My favorite place in the hospital is the lobby between the chapel and Dunkin Donuts. Every evening I look forward to passing into the open ceiling veranda, to elevator jazz-music, awaiting my coffee fix for the evening. I wonder if this is the most sacred space in the hospital. Certainly the chapel doesn’t hold a chance – situated in a high traffic hallway, the chairs lined up in perfected geometry, like the DMV without the wear or tear and less gum under the seats. Lest one think that I am an overly sentimental doctor looking for meaning in the wrong places, there is good science behind my emotions. As I step into the veranda, my dopamine reward center goes bananas for coffee, the high ceiling activates neurons of more transcendent chapels, and the muted, improvisational jazz draws me out of the procedural, linearity of medical practice. All great architects could tell you this on an intuitive and structural level.
In a medical complex that costs hundreds of millions of dollars, I wonder how much time and energy were devoted to such lofty concepts as “sacredness,” and “healing spaces.” I believe this is of grave importance. It is in these very verandas that people gather, call loved ones over failed surgeries, and scream and weep. On a deep level, the space we occupy determines our capacity to respond to pain and suffering. Consider burial ceremonies, which predominately take place in arboreal cemeteries. Or the great rivers and oceans people use to spread their loved one’s ashes. Many hospitals hire consultant groups to redesign hospital workspace to make it more elegant, user-friendly and open. The language used is decidedly secular – with “patient-centered” the most recent buzzword. This concept is much needed in health-care and has a lot of positive connotations – more pleasant public spaces, brighter colored walls, and more natural light. All of these elements are much needed, but have little to do with the character of the hospital as a place of healing. In fact, much “patient-centeredness” results in large institutions that greatly resemble shopping malls.
We are currently structuring our healthcare delivery on the great misconception that we are a service-oriented profession. We are not. We are not the mall. We are not Dunkin Donuts. Our patients ask more of us, if we are willing to ask. Today I saw a 57 year-old alcoholic with a long history of cocaine abuse. He hadn’t seen a physician in five years. The first thing he asked me was “I came to you because I saw you are interested in meditation. I don’t like your profession, and thought you might be different.” He proceeded to bemoan sanctimonious doctors, and I dutifully listened, trying not to provoke him. Then I told him my background – that I grew up in a rich suburb, love reading philosophy and that my vision of medicine includes yoga, meditation, and thinking about many possible complementary therapies. I told him I was not married, had no children, and would be around for a few years, but had no idea what my next steps were in medicine. My offering this information felt uncomfortable to me – after all, what about professional boundaries? Yet, I believe he will come back to me to work out substance abuse issues not because I provided him the service of Hepatitis labs, but because he trusts me.
Tonight, Hilary, a 16 year-old girl, came to the ED with first-trimester bleeding. We assessed her for multiple causes of bleeding and determined conclusively that she had miscarried. After I broke the news to her, I asked, “What did you expect when you came to the hospital? She replied, “That somehow you could fix me.” She sat bemused, wondering out loud how she should feel about miscarrying an unplanned pregnancy at six weeks. I wondered aloud with her, and asked her how she did feel. It is at this point we rush to “fix” the next patient and offer her the discharge paperwork. We implicitly tell our patients “Figure out that meaning stuff at home. Not here.” We have provided her with a service, but not a story. I would argue that crafting such a stories involves both personal curiosity and a transformation of physical space. In theory, we know all about personal curiosity - we train physicians to recognize the distinction between a patient’s illness (their subjective lived experience) and disease (their physical ailment). We are less attuned to the emotional, psychological, and existential consequences about the physical space we occupy. In the words of Carol, a nurse of 20 years in the Emergency room, “this is the least spiritual place I have ever been in my life.” What if we made break rooms for Carol where the nightly news wasn’t blaring, and people didn’t eat standing up? What if we made sacred spaces for Hilary: rooftop gardens, non-DMV-like chapels, where she and her mother could sit and talk before going home?
When I hear “sacred space,” I am reminded of the vaulted ceilings of an Episcopal church and of Tuckerman’s ravine on Mt Washington. The last image that comes to my mind is of a hospital, with sterile walls and no trees in sight. But why should health care settings, where people experience the greatests joys and sorrows of their lives, become secularized to the point of diluting the possibility for silence, contemplation or transcendence? Part of the reason is that we have commodified not only healthcare, but how we talk about healthcare. Even the language “patient-centered” sounds derivative of “customer-centered,” a concept designed to measure satisfaction and efficiency, not comfort or peace. More than this, being “patient-centered” fails to capture the difference between illness and disease. We can set up our institutions to manage patient appointments for isolated diseased organs, yet forget to provide an environment that offers the possibility to confront illness in a space of calmness, peace, and reflection.
So far I have been giving a somewhat moralistic argument, based on, some may argue, overly general principles of humanism. But there is a scientific argument as well. We know that terminal patients who occupy rooms with windows live on average days longer than patients without windows. We also know that introverts (about 30% of us), are more prone to information overload, and need solitude to decrease the burden of their hypothalamic-pituatary axis, our hormonal regulation system of stress. There is a moral, scientific, and dare I say, spiritual impetus for change. This change will not happen overnight. But it will not start without an awareness and change in our language. We need to be mindful of talking about health-care exclusively in terms of delivery, service, and satisfaction, and be courageous enough to bring concepts of sacred space and stories into patient rooms, break nooks, and corporate suites. For now, I’ll settle for louder jazz, higher ceilings, and better coffee.
(Image used with permission from WikiCommons.)
Tom Peteet is an internal medicine resident at Boston Medical Center. He studied philosophy and physics as an undergraduate, and was a middle-school teacher for three years before pursuing a career in medicine. His interests include medical ethics, palliative medicine, yoga, global health, medical education, and writing.