Designing for Health: Interview with Diana Anderson, MD [Podcast]

Architecture in healthcare plays a pivotal role in shaping patient experiences and outcomes, extending far beyond mere aesthetics. Thoughtfully designed healthcare facilities optimize patient flow, enhance accessibility, and foster healing environments conducive to recovery. This isn’t based on mere conjecture, either; a plethora of peer-reviewed research has shown the significant effect evidence-based design can and does have on patients and their well-being. With this research readily available, industry leaders should consider leaning on health architects and other experts to prevent undue harm and promote health and wellness.

On today’s episode of In Network's Designing for Health podcast feature, Nordic Chief Medical Officer Craig Joseph, MD, talks with triple board-certified physician and architect Diana Anderson, MD. They discuss her background in design and architecture, her transition into the healthcare industry, and where her expertise in both has intersected. They also discuss the importance of user feedback in healthcare design, the challenges of creating staff spaces that promote wellness, and the need for evidence-based design at every level.

Listen here:

Read more about the Salk Institute here.
Click here to read more about Dr. Anderson’s Hastings Center Report.

In Network's Designing for Health podcast feature is available on all major podcasting platforms, including Apple Podcasts, Amazon Music, Google, iHeart, Pandora, Spotify, and more. Search for 'In Network' and subscribe for updates on future episodes. Like what you hear? Make sure to leave a 5-star rating and write a review to help others find the podcast.

Want to hear more from Dr. Joseph? Order a copy of his book, Designing for Health.

Show Notes:

[00:00] Intros

[00:56] Dr. Anderson’s background

[05:35] The impact of architecture on disease and health

[19:48] Considering both user feedback and professional insight

[35:40] Common mistakes in hospital architecture

[38:24] Something so well designed, it brings Dr. Anderson joy

Transcript

Dr. Craig Joseph: Let me welcome you to the pod. It's great to have you here, Dr. Diana Anderson.

Dr. Diana Anderson: Thanks, Craig. I'm glad to be here.

Dr. Craig Joseph: You are our first physician who also happens to be an architect. And I know that there are just millions of physician/architects out there. It's just it's just that we. We haven't had folks like you. can you give us a little bit of a background about how one becomes an architect, practicing architect, and a practicing physician in the same lifetime?

Dr. Diana Anderson: Yeah. No. Sure. Craig. and I get the question a lot. Most people ask which came first, the medicine or the architecture. So that may be of interest to the listeners. So architecture came first, having come from a family of architects and a big sort of design background, spending a lot of weekends as a child in the architectural studio, in the dark room, that really appealed to me. But I made a shift at some point in my career over to medicine. and people also like to ask me, in which program did you sleep less? Was it architecture or medical school? And the answer might surprise you, but it was definitely architecture school. however, there's been a big lack of sleep for both, but architecture students work very, very hard in the studio. So, it was a long road, but it's been actually really exciting to combine the two paths together.

Dr. Craig Joseph: And what kind of medicine do you practice now?

Dr. Diana Anderson: So I trained in internal medicine with the intention of going on to geriatric medicine, which I have done, and actually super specialized beyond, general geriatric medicine to dementia care. So my focus is really on older adults and very strategically so. One, because I really enjoy that patient population. And I really like working with older adults and their families because most of these patients come with caregivers. But I think it's the one area of care that architecture and the built environment can actually have a huge impact, because we don't necessarily, have a lot of pills and pharmacologic therapies for some of the aging processes. But the built environment can actually have an even bigger impact than drugs can and can be a hugely important factor in how people age and age well.

Dr. Craig Joseph: Well, that's actually a fascinating thing. So why don't we just dig right into that. You know, we often talk about how design impacts healthcare. And you're giving us an excellent example right off, first of all, before we even get into that, like specifically, what are the differences between architecture and design? Do those overlap like 90% or there's very little overlap there?

