of nature and lots of natural light, lots of color. The architect even designed all of the furniture thinking about the patients and their symptoms, chairs that had the exact angle of reclining so people with lung problems could breathe better, sinks that would separate handwashing from sputum production, just thinking about infection control. I mean, he even raised the furniture off the floor in the patient rooms so you could easily clean the floor. Walls were painted bright yellow, lots of terraces for what they called the cure time in the afternoon to have fresh air and people did very well.

Alex: It sounds wonderful. So you came back, this is before you became a physician.

Diana: That's right. So I began a two year process in designing a hospital for McGill up in Canada where I'm from, thinking about all those elements. As part of that I toured lots of hospitals, lots of nursing homes, lots of ICUs, and started to think wow, I think I want to be on the side with the patients and really caring for people it's something I had thought about. So I went on to medical school, and I have to say that during all my rounds as a medical student, all I did on rounds was look up at the ceiling and down at the floor and count the tiles and figure out the square footage and think what can we do in this room differently? So I could never quite get out of one and into the other, I always have had two hats on at the same time.

Eric: Yeah. Spoken like a true dochitect.

Alex: That's right. And Emi, how about you, what's your story?

Emi: I was born and raised in Japan, you can tell by my last name. I was working in the government sector, and at that time I visited my grandmother in a nursing home, and I was quite shocked by that environment and the care that she was receiving. No one remember her name, but everybody knew her room number and medical diagnosis, but no one care to pay attention to what she wanted to do, so she had a very difficult time actually at the end of her life. And when I was visiting I realized I was young and naive at the time thinking I'm going to have to do something. So I quit my job next day, knowing nothing, but thinking, I want to study about improving environment for the people.

Emi: Then I look around a graduate school and I was in Japan at the time, I was 27. I was too old to be a graduate students in the Japanese context 20 years ago. So I applied for university in the United States and I studied gerontology and then Architecture here, that's how I ended up.

Alex: So gerontology and architecture?

Emi: Yes.

Alex: Combined at the same time?

Emi: Yes.

Alex: Yeah. Interesting.

Emi: Makes sense, doesn't it?

Alex: Yeah. So let's get into it about what is it about? Does architecture matter? So, let's talk about one of the most common spaces that we think of, the hospital setting. Can you help us understand how architecture might matter for older adults who are in the hospital?

Diana: So maybe I'll take this one. So, I think maybe we're biased, but I think architecture matters a great deal and has a huge capacity to impact our behavior as human beings, specifically impact our health and health outcomes. Some of the listeners might be familiar with the term evidence based design, which is relatively new and based after evidence based medicine, whereby architects today who design healthcare facilities actually look at the research and say, "Are we doing things with good reason? And are they impacting outcomes?"

Diana: But hospitals are places where the staff is working very, very hard and is exposed to very difficult situations on a daily basis, patients are obviously sick and feeling unwell and going through a lot of trauma in their own lives and they have families who are also struggling. So the environment becomes a really important component of that type of care environment.

Eric: When I think about hospitals, I often don't think that they're the most patient Center... We talk a lot about patient centered medicine. But I don't think hospitals are very well designed for patients, do you get that sense to?

Emi: Yeah, I always think about how to define user, when we think about user centered design. I think we have done quite a good job for clean and efficient environment for staff members, maximizing staff members manpower. But we haven't really done much about users as patient, when we designed well, and just try to reach that sense of comfort and sense of privacy and all the things that improve our quality of life on top of quality of care.

Eric: So maybe it'll help our listeners if we paint a picture of one type of let's say, should we say emergency department or ICU? And then what the possibilities are? Think of like, what's the worst case from design standpoint? And what outcomes might be we need worried about? And what's the best case?

Diana: So maybe I can comment on the intensive care unit because it's an area I focused on for quite a few years, I sit on the ICU design committee at the Society for critical care medicine, where we think a lot about this and we actually wrote some design guidelines that were published a few years ago, thinking about how does the environment impact patient outcomes and staff care delivery? I see user difficult environments, they're under stimulating and overstimulating at the exact same time. And as many of you who are listening know, delirium is a huge problem that we're noticing takes place quite frequently in intensive care units, and there is some research and suggestion out there which I fully support that the environment plays a role in that.

Alex: Can you say more about, I get the overstimulating, because I go in the ICU I feel like I'm in an amusement park, you got loud things blaring, you got people rushing around, the doors are all open, there are machines everywhere.

