<b>All right everyone, howdy.

How are you</b> <b>all doing?

Good.

So today we have Dr.</b> <b>Diana Anderson joining</b> <b>us.

Dr. Anderson is a physician and</b> <b>healthcare architect.

So she's a</b> <b>physician and a healthcare</b> <b>architect, a very unique combination of</b> <b>credentials, and she's specializing in</b> <b>internal medicine and</b> <b>geriatric medicine.

As a healthcare</b> <b>principal and assistant</b> <b>professor of neurology, she</b> <b>bridges medicine and design to create</b> <b>patient-centered healthcare environments.</b> <b>And today she will discuss frameworks for</b> <b>health, applying</b> <b>clinical models to design.</b> <b>So please help me welcome Dr. Diana</b> <b>Anderson to the lecture.

Wish I could</b> <b>have been there in person,</b> <b>but I had some trouble traveling, but I</b> <b>did live in Texas for a while</b> <b>and it was probably the best</b> <b>few years of my life and I have the best</b> <b>memories.

I had the best sushi</b> <b>in Houston that I've ever had.</b> <b>So I always remember that.

I'd love to</b> <b>come back and visit and of</b> <b>course I know George and I've</b> <b>been to the campus many times.

So I'm</b> <b>very excited.

You guys get great lectures</b> <b>for these, this series.</b> <b>So I'm honored to be invited.

So I do</b> <b>wear multiple hats.

That was a nice</b> <b>introduction.

Mostly I'm</b> <b>just a professional student and love</b> <b>exams and love to study.

I guess that's</b> <b>another way to put it.</b> <b>And today I thought what I would do is do</b> <b>something different.

I</b> <b>haven't done this lecture before,</b> <b>but I wanted to talk about frameworks in</b> <b>health design and I wanted</b> <b>to kind of make some parallels</b> <b>to our clinical frameworks and models</b> <b>that we use every day in the clinic and</b> <b>the hospital and see</b> <b>if those might apply to architectural</b> <b>practice.

I have some</b> <b>disclosures just up front.

I am grant</b> <b>funded by a number of organizations, the</b> <b>Alzheimer's Association, Mass General</b> <b>Brigham, up in Boston,</b> <b>and the Greenwall Foundation.

All right,</b> <b>so a quick outline.

This</b> <b>maybe is 20-25 minutes.

I want</b> <b>to leave time for us to talk.

I'd love to</b> <b>hear from students.

Just,</b> <b>you know, not even questions.</b> <b>If you have observations or stories, I</b> <b>love those too.

But I'm going</b> <b>to touch on empirical practice.</b> <b>I'm a big proponent of shifting</b> <b>architectural practice towards</b> <b>empiricism, the way medicine</b> <b>and law and nursing have gone.

But I</b> <b>think we also have to understand how we</b> <b>would implement data.</b> <b>And so clinical frameworks is something</b> <b>I'm going to really delve</b> <b>into.

And I'll talk about the 5M</b> <b>framework, shared decision making models</b> <b>in medicine, and then a</b> <b>peer review process.

And</b> <b>then I'll sort of wrap it all up with a</b> <b>bow through a bioethics</b> <b>lens.

I did a fellowship in</b> <b>bioethics a few years ago and of course</b> <b>my family said, "Oh boy, a third career,</b> <b>we're done, you know,</b> <b>stop."

And I said, "No, no, no."

The</b> <b>bioethics actually was</b> <b>really the glue that put together</b> <b>the two professions of architecture and</b> <b>medicine for me.

So now I approach</b> <b>everything with that</b> <b>type of lens in terms of a bioethical</b> <b>inquiry.

All right, so I</b> <b>know there's different types of</b> <b>students in the room.

There's doctorate</b> <b>students, undergrads,</b> <b>professors.

So I generally give a</b> <b>slide like this at the beginning to talk</b> <b>about the fact that design</b> <b>can impact health.

Many people</b> <b>have never heard of this concept.

And I</b> <b>know all of you know this.</b> <b>This is sort of second nature.</b> <b>So I won't belabor it.

But a group of</b> <b>colleagues of mine, and hang</b> <b>on, this is in the way, a group</b> <b>of colleagues and I a few years ago</b> <b>during the pandemic really sat down and</b> <b>said, "Wait a second,</b> <b>the built environment in healthcare is</b> <b>more than just something</b> <b>that impacts us.

It's a medical</b> <b>intervention.

You know, it impacts our</b> <b>bodies and brains as much as a pill we</b> <b>swallow or a surgical</b> <b>procedure we undergo."

And we wanted to</b> <b>write a paper with that</b> <b>thesis.

And so we approached</b> <b>a journal editor and they essentially</b> <b>shut the door.

And they said, "That</b> <b>sounds a little crazy.</b> <b>Bye-bye."

And we worked on it for several</b> <b>years and we actually</b> <b>amalgamated quite a lot of evidence</b> <b>based design articles.

And we made our</b> <b>case and actually they ended up</b> <b>publishing it as the cover</b> <b>story in the Hastings Center report,</b> <b>which is a bioethics</b> <b>journal, but it does go on to inform</b> <b>policy in Washington.

And you know, we</b> <b>made the case that built environments are</b> <b>medical interventions</b> <b>and deserve that much scrutiny just like</b> <b>any other intervention.</b> <b>This is the famous Roger Ulrich</b> <b>study, 1984, that sort of kicked off the</b> <b>thinking behind everything</b> <b>we're talking about today.

You</b> <b>know, evidence-based design, looking at</b> <b>post-operative patients</b> <b>in hospital rooms with</b> <b>windows looking at nature.

They did</b> <b>better, better outcomes.

So windows in</b> <b>this study and views</b> <b>were pivotal.

And so we're, you know,</b> <b>over 30 years out from that initial</b> <b>study, we have thousands of</b> <b>evidence-based design studies, right?

And</b> <b>windows have always been a</b> <b>topic we've been fascinated to</b> <b>study and try to quantify.