Dr. Diana Anderson: So I'm really glad you asked that question. I think those two terms get a little bit twisted around and interchanged in the popular press. They are quite different. So a true architect is, you know, a professional person who's done a lot of training to become a licensed professional. We do design as part of that, although we focus on the infrastructure. So the bricks and mortar and the spaces we live and work in. Design is a much looser, more general term. Anyone can do that. Anyone can dabble in design and call themselves a designer, but calling yourself an architect is a much more complicated process and really involves a whole professional guild and training structure. So it's quite different. I should say, though, that there's more and more clinicians, and I use that term broadly to include physicians, nurses, pharmacists, anyone involved in patient care. I don't want to single anyone out because I think all of the clinical professions are quite interested in this. People really are starting to want to integrate design skills into their practice. So I get a lot of early mid-career professionals, mostly in medicine I should say that say, you know, I want to do some kind of design. Should I go to architecture school? I say, I don't know, it was a really long road. And I don't know that you need to be a full-fledged licensed architect to influence how design integrates into health practice. But certainly design thinking and design skills would be really useful, sort of a sort of a subset of architecture and focus, I think more broadly. Right? The word design goes way beyond just the built environment. I mean, anything and everything should have an aspect of design, right? Everything we touch in a day from the can opener that you're using, the coffee machine, the chair you're sitting in, the building you're in, you know, there's a lot of factors that are influenced by design. even you think about the design of clinical operations, the flow of patients and how we deliver care. But there is definitely a growing interest in the last, I'd say, a couple of decades, but in the last few years, certainly since the pandemic, in terms of clinicians wanting to integrate design thinking into their practice because they really, truly believe it can impact and improve how they deliver care and how patients do.

Dr. Craig Joseph: Okay. So the, what I took home from that was I should not tell people I'm an architect because I took a ninth grade graphics class. That's what I'm that's what I'm hearing. I think you said more than that, but that's really the focus for me. No, That's great. I think that kind of that overlap between architecture and design and that, the big picture that architecture takes and design really it can be a lot of different things. And to, you know, it's really in the eye of the beholder. Let's talk about that example that you just gave a minute or two ago about dementia care. you mentioned there's not a lot from terms of, surgery or medication. for a lot of patients with dementia. But there are other things that you can do, and a lot of them are design and or architecture based. So how does that work? how do you come to the conclusion that you can really impact the disease that way. And, and then what are the impacts you you've brought there?

Dr. Diana Anderson: Yeah, no, that's a big question. So I'd like to unpack it in a few different answers. you're asking how and I think that's an important question because the field of architecture and specifically health architecture has really shifted, just like medicine has shifted towards an evidence based medicine practice. And the clinicians out there will know this well. We don't make any decision lightly in the clinical setting. We utilize any known evidence. And then we also integrate patient's goals of care and their wishes. But we look at the data right. We look at published studies. We look at what we know from research. Well, architecture actually took a similar stance. And in the mid 1980s, a very impactful paper was published whereby people who had had their gallbladder removed had sustained surgery, and these were for middle aged, A group of middle aged men and women, they recovered in a hospital whereby half of the ward or unit had windows that looked out onto a park. So a lot of green. And the other half of patients also had windows in their rooms, but looked at a brick wall. And this environmental psychologist, Roger Ulrik, who's who sort of coined as the father figure, a founding father of evidence based design, found that people who looked at nature stayed in the hospital less. So they went home sooner. And anyone who's into, like, dollar signs out there will know that that has a cost implication. They took less pain medicine in terms of their recovery, and nursing staff had much higher levels of satisfaction with the whole care delivery process. So a lot of interesting outcomes just based on the type of window view they had. And that really sort of started this whole area of thinking around the physical determinants of health, because we spend 90% of our time in North America in buildings. What if they're impacting our brains and our bodies? Right. We never really thought about that to any length. So a couple years ago, a few colleagues of mine met up and we were talking about how important the built environment is to health. And we said, let's write this paper. And our central thesis that we pitched to the editor was to say that the built environment is as important on our health as a pill you might take or a surgical procedure you might have. It impacts us that much, our brains and our bodies. And actually, you know, initially we had a lot of trouble publishing. People said, that's crazy. You can't substantiate that. But we actually did. And it became a cover story. It was published in the Hastings Center Report. We utilized existing evidence to basically prove our point that buildings impact us. Now, the social determinants of health, which I have to say, when I was in medical school a few years ago, that was sort of beginning, right? People thought, oh, yeah, I guess that's accepted now. It's very commonplace to understand that where people live, socioeconomic status, geography, diet, exercise, all of that impacts us. We know that. there's a lot of great published literature, but we still haven't quite delved into the physical determinants of health as much as I'm hoping we will, and I hope in the future this grows. But the space that you're in actually impacts much more than you think. So I want to come back to your question about older adults and dementia care, and maybe I'll broaden it to include older adults with and without cognitive impairment. But non pharmacologic treatment modalities are so important. So I think some examples might help. Everybody knows that falls are bad, right? Falls at home, in the hospital, in nursing homes. They cause a lot of physical suffering. They cause a lot of financial issues. It's very expensive to have people fall. And there's good cost data around this. How much does a fall cost? If a patient sustains a fall in a hospital or nursing home, how do we prevent them? We've had a lot of theories as architects, the clinical community has published many papers on bed alarms, door alarms, floor alarms, robotic fall prevention systems, lots of fancy technology, right, to notify people before somebody falls if we can. But there's a really great study that was recently published out of Boston that says if you just change the light bulbs in your nursing home, just change them, more sustainable, there's a little bit of upfront cost to change a light bulb. They were able to reduce falls by 43%. I sort of pause for effect because 43% is a huge fall reduction rate just by changing your light bulbs.