Eric: Beeping and buzzing.

Alex: Yes. I get the overstimulated, what's the under stimulated?

Eric: I also remember as a resident, I remember going to sleep, my room is right next to the ICU, and I would wake up and then I would go home and I would still hear the beeping and buzzing of all the machines as I'm sitting in my quiet room at home.

Alex: That's not deliriogenic at all, what?

Diana: So we actually had as a, when I was a resident, a room that people would call the delirium room. And this is interesting, because we talked a little bit about patient centered care, but I think it's important to listen to the staff as well. And there was just this anecdotal story that this room caused more delirium, it wasn't in an intensive care unit, it was on a regular acute care floor, but when I went to see it I think what jumped out of me was the door squeaked every time it open and closed, it was near the nurse's station, so it was a little bit noisier in terms of acoustic, there wasn't much of a window in there if any, the colors were quite drab. So you're right, I think you get the noise factor and somebody is always poking and prodding you, but there's under stimulation in these environments too, and there is some thinking that if we promote somebody sense of agency and we provide environments that lead to interaction and mobility, that people will do better and potentially prevent delirium.

Eric: I see. So, it's stimulation in terms of getting people up and interacting with them, rather than looking at their numbers on the screens and making sure that that beep stops, because of some blood pressure value?

Diana: But I think with critical care units, we're looking at delirium as something that we can intervene on as architects, very high acuity environments delirium has very negative consequences, and if you look at all of the non pharmacologic methods to prevent delirium, treating might be a little bit harder, but a lot of that includes the physical environment.

Eric: So paint a picture for us of the ideal ICU? What does that look like?

Diana: So I might broaden that and think about, and Emi can help me, but thinking about environments that support older adults and older patients in hospitals, because I think it's a little bit hard to categorize what is a geriatric ICU? Or what is a geriatric emergency department? I think we think a little bit about how to just make all environments pretty supportive of people who might be aging or might be frail or be sick. Overseas in Ireland they talk a lot about something called Universal Design, which I actually support quite a bit, it's the thinking that an environment should support and be all inclusive no matter who's using it. So, the hospital lobby or the patient room should support anyone no matter what their age or ability or disability, let's say.

Diana: So if you're two years old and learning how to walk, the environment should support that. If you're 92 and extremely frail and have a walker or a cane, that same environment should be flexible enough to support that scenario. Even if you're 32 and sprained your ankle, so you're on crutches for a few weeks, you should also be able to use that environment.

Eric: Interesting, and this is in contrast to the geriatric ICU, geriatric emergency department, the hyper specialization of spaces. Is that right?

Emi: Yeah, I think so. I think there are benefit and also downsides. To me if you were to specify a segregate age cohort or just the group of people. First of all that creates stigma to begin with, and the second just create another unification of care that doesn't fit with everyone. You hear I get questions like how do you design emergency room for dementia? I said, "Do you really want to design only for dementia, or is that going to be the space that's conducive to dementia but also to other people?" I think We really have to think about what kind of functionality we want to support, like emergency room for dementia, I went to a few, and I'm not a doctor, so I'm looking at environment from users point of view.

Emi: First of all, waiting room is too loud and it's too confusing, and a lot of time you can't even find entrance to the emergency room. If your loved one is carried by ambulance, and you have to go through the main gate, and try to find your loved one in the treatment area, and everybody is confused. Yet we're not really paying attention to designing better orientation for family members and people with dementia how to find space knowing that they have cognition problem.

Emi: I think a lot of design principles at this moment based on mobility issues, but we don't really have clear understanding about how to accommodate a hearing loss, it could be visual impairment is a little bit better developed, but when we think about cognition, I know how to figure out about the signage and how to figure out about orientation, it is something we really have to think about.

Emi: But at the same time, if you design perfectly conducive environment for dementia residents and elders, that works for everyone at the end.

Eric: Diana didn't you say there's an ICU where each room has a giant glass door and a porch, people can go outside or something like that?

Diana: I think the porch model has been used in some nursing home contexts, we tend to not use it in such an acute care environment. But I like the idea a lot, and when I lecture on this topic, I always talk about the idea of getting people up and out of bed from the hospital, whether they're in the intensive care unit, I mean, as clinicians we know somebody can be intubated, ventilated and up and walking in the ICU. Where are they going to walk? Well, they're going to go into the corridor. So to me as an architect designing these spaces, the corridor is a really underused or underdeveloped space in the hospital. I think we focus all of our resources and energy on the patient room, and of note, bedrest we know is quite bad for anyone but especially someone who's older and has different physiology, but we design around that bed, it becomes our focal point for design.