I usually do</b> <b>lectures where I talk about</b> <b>evidence-based design, but I'm</b> <b>not going to do that here.

I will show a</b> <b>recent study that we just</b> <b>published out of Boston,</b> <b>out of our Mass General Brigham Health</b> <b>Design Lab.

Mass General</b> <b>came to us and said, "We have</b> <b>a critical care unit, an ICU, intensive</b> <b>care.

Here's the floor</b> <b>plan.

And patients aren't doing</b> <b>very well.

And seven of those rooms have</b> <b>no windows.

Can you help</b> <b>us figure out if those rooms</b> <b>are part of the problem?"

And we said,</b> <b>"Sure, no problem."

So we did a</b> <b>retrospective, a study that</b> <b>looks backwards and pulled over 3,500</b> <b>patient charts, and we</b> <b>looked at the data.

And what we</b> <b>were specifically looking at is a medical</b> <b>condition called delirium, which is not</b> <b>very well publicized</b> <b>for the general public, but it's</b> <b>essentially an acute brain failure.

So</b> <b>each of our organs can</b> <b>fail acutely.

You've probably heard of</b> <b>acute heart failure or acute sort of</b> <b>sudden kidney failure or</b> <b>liver failure, but the brain actually can</b> <b>also have a kind of</b> <b>emergency.

And it's often triggered</b> <b>by a hospital environment.

So people,</b> <b>especially older people, so I'm a</b> <b>geriatrician and I work</b> <b>with older adults, so that's my lens.

So</b> <b>I'll talk a lot about older</b> <b>adults today, but most people</b> <b>using hospitals are older adults.

They</b> <b>somehow get very agitated and</b> <b>confused.

And you've probably</b> <b>heard of this on TV or seen it with</b> <b>family or friends, patients who are</b> <b>pulling out their IVs,</b> <b>who are hallucinating, thinking they're</b> <b>somewhere else.

This is a very serious</b> <b>condition and we have</b> <b>no drugs to treat it.

We try to prevent</b> <b>it, but what we do know is</b> <b>something in the environment</b> <b>triggers it.

We've thought in the past</b> <b>that maybe it's noise.

We've thought</b> <b>about light.

And so in</b> <b>this particular study, we thought maybe</b> <b>it's the windows, the</b> <b>presence of them or the absence.</b> <b>So we hypothesized that, of course, the</b> <b>windowed rooms that you</b> <b>see on one side of the plan</b> <b>would do much better.

Shockingly, the</b> <b>data showed the complete opposite, that</b> <b>the windowed rooms in</b> <b>this unit were associated with a higher,</b> <b>an increase in the odds of</b> <b>developing this condition</b> <b>versus the windowless rooms.

And we</b> <b>actually controlled for</b> <b>patients moving around or patients</b> <b>who were more at risk for this condition.</b> <b>We tried to eliminate</b> <b>those.

And here's the actual</b> <b>statistics.

This was statistically</b> <b>significant.

We're looking at some</b> <b>p-values.

I won't go into</b> <b>some of the other stats.

And we published</b> <b>this in Critical Care</b> <b>Medicine.

I put this up just to</b> <b>show the contrast in terms of where we</b> <b>are with window studies in</b> <b>evidence-based design.

So it</b> <b>becomes tricky in how you implement this</b> <b>in a design project.

We</b> <b>took all this data on windows</b> <b>in Critical Care and looked at it for our</b> <b>current ICU design</b> <b>guidelines.

When I was in Texas,</b> <b>actually, a number of years ago, a few of</b> <b>us architects and Kirk</b> <b>Hamilton sat down a few</b> <b>weekends in a row with pizza just like</b> <b>you're having.

And we wrote</b> <b>the 2012 ICU design guidelines</b> <b>back in the day.

And the Society of</b> <b>Critical Care Medicine five years ago</b> <b>said, "We want to rewrite</b> <b>it, but we want to make it really</b> <b>comprehensive."

And so we literally</b> <b>pulled tens of thousands of</b> <b>papers on anything to do with Critical</b> <b>Care Medicine and</b> <b>outcomes.

And we developed this</b> <b>guideline.

It's coming out in a couple of</b> <b>weeks.

Happy to send any</b> <b>of these papers to you.

This</b> <b>is our visual abstract, but we don't need</b> <b>to get into the weeds.

I</b> <b>want to point out two things.</b> <b>Look at the bottom of the abstract.

We</b> <b>made certain</b> <b>recommendations for people designing</b> <b>or building ICUs.

We either did strong</b> <b>recommendations or, you</b> <b>know, best practice and no</b> <b>recommendation.

We had to make a decision</b> <b>of what would be a strong</b> <b>recommendation based on our</b> <b>certainty of evidence.

How good was the</b> <b>evidence?

Now, just scanning</b> <b>over here, we don't even have</b> <b>moderate level quality compared to what</b> <b>we have in medicine,</b> <b>right?

We have very low or low</b> <b>quality of evidence-based design data,</b> <b>all right?

We just don't have the large</b> <b>studies, the rigorous</b> <b>studies that we see in other disciplines.</b> <b>But look up here.

We</b> <b>actually made a very strong</b> <b>recommendation for windows and natural</b> <b>light in all patient rooms</b> <b>despite not having very good</b> <b>evidence.

The data is not decided.

Many</b> <b>studies have shown no</b> <b>benefit to windows at all, and some</b> <b>have shown some benefit.

But this is what</b> <b>I'm trying to say with</b> <b>this whole spiel, is that just</b> <b>because the data says something, we also</b> <b>have to put on our</b> <b>professional cap.

So in medicine, it's</b> <b>our clinical judgment.

You know, the more</b> <b>you treat patients, the more</b> <b>you see you develop a sort of</b> <b>gestalt for what might work, what might</b> <b>not, and how you should apply</b> <b>the data, and the same thing</b> <b>in design.