Dr. Craig Joseph: Yeah. What was the change? Brighter, or they didn't turn them off, or?

Dr. Diana Anderson: Changing the light bulbs to actually support circadian rhythms. Right? So they had an experimental site in a control site. And in the experimental site they changed the lighting in terms of intensity and the spectrum of light. So increasing our short wavelengths or blue light during the day and then decreasing it overnight. It sounds actually really simple, but it's not often done. And so do we have a duty now as architects and as policymakers to say, if we know this and this has such an impact on our health, do we have a responsibility to do this on a widespread basis and change all the light bulbs in all our nursing homes? Right. If we know that the standard lighting can cause harm? And so I mention this because the sort of ethics lens that I'm implying is very important to me. I did a fellowship in bioethics and by no means a bioethicist or I'm certified, but it sort of opened the door to thinking about how you apply a bioethics lens to healthcare architecture, right. What's our moral imperative to make sure that the buildings that we are in, and specifically the healthcare buildings we work in and we are sick in, what's our responsibility to make sure we don't get people sicker, you know, we don't make people suffer more because of the building they're in? There's another great study out there around an intensive care unit, whereby a resident position noticed his patients were not doing well in certain rooms. And he actually wondered, maybe it's not the care we're delivering as the staff. Maybe it's the room itself that's impeding recovery. And he found that that was actually the case. So in this particular study, it was corner rooms that had poor visibility from the centralized staff nursing station. Those patients who were quite sick and put into those rooms where it was hard to visualize them, they ended up doing worse, and by worse, I'm talking about increased morbidity rates. Okay. So that's pretty important. so if you're sick and you get admitted to an intensive care unit, you might think and expect that you get equal care to your neighbor from the staff. And you certainly might get that. But what if the four walls that are around you aren't providing you an equal opportunity to get better? And so knowing that, how do we then understand how we process patients, what rooms they go into, and the research we need to do to improve these outcomes?

Dr. Craig Joseph: Wow. Those are two great examples. I like it because for one, it's as you mentioned, it's kind of just a light bulb that changes frequencies and color I'm assuming, a little bit during the day and at night. And then another where it really is the wall. Right? Like do you have a wall of glass and how do you have privacy versus being, available for the nurse who's walking by to see that you don't look as good as you did an hour ago? Right. And I'm assuming that's where the morbidity comes from, that, they don't have eyes on just as they're walking around. Or am I mistaken?