Diana: We've been trying to come away from that as architects and say, how can we obviously maintain a bed for people to rest when they need, but get them up and out of bed through the design of the environment? And do we need an intermediate space? Patient rooms can be very isolating and under stimulating for people. People want stimulation to see other people walking by, so can we develop these porch like units just outside the patient room in between the room and the corridor, and that's been done in nursing homes, and it's often done in pediatric units, which works very well and it begs the question in pediatrics, we use things like colors, textures, we even overstimulate with lighting and textures and different materials, and we tend to not do that in nursing homes, but I think everyone of any age would enjoy colors and whimsical themes, themes of nature, it doesn't have to be a pediatric theme, but it can still be quite enjoyable. So the porch idea is a good one and something I think about a lot.

Alex: So we had a big change in our community living center nursing home, here at the VA a few years back. I remember when I was here as a medical student, Eric probably remembers this, it was very, what is the right word? Industrial is not the right word. It was very institutionalized, it was the opposite of a home like setting. And they, I think had some grant funding, they put in hardwood floors instead of tile floors, they opened up the nursing area, so instead of being this walled off enclosure, it was a space where there was good flow in and out of it. And they-

Eric: It was open so everybody could see what everybody else is doing, it wasn't siloed off, walled off area that nobody can look into, right?

Diana: And I think, talking about that, you're touching on some evidence based design points, where we actually do have some research to show that those types of environments have better outcomes. So we do a lot of single patient rooms now, because we know that they prevent falls, have better infection rates, family gets more involved. So we have some data, it's not the best and hasn't necessarily been reproduced a lot, but it's there, mostly anecdotal. But I think we have a long way to go with respect to the research, but social isolation is a problem and I think health architects are trying to tackle that. So your example of the nursing home, opening it up, visibility is very important.

Diana: I think, and Emi can comment, but in design it's challenging, right? I think I encounter a lot of clinicians who say, Well... As a resident on rounds, people would pull me aside because they knew I was an architect and say, "Let me tell you what's wrong with my space." Everyone had something that was wrong. It's interesting when you write all this down and make little sketches and compile the notes, people are thinking about this, it's affecting them quite a bit. So that was always interesting to see, but I think the research side has a long way to go with respect to design, and that's something that we try to push for, and I think integrating clinicians into that is really important going forward, because they're the ones using the space and everyone out there has something to say about their space, their clinic, their office, and how it's working for them.

Eric: So I was just listening to one of my favorite podcasts, it's called 99% Invisible, 99PI. And one of their earlier episodes included a design episode on hospitals and they had somebody from VCU, Virginia Commonwealth University, and they brought in somebody from Japan on a Toyota method and they actually had somebody follow where do patients in clinic go and the fact that hospitals are filled with waiting rooms was insane to the Japanese sensei from his Toyota method. But the other thing that they did is they moved all of the physicians and healthcare offices to the inside and all the patient rooms to the outside with the windows, and helping with bright light, and really prioritizing patient centered care, but that came at the cost of now the health care staff are in these windowless cubicles in the middle. Is that the right priority when we're thinking about design?

Emi: I think that dichotomy is not right, I think we should be able to accommodate different needs and different user groups, rather than just taking one side to extreme actually, I feel like. So I was involved in one of the waiting room innovation when I was in Singapore, we had that idea, but we didn't-

Eric: That idea meaning?

Emi: Just giving perfectly person centered, patient centered, so doctors and nurses are going to just give up on their nice places.

Eric: They added a basement room, a windowless basement room, and you get one stapler.

Emi: They had to walk more than before although they were already walking a lot. But we didn't do that at the end because we were afraid that changing environment is the easiest part of transformation of the hospital, if people don't follow the ideas about what we wanted to do, which is to really push the person centered and patient centered, environment itself cannot change anything, it's just like I always have to tell people that environment is like a glove, organization is like a hand. So you can actually design a beautiful glove, but if you don't know how these hand is going to move, it never fit.

Emi: So you have to be able to understand the capacity of the organization, also the desire of how much staff members wants to change, and then we have to design around that. So we cannot really parachute ourself in and just say, "Oh, we're going to save the patients and we're going to just go back to the back room and it's just not going to work.

