The belly pain is so bad that Mrs. Alves*, a woman in her 40s, is worming uncomfortably on the ER stretcher. “I need an answer,” she says. I promise her that pain medicine is on the way. What I can’t promise her—despite countless tests and specialists’ opinions already on record—is the definitive answer. The diagnosis, the root cause of her symptoms, proves elusive. But her distress is real. And when there’s distress, there’s a story.

To be an emergency physician for nearly 30 years is be humbled again and again by the mysteries of the body and the humans inhabiting them. Mrs. Alves is one of an endless number of patients I’ve seen with the urgent need not just for a diagnosis or treatment of some kind, but to be heard, to have an ear turn its clinical attention to their story.

Stories are not just listened to, they’re constructed, and both tellers and listeners are part of the process. And yet, discussions around doctor/patient communication ignore this fundamental truth.

Healthcare stresses evidence-based practice, clinical decision-making informed by well-designed research studies. However, it’s less interested in scholarship that complicates this paradigm. Knowledge is tied to belief, and the greater our confidence in our beliefs, the more likely we’ll consider it knowledge. Our confidence in our beliefs, experts say, depends less on the quality of the evidence than the coherence of the story constructed in our minds.

The best evidence-informed decisions are useless, if not dangerous, unless we first get the patient’s story right.

In healthcare professionals’ training, a patient’s story is generally shorthand for a medical history—current and past symptoms, medical and surgical problems, and social history. But a medical history isn’t the same as the patient’s story. A detailed description of symptoms can still miss the deep troubles and unspoken needs plaguing a particular person at a specific moment in their life.

I was taught that my job as a doctor was to find the patient’s story—this solid, complete entity—and bring it back by listening diligently, paying attention, and being present. Important practices, but they ignore a central challenge of working with stories—they’re less like polished jewels and more like first drafts.

Patient stories, like all stories, are created out of fragments of information. Deciding which details to include and what to leave out is daunting for writers blessed with quiet and time to revise. Imagine an ER patient in that pressured moment, surrounded by loud noises and strangers, expected to describe experiences that can be complicated, frightening, and embarrassing—and not knowing which details are relevant to their problem and which aren’t.

When we’re listening in this moment and others, doctors are not just receiving information. We’re continuously sorting, prioritizing, and interpreting fragments to create an orderly and coherent narrative. We’re making micro-decisions about which details might be relevant to the problem and discounting others. And our story-making brains don’t need much to construct a believable reality.

This tendency is demonstrated in a well-known 1944 social psychology study. Researchers Fritz Heider and Marianne Simmel showed subjects a simple animated movie where a large triangle, a small triangle, and a circle moved in and out of an opening and closing rectangle. Then, they asked research subjects to describe what happened. Respondents took these inanimate shapes and described drama, bullying, jealousy, and romance. Only one person told what their eyes observed—geometric objects moving about a screen.

When I played this film for my students, they created confident, specific, and even passionate narratives: a lesbian love story with a disapproving father, a terrified mother and child escaping from an abuser, children’s playground dynamics.

They laughed uneasily, as if catching their mischievous minds in the act. They also learned how subjectivity, assumptions, and their own personal histories contribute to the construction of an apparent objective experience. I illustrated the point with my own narrative mistakes, like the one I made with an uncooperative man with severe back pain and a history of opioid use disorder. I suspected drug-seeking behavior. I thought my words respectful and unbiased, but we began to knock heads. Then, he told me about how he was in recovery, and desperate for other types of treatment to control his pain. He was finally back at work and didn’t want to lose this job. He went on to explain how he could tell from the tone my colleagues and I used that we came into the room with a story fixed in our heads. And to my shame, he was right.

For all the attention given to medical harm in hospitals, or instances where patients felt their needs went unheard by clinicians, doctors rarely examine these situations as narrative missteps.

Narrative is defined in various ways, including a report of connected events and chronology with meaning. A more expansive interpretation draws on the word itself, which is derived from the Latin narrare, which means “to tell” or “to know,” and invites us also to consider narrative’s capacity for knowledge production. Sometimes, the narrative the patient wants us to hear is what’s unsaid. But physicians are poor at picking up on these cues.

Take the older patient who presents to the ER after a fall. The physician asks about the circumstances, including why he fell, his history with falls, and possible injuries. She learns he’s not eating or drinking. He’s not getting around like he used to. He lives alone. She could stop there and move on to the physical exam. Or she could keep him talking.

Studies show that patients may cue their negative emotions or their real concerns indirectly. In this case, the man’s family lives out of state, his wife recently died, he’s been grieving, and he won’t leave the apartment that holds a lifetime of memories. He’s not eating because getting up and down the two flights of stairs is not as easy as it once was. This proud man wearing a Navy cap won’t offer up these details, but his vulnerability unspools once he’s asked.