Dr. Diana Anderson: Yeah. I mean, that's the that's the hypothesis. There may be other factors. I think that you raise a good point about the complexity of studying the built environment. There's lots of variables. Right? And we have to control for that in our study design and in our analysis. But sometimes it can be very difficult. in this study, another sort of nuance that I maybe didn't mention is the acuity of illness was important. Right? So sicker patients who were put into these rooms actually did worse. So trying to calculate acuity scores was very important in this context. Another great example for older adults and these ones with cognitive impairment. So there are many people all over the world, but certainly in the United States suffering from dementia, and a number of people are living in locked memory units, patients who will or residents who elope from these units is a big concern, right? We don't want people wandering out and getting hit by a bus if they go into the street. So we want to prevent that. We do that in a sort of carceral way, right? We locked doors. We sometimes conceal exit doors by painting murals over them, so it doesn't look like a doorway to people who might have cognitive impairment or brain changes. We put alarms and, you know, we do different things. There are architectural ways that we can actually control people's behavior. It's really interesting. There's about a dozen studies out there that looked at a floor pattern. So if you paint a series of horizontal stripes in front of an elevator or an exit door in one of these facilities, you will find that it deters people from even approaching the doorway. And when you sort of understand what's happening with the brain, as people dement, you understand that this creates an illusion to them and they don't want to actually cross these lines. It's really fascinating. But if you turn the lines 90 degrees and they're more vertical, people will go right on out the door. So one could say, well, you know, that might cause some fear, anxiety in people. You know, if you paint a black square in front of an elevator, some people say that demented people might interpret that as a hole or a void in the floor. And I don't know about you, Craig, but I don't want to walk into a hole. so I would avoid it, but that might cause a little bit of anxiety. However, is it better or worse than putting an alarm, using a physical restraint, or sedating someone to keep them in bed so they don't go outside? So my point is, really, there are architectural solutions that may not be perfect, but it might be better than some of the other alternatives. So we really have a responsibility to think about that. Now you can use that example in a different way. There was a geriatric unit I worked in on the West Coast that had a striped floor throughout the entire unit, and I'm certain that this was an innocent and well-intentioned design decision made early on in the design process by somebody based on how it looked, but not understanding the science behind it. Patients who are in hospital and stay in bed usually do much, much worse, right? You stick someone in bed for a few hours, a few days, especially if they're older, 60, 70, 80, 90. They're going to take a lot of rehab. We want mobility. We want people up and out of bed. Bed rest is bad, right? You want people to walk. But on this particular unit, if you ask the clinicians, they will tell you patients are not walking on that floor. And I suspect part of the reason is because of that floor pattern. So we have to be very careful how we utilize design interventions.

Dr. Craig Joseph: And that floor pattern, I'm assuming, was not something that an architect would generally have anything to say about. Right? Wouldn't that typically be a designer?

Dr. Diana Anderson: True. We would probably and hopefully would work with architects on that. And architects, you know, you actually raise a very good point. Architects can certainly do the interior design as well. And one of my most impactful career moments was walking into a hospital building that was designed as a tuberculosis sanatorium in Finland. Right? The Pioneer Sanatorium. And in that particular instance, the architect designed everything. Right? He designed the overall layout of the building, the landscape architecture around the building, all of the chairs in the building, the sink, the spit basins that people would use if they had sputum in their lungs. He designed everything and he designed it for that particular illness, right? At the time, they knew tuberculosis affected people's lungs, and this architect, Alvar Aalto, really wanted to make the environment a healing space. And I have to say that walking into that hospital for me was a moment in my life where I had this aha moment. I couldn't believe how good I felt in a hospital. I'd never experienced that before. It's an uplifting space. It felt good. You actually wanted to be in there. Now I might go into that building and have lunch. Even if it is a hospital, I might go to that cafeteria and talk to my friends, and that might be a destination. I'd never experienced that before, but certainly, I do believe the architects should be aware of the science behind the floor patterns and interior design. There's some data coming out now on color and how color can affect patients and waiting rooms and inpatient spaces. So certainly every aspect of design should be understood. And if we don't, then we have a responsibility to study it. Evidence based medicine is a very robust field. There are millions of published papers. Evidence based design is quite small. And many of the research papers we have are not as rigorous as we would expect as clinical practitioners. Right? These are not randomized controlled trials with thousands of people across multiple sites. You know, some of these are just small anecdotal studies not even done under peer review. And so I think a lot about and I advocate for building evidence based design and increasing our grant funding and actually thinking about who should do this research, right, who should be studying these floor patterns and maybe randomizing patients to two groups. Should it be the architects? Architects are pretty busy people, and they don't actually have any training in research, so they're the ones who are trying to do it currently. But I actually don't think they're the right group. Right? Should it be the doctors who are busy seeing patients 40, 60, 80 hours a week? I don't know about that either. I almost think you need a whole research field on its own, and even some regulatory body at the sort of federal or country level that might oversee this. so I it's not a perfect system yet, but I really think we need to consider how we should do this research, because we really do have a responsibility. We spend billions of dollars on these new buildings, and they don't just impact 1 or 2 patients. Right? These are generations of people. This is a big public health issue. Architecture is a public health issue.

Dr. Craig Joseph: So you bring out an excellent point. Really this is the responsibility of everyone. But that means it doesn't really fall obviously on any one person. How does one, you know, if one's opening up a new hospital? What is the how does that go? Do does just want to start with asking doctors and nurses, what do you want to see in this hospital? Or are we already you know, we have kind of specialists like you who might be involved, who are like, well, we don't need to ask you because we already know. And your answers are or may not be as well informed as ours are because we've seen this across the country, across the world.