Alex: Can you give us some more examples of spaces you've seen designs that are geriatric friendly, if not specifically designed for older adults?

Diana: I mean, maybe this is a good time Alex to touch on the idea of the dementia village that has come under some popular press questioning just in terms of the ethics around building a village that still has some illusion, it's still essentially a lockdown environment even though it's not a room with a bed with a door, but it's a village that's gated. That model was developed in Europe and we've talked about it a lot as architects and looked for data and evidence. We have some anecdotal stories to say that this works, the idea of purposeful movement and permissive wandering is something that works in design for patients.

Alex: Can we talk a little bit more about what it means, what is a dementia village? Our listeners may not know.

Emi: Yeah, I think the one that I've been to it's in Netherlands. So they have series of small houses where people with dementia live and they have Town Center, they have shopping center, they have café, so it's like a small village but it is a larger institution, because there is a wall and there is entrance, but residents are able to move around and walk around in a large area that is designed specifically for the dementia.

Alex: Contrast that to a standard US nursing home where you have long corridor patients warehoused in their rooms throughout, and maybe some unattractive common space that is rarely used.

Emi: Yeah. And also that in the US we have a small house, it's called the Green House movement. That is a small household, but you can't get out freely to outside and roam around that. So this dementia village create this home like small setting, and they're able to have a feeling of being able to get out from the house and walk around, that's the whole purpose.

Diana: And maintaining your activities of daily living and just what you enjoys, in the dementia village if you want to go and buy some groceries, you can do that, if you want to go to the pub and have a beer at five o'clock, you can do that. You can take a walk, it's gated in a larger sense, but contrast that to here, you've got your own room perhaps, maybe it has an alarm so you can't leave the door, and if you try to leave the unit, we often paint doorways to conceal them. So patients with dementia or cognitive impairment don't realize it's even an exit door, so the building is acting as a restraint in a way.

Eric: So we actually one of our very first episodes, I think it was number five, was when is it okay to lie to patients? And when you think of dementia villages, these are facades, it's a facade that it's a house, right? It's a facade that it's... they're often like one building that looks like multiple different houses, right? Then for many of them, you're still indoors, but it looks like you're walking outside. Is that the sense that I'm getting from these dementia villages? And if so, is it okay to deceive our patients to believe that they're free to roam around? In like The Truman Show, you think you have this freedom but you're actually in this dome doff city.

Alex: Good movie, The Truman Show.

Emi: Yeah, I feel like we have to really challenge the way of our thinking, because a lot of times we create deception thinking that they would know, or it's good enough, thinking they won't know, but we're just not treating them with dignity, I feel like if it was me, I would not like to be living in that kind of place, but we do that to the people who has dementia or older. Just that by itself needs to be challenged, I think. And again, my problem is, so, to the doctors, we have a group of doctor here. So they have dementia, for example, so what worse things to happen if they get out from their house? How can we design existing community where they can actually roam around and be safe.

Eric: So maybe bringing that universal design principle, not just from a hospital standpoint from a community, that we should be designing our communities to be accessible to everyone, and if we focus on making it accessible, let's say to the dementia patient, we're making it accessible to everyone.

Diana: Yeah. And then I think, if you think about architecture Emi, and I can probably think of some examples where we do use these, I'll call them therapeutic illusions perhaps, but architecture is full of them, we have these trompe l'oeils, facades that are painted to seem one way, but really it's a flat wall underneath. We all exist in these boxes of buildings, offices and homes, and to bring it back to Frank Lloyd Wright, he designed a specific type of home called the Prairie house, which is interesting, and he talked a lot about the space over the enclosure.

Diana: So I think when we think about dementia villages, we focus a lot on the idea of the enclosure, but the space itself is I think what's important, and we can't forget about the space. So Frank Lloyd Wright thought of houses and thought of every room and it didn't matter if it was the bathroom or the kitchen at the back of the house, it was equally as important in terms of use, not just the foyer at the front and the entertaining room. So I'd like to see that thinking carried over to healthcare.

Alex: Isn't there some movement, so moving a little bit away from healthcare, I'm not sure if you're involved with this, but the San Francisco Airport has a grant out, I know Brie Williams is involved with this, one of the geriatricians at UCSF, I think you might be as well Diana, to redesign the airport to be more geriatric friendly, if you can talk about that at all.

