Brutalist medicine: a reflection on the architecture of healthcare

Emphasis on utility

The brutalist architectural style is an appropriate analogy for the modern healthcare agenda. In a vigorous rejection of the “art of medicine,” we have placed a special emphasis on utility. Today’s physician must use interventions to produce outcomes, plain and simple. This new utilitarian strain believes evidence is the raw material, and hospitals and clinics will be built from this foundation into sturdy sanctuaries against disease. My definition of brutalist medicine is “medicine so intentionally functional that it erects its own barriers.”

One element of this brutalist mode in medicine is the clinical guideline. The proliferation of clinical guidelines promises to “operationalise” the research literature, turning it from an intellectual exercise into a rugged carapace for the vulnerable doctor. Small trends become universal guidance, contorted to apply to disparate situations. Like a geometric slab of concrete, clinical guidelines at first seem to ward off the dangers of our environment. Yet too often they are designed in isolation, so focused on being decisive that they cannot blend into their clinical milieu.

We all have stories of sepsis or stroke protocols being applied haphazardly, for example, producing absurd and sometimes dangerous results. The need to meet rapid treatment goals, the ease of automated order sets, and an over-reliance on metrics could lead a physician to deliver a fluid bolus to a patient who has pulmonary oedema not pneumonia. Clot busting drugs may be given to a patient during a “stroke alert” who would have been found to have a conversion disorder if our system talked about “door to clinical history time” the way it emphasises “door to needle” time.

“Point of care” has become another one of brutalist medicine’s battlefronts. Academics and entrepreneurs alike are convinced that bedside applications, equations, and heuristics will save doctors from themselves. The PHQ-9 depression questionnaire is one of the iconic looks of this form of brutalist medicine. Instead of asking patients about how they’re feeling, we can simply administer these surveys. I suspect the numbers and boxes of the PHQ-9 will one day look as out of place in medicine as grey jutting geometries do in many of today’s neighbourhoods. Task specific applications may be the quickest path between symptoms and treatment, but strengthening patient understanding, comfort, and self efficacy require a more convoluted route.

Perhaps medicine’s most notable brutalist landmarks are electronic medical record systems. Many clumsy medical record systems are in use worldwide, but the dominant record keeping system for 200 million Americans is Epic, making it one of the US’s biggest landmarks.

Epic has achieved ubiquity and prosperity through its unfettered drive toward usefulness and compliance. Whenever healthcare faces a documentation quandary, Epic is right there. From documenting a patient’s blood pressure to reporting the patient’s autopsy results, Epic can do it. The evidentiary life of the patient lives in this behemoth piece of software. It is in connecting to our existing infrastructure and creating pleasant usability that Epic falls short. The architectural equivalent is the grand but dysfunctional city of Brasília.

As physicians succumb to burnout, they spend increasing time on the regulatory nightmare that contemporary medicine has become, with Epic taking over. We are tasked with not only doing more but documenting more. This responsibility comes from many angles. Reimbursement depends on it. The “standard of care” requires ever more rule-in and rule-out tests. Well meaning administrators and public health researchers “nudge” us toward the “right thing,” as evidenced by some clinical trial or case study. But the benefit to individual patients is not always apparent.

Lessons from brutalism

I don’t mean to sound too sardonic. I love brutalist architecture: the buildings are insistent, powerful, and dependable. Endearingly, they mirror the ungraceful way that people age, accruing both structural cracks and new uses over time.

But brutalism’s flaws must also be recognised. These buildings can get in the way. Hanging up a picture or repainting when your wall is made of concrete isn’t exactly an intuitive act. Heating and cooling these buildings can require some deft physics.

If as physicians we are going to be architects of useful, dependable care, we should heed the lessons of this movement. Our systems must not stand alone. They must not define themselves solely as “evidence based” or “standardised.” As Epic shows, our tools will not be our refuge, no matter how complete they are. Many of medicine’s instruments, regulations, and practices are currently designed as monuments to themselves.

At the same time, we may wish to adopt brutalism’s desire to ignore unnecessary adornments. Both healthcare and architecture use pretentious flourishes as dazzling distractions. Let’s reflect on whether high resolution imaging, precision genomics, or unflinching screening protocols are really making patients better.

Medicine is neither a planned community nor a city of monuments. I think there is wisdom within the chaos of the clinic or hospital. The power of evidence based medicine is its isolation of an intervention, which promises to clarify some universal principle. But many solutions in medicine are self emerging and local, not engineered and universal. The look of relief on a patient’s face will never surrender itself to a metric, nor will the wellbeing of my community. If the outcomes themselves can never be fully defined, medicine’s tools and structures must also incorporate leniency.

Let’s begin to imagine what a post-modern architecture in medicine could look like. Urban activist Jane Jacobs famously described the “eyes on the street:” the loyal residents who keep a neighbourhood safe and liveable. In medicine, our eyes on the street are patients, who maintain a natural awareness of the values most meaningful to them. Evidence based medicine is a fine raw material and must not be discarded. But I am certain that evidence based medicine’s utopia does not look like today’s healthcare landscape.