The Human Side of Health Care

I’ve admired Bill Stuntz’s frank discussions of his struggles with illness for some time. In the new blog Less than the Least, Stuntz describes a Massachusetts-area hospital (the Yawkey Center) that he finds exceptional:

Sitting in that waiting room, I twice saw a volunteer wheel a cart past my seat, asking whether I wanted something to drink or a snack—no charge. I didn’t, but the offer made me smile more. I felt like a human being, not a number or an item on someone’s checklist. The same was true when I met with my oncologist—actually, it has been true in every conversation I’ve had with anyone at the Center so far. . . . That kind of behavior lends dignity to the patients who experience it. And for people whose bodies are assaulted by this disease, dignity is in short supply.

Most hospitals are the last places to seek dignity. The physical spaces are, for the most part, ugly and cold . . . Some of the doctors and nurses go out of their way to show patients warmth and consideration—and may God bless each and every one of them; the smallest interactions with them are like a drink of cool water in the desert. But for the most part, hospital conversations are tickets being punched, not human beings communicating with one another. . . . However excusable . . . bottom line[-driven treatment] may be, it’s deeply wrong. Sick human beings need to know that we’re still human beings.

Having taken my mother to the predecessor of that center many times, I can second Stuntz’s observations. I think they can be taken in a few directions by policymakers. I’ll explore a couple beneath the fold.

First, Virginia Postrel brings up evidence that more aesthetically pleasing hospital settings can speed better health outcomes:

“[E]vidence-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.

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.

Personally, I find Postrel’s faith that “competition” will solve the problem a little puzzling. Not many seriously ill people are shopping for health care on the aesthetic dimension. As she admits, they are looking for the best doctors and technical treatments they can find. But I do think that if hospitals were under less pressure from ever-declining government reimbursements, they might have the resources to implement “evidence-based design.” Postrel might find a good model for her program in the government’s requirement that food labels clearly display nutritional content. The market didn’t bring us that information and design improvement–government did.

Postrel’s and Stuntz’s work lead me to reconsider the degree to which the health care system generally should subsidize design and aesthetics. In prior work, I criticized boutique physicians for “bundling medical care with unrelated amenity services.” I was agnostic about the value of amenities at the time I wrote that. But now I’m more concerned about getting them supplied to the chronically ill. . . and just hope that we as a society can recognize that everyone battling serious illness deserves to be treated well at a time of great need.

As Daniel Goldberg has perceptively observed for a long time now, health outcomes have a lot more to do with social care and stress-reduction than conventional wisdom recognizes. He highly recommends a documentary on the social determinants of health. As the documentary web page notes,

Economic and racial inequality are not abstract concepts but hospitalize and kill even more people than cigarettes. The wages and benefits we’re paid, the neighborhoods we live in, the schools we attend, our access to resources and even our tax policies are health issues every bit as critical as diet, smoking and exercise.

The unequal distribution of these social conditions – and their health consequences – are not natural or inevitable. They are the result of choices that we as a community, as states, and as a nation have made, and can make differently. Other nations already have, and they live longer, healthier lives as a result.

Participants in the documentary talk about “chronic stress and the neuroendocrine pathway,” scientifically linking stressful situations to poor health outcomes. If hospitals should “first do no harm,” improving patient experiences is a smart way to start.

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