And so we sat there as</b> <b>architects and doctors and nurses, and we</b> <b>said, "We can't in good</b> <b>conscience say that we should not put</b> <b>windows in ICUs because we know we are</b> <b>humans, that they are</b> <b>beneficial, even if the data doesn't say</b> <b>that."

And it's a real challenge with</b> <b>utilizing evidence-based</b> <b>design, and so I think we have to kind of</b> <b>move this needle around</b> <b>depending on the issue at hand.</b> <b>One framework or way I think we could try</b> <b>to fit the data into the</b> <b>design process is utilizing a</b> <b>framework.

Clinicians love frameworks.

We</b> <b>carry little pocket cards</b> <b>with tons of frameworks,</b> <b>but I like this one very much.

It's</b> <b>called the 5M framework.

It's developed</b> <b>by the Institute for</b> <b>Healthcare Improvement, or the IHI, and</b> <b>the John Hartford Foundation, to</b> <b>basically designate a</b> <b>hospital or health system as</b> <b>age-friendly.

So it's about five</b> <b>evidence-based elements that represent</b> <b>high-quality care for older people, and</b> <b>those elements are</b> <b>mind, mobility, medications,</b> <b>multi-complexity, and matters most.

They</b> <b>actually started with four</b> <b>M's, and along the way they</b> <b>added a fifth.

And this really is</b> <b>inclusive of all biopsychosocial</b> <b>conditions and situations,</b> <b>and I use this model when I walk into an</b> <b>exam room with a patient in front of me.</b> <b>I go through each M with them, and even</b> <b>if they're coming in today to</b> <b>see me for something related</b> <b>to mind, let's say their depression is</b> <b>worsening, they're having more symptoms,</b> <b>it's affecting their</b> <b>life.

I still ask about mobility and</b> <b>medications and everything else, and I</b> <b>actually chart using</b> <b>the 5M's as my framework for my note.

And</b> <b>this framework is actually</b> <b>validated for operational</b> <b>systems as well.

So how a hospital</b> <b>operates, we think about the</b> <b>5M.

So if we're using it for</b> <b>clinical practice and operational</b> <b>practice, can we utilize it</b> <b>towards our design practice?</b> <b>And so I'll just take you through each M</b> <b>and make a case for its applicability</b> <b>with an architecture</b> <b>lens.

So mobility, mobility, the M I</b> <b>think a lot about people</b> <b>ambulating, how fast they can walk,</b> <b>how far they can walk, and falls.

We</b> <b>don't want people to</b> <b>fall.

This is a great paper.</b> <b>If you've heard me talk before, I talk</b> <b>about this paper all the</b> <b>time, from 1993 Dr. Morton</b> <b>Creditor, "The Hazards of</b> <b>Hospitalization."

The worst part about</b> <b>hospitals and nursing homes</b> <b>are the beds.

If you take an older person</b> <b>or a younger person,</b> <b>you don't have to be old,</b> <b>it's just a matter of timing of how long</b> <b>it will take to get to this</b> <b>cascade.

And you put them in</b> <b>a bed within a matter of hours, not days,</b> <b>but hours, you are going to</b> <b>have lower muscle strength,</b> <b>lower bone density, decreased ventilatory</b> <b>capacity, the skin is</b> <b>going to break down.</b> <b>And even if they come in with something</b> <b>you can treat, like a</b> <b>pneumonia, a skin infection, a rash,</b> <b>they're going to decompensate just</b> <b>because of the bed rest we</b> <b>subject them to in a hospital</b> <b>environment.

And so we have to think</b> <b>about confinement by</b> <b>design, and we have to shift</b> <b>our thinking to basically design for</b> <b>mobility and not design for bed counts.</b> <b>It drives me a little</b> <b>crazy when people talk about how many</b> <b>beds they need for projects</b> <b>because it shouldn't be about</b> <b>the bed.

That's not the healthy way to</b> <b>think about it.

And Dr.

Creditor says</b> <b>there's no evidence for</b> <b>therapeutic bed rest at all, so get</b> <b>people up and moving.

The</b> <b>second M, mind.

I'll talk about</b> <b>dementia, but mind encompasses a lot of</b> <b>other things.

In dementia,</b> <b>memory impairment, or loss</b> <b>of memory, is really sort of the minor</b> <b>symptom.

It doesn't seem</b> <b>to bother patients as much.</b> <b>What really bugs people are some of the</b> <b>behaviors we see, the</b> <b>agitation, the depression,</b> <b>and also the lack of eating and drinking.</b> <b>As somebody progresses</b> <b>through dementia diagnoses,</b> <b>they eat and drink much less.

This</b> <b>doesn't really bother the</b> <b>patients, but it does sometimes</b> <b>distress families.

And physicians have</b> <b>tried various things like</b> <b>feeding tubes, which are</b> <b>very invasive, appetite stimulant</b> <b>medications, which have a</b> <b>lot of negative side effects.</b> <b>But look at this.

This study did</b> <b>something cool.

They just said, "Well,</b> <b>what if we understand</b> <b>what's going on in the brain and we know</b> <b>that low contrast scenes</b> <b>do not trigger anything?

So</b> <b>instead of having white plates and bowls</b> <b>and mugs, let's just have</b> <b>high contrast, really bright red</b> <b>tableware."

And shockingly, people ate</b> <b>25% more food and 84% more</b> <b>liquid just by changing the</b> <b>colors of the table settings in this</b> <b>nursing home.

People always say, "Well,</b> <b>what does medication</b> <b>have to do with design and built space?

"</b> <b>Well, actually, there's</b> <b>quite a few studies, and</b> <b>probably people in the audience know more</b> <b>to even add.

