A Hospital Room With a View

Bloomberg View , August 24, 2014

Hospitals are, by their nature, scary and depressing places. But they don’t have to be ugly as well -- and there’s ample evidence that aesthetics matter to patient health.

When the University Medical Center of Princeton tested a mock-up room with nice views, a sofa for guests and no roommates, it found that patients asked for 30 percent less pain medication, reports the New York Times architecture critic Michael Kimmelman. This result shouldn’t be surprising.

The seminal study on the subject was published in 1984 -- that’s right, 30 years ago -- in Science. Roger S. Ulrich, now an architecture professor at the Center for Healthcare Building Research at Chalmers University of Technology in Sweden after many years at Texas A&M University, compared two groups of patients recovering from gallbladder surgery in the same hospital, matching patients for characteristics such as age and obesity that might affect their recovery. One group looked out on some trees while the other faced a brick wall; their rooms were otherwise almost the same. Patients with a view of the trees required significantly less high-powered pain medication and left the hospital earlier, after 7.96 days versus 8.70.

Thirty years of follow-up research later, and it’s still news when someone designs a hospital room with a view.

The problem is not a lack of knowledge or, as Kimmelman suggests, neglect by “front-rank architects.” There are specialized architects and interior designers who have spent decades studying how to improve health-care environments. There are articles in peer-reviewed journals -- even an “Evidence-Based Design Journal Club” to discuss new articles -- and annual conferences. In other words, there’s plenty of information on how to make hospital-design better.

The real problem is a lack of incentives and feedback. New hospitals that hire fancy architects tend to lavish money on public areas -- the places donors see -- and treat hidden departments, such as the imaging suites, as purely functional. Even when money isn’t an issue, they make choices that please administrators but ignore research. The old-fashioned insistence on highly polished floors, a hazard to older patients with fading eyesight, is a pet peeve of health-care design experts. Evidence suggests that patients react better to landscapes than abstractions, and that “chaotic abstract art” and "close-up animals" looking directly at the viewer should probably be avoided. Yet the $1-billion Ronald Reagan UCLA Medical Center, which opened in 2008, features a cafeteria mural whose violently jagged abstractions are made all the more threatening by other shapes resembling lions staring out. There’s nothing wrong with the mural as art. It just doesn’t belong in a hospital.

Last year, JAMA published an opinion column by a University of Pennsylvania medical student who had been struck by the contrast when he moved from adult departments to a pediatric rotation. Suddenly the environment was cheerful, “almost celestial,” wrote Mark A. Attiah.

“Hospitals are scary places -- kids, you want to reduce their anxiety and stress as much as you possibly can," a hospital executive told Attiah. "You want it to be bright and cheerful, not drab, dreary, and dark.”

Adults deserve the same consideration, if not the exact same design choices. “Adult hospitals, as they begin to fully realize the importance of the environment to a vulnerable patient’s well-being, can take a page from the pediatric playbook by creating surroundings that distract and reduce stress, and by making clinical practices more patient- and family-oriented rather than more convenient for the caretakers,” Attiah wrote.

Except when they shop for birthing centers or daily radiation treatments, patients who might benefit don’t exert enough pressure on hospitals to change. As I wrote in a 2008 Atlantic piece on the subject:

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. …
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.

Ideally, the aesthetics of hospital rooms would trade off costs and benefits in ways that reflect patient preferences and scientific evidence. Those factors do play a role. But, like the rest of medicine, health-care design is also determined by habit, prejudice, covert rationing, prestige and public pressure. So a notice on the front page of the New York Times is a small example of progress.