Transforming the Doctor's Office

Principles from Evidence-based Design

Ann Sloan Devlin

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317750000
• Edition: 1
• Topic: Architecture
• Subtopic: Architecture Design

From the parking lot to the exam room, doctors can improve the physical surroundings for their patients, yet often they do not. Given the numerous and varied duties doctors must perform, it may fall to the design profession to implement changes, many based on research, to improve healthcare experiences. From location and layout to furnishings and positive distractions, this book provides evidence-based information about the physical environment to help doctors and those who design medical workspaces improve the experience of health care.

Along with its research base, a special aspect of this book is the integration of relevant historical material about the office practice of physicians at the beginning of the twentieth century. Many of their design solutions are viable today. In addition to improving the physical design of healthcare facilities, author Ann Sloan Devlin is the granddaughter, daughter, and niece of physicians, as well as the granddaughter and daughter of nurses. She worked in a hospital during college, and has visited a good many practitioners' offices in medical office buildings and ambulatory care settings. This book addresses an overlooked location of care: the doctor's office suite.

Office Location, Signage, and Identity: Where and Who You Are

1

Overview: Schemas and patients’ expectations

“If it is not obvious where to park, if there is no room to park when you get there, if you stumble into the back door looking for the front entrance, or if the entrance is badly lighted, your guests have been subjected to a series of annoyances which will linger long in their subconscious.”¹ In this quotation the distinguished landscape architect Thomas Church was writing about arriving at a residence, but his admonitions apply to the practitioner’s office.

Like guests’ expectations upon arrival, this chapter focuses on patients’ expectations about where doctors’ offices are likely to be located, the meanings ascribed to such locations, and the role of signage in helping patients reach these destinations. In addition, it covers aspects of external landscaping and parking. Providing an historical perspective, the chapter also includes examples of how and where physicians established medical practice at the beginning of the twentieth century. The emphasis here is on primary practice physicians with offices located in a small complex of medical buildings, a freestanding building, or within the hospital itself. The focus is on the physical context where care is delivered and how physicians are consequently perceived.

The schema: What people expect

Based on their experience, people expect physicians to look a certain way (e.g., to wear a white coat) and proceed a certain way (e.g., to first ask about symptoms). When we go out to dinner in a restaurant, there is a predictable chain of events that psychologists call a script or an event schema. Similarly, an office visit to a doctor involves a particular sequence of activities: check in with the receptionist, wait for a length of time in the waiting room, and have your vital signs taken; speak to your physician about the reason for your visit; pay in some form; and exit the way you entered. We have a script for our visit. Not only do we have expectations about the activities, but also about the appearance of the office and its surroundings.

A major theme in this book is the role of schemas, or mental representations of knowledge, that people have about their world and how these schemas shape our reactions to physical environments and those who inhabit them. Humans are limited information processors; we cannot process all of the stimulation around us at a given moment in time. One of the major reasons telephone numbers and zip codes are short is our inability to remember much more than seven digits, written about by the psychologist George Miller.² With auditory (e.g., conversation) and visual (e.g., signage) interference in the environment, that limit is likely to be even lower.³ Further, despite what those born toward the end of the twentieth century (the Millennials) think, multitasking is not making us more efficient or able to perform diverse tasks at the same time.⁴ Thus, layout and signage must compensate for our memory limitations.

Fortunately we function in a reasonably predictable although complex world, at least with regard to the built environment. We know that hospitals are not typically located in quiet residential neighborhoods, given traffic and ambulance noise. The predictability of our world is advantageous because humans are quite easily overcome by information. To manage the complexities of our environment, we rely on schemas or representations of both how things usually are and where things usually are. The human brain has modules to register these categories of information, known respectively as the “what” and “where” systems.⁵

The physician’s identity in the early twentieth century

The practice of medicine was significantly less complex 100 years ago than today. When my maternal and paternal grandfathers practiced medicine in Brownsville, Ohio and Clarksburg, West Virginia, respectively, beginning in the early 1900s, practice was either in a physician’s home or a small office (see Preface illustration); many practitioners were not yet licensed. My paternal grandfather’s major means of transportation was a horse, later replaced by a bicycle because it was more convenient than waking the attendant in the barn to saddle the horse for night calls.⁶ Eventually my grandfather acquired an automobile. When he retired in 1952, medicine had been transformed from those early years.