Diana: Yeah, I mean, thinking about the airports which are massive buildings with challenging distances and way finding, so that's underway, but thinking about even prison design and people who might be aging in prisons, and just anywhere in society, I think where we're at, Emi is right, we really have to extend this to urban design and urban planning and away from just pure architecture in the built environment. So I think it's a great way to go, I think, do we develop design guidelines to follow? Can we prototype this or is it really individual to each type of building? And setting is a big question that we're trying to tackle as designers and architects right now.

Eric: So the dementia village seems like a revolutionary idea, right? That's really pushing on the boundaries. It's much more than a skylight or an artificial skylight or more windows, it's completely rethinking from the ground up how to care for older adults in spaces and communities in which they would want to reside even living with dementia. Are there other examples of revolutionary thinking in the way we design our spaces?

Diana: Well, I think there's a move in some countries specifically in Europe to think about aging in place and aging in the home, and developing homes early on that you could age and potentially go through cognitive decline in your own home. I don't know if it's revolutionary, but simple in theory it's harder to actually implement. But to me that's something that other countries are thinking about quite a lot. Some people say, I have a geriatrician colleague friend who says, "In 20 years, we won't have hospitals anymore, and maybe we'll have critical care freestanding facilities, but we won't have hospitals as we know them." And if that's the case, I think, as architects and designers and clinicians we have to put our heads together and figure out how that would work.

Emi: I think that so far the options that we have for elder care to me, it's relatively limited. You go hospital, you go to nursing home, maybe you go to adult day center, you go to senior center, I feel like the services and options for the healthy educated, although people might be limited, I feel like we just need to push a little bit more options for two reason, why? Because that's what people want, I think older people wants to be useful to others regardless of their health and cognition, but they don't have a chance to be able to do something because the older care system is designed toward we'll look after you, you are the receivers end. So that is one thing that we have to change I think.

Emi: The second because I grew up in Japan and my whole family is in Japan, we don't really have enough resources to make current institution care better, because we have a limited budget in 5, 10 years. Yet we are still using same mindset to care for older people, means that we don't have economic strength to be able to support more older people with lower tax income. So how to change the way that social isolation by giving people to have meaningful relationships staying at home, being involved in the social space, and also to be able to just stay at home, so that the government doesn't have to really spend that much institutional care that no one wants to live in at the end.

Eric: I learned a new word today from you, you have a book and the word is, I'm going to totally mess up this word, Ibasho?

Emi: The first one is right, Ibasho.

Eric: I did like six of them. What is Ibasho?

Emi: So this Ibasho came out from my volunteer work when I was in a PhD school actually. So I was helping for Sri Lanka, Africa, Bhutan, for the retired monks and retired Catholic priest and retired teachers to have the housing, because those three countries don't have nursing home and institutional care. And they were very clear to say, "I don't want a nursing home, we don't want a nursing home, we want a meaningful relationship and purposeful life when we get older, what can you do? Can you please help me?" At that time I realized that what care was really catered toward looking after older people.

Emi: And older people the other side were saying that we want to do something, so we created this cafe, it's located in a community where they can gather every day to do something for younger generation so they can actually get back to their community, but they're able to stay at home. That's where people actually have conversation and the one we created in Japan was after tsunami. Those elders after seven years later started to knock on people's doors who are isolated, because although people can reach out much more effectively to other older people who are strong.

Eric: Help me out... Go ahead Diana.

Diana: I guess the main message that I think Emi and I want to convey is the power of architecture and design, and it's something to keep in mind, especially in the healthcare turmoil that we seem to be in looking for solutions and ideas going forward, how to deal with different issues especially with aging populations, there's a big push to even look at neuro architecture and combining ideas of spatial navigation in the brain and developing way findings.

Diana: So I think the key is this multidisciplinary collaboration is what we're going to need going forward.

Eric: Is there a research base around this? Are people actually doing these studies?

Diana: So there is a research base, so we call it evidence based design. I think the word research in the architectural world is controversial. Architects are not necessarily trained in research methodology, or to review the research the way clinicians might be, but they're eager to get involved. I think having the tools to do so, going into a building after it's built and saying, how does this work for you? Great, it's going well is not necessarily something that we can then use and replicate, but there is a push to try to develop a more robust set of literature, because I think you can study the built environment.

