One summer afternoon, when I was eight or nine, I impulsively chose to ride my bike down a steep hill near my childhood home. From the top of the hill my bike accelerated at a frightening rate and I remember for brief moments somehow being airborne before landing in a pile of bent metal and bloody asphalt. My adventure ended with a trip to the children’s hospital for a cast and a sling.
After all of these years what I remember most from that visit was being in pain and almost vertiginously looking down a corridor into the massive, soaring atrium of a hospital packed with people that went on forever.
I often remember my childhood injury as I reflect on human scale in healthcare. It’s no secret that hospitals and healthcare systems are consolidating. Medicine is moving from what the great healthcare thinker Brent James calls a “craft business” to a robust system of care delivery. Which is a good thing generally.
But, one of the consequences is that medicine has become big and complex. It’s easy to feel small and lost in an ever growing and often indecipherable system.
In Montreal, last week, I saw that McGill University had consolidated their several small, Victorian era specialty hospitals under one (new) roof. The new edifice is stunning, and massive. I’m sure the McGill doctors will tell you that it’s hands-down better than the ancient facilities they used to work at. I wonder how the patients feel.
Bigger, yet, Texas Medical Center is now a dense collection of 54 healthcare organizations (including 21 hospitals, four colleges of medicine and six schools of nursing) stretching over 1000 acres in Houston.
It’s not just the size of the buildings. It’s also the complexity of the system: people can feel small in normal-sized hospitals too. In a disheartening opinion piece in a recent JAMA, Dr. Helen Ouyang describes a friend struggling to understand her diagnosis after a workup for a colon mass. Confused and infantilized, she sat in her room looking for answers:
After a three-day inpatient admission, at the time of discharge, she still didn’t know whether the mass was cancer or what her next steps for diagnosis and treatment would be. So she spoke up and asked to speak to her physician again after the nurse handed her the discharge instructions. Expressing her confusion, she asked questions about what she should do next and what this mass really was. She was shocked when she later received her bill and was slapped with a $300 surcharge on her hospital bill for a “delayed discharge” because she took longer than the 30 minutes that the hospital had allotted for patients to be discharged. Still, no clear answers were provided.
I can imagine the scene perfectly. As a physician, I’ve no doubt been guilty of rushing patients out of the emergency room without providing a clear explanation for what ails them as I tried to keep the department afloat on a busy night shift. Study after study shows that most patient leave the ER not understanding their visit or follow-up instructions.
In philosophy and design circles there is a concept known as “human scale”. The general idea is that we humans are best able to engage with a world that is similar in scale to the way we are built. In a universe that ranges from atomic to cosmos-sized, measured by time periods ranging from subatomic to geologic, we humans optimally engage with what the brilliant scientist Richard Dawkins calls the “Middle World.”
This Middle World is measured in pounds and feet, and in minutes and lifetimes. Steps, corridors and wall-heights in our buildings reflect the length of our legs. Our senses and intuitions work best at this scale: nobody has “commonsense” ideas about the orbit of an electron, but we do about, say, catching a bus.
When things become too big or complex, they can become abstractions and our “commonsense” no longer applies.
What can we do to make necessarily complex systems more approachable? More human-scale? The answer may be simpler than we might imagine.
The Atlantic magazine this month has a great piece on Starbucks’ plan to subsidize college tuitions for their employees.
Howard Schultz, the CEO of Starbucks, announced that his company would team up with Arizona State University, one of the nation’s largest public universities, to help Starbucks employees finish college. As long as they worked 20 hours or more per week, any of the company’s 135,000 employees in the United States would be eligible for the program. Those who’d already racked up at least two years’ worth of credits would be fully reimbursed for the rest of their education. Those with fewer or no credits would receive a 22 percent tuition discount from Arizona State until they reached the full-reimbursement level.
What’s fascinating about the program is Starbucks’ recognition that the big barrier to completing a degree for its employees wasn’t getting in or beginning an academic program: it was finishing. Students across the country seemed to get into college, but a massive number of them dropped out. Why? Even the most seemingly minor blip in an academic plan, or modest fee that a student couldn’t pay could be enough to force a student out of the system.
Just like patients who get lost in the medical system, students often don’t reach out for help to learn that there are resources that can help with an unexpected bump in the road.
Starbucks’ solution was to humanize the system:
The most revolutionary part of the program had nothing to do with tuition and got far less media attention. In their announcement, Starbucks and Arizona State also committed themselves to providing all enrolled employees with individualized guidance—the kind of thing affluent American parents and elite universities provide for their students as a matter of course. Starbucks students would each be assigned an enrollment counselor, a financial-aid adviser, an academic adviser, and a “success coach”—a veritable pit crew of helpers.
The novel program, in other words, was about hiring a few caring, engaged advisors to serve as the interface between patients and a big bureaucratic system. The interface was the difference between getting lost and graduating.
There are many lessons for healthcare from the Starbucks experience. Increasingly I’m coming to recognize that nurturing the interface between patients and healthcare systems will be the essential work ahead. In this era of mergers, consolidations and acquisitions, we are going to need to pay a lot of attention to how real humans interact with the buildings and systems we design. The answers may be as simple as some lines on the floor and a group of dedicated patient advisors.
But without real work in this area, our increasingly big (some might say dystopian) systems aren’t likely to help us make the meaningful improvements in health we’d all hope for.
Photos: cc license, Wikipedia and Wesley Fryer