In this</b> <b>long-term care study,</b> <b>making something more home-like in terms</b> <b>of its design led to a</b> <b>statistically significant</b> <b>decrease in the dosing of psychotropic</b> <b>drugs to residents.</b> <b>Psychotropic drugs are like sedatives,</b> <b>so when people are agitated, and I don't</b> <b>know about you, but I'd</b> <b>be agitated if I was put in</b> <b>a nursing home after being in a home for</b> <b>50 years, and I was stuck</b> <b>in one room with one little</b> <b>wardrobe for all of my belongings.

But we</b> <b>dose things to sedate</b> <b>people, or we use physical</b> <b>restraints.

But in this study, it showed</b> <b>that based on how you</b> <b>design, you can actually lessen</b> <b>the need for medication, and therefore</b> <b>have a better quality of</b> <b>life.

This study looked at</b> <b>lighting, so they supplemented</b> <b>traditional fluorescent lighting in a</b> <b>hospital with blue-enriched</b> <b>light, and they found that while there</b> <b>were no changes to medical errors</b> <b>overall, when they did</b> <b>subsequent analyses, they found that high</b> <b>severity, very harmful errors were</b> <b>actually significantly</b> <b>lower by supplementing this lighting.

The</b> <b>fourth M is matters most.

This</b> <b>we're more aware of, I think,</b> <b>in clinical practice and maybe even in</b> <b>healthcare design.

What</b> <b>matters to the users and the</b> <b>stakeholders?

Willa Granger wrote this</b> <b>fabulous article about nursing home</b> <b>design, and she says</b> <b>that even in older age, there's joy and</b> <b>companionship that's</b> <b>facilitated by the material context,</b> <b>right, the bricks and mortar around us,</b> <b>the porches and places that allow the</b> <b>elderly to touch the</b> <b>world beyond.

If you look at older</b> <b>nursing home designs 100 years ago, they</b> <b>all had porches at the</b> <b>front door or solariums or screened</b> <b>porches even, and people would go and</b> <b>sit, and watching the</b> <b>outdoor activity is an actual activity,</b> <b>right?

It connects people</b> <b>and provides social contacts,</b> <b>which is very important.

And I'll talk</b> <b>more about loneliness and</b> <b>isolation later and some of the</b> <b>health risks.

But if we think about what</b> <b>matters most as a designer</b> <b>or architect, to me, it's</b> <b>probably aligning what we're designing</b> <b>with existing care</b> <b>models.

So we could deliver the</b> <b>most perfect hospital or clinic building,</b> <b>but if it doesn't fit with</b> <b>how people practice within it,</b> <b>it's never going to work.

This is a</b> <b>sketch to illustrate what we</b> <b>now do in clinical practice</b> <b>called shared decision making.

I'll talk</b> <b>about this in more detail, but</b> <b>essentially, we are no longer the</b> <b>physician behind a big desk telling</b> <b>someone which medication to take or which</b> <b>surgery to have.

We do</b> <b>not do that anymore.

So we are really</b> <b>equal partners to</b> <b>patients and their caregivers.

We</b> <b>are meant to impart our knowledge,</b> <b>understand what's important</b> <b>to the people in front of us,</b> <b>and then be their guide in making the</b> <b>best decision for them.</b> <b>And so how does the built</b> <b>environment mirror that care model shift?</b> <b>Perhaps it's a round</b> <b>table where everybody's equal,</b> <b>nobody's better or worse or higher or</b> <b>lower in hierarchy than</b> <b>another, and maybe it's multiple</b> <b>chairs because now we recognize the</b> <b>allied health team is equally as</b> <b>important and patients come</b> <b>with their extensions, which are families</b> <b>and caregivers and</b> <b>friends.

The fifth M, remember I</b> <b>said only four M's began, they added this</b> <b>M, multi-complexity, because older</b> <b>adults, and we have a</b> <b>lot of older people, as you age, the</b> <b>chance that you're going to have a</b> <b>complex chronic condition</b> <b>and probably multiple of them goes way</b> <b>up.

Shifting our</b> <b>thinking towards design, I think</b> <b>we can consider multi-complexity across</b> <b>spatial scales.

So yes,</b> <b>we're having to design an ICU in</b> <b>front of us for our client or a hospital</b> <b>building, but we have to</b> <b>keep the context in mind, right,</b> <b>at different scales, not just what's</b> <b>going on across the street,</b> <b>but even the neighborhood.</b> <b>There's a lot of data to suggest where</b> <b>you live impacts your health.</b> <b>There's a great paper to say</b> <b>the number of trees on the street where</b> <b>your home is located actually predicts</b> <b>whether or not you're</b> <b>going to take antidepressants and how</b> <b>much you're going to take.

So</b> <b>neighborhood context is very</b> <b>important with respect to health.

I</b> <b>mentioned social</b> <b>connectedness with the porches.

Probably</b> <b>all of you are aware of this, but you</b> <b>know, if you look up isolation and</b> <b>loneliness 10 years ago,</b> <b>you're not going to find much research.</b> <b>It's all exploded since</b> <b>the pandemic, but we know now</b> <b>that if you're lonely or you're not well</b> <b>connected, even in middle age years,</b> <b>20s, 30s, 40s, your chance of dementia</b> <b>goes up later in life.

It's</b> <b>a huge risk for your health.</b> <b>It's as bad as smoking, possibly worse.</b> <b>And the surgeon general put out this</b> <b>report two years ago,</b> <b>calling it an epidemic.

And he actually</b> <b>writes in the report that</b> <b>design of the built environment</b> <b>can promote social connection and thus</b> <b>alleviate some of this risk.</b> <b>And so those are the five M's and how,</b> <b>you know, this slide is meant</b> <b>to say, how do you package it?</b> <b>Then what do you do?

So this is something</b> <b>we've done for several</b> <b>clients.

So I'm trying to make</b> <b>it more tangible.

It's like talk a lot</b> <b>about sort of the academic stuff and</b> <b>okay, but how do you</b> <b>actually apply it to the drawing board in</b> <b>a real office like</b> <b>environment?