Patients want their physicians to ask questions. Unfortunately, health providers often respond by focusing on logistical or biomedical issues. By neglecting emotional communication, we miss opportunities to express empathy.

Such behavior is often attributed to time constraints, but research shows that when we pick up on patients’ often quiet or even silent cries for help about psychological or social issues, time is often saved.

When we work with stories and recognize the different ways they are constructed and communicated, we begin to appreciate not only their power but their fragility. For patients to tell their stories, they must first overcome the vulnerability that results from admitting fears and insecurities, new frailties, and limitations. And as physicians reaching branch points in the conversation, we must be sensitive to the presence of other directions the narrative might go, and how and why we might be motivated to steer it down a particular path. Is this path safer, or clearly marked, leading to an identifiable destination?

We must be willing to interrogate our story-building process as rigorously as our research methods. What stories are we listening for, what assumptions or beliefs are we bringing into the story, and how are these value judgments influencing the stories we hear?

As I listen to Mrs. Alves crying for an answer, my first instinct is to order more labs and diagnostic imaging. Instead, I take a seat, and ask her not only to describe her pain but the experience of being in pain, and what distressed her enough to come to the ER. She tells me about the specialists who won’t call her back or dismiss her symptoms when tests come back normal. Her doctor is hard to reach. Besides, he thinks it’s all in her head. What she wants from them is what she desires from me: someone willing to listen for a few minutes, who will be curious about the pain, but more importantly, appreciate how it’s disrupted her life. Quality and compassionate patient care are only possible when the physician and patient work from the same story.

*The names in this piece have been changed.

The post The Stories Doctors Tell appeared first on Zócalo Public Square.

The feature that made his plan so innovative—and therefore risky? It included rooms that had no windows.

A windowless room hardly seems daringly innovative nowadays, but in the 1940s it was a shocking proposal for a patient wing. It violated a long-lived understanding of what, exactly, the role of the hospital building should be in terms of promoting health.

For nearly two centuries, hospital designers had based their layouts on a fundamental assumption: In order to remain disease-free and health-giving, hospital spaces required direct access to sunlight and fresh air. This rule was the product of a centuries-old belief that disease could be spread by, or perhaps even directly caused by, dark, stagnant spaces where bad air—smelly, vitiated, stagnant, particulate-laden air—accumulated.

In the late 18th century, this correlation was statistically certain. Epidemics always hit the tenants of crowded, impoverished urban districts harder than the inhabitants of airier, wealthier neighborhoods. Patients in large urban hospitals suffered cross-infections and secondary infections far more frequently than patients in rural or small-town hospitals. It was common knowledge that if windowless rooms didn’t directly breed disease, they bred the conditions that led to disease.

Given this correlation, before the 20th century, every single room within a hospital typically had access to the outdoors. Corridors had windows. Linen closets had windows. In some hospitals, even the ventilation ducts and enclosures for plumbing pipes and risers had windows. Windows in patient rooms and operating rooms were so large that the glare caused problems—keeping patients awake and causing momentary blindness in surgeons during operations.

Late 19th-century and early 20th-century advances in medical theories and practices altered, but did not erase, a faith in windows. With the development of germ theory, sunlight and fresh air had new purposes. Experiments proved that ultraviolet light was germicidal. So windows of clear glass, or even of special “vita-glass” that did not block the UV rays, were a means of surface decontamination.

Similarly, tuberculosis sanatoria records proved that simple exposure to fresh air could be curative. The hospital building itself was a form of therapy. In a 1940 issue of the architectural journal Pencil Points, Talbot F. Hamlin confidently noted that “the quality of the surroundings of the sick person may be as important in the cure as the specific therapeutic measures themselves.”

But surroundings were important, partly, because of who went to hospitals in the first place. Indeed, until the late 19th century, medical treatment was not the reason to go to a hospital—poverty was. The vast majority of 19th-century hospital patients were charity cases—sick people who could not afford a doctor’s house call, had no family to care for them, and had no place else to go. A patient would occupy the same bed in a hospital ward—which housed anywhere from half a dozen to 30 patients—for weeks, sometimes even months. The doctor made rounds once a day. Nurses provided food, changed bandages, cleaned, and changed linens—but provided very little in terms of hands-on treatment. The hospital’s scrupulously clean, bright, airy rooms were an environmental antidote to the tenement surroundings from which impoverished patients came.