Dr. Diana Anderson: Yeah. Another interesting question that has maybe a more complex answer. And I don't think there's an exact answer. You know, healthcare architecture is actually a subspecialty of architecture. And I don't know if people realize, but to become a healthcare architect, it's a whole other process. So it's almost like subspecializing in a particular organ system. And so if you're going to work on a healthcare campus or renovate a hospital, nursing home or clinic, I would really recommend you get a healthcare architect to help. Now, this is a North American model. We have a certification process in North America through the American College of Healthcare Architects. Once you're a general architect and you've license and you've done the rigorous residency in an office and many, many, many, many exams, then you go on to do more work experience portfolio stuff and more exams to become a healthcare architect. and there's like licensing fees for everything, as you and I know. Well. So healthcare architects are subspecialists, so they have the knowledge around healthcare programing and operations. So I think that's very important. The field of healthcare architecture is pretty new. Only a few decades old. how we integrate clinician feedback is has been an area of controversy, I would say. So it's almost done by individual firms. Right? So we typically will be commissioned by a health systems that we need a new inpatient tower. We need, you know, 150 beds, two ICUs and four hours. Come and build it. And so that will develop a space program. We know we need this many rooms to support that program. And then we'll hold what we call user sessions, where over a number of weeks or months we’ll come in person or now virtually. And we'll have some representative clinicians there, and they'll tell us what they like or they don't like about the plans. I have some issues with that process personally because I just don't feel that it's very standardized. So every firm, every health system will do it a little differently. And we don't tend to record these answers. So, you know, five years down the road when the buildings open and people have used it for a few years, someone says, why is it like this in this space, nobody will know, right? And so I almost think we need to shorten, need to rejig the architectural process, and make sure that we have inclusive stakeholder involvement. So it's nice that we get sort of the token patient representative, or sometimes we don't get patient representatives and we're only hearing from staff. How do we know we've actually represented the users in a proper way? Right. There's a lot of different people who use the building. It can't just be the clinicians. It has to be the patients, even the caregivers, the non-clinical staff. There's a whole lot of non-clinicians using these buildings day and night. So we really don't have a great way, I think, to achieve feedback from the end users of this process. in a very rigorous way. But some people are trying to work on that.

Dr. Craig Joseph: Okay. But what do you do? I guess my question is, you know, I've certainly seen where— let me let me give you a technological example and maybe you'll see if there's an architectural or design kind of, parallel there, where we're hey, we're going to implement a new, cardiology module as part of our electronic health record. So let's go talk to the chief of cardiology who barely sees any patients now. And when, they do see patients, they have, they're surrounded by a group of trainees who are pretty much doing everything, at their beck and call. Yet that person is the one that is often sought out to say, like, hey, how should this thing work? It's clearly not representative of the of the users and, an uncommon and infrequent user at any, any stretch. So, you know, how does one, get opinions of, of patients. and, and does any 1 or 2 of us as patients really represent or know what we need? I, I, I think back to that example about looking out the window and, you know, seeing that that really is quite helpful. But I suspect if you asked people, what do you want? Do you want to look out the window? Would you rather have a bigger room? I think most of us would say, oh, I'd rather have a bigger room. I think that would be much more helpful to me as a sick patient. which is probably not the best advice. so how do you how do you how do you kind of take those two opposing, viewpoints and make them into one good one?