We've taken floor plans</b> <b>and basically gone through each M and</b> <b>reviewed it in that</b> <b>context to basically highlight,</b> <b>you know, maybe mobility is a concern or</b> <b>mind comes up and then</b> <b>site data.

It's very important</b> <b>to always have citations to back up what</b> <b>you're trying to say, to</b> <b>try to ask questions of the</b> <b>architectural teams and the clients.

You</b> <b>know, it's really meant to supplement</b> <b>what's already going on.</b> <b>In this case, we were talking about</b> <b>views, outdoor access, adjacencies.

And</b> <b>so we've used the five M</b> <b>framework in a type of schematic design</b> <b>review.

So that's one</b> <b>framework.

The second framework I</b> <b>wanted to touch on more briefly is shared</b> <b>decision making.

And several of my</b> <b>colleagues in medicine</b> <b>have been asking, well, who decides how</b> <b>stakeholders needs are met if you're</b> <b>doing a hospital design?</b> <b>And thinking about it, I think we can</b> <b>answer this in the same way</b> <b>that we make other decisions in</b> <b>healthcare, essentially shared decision</b> <b>making.

When we do that, we</b> <b>use what we call this four</b> <b>box method.

It's a little more</b> <b>complicated.

Usually these</b> <b>graphics have a lot of questions</b> <b>underneath as trigger points.

But here,</b> <b>we're just going to talk about the</b> <b>categories, but we have to</b> <b>incorporate patient preferences, the</b> <b>clinical data, quality of life of someone</b> <b>or users, and then a lot</b> <b>of the other contextual factors.

And in</b> <b>some of the papers you can</b> <b>look at, this is from a pediatric</b> <b>journal, there are these nice shared</b> <b>decision making frameworks where you can</b> <b>kind of transition it to</b> <b>an architectural context, which we have</b> <b>tried to do in several</b> <b>publications.

But does the decision</b> <b>include more than one option?

If it does,</b> <b>then you should implement a shared</b> <b>decision making framework</b> <b>or model.

And if there's one option that</b> <b>really stands out as more</b> <b>beneficial than the rest,</b> <b>the physician really guides the process.</b> <b>But if you have a lot of</b> <b>options that are sort of equal</b> <b>in their benefit, then it really needs to</b> <b>be a sort of patient</b> <b>guided or stakeholder guided</b> <b>process for shared decision making,</b> <b>because there's not just</b> <b>one clear data driven answer.</b> <b>And so this is an article we published</b> <b>recently in the American Medical</b> <b>Association Journal of</b> <b>Ethics, taking this shared decision</b> <b>making model and applying it to</b> <b>architecture.

So in a construction</b> <b>of a hospital, we have lots of decisions</b> <b>to make.

That's similar to</b> <b>our plans of care with patients</b> <b>every day and the effects they have on</b> <b>all the people involved.

And so we</b> <b>developed this framework.</b> <b>So if you're building code or standards</b> <b>dictates the option with</b> <b>quantitative certainty,</b> <b>then probably your shared decision making</b> <b>is not so indicated.

But usually it</b> <b>doesn't.

And so usually</b> <b>there are other options.

And then it's</b> <b>about weighing the evidence.</b> <b>And we felt if the evidence</b> <b>is very clear for one option over all the</b> <b>rest, the healthcare</b> <b>architect really drives the process</b> <b>and is really meant to be an educator.</b> <b>But if there's many options</b> <b>again with lots of different</b> <b>data points, then maybe we act more as a</b> <b>synthesizer and we involve multiple</b> <b>players to make that</b> <b>complex decision.

And then the third</b> <b>framework before we open up to more</b> <b>discussion is the idea</b> <b>of peer review.

So peer review is</b> <b>evaluating your work by others, sometimes</b> <b>in a blinded way.

We do</b> <b>this all the time in research.

Anyone</b> <b>who's doing a PhD or has one knows this</b> <b>process or publishing.</b> <b>I get very upset when I get peer</b> <b>reviewed.

I get manuscripts full of red</b> <b>ink.

But ultimately when</b> <b>something gets published, you really</b> <b>realize that that helped make</b> <b>a better product in the end.</b> <b>Okay, people are just doing it to improve</b> <b>the work.

I think we need</b> <b>a peer review process in</b> <b>healthcare design.

It's not at the</b> <b>current time a standard as part of our</b> <b>design process.

But what</b> <b>I think is important to consider is it's</b> <b>not enough to just take evidence-based</b> <b>design and peer review</b> <b>using existing studies.

We also have to</b> <b>look at clinical practice</b> <b>and models of care and some of</b> <b>the operations because healthcare</b> <b>buildings are driven on operations and</b> <b>those frameworks and</b> <b>models.

And you have to integrate all of</b> <b>that not just at the</b> <b>beginning of a project but through</b> <b>various time points, even probably after</b> <b>something's finished.

Although then we</b> <b>get into post-occupancies</b> <b>and that's a whole other lecture.

I have</b> <b>a lot of opinions on that.</b> <b>So maybe we'll talk about that</b> <b>another day.

But I've been thinking a lot</b> <b>in recent years about peer review in</b> <b>design.

Here's an example</b> <b>of the way we've peer reviewed a floor</b> <b>plan for compliance with codes and</b> <b>guidelines.

You know,</b> <b>someone else has done the design but we</b> <b>come in and we look at it</b> <b>and we identify little pinch</b> <b>points and we kind of question different</b> <b>things to see, you know, one person has</b> <b>designed this or one</b> <b>firm but a peer review is definitely</b> <b>warranted a new set of eyes.

What's</b> <b>really important I think</b> <b>to mention is user and stakeholder input</b> <b>increases the value.

So we have to ask</b> <b>people using buildings.</b> <b>I don't think I've ever looked at a</b> <b>nursing home plan where we've asked</b> <b>somebody who lives there</b> <b>what they think.

You can ask people with</b> <b>dementia what they think, okay.

They</b> <b>might not be able to</b> <b>consent to having surgery but they can</b> <b>tell you what they enjoy and</b> <b>what they would like in terms</b> <b>of the room they're in.