Diana: We had a landmark study in the early 1980s that was small but powerful and basically changed the way we know it in terms of healthcare architecture today. It was a simple cholecystectomy, get your gallbladder out and divide patients into two groups, one had a window that looked at a brick wall, the other looked at a nature park. You can probably guess who did better, but the green views and the park views went home sooner, use less pain medication everyone was happier.

Alex: Oh interesting.

Eric: That reminds me of those monkey studies where you have this baby monkey, one is a wire cage mom and the other one is like a fluffy mom and the kid who got the wire cage mom did not last very long. It's the same thing with humans, you show a picture... your window is a brick wall versus your window is nature.

Diana: I mean, it sounds simple and it sounds obvious. And some people say we don't even need evidence based design because it's just good design, pure and simple. Everyone should have daylight it's a human need, why do we need to study this? But I think-

Alex: It a basic commodity, yeah.

Diana: ... I think there's value to doing it, and we can find some shocking results.

Eric: And it's an expensive design though, right? Sometimes the stuff that works like to have access, let's say to an outdoor environment, while you're in the hospital.

Alex: Windows, parks, these things are not cheap.

Eric: I feel like every time I see an outdoor environment in a hospital, it's always locked off because people are worried, somebody is going to do something out there. Are there examples of hospitals that you've seen that get it and continue to get it and not just block it all off?

Diana: I think there are, I think what comes to mind are some pediatric hospitals that really incorporate gardens, and depending on the climate as well I think becomes a challenge and gardens for staff is also very important, because I'll make a plug that I've been thinking a lot about equitable design and making sure staff have good design as Emi was mentioning, but you might think it's a bigger cost up front, but there is data on that as well. There's actually a hospital analysis that looked at spending more on evidence based design features up front, and there was a return on investment and it was quite shocking in terms of how much money you would save. It doesn't need to be expensive fountains and crazy artwork, you don't have to invest a lot, but good design principles actually save money, but more importantly have better health outcomes for patients and I think better care delivery from staff.

Diana: As I've been combining this dual career, at the beginning it was the sanatorium that triggered me to combine things, but along the way many people talk to me on a weekly basis and reach out saying, I'm a surgeon, and I think if my operating room was designed differently, I could operate better, faster and more efficiently. I've had other calls to say academic medicine has changed in terms of its model of practice, but our academic campuses are the same, what if we change the design, would it go along with our care model and our academic teaching model.

Alex: They tried to do that Mission Bay, pull UCSF, all these new buildings where they built them on the dotcom principle, like, Hey, we'll just make everybody have one big room and no separate offices, and then they'll all interact and talk with each other and come up with all these great ideas. Turns out academic docs are not so much the same thing as dotcommers, and we actually do need private rooms to call patients and our own spaces to think, and it didn't go over so well with... everybody's on their headphones with this space rather than talking to each other.

Diana: That anecdote is really interesting, and also Emi can speak to this, but bridging the gap, how do we bridge this gap between medicine and healthcare and architecture and design? We're at this place now, I mean, we have to marry the built environment with the operations and care models, and her example of the glove and the hand is exactly that. And how do we do that? I think one of the ways is getting clinicians, everyone listening, aware of the physical environment, be aware of it, most physicians will go through at least one renovation project or new construction project in their careers. So they'll have a say, and they'll be able to attend meetings, we would encourage clinicians to advocate for designs that they would find helpful.

Emi: I think if I may, I would like to add the fact that we really need a systematic change also, because I've met so many doctors, has an idea and they talk about it, yet how that's going to be implemented it just gets lost somewhere. So we really have to have a better design process, system that when we invite users to just give us advice, we have to integrate it, because a lot of time it gets lost somewhere. And also sometimes when you say user centered design, who's going to be at the meeting, hospital administrators, they're not even doctors, and they're not even nurses but we really designing for patients, but have I ever been to any of the meeting where patients sitting and just giving advice on it?

Emi: So I think that's the system we have to change, because each individual can do a lot, but they have a lot of limitation also. So if we were to be aware how the process of the design should change, then those has to just go both ways, just like individual change and also systematic change.

Eric: I guess it's hard because everything is a moving target, if we think about airports, airport design changed dramatically after 9/11. So much so if you go to our international terminal SFO, it's like pre 9/11 design and you have this huge like area, people can walk in go get their tickets, but nobody is in there, it's like dead, because everybody just rushes to the TSA line so they can get inside of these secure terminals instead of waiting. I can imagine the same thing in healthcare, what we design now may not be around in 10 years, or we may have different ideas of what it should look like. When you're thinking like five or 10 years down the line, do you have an idea of what we should be doing?