Dr. Diana Anderson: Yeah. So I think it probably comes down to our process. I think it's important to get user feedback, and I think it's important to get user feedback from users who are using the space and sort of understand that the day to day issues with sort of boots on the ground. But maybe that's not all there is in terms of the answer to the question, because even if you developed, a strict framework for how to do that and how to incorporate that, I don't know that it's enough. But I think what we really need to do is what we're already sort of doing, but not doing well. It's what we call POEs in architecture, post occupancy evaluations. So once a building has been opened and used or renovated, we go in and we study it. And you should do that at multiple time points. So, you know, you have a shiny new building. You cut the ribbon; you open the new doors. It's not going to be perfect. There's going to be tweaks. And as people use it and time goes on, there's going to be revisions that need to be had. Obviously not tearing it down and rebuilding it. Sometimes these can be small interior design fixes, but I, I think it's a misnomer. People think you do a new building and you'll never need to adjust anything inside. But certainly healthcare is a fast paced business, right? There's technology that's changing every day. There's clinical processes. How we care for patients has changed, right? Like I have an example where I've sketched out what I would like as an ideal geriatric clinic room, because we're not how we used to be. We're not a physician sitting behind a big desk with a big computer screen, talking to the patient in front of us who's just on their own and telling them, take this medicine, you've got to do this. See you in a few weeks at least. I hope we're not doing that. We shouldn't be. We are supposed to be at a round table where we're all equal players because we're actually practicing shared decision making. Right? And our role is really to guide people through decisions around their health that meet their needs and goals. And so I really think the physical environment needs to reflect that. And we would understand how to change that if we went in and measured how the built environment was doing, not only getting feedback from users during the design process. I like this. I don't like that I want this wall here, but going in with actual data tools and actually evaluating it, we can do that before a building is built also, because, you know, if you think about it, why wait ten years? Because that's about the time it takes to do a very complex big building to then measure it and realize, oh, we should have done it some other way. What if you could do a POE in terms of a pre experiencing the space? We have a lot of technology. We have virtual reality. Could we build the space virtually and sort of experience it beforehand and then tweak things before we actually put down the bricks and mortar. So there's sort of lots of ways to think about it. but I'm not sure we can only utilize people's viewpoints. We'll never get a good representation of everyone using these buildings, especially thinking ahead into the future. But I think we have to have a way to measure the building's performance at various time points and integrate that as we go. Who should do that is a big question in our industry, right? Many clients don't want to pay for that. architecture firms maybe aren't the best people to do it because it's sort of a rigorous research process. So that's why I sort of, I've been thinking more and more in recent years, there needs to be another entity, maybe even a regulatory entity, or it's rolled into an existing entity that goes in and makes sure health systems are doing this in some way.

Dr. Craig Joseph: Yeah, I can be if I, if I play, healthcare administration, put that hat on, I've just paid gazillions of dollars for a new building. The last thing I would like to do is some research to find out that I did it wrong. that would be, that would be suboptimal. So. So where does one, where does one, you know, find this research? is there are there are there journals specifically for this kind of an environmental for like, I actually I don't even know what the right word is for what we're describing, is it healthcare architecture daily? Like what? What journal is this, that should exist if it doesn't already?

Dr. Diana Anderson: Yeah. No. Good question. So I call it the evidence-based design or the field of EBD. there is a specific journal, actually, that was or spearheaded by one of my colleagues, Kirk Hamilton, Texas A&M, also went to one of the sort of founders of evidence-based design started in, I think, 2008. It's called Health Environments Research and Design. Or HERD, H E R D, that really features evidence based design research. But interestingly, because I've done a bunch of published articles, when you do the literature searches, this kind of research is all over the place. You can find it in environmental psychology journals, social science publications, clinical medicine journals and neurology journals, textbooks.

Dr. Diana Anderson: So yeah, we do have one EBD-focused journal, but not a lot more. It's sort of all over the place. and I think that speaks to how architecture is architecture, a sort of a very broad training where we get a little bit of expertise in a lot of different fields. Right? Architecture integrates fine arts and engineering and social sciences, psychology. So, I don't know, I think, we probably need more specific journals and domains for this. but I think it's also right that it crosses into other expert journals and subject matter. I think that's right.

Dr. Craig Joseph: Yeah, well, it makes sense. It's just it's such a broad area. And as you kind of noted, there's no kind of central authority who kind of takes the lead and, and, you know, information's everywhere, I guess.