So we need to</b> <b>make sure we include users.

I</b> <b>think this is something that</b> <b>we need to see some change in with</b> <b>respect to practice.</b> <b>Sometimes it's very difficult</b> <b>in terms of the client architect</b> <b>relationship to do that and it's</b> <b>beneficial.

Clients have said,</b> <b>you know, this information can translate</b> <b>into better quality of care.</b> <b>During the pandemic I formed a small</b> <b>little group of thinkers.

We started</b> <b>noticing data that suggests</b> <b>bioethics might be something to overlay</b> <b>into the peer review</b> <b>process.

So this is Canadian data</b> <b>showing that if you were in an older</b> <b>designed nursing home in</b> <b>Canada during the pandemic</b> <b>your chance of dying was doubled just</b> <b>because of the type of</b> <b>building you were in which actually</b> <b>caused the Canadian governments to</b> <b>realize that something was</b> <b>going on and they had to change</b> <b>their building guidelines and improve</b> <b>design.

Around the same</b> <b>time I was doing a paper as</b> <b>part of my lab in Boston and I came</b> <b>across some studies showing that</b> <b>depending on the pattern you</b> <b>put on the floor in front of a doorway</b> <b>people with dementia may or may not be</b> <b>able to get to the door</b> <b>and get out.

Some of these patterns can</b> <b>create very distressing</b> <b>illusions for them and therefore</b> <b>they don't exit.

I started thinking about</b> <b>the fact that we can</b> <b>really create harm if we're not</b> <b>careful with design.

Little things that</b> <b>have good intent really may</b> <b>have some pretty significant</b> <b>results and so we sort of cultivated this</b> <b>idea of the bioethics of</b> <b>built space.

We've written a lot</b> <b>of papers about it but we've noticed that</b> <b>design is really being</b> <b>used to in some cases modify</b> <b>people's behavior even especially in</b> <b>situations for older adults long-term</b> <b>care but these efforts</b> <b>aren't any different to what we're doing</b> <b>in medical and pharmaceutical research so</b> <b>we have to make sure</b> <b>that we assess them and that research is</b> <b>an integral part to the process.</b> <b>And so from all of that we've developed a</b> <b>framework called bioethical peer review</b> <b>and what we've done is we've modeled it</b> <b>after the clinical ethics</b> <b>consultation.

In hospitals we</b> <b>encounter lots of really complex</b> <b>distressing situations and</b> <b>we often call the ethicists to</b> <b>come and sort it out.

What they</b> <b>essentially do is they you know they do</b> <b>this little cycle.

They</b> <b>clarify stakeholder values what's this</b> <b>really about and then</b> <b>they identify the tensions.</b> <b>Where are the pinch points and then they</b> <b>sort of dissect each one</b> <b>and give the pros and cons and</b> <b>really figure out a balance in the end.</b> <b>There's never really a</b> <b>right answer in ethics right you</b> <b>sort of have to figure out who your</b> <b>audience is.

And so what we've done is</b> <b>developed BPR as a model</b> <b>where we look at designs in progress and</b> <b>we use a benefits and harms analysis.</b> <b>So we want to evaluate potential positive</b> <b>outcomes of our design decisions versus</b> <b>negative consequences you know is that</b> <b>floor pattern going to</b> <b>do harm but does it do any</b> <b>good.

Maybe it prevents people from</b> <b>leaving the facility and</b> <b>getting hit by a bus if they have</b> <b>dementia.

So then maybe it's worth doing</b> <b>it if few people find it distressing</b> <b>right.

So we think a</b> <b>lot about that.

This is something the</b> <b>architects aren't necessarily thinking</b> <b>about and that's why</b> <b>the peer review is important.

And then we</b> <b>also implement the 5M</b> <b>framework as part of our bioethical</b> <b>peer review.

And then a few months ago we</b> <b>were awarded a Greenwall</b> <b>fellowship a grant to basically</b> <b>take these ideas to Washington and speak</b> <b>to the senate special</b> <b>committee on aging and several</b> <b>senators to see if we can really get this</b> <b>into policy.

I've thought</b> <b>a lot in recent years about</b> <b>our role as designers and architects in</b> <b>advocating for better quality</b> <b>spaces and impact on people's</b> <b>health.

And we have a huge public health</b> <b>role.

We are essentially public health</b> <b>agents right.

We can</b> <b>impact the health of thousands of people</b> <b>of generations of people</b> <b>in terms of use of built</b> <b>space going forward into the future.

So</b> <b>we have a huge role to play.</b> <b>That was really all I had to</b> <b>say.

I know I went fast and there was a</b> <b>lot there but I'd be happy</b> <b>to unpack any of that or take</b> <b>questions from the audience.

And even if</b> <b>you don't have a question, if</b> <b>you have an observation based</b> <b>on something I showed, I love little</b> <b>anecdotes or stories that you've seen in</b> <b>terms of built spaces</b> <b>or scenarios.

So please feel free to</b> <b>share anything you'd like.

Thank you so</b> <b>much Dr. Anderson.

What a</b> <b>wonderful presentation.

So we're going to</b> <b>open the Q&A session for</b> <b>students and faculty of course.</b> <b>So who would like to start?

Okay Carson.</b> <b>Can you hear me?

Yep I can hear you.

Go</b> <b>ahead.

Okay.

Well you kind</b> <b>of went over pretty fast so</b> <b>I'm biometrics but you're talking about</b> <b>the different patterns on</b> <b>the floor that lead up to</b> <b>doors for Alzheimer patients and things.</b> <b>I thought that was very</b> <b>interesting and I was curious what</b> <b>you all found was like the best I guess</b> <b>floor pattern was a vertical or</b> <b>horizontal.

I saw both</b> <b>the pictures up there but you didn't I</b> <b>don't know if I missed it</b> <b>but I didn't hear an actual</b> <b>definitive answer of what you found was</b> <b>best.