Diana: So I think the challenge Eric is I don't know, do you know how long it takes to actually design, implement and build one of these big healthcare campuses or facilities.

Alex: One month?

Eric: Yes. I've been at my facility, and I think it gets designed, but it never gets built, so it's an infinite loop.

Alex: Never.

Diana: Some of these big projects take a decade, I mean, it's a long process, and honestly, by the time the bricks and mortar get laid down, whatever was drawn on paper is now obsolete with technology and the way care practice has changed, that's a big challenge for architects. I think one of the ways we're trying to deal with that is use virtual reality and technology to maybe pre-experience the space and try to see can we study the space before we build it? But right now, we're not building hospitals to last 100 years, we're spending 10 years to build them and maybe make them last 50 if we're lucky.

Diana: I think another thing to keep in mind for the listeners is everybody assumes once you cut the ribbon and open the space that it's perfect and will never need any adjustment. That's just simply not the case, and I think the onus is on the administration and the staff to continuously check in and say what things can we do? There's an example of a critical care unit in New York City, they opened and patient started saying, "There's no hook in the room, I can't hook anything." So we add the hooks, these are important post occupancy, evaluation type elements that are just... Spaces are going to need upgrading and changing, and that's okay.

Alex: Yeah, I think one of the biggest upgrades in our hospice unit, we had chairs that you could hang on the wall, so now they're easily accessible chairs. Wouldn't it be nice if we had that in the hospital, availability of chairs to sit down to talk to your patients with, or even a family meeting room on every ward, some place where you can sit down and actually chat with families instead of this small tiny room that you can't fit more than three people in.

Diana: So that's such an important space and it's not even really mandatory in our minimum standard code documents, we are recommended to put in a space for family meetings, often we just don't hire real estate as patient rooms that make more revenue. There's a critical care unit just outside of Boston where the physicians felt so strongly that this would change how families took bad news and potentially impact them for the rest of their life when they remember that moment that they actually donated their own money and built two Breaking Bad news rooms with Windows and comfortable seating and it's made a huge difference to their practice.

Eric: That's great. That's a good story. Well, I want to thank both of you for coming on today. Learned a ton about evidence based design, where we should go for the future. If there's one practical thing that our listeners can do around this, what should they do?

Diana: So I think being aware, we're not expecting everyone out there to become architects tomorrow after listening to this podcast. Lot of physicians seem to want to these days, which is a ...

Eric: It sounds fun.

Diana: ... long road, it sounds fun. I think being aware of issues in the environment and advocating for that, and talking to administrators and thinking about getting involved in these building guidelines, we try to get clinicians involved and say, what works? If you're looking at a geriatric outpatient clinic, what are the things you're thinking about? Because clinicians will know what they need and if it's as simple as a hook on the door with a foldable chair that's pretty feasible to change. So I think becoming aware, advocating and trying to create change, I think the onus is on us using the space to think about that.

Emi: I will go with a little more specific. If I could ask physicians and citizens, clinical staff members, I would like you to think about, what makes it better for the patients with your input? A lot of time people ask you what kind of space do you need? Do you need a space for office? Do you need a computer and stuff? But maybe the designers forget to ask you about what makes patients' life better, or what makes it easy for you to have a better relationship in your exam room. But if you could advocate that, for the patients experience to have a better, comfortable experience there, to me it's very important, because no one is advocating at this moment.

Eric: Well, I want to thank you both for coming on our podcast today.

Alex: Thank you so much.

Eric: Maybe this time we can hear a little bit more of Frank Lloyd Wright.

Alex: A little bit more ...

Alex: (Singing)

Eric: Nice. Thank you Frank Lloyd Wright. Thank you for our Marin Civic Center, and thank you to both Diana and Emi for coming on our podcast today-

Alex: Thank you Diana, thank you Emi.

Eric: ... and thank you to all our listeners for joining us. We are going to make one final plea, that if we're having our hundredth episode soon, so if you can take a moment call 929GeriPal and leave a message about one thing that you enjoyed about our GeriPal Podcast.

Alex: Or didn't enjoy.

Eric: Or didn't, we love those too - we actually do.

Alex: What can we do better.

Eric: And leave a message, we always love listener mail. Thank you everyone.

Alex: Thanks, bye.



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