But the population of hospitals changed in the first decades of the 20th century. Medical advances, urban growth, and philanthropic transformations turned hospitals into a new kind of institution—where persons of all classes went to get cutting-edge treatment. Anesthesia and asepsis made hospital surgeries not only safer but also more bearable. New equipment like X-ray machines, ophthalmoscopes, and cardiographs improved diagnostic and therapeutic options. Bacteriological lab technicians could identify pathogens with a certainty undreamed of during the preceding era of symptomatic diagnosis. By the early 20th century, what happened in hospitals was increasingly about medical procedures and efficient workflow, not the ostensible healthiness of the environment in itself.

These changes made the limitations of the earlier “therapeutic” hospital designs glaringly apparent. In order to provide a window in every room, buildings could not be wider than two rooms deep; this inevitably required multiple long narrow wings. Such rambling structures were expensive to build, prohibitively expensive to heat, light, and supply with water, and inefficient and labor-intensive to operate. Food reached the patients cold after being trucked from a distant central kitchen; patients requiring operations were wheeled through numerous buildings to the surgical suite.

Hospital designers thus began to arrange practitioners, spaces, and equipment into a more effective layout. Catchwords changed from “light” and “air” to “efficiency” and “flexibility.” An emphasis on efficiency rapidly took over the utilitarian areas of the hospital; time and motion studies determined layouts and locations of kitchens, laundry, and central sterile supplies. Diagnostic and treatment spaces were re-designed to establish efficient, but aseptically safe, paths for the movement of patients, nurses, technicians, and supplies.

But, initially, it left the design of inpatient departments unaltered.

Hospital designers and practitioners worried that patient areas designed for efficiency, not healthiness, would prolong treatment, impede recovery, or even cause deaths. In a 1942 issue of Modern Hospital, Lt. Wilber C. McLin considered it “unthinkable even to consider the possibilities of applying time and motion studies to the methods of direct patient care.” Inpatient departments remained sacrosanct temples of light and air.

By the 1940s, therefore, most hospital buildings were odd mixtures of efficiently arranged medical treatment spaces and inefficiently arranged nursing units. Nurses trudged up and down long, open wards that held 20 or more patients, or long, double-loaded corridors that connected smaller (six-, four- or two-bed) wards and private rooms. Service areas were at the far end of that walk; getting even basic supplies was a long hike. Pedometers proved that the daily distance was best counted in miles; some nurses averaged eight to 10 per shift. In 1939, prominent Philadelphia doctor Joseph C. Doane drily observed that “some hospitals are apparently planned on the erroneous theory that nurses wing their way from distant service rooms to far off beds without incurring fatigue.”

This was the design dilemma that confronted Neergaard, an iconoclastic rising star in the brand-new profession of “hospital consultant” (doctors who advised building committees and architects on best practices). He proposed streamlining nursing unit design, keeping windows in the inviolable patient rooms, but prioritizing efficiency over direct access to sunlight and fresh air in the adjacent service rooms. His plan allowed two different nursing units (groups of patients overseen by one head nurse) to share the same windowless central service rooms, reducing spatial redundancy.

Neergaard calculated that this “double pavilion plan” required only two-thirds of the floor area of a traditional nursing unit layout. It also moved the service rooms closer to the patient rooms, drastically reducing a nurse’s daily travels. His design was a first foray into treating the hospital as if it were any other building. The structure was a tool, facilitating the delivery of medical care, not a therapy in itself.

Neergaard knew his ideas would be contentious. In 1937, his presentation at an American Hospital Association convention prompted the prominent hospital architects Carl A. Erickson and Edward F. Stevens to resign from a committee rather than be seen as supporting Neergaard’s proposals. One prominent hospital architect called the double pavilion plan “essentially a slum.”

Neergaard’s ideas, however, won out. Rising costs and decreasing revenue sources made reduction of hospital construction and operational budgets a fiscal imperative. Centralized design reduced the amount of expensive exterior wall construction, facilitated centralization of services, and minimized nurse staffing requirements by reducing travel distances. By the 1950s, with the advent of antibiotics and improved aseptic practices, the medical establishment also believed that patient healthiness could be maintained regardless of room design. Some doctors even preferred the total environmental control offered by air conditioning, central heating, and electric lighting. Windows were no longer necessary to healthy hospitals, and by the 1960s and 1970s even windowless patient rooms appeared.

The efficient, inhuman, and monotonous buildings of the second half of the 20th century bear witness to the extent to which hospital design became a tool to facilitate medicine rather than a therapy in itself. Today, a stay in a hospital room is endured, not enjoyed.

The pendulum, however, is still swinging. In 1984, hospital architect Roger Ulrich published an article that had one clear and influential finding: Patients in hospital rooms with windows improved at a faster rate and at greater percentage than did patients in windowless rooms.

The post How Hospital Rooms Went from Airy Temples to “Inhuman” Machines appeared first on Zócalo Public Square.