Right good question.</b> <b>Thank you for bringing that up.</b> <b>I would love to send you guys so there's</b> <b>about 12 studies out there</b> <b>that have looked at methods</b> <b>of deterring people from going through</b> <b>doorways.

These are in</b> <b>memory care units where we want to</b> <b>keep people essentially locked in but for</b> <b>their own good so</b> <b>complicated ethics issue.

So I can</b> <b>send you that but yes the floor pattern</b> <b>is fascinating.

The</b> <b>horizontal stripes right the</b> <b>ones going from left to right across when</b> <b>they put mat when the</b> <b>researchers put eight or ten strips</b> <b>of masking tape on the floor spaced out a</b> <b>certain distance they found</b> <b>that people with dementia did</b> <b>not approach the doorway but when they</b> <b>turned the stripes 90 degrees</b> <b>people went right out the door.</b> <b>Now we think the reason is and it's a</b> <b>whole other lecture happy to</b> <b>come back and do a dementia</b> <b>lecture because of what's happening in</b> <b>the brain.

There are visual variants to</b> <b>Alzheimer's and there</b> <b>are changes in the visual areas within</b> <b>the brain but we think people are</b> <b>interpreting the horizontal</b> <b>stripes as a three-dimensional illusion</b> <b>almost like a staircase and</b> <b>therefore not really excited to</b> <b>to go through that to get to a doorway</b> <b>versus the vertical stripes</b> <b>don't create the same illusion</b> <b>in the brain.

There's some data to show</b> <b>that if you paint just a</b> <b>black square in front of an</b> <b>elevator or door sometimes people with</b> <b>dementia might interpret</b> <b>that as a big hole in the floor</b> <b>and therefore don't cross it.

I get</b> <b>concerned about things like</b> <b>that because that would be very</b> <b>potentially fearful or anxiety provoking</b> <b>and is that really the best</b> <b>way.

There's other techniques</b> <b>like concealing a door a trompe l'oeil</b> <b>which we do in architecture</b> <b>all the time or building facades</b> <b>and classical architecture.

That also</b> <b>gets a little bit tricky</b> <b>because you're sort of tricking</b> <b>the eye of someone and you're making that</b> <b>decision and is that okay.</b> <b>We've had some instances with</b> <b>fire safety that staff can't find the</b> <b>door to get out so that's a concern but</b> <b>yeah no good question</b> <b>and I'm happy to send you the article.</b> <b>There's some other pictures</b> <b>in there and an explanation.</b> <b>Next question.

It's up for Lou.</b> <b>And I'm happy to really regret that I</b> <b>come here to hear that</b> <b>presentation about the 5M framework.</b> <b>So that's really good framework for us to</b> <b>learn from and also at the</b> <b>beginning you mentioned your</b> <b>study on the ICU about the delivery room</b> <b>and then it's</b> <b>interesting to see how different</b> <b>studies come up with different you know</b> <b>or you know humanist</b> <b>things come up with different</b> <b>results and I think you know that I want</b> <b>to read the whole article</b> <b>to see what's the reason</b> <b>behind that but at the same time I think</b> <b>you know all the study the</b> <b>student had to read the whole</b> <b>thing to be able to understand the</b> <b>reasons right when they apply that to</b> <b>their design and again</b> <b>a lot of study being published although</b> <b>peer review and a lot of</b> <b>study I don't mean to yours</b> <b>I believe your study is really really</b> <b>rigorous design but a</b> <b>lot of published study</b> <b>they are not you know may not have the</b> <b>right research method to</b> <b>lead to the right results</b> <b>so I think you mentioned really good</b> <b>point we have to be able to understand</b> <b>you know the study to</b> <b>to see where the evidence we got from the</b> <b>research and then you</b> <b>know it's good enough for</b> <b>for us to apply to the design project.

I</b> <b>really like your you know</b> <b>the peer review process.</b> <b>I think you know each study each building</b> <b>being built they went</b> <b>through a lot of peer review</b> <b>process as well you know file code you</b> <b>know building code and</b> <b>then but you know if you don't</b> <b>involve the user and for the peer review</b> <b>process sometimes the</b> <b>building that doesn't work right</b> <b>and I am I what you have done you know to</b> <b>be able to go to the DC to</b> <b>engage the policy makers to</b> <b>think about you know you incorporate that</b> <b>into the policy and</b> <b>thank you so much that's that</b> <b>really inspiring lecture yeah.