Dr. Diana Anderson: Well, the thing is, hospitals are already collecting a lot of data. They're measuring things all the time. And now there's a big emphasis on quality improvement data. Right? Hospitals have lots of data on fall rates, length of stays, infections. All of that has some element to the built environment as well. So, you know, make sense that you maybe you could expand that data collection to include built environment factors, in some way, and that, you know, maybe expand our research funding. it's quite challenging, I think, to get research funding around the built environment, probably because the awareness just isn't that high and there's not a lot of existing data out there, but certainly as we have an aging population, we're looking to build lots more long term care beds. We sort of have a responsibility to understand what we're building and how it's going to affect people. going forward, you know, the built environment has been suggested to affect everything I mentioned falls, I mentioned length of stay, I mentioned pain medicine. There's also staff burnout and staff retention. We don't have a lot of good evidence that the built environment can impact burnout, but certainly there's some evidence to suggest environments can help employers retain staff, which is really important. It costs a lot of money to replace healthcare staff. so there's some really good evidence that you can put cost data to, you might even think that we could get sort of high tech about it and, have technology help us as architects. What if you could sketch out a floor plan and have an app or some high tech technology, look at it and predict where people will do well or not do well in whichever room they're in? Why do we have to actually build the building? So what I will say is, though I hope, architects tend to not be very vocal advocates for things, and I think we don't tend to sit at the policy table. We we're very good at what we do, I find, and we're very good at thinking outside the box and putting our design hat on. But I'd like to see health architects have more involvement in some of the bigger public health and policy decisions, especially after the pandemic. you know, I'm Canadian and in some of the Canadian provinces, they're facing a public health crisis. They need to build, you know, 50, 60,000 Long-Term care beds in the next few years. That's a huge undertaking. And so there are words being thrown around like design standardization. That is the buzzword of the month, if I could pick one to tell you about today. So why can't we just design one nursing home and then cookie cutter it sort of like we do suburban housing. Why can't we do that? That just makes my skin crawl, and I'll make every architect sort of shiver and say, no way, that sounds wrong. But why does it sound wrong? And so I think now we're starting to think about how you can balance an idea around design standardization with innovation and make sure that we retain some of that design stuff, but still maybe replicate designs that work well. And so that's really, I think the, the buzzword now and the hot topic. But we've got a lot of work to do, especially when it comes to nursing homes and long term care. And if you think about it, hospitals are not always full of very young people, right? Older adults frequent hospitals a lot. and we're constantly looking at renovating and building new. Design also doesn't need to cost a lot. So I'm sure people listening are thinking, wow, this sounds expensive, right? All these windows with nice views and fancy artwork and nice lobbies, that's going to cost a fortune. But there is some great published literature out there to talk about the business case for better hospital design. So if you employ some of these in evidence based design techniques up front and do it right, you can actually save money and you have a pretty fast return on investment. Some of the data says up to two years, which is pretty quick to see a benefit cost wise. So I think the key might come in this hybrid model. Right? Architect's not thinking alone, but combining forces with policymakers, public health officials, clinicians, engineers thinking together, politicians, you know, how can we all come together to collectively solve some of the biggest healthcare challenges we're seeing? We're not going to do it alone. And that's really, I think the benefit of the architect model and integrating architecture in medicine, right? Thinking different dimensions and combining different fields to solve complex problems in unique ways. So I think that's going to be what we're going to have to do going forward, because we've got a lot of big things coming, I think, to figure out, especially post-Covid.

Dr. Craig Joseph: Yeah. Well, yeah, it sounds like it. And how many, how many, healthcare architects are there in North America about, like how many zeros are we talking about here?

Dr. Diana Anderson: So not too many. I don't have exact current figures, but last I checked, a few months ago, probably ballpark 500.

Dr. Craig Joseph: Wow. Okay. Well, it takes a lot to kind of, to, to get to that point where you're, you're certified as a healthcare architect. So that makes sense.

Dr. Diana Anderson: I mean, in many of these building types, I should say they don't involve architects, right? These buildings can be developer led. They don't necessarily have architects on board. I think people assume that that's a very expensive endeavor. Personally, I, I'm biased, I suppose, but I don't think so. And I think it's very much needed. We need to integrate this. If this research exists and we are not applying it to our designs, then we are causing harm, right? We have a responsibility and a duty, just like as clinicians, to utilize existing knowledge and make sure that what we're designing improves health and doesn't harm us.

Dr. Craig Joseph: I assume that you've seen your fair share of hospitals, both as, from an architecture standpoint and also as a clinician going through medical school and residency and all of that training. what part of the hospital is the one you least want to walk into in general, based on the things that you've learned?

Dr. Diana Anderson: Probably any staff lounge is what I would say.

Dr. Craig Joseph: Awesome. Why is that?

Dr. Diana Anderson: Well, I've worked in some pretty poor staff spaces. and I think these are areas that are supposed to be present for respite and wellness breaks. And I have a vivid memory of one. And I, I guess I won't say exact place, but picture probably a beige door on the outside, and you turn the knob and you go in. And inside are four beige walls, a beige ceiling, a beige floor, a couple of outlet plugs, and a brown plastic couch.

Dr. Craig Joseph: Wow. Sounds like heaven.

