Brutalist medicine: a reflection on the architecture of healthcare
BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5676 (Published 11 December 2017) Cite this as: BMJ 2017;359:j5676
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Mazer describes an era of medicine "so intentionally functional that it erects its own barriers” (1). To fresh eyes, innovations like electronic recording systems look no less ergonomic than the traditional method. Wheeling a computer around the ward is no less clumsy than locating stray drug charts and juggling bulky notes. Although it would be a huge logistical undertaking, a common electronic system would provide long-term benefits. The current state of play - sticking to disparate systems because change is costly and inconvenient - is myopic. Electronic recording systems initially fail to provide an ergonomic alternative to paper systems because it takes time for clinicians to integrate the unfamiliar into their well-tuned practice. It would be foolish to think that all change is progress, but resistance to systematic change will not help a failing NHS.
A “Brutalist” approach is uncompromising, but clinical guidelines are not unyielding directives. The need to respect patient individuality is recognized by NICE. Years of training should not produce doctors that administer guidelines to patients. Mazer alludes to an alternative to “Brutalist medicine” where practioners have more freedom. This bears resemblance to the paternalistic age of medicine, where maverick surgeons and arrogant medics could dictate how things were going to happen. Clinical guidelines shouldn’t remove clinicians’ freedom excepting choices that constitute poor practice. Perhaps rather than “engineering with flair,” (1) a more appropriate parallel between architecture and medicine is “engineering with care”. Flair and creativity are not traits patients demand from doctors, but trustworthiness and compassion are essential. Guidelines or electronic systems cannot threaten the fundamental elements of the doctor-patient relationship, which are delivered through an interaction between people. Medicine is analogous to architecture in that it is a human application of trusted principals. Rules and regulations do not remove the human component from medicine; it is in the actions of delivering of care that we experience or fail to experience humanity.
(1) Mazer B .Brutalist medicine:a reflection on Healthcare Architecture. BMJ 2017;359:j5676
Competing interests: No competing interests
Mazer’s article (1) points out the issues of following protocol without considering individual cases. However, his analogy is somewhat flawed, as is his impatience at a system still in its infancy.
While “architecture” is a succinct way of analysing the “landscape of medicine”, a large part of the speciality focuses on aesthetics. For example, Le Corbusier worked on beauty through mathematic precision, and the contrast between collective and individual compartmentalised spaces. What Mazer is criticising actually involves the way a design has been realised. The pros he observes concern the evidence-based ideology of the medical system, whereas the cons generally concern the application of that ideology on an individual basis. While architects may consider functionality, they don’t guarantee it first time. Mazer overlooks the process of revision and adjustment needed in the field of medicine.
Where aesthetics is important is in building relationships with patients. Aesthetics is part of humanity; it is in understanding patients that the optimal treatment can be found for them as individuals. The challenge presented by the current ‘healthcare architecture’ is how to juxtapose the value of the collective and the individual patient in an efficient and sufficiently human way, which is precisely what Le Corbusier achieved with “Unité d’habitation”.
(1) Mazer B .Brutalist medicine:a reflection on Healthcare Architecture. BMJ 2017;359:j5676
Competing interests: No competing interests
Dear Editor,
With brutalist medicine, we are losing or have to a large part already lost sight of the value of the magic of medicine, which is many things that benefit patients and comprises, inter alia, trust, confidence in the doctor and the doctor-patient relationship. It is these that underlie the human side of medicine and are integral to the uplacebo response. Patients, especially women, sense they are missing something from conventional medicine nowadays, they are losing confidence in it and are seeking alternatives. Practitioners of alternative medicine spend time with patients; patients appreciate this attention and miss it in the brief mechanistic problem-oriented encounters of cost-driven socialised or insurance-financed medicine. In the brutalist medicine of algorithms, guidelines, protocols and computer checklists, the placebo response is undervalued and generally ignored, even to the degree that it is viewed with suspicion, almost as if it were a form of witchcraft. The patient is the poorer if their doctor cannot engender the placebo response. Ironically, we know scientifically that this is true.
Yours etc.
Christopher Rowland Payne
Consultant Dermatologist
The London Clinic
149 Harley Street
London W1G 6BN
Competing interests: No competing interests
Re: On Medicine, Mental Health, and Guidelines
Mazer’s article on Brutalism in Medicine (1) raises an important point regarding evidence based medicine, the assessment of patients with depression and guidelines generally the point of view of the person’s interaction with the environment, expressed in part by epigenetics.
Certainly, we should be using the best available evidence in order to plan our interventions with patients, but we should not see this as the simple following of guidelines or the filling in of questionnaires when assessing human persons and planning our interventions with them.
Guidelines and standard questionnaires do give us what is generally thought to be the best treatments for the generality or ‘average’ patient, according to the evidence, but each human person is a unique individual, both from a biological point of view, as expressed by genetics, from and from the point of view of individual beliefs and choices in terms of decision about acceptance and choices of treatment. Thus, when assessing patients, the whole story of the patient needs to be taken into account, not simply the results of a questionnaire such as PhQ9 even though the questionnaire ensures that important questions for diagnosing depression have been asked. Also, while guidelines enable the best evidence to suggest the treatment we may most likely expect to succeed in the generality of cases, we can expect a number of cases where individuals will choose different treatments, or in which evidence based treatment may not succeed while another ‘second line’ treatment might do so. Such deviations from guidelines and the reasons for them should be recorded in the patient’s notes.
Hence in auditing the adoption of guidelines in Mental Health, we should never expect 100% adherence to them, since treatment must be appropriate for each unique human individual. Respect for each individual person and story needs to remain paramount.
High quality medicine requires a wise balance between adoption of evidence based guidelines and deep respect for each individual human person.
(1) Mazer B .Brutalist medicine:a reflection on Healthcare Architecture. BMJ 2017;359:j5676
Competing interests: No competing interests