A century ago, there were perhaps three or four times more doctors than were needed,⁷ competition for patients was strong,⁸ and as a rule, physicians were advised not to send patients elsewhere for fear income would be lost. The concern about how to make a living was reflected in the titles of books written to help the physician, including Cathell’s 1882 The Physician Himself and What He Should Add to His Scientific Acquirements, Wood’s 1903 Dollars to Doctors or Diplomacy and Prosperity in Medical Practice, Mathews’ 1905 How to Succeed in the Practice of Medicine, and journals such as Albright’s Office Practitioner. Today, as then, there is concern about how to make a living, especially in this era of managed care.

Where physicians practice has also changed since my grandfathers’ era. Today physicians’ offices are typically in medical office buildings or connected to the hospital. Sometimes they are in renovated houses but certainly not in the physician’s home unless the practice is psychotherapy; even then, home offices are the exception.

Despite these changes, many of the tasks in setting up practice in a private office remain much the same as 100 years ago; doctors must select the location of the office and furnish it. Coursework on how to establish an office is not a formal academic subject, and the environment reflects this neglect. How these offices look, both from the street and as you enter, often disappoint us, if we judge by what patients say. In research on waiting rooms,⁹ one of the participants commented that the decorations looked like torture devices. We can change that; some of the early twentieth century recommendations provide advice that makes sense today.

The medical office in the home was the common practice before the turn of the twentieth century, yet few patients visited doctors in their office; if you were “sick enough to have the doctor,” you essentially couldn’t get out of bed. Doctors came to your house. When the office was outside the home it was typically located on the second floor of a building, above a commercial enterprise such as a bank or store.¹⁰

The physician’s identity today

Who the individual is as a practitioner is reflected in all aspects of his or her behavior and surroundings. The location, the look of the office building’s exterior, and the interior of the office itself all reflect on the physician. The architecture of the building, the landscaping, and even the lighting communicate aspects of identity. All aspects of medical practice comprise a system of identity.¹¹

Location

The implications of location

For city practice in the early twentieth century, the recommended location for the office was near a major thoroughfare, but not directly on it, and in the central part of town. Such a location was convenient for both the physician and his patients; being near but not on a major thoroughfare provided greater privacy. A convenient and central location was important because the patient might remember that location, but perhaps not your name.¹² Other advice comes from Cathell in 1882: “If you were to locate on a back or unfrequented street, or other out-of-the-way place, it would naturally suggest to the public either defective ambition or distrust of your own acquirements.”¹³

The office should be in a place that communicates safety as well as convenience; that is, located in a place where it is safe to get out of the car, taxi, bus, or subway, and safe to walk on the surrounding streets. This recommendation seems obvious, but competing interests such as real estate costs (the cost/square foot) and/or availability of parking may override factors reflecting patients’ concerns and perspectives.

Being a patient is stressful. Designers and healthcare practitioners can and should take steps to reduce that stress. Helping people to more easily find the physician’s office is one area amenable to stress reduction. Yes, by the second visit, the location is not a mystery; but the first visit is important in beginning a positive relationship. As one author commented, “Signs are a form of public relations.”¹⁴ When efforts are taken to create a clear signage system and tactful messages, users may sense the physician cares about them and understands how important it is to reduce stress.¹⁵ Related to this idea of public relations is the recognition that people don’t like to feel inadequate or incompetent; they like to figure out how things work. Having to ask for directions may make people feel insecure and increase stress.¹⁶ This idea reflects the human need to exhibit mastery, a theme presented in the Intr...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Acknowledgments
• Introduction
• 1 Office Location, Signage, and Identity: Where and Who You Are
• 2 Arriving, Waiting, and Taking Vitals: Setting the Stage
• 3 Consultation and Examination Spaces: “You Feel Healthier When You’re Dressed”
• 4 The Ambient Environment: Changing the “Sick People’s” Atmosphere
• Notes
• Image Credits
• Index