Dr. Diana Anderson: Very dismal space. I find that those spaces are not very well utilized. I find that they're not very well located. There was a design trend for a while to move towards what we call an on stage, off stage design model. And this was really centered around Disney World and what they were doing in amusement parks. Right? When you're at Disney World, you're not necessarily seeing the dirty food trays in the laundry. All of that's going under some tunnels or corridors that just being kept away from the public. Right? That's the off stage part, but it keeps the place running. Well, what was happening in healthcare is staff were becoming off stage in any of their spaces. So separate corridors not seen to the public, separate lounges, you know, everything was kept away and the amenities were not put into those spaces. No art, no windows, keep them away. I think the shifting, the thinking around that has shifted a little bit. You know, that pendulum of design swung very heavily towards patients. And I think that's because of our payer model in the United States, patients as consumers, satisfaction is very important. It's different in other parts of the world. But, you know, we've all been in that hospital with the beautiful lobby with the water feature and the digital screen and the atrium, and then you go a few doors down to the staff space, and it's just dismal and depressing, crummy, noisy, smelly. And I find the staff spaces are kind of the most depressing ones in hospitals in general. We're working to try to change that. I think, you know, staff burnout is a real thing, and I do firmly think, and I'll put money on it, that the built environment impact burnout rates. We don't have good quality studies to prove that yet, but I'm sure it plays a role. I remember in medical school my obstetrics rotation. The staff lounge was two floors above and over, so I never even went there because as you know, deliveries don't wait for you to come downstairs from your lounge. So as medical students, we would just sleep on a chair in the nurse's station. So, you know, these things are really important.

Dr. Craig Joseph: All right, Dr. Anderson, at near the end of our of our talk, we don't have a lot of time left. I wanted to make sure to ask you a question we like to ask most of our guests, which is, is there a design or a workflow that is so well designed that it brings you joy and happiness? You've told us about one building already, sanatorium that, really, you'd want to go and hang out there even if you didn't have, tuberculosis or you were treating such a patient. Is there another building that is similar to that one that you want to call out?

Dr. Diana Anderson: Definitely. I think I'll tell you a little bit about my most favorite space on the planet. It is a building, but it also involves more than a building because the building is around nature and frames the sky and the sea. Some of your listeners might know the Salk Institute in San Diego, in La Hoya, California, designed by Louis Kahn and designed for Jonas Salk, who discovered the polio vaccine. And the building is very strategic. And I if you've ever I don't know if you've ever been there. Craig, have you been to the Salk Institute?

Dr. Craig Joseph: No.

Dr. Diana Anderson: Oh, book the ticket, go tonight. Fly over there. Beautiful. Every time you go, it's such a different experience. So the Salk Institute was designed for medical research, right? A bunch of laboratory buildings. And actually, laboratory design is a whole other specialty within architecture that you can do another podcast on that I'm not an expert in, but is quite specific as well. But what the architect really wanted to understand is how medical discoveries were done. And what was realized throughout this whole process is that they don't happen at the lab bench. And that's kind of a surprise to me, right? I would think that's where they happen. But where they happen is when scientists come out of the lab where their head is down and they're working hard individually and start talking together. So the very first time I went to the Salk Institute a number of years ago, there's a beautiful outdoor courtyard and I can't eat. You'll have to Google it. I just can't describe it. But it frames the sky and it frames the ocean. And there's a wonderful water feature that sort of carries you to the edge of the cliff, and you just sort of see the horizon in front of you. And it's a very beautiful moment, especially if there's no one else there and you're on your own. But what you'll see is the architect integrated these outdoor courtyard spaces and blackboards. And when you walk around, there are blackboards with all kinds of scientific garble formulas and ideas and sketches, because these scientists have come out and there's an interesting statistic out there that's been published that 90% of scientific discoveries don't happen in the lab. They happen when people come together and socialize. And it's the most beautiful space I could think about to go and actually think and discover something. And I don't know if I did it justice, but it's definitely my most favorite space, and it's not actually in the building. This is the space outside that the building frames. So the exterior courtyard space, which is a very interesting feature, right? Architecture can also frame the outdoor space for us and create these wonderful outdoor rooms.

Dr. Craig Joseph: Wow. Yeah, it sounds fabulous. Yet another reason for all of us to hate people who get to live in La Hoya and in San Diego.

Dr. Diana Anderson: And the fish tacos are actually amazing over there. So another reason to visit.

Dr. Craig Joseph: Oh my goodness. All right, well, it's definitely gonna have to be on my on my list. Dr. Anderson, thank you so much. This has been great. We've really learned a lot. And my horizons have been expanded and understanding architecture and healthcare and the overlap. And I look forward to seeing some more of the research and data in the evidence, and added into how architects kind of do their jobs. Exciting place to be. And thank you for sharing with us all of that.

Dr. Diana Anderson: Thanks for having me on the podcast.