Thanks for</b> <b>those comments I actually</b> <b>uh lots to say but right so</b> <b>critically appraising the research</b> <b>yourself this is a great skill set</b> <b>architects are not researchers</b> <b>and I've struggled a lot in my career</b> <b>because it's easy to say well</b> <b>architects should be able to</b> <b>find the data find the studies read them</b> <b>and understand them</b> <b>that's a big ask right that's</b> <b>a huge skill set that especially in</b> <b>general architecture school</b> <b>not in a healthcare program</b> <b>people are not learning we do we do it in</b> <b>medicine because we have to</b> <b>use it as part of our every</b> <b>day but I do think some amount of skill</b> <b>set in terms of</b> <b>interpreting a research paper and</b> <b>understanding the methods behind the</b> <b>study to make your own decision you'd be</b> <b>surprised but you know</b> <b>in the hospital we have journal clubs</b> <b>regularly where we look at</b> <b>articles and they're often from</b> <b>great journals right the New England</b> <b>Journal of Medicine the</b> <b>Lancet and people just assume it's</b> <b>in the New England Journal it's great why</b> <b>even question it but</b> <b>you'd be surprised you go in</b> <b>there to the methods and there's always</b> <b>something to look at and say</b> <b>um you know not no study is</b> <b>perfect and you have to be able to decide</b> <b>for yourself if it you</b> <b>know is good quality or not</b> <b>that's a very important skill set um the</b> <b>other thing is how do you</b> <b>take that data and apply it</b> <b>to the project or the person in front of</b> <b>you many studies enroll you know a</b> <b>middle-aged white man</b> <b>uh and then you have a patient who's from</b> <b>a totally different</b> <b>cultural background who's</b> <b>female in front of you does it apply how</b> <b>do you do that um how do you</b> <b>take the data on windows in</b> <b>icus and use that to design a clinic is</b> <b>it the same environment no</b> <b>so i think also understanding</b> <b>how you might apply data recognizing that</b> <b>it's not always a perfect</b> <b>fit um is a is a concern but uh</b> <b>yeah the the window study was interesting</b> <b>my feeling deep down is</b> <b>that obviously windows are</b> <b>complicated and it's really nothing to do</b> <b>with the presence or</b> <b>absence of a window it's probably</b> <b>something more to do with light levels</b> <b>which we did not measure or the view</b> <b>itself and the vista</b> <b>that you get right these windows actually</b> <b>which i probably didn't tell you they</b> <b>look at a neighboring</b> <b>building that isn't too far away so</b> <b>they're actually not getting</b> <b>the vista that roger ulrich</b> <b>had with half of his subjects in his</b> <b>famous study which was a</b> <b>park and so to tease that out is</b> <b>actually quite complicated and the area</b> <b>of health care research is not</b> <b>a huge one in terms of funding</b> <b>and um studies that are able to be done</b> <b>it's very hard to also</b> <b>blind this stuff and make it</b> <b>randomized but anyway uh good points good</b> <b>points but learning some</b> <b>research um methods or lingo is</b> <b>very important thank you so much dr</b> <b>anderson i was also very</b> <b>intrigued by the study that you</b> <b>conducted in the icu i conducted a</b> <b>similar study between the year 2019 and</b> <b>2021 and uh this study</b> <b>was conducted in a cardiac intensive care</b> <b>unit and it's</b> <b>interesting to your point um we had</b> <b>windowless rooms and window rooms but in</b> <b>the window rooms we also</b> <b>had we also had different</b> <b>bed orientations towards the window so in</b> <b>some rooms we had the bed</b> <b>parallel to the window so</b> <b>it allowed patients to have to have</b> <b>direct access to daylight and outside</b> <b>views and in some we had</b> <b>the patients um let's say the head of the</b> <b>bed was placed against the</b> <b>window so the patient was</b> <b>facing inside so they could not see</b> <b>outside window outside views and they</b> <b>could only get daylight</b> <b>while they were staying in the room so it</b> <b>was very interesting to</b> <b>see how even different bed</b> <b>orientations could impact health outcomes</b> <b>such as length of stay delirium and</b> <b>mortality and i wanted</b> <b>to ask you um as for example for the</b> <b>study that i did um we</b> <b>also um did some we did the</b> <b>retrospective part we looked at the</b> <b>electronic health records</b> <b>and we also did a prospective</b> <b>study because we noticed that some of the</b> <b>data that we really</b> <b>needed such as for example</b> <b>uh anxiety depression or even sleep</b> <b>quality that can directly impact outcomes</b> <b>they were absent from</b> <b>electronic health records so basically</b> <b>when we look at these um patient data</b> <b>points and when we are</b> <b>adjusting um let's say for example the</b> <b>predictive models the regression models</b> <b>you have to work with</b> <b>whatever we have right so um from your</b> <b>point of view how can we</b> <b>address this limitation when we</b> <b>are conducting retrospective studies like</b> <b>that yeah i mean that's a</b> <b>good question i think chart</b> <b>reviews are always somewhat problematic</b> <b>um also because they don't</b> <b>contain a lot of data points</b> <b>that as designers and architects we wish</b> <b>there were in terms of</b> <b>room location or other things</b> <b>that are sometimes actually really hard</b> <b>to find um probably i'd say</b> <b>it's probably not the the best</b> <b>methodology if we can do intervention</b> <b>studies or prospective trials</b> <b>that would be better but maybe</b> <b>a way to get around some of the</b> <b>retrospective issues is to do a mixed</b> <b>method study and overlay</b> <b>some qualitative data as well and really</b> <b>gain some feedback from</b> <b>the users and integrate that</b> <b>you know i think medicine has really</b> <b>opened its eyes more to</b> <b>qualitative data talking to people</b> <b>holding focus groups developing sort of</b> <b>transcripts themes there's</b> <b>a lot of value in that and</b> <b>this may this is a good little nugget</b> <b>that someone told me once and sort of</b> <b>carried through my career</b> <b>um as you know i'm a assistant professor</b> <b>of neurology so i'm sort</b> <b>of with the old-fashioned</b> <b>neurologists who are always pushing me to</b> <b>do data-driven papers</b> <b>whenever i publish something</b> <b>architecturally say that that doesn't</b> <b>count for academic</b> <b>promotion nobody cares it's not data</b> <b>actually one of my mentors at UCSF said</b> <b>wait a second</b> <b>architectural plans are data that is a</b> <b>form of data if you are looking at plans</b> <b>and you're talking to</b> <b>people and you're looking at</b> <b>codes and guidelines that is a form of</b> <b>data and so sometimes i find</b> <b>research can have real tunnel</b> <b>vision and so i think we have to open our</b> <b>minds that research isn't</b> <b>sort of fixed there's lots of</b> <b>options there's lots of forms of data out</b> <b>there and that's okay but</b> <b>as you know healthcare design</b> <b>is a newer sort of hybrid field and it's</b> <b>still very hard i think to convince</b> <b>people of its value in</b> <b>certain contexts but uh yeah so it's i</b> <b>run into a lot of issues</b> <b>there with the clinical community</b> <b>as a sort of advance as medicine is</b> <b>there's still some sort</b> <b>of areas that are harder to</b> <b>open up the thinking</b> <b>around thank you and george</b> <b>diana thank you very much for coming uh</b> <b>via zoom i hope you feel</b> <b>better it was an excellent</b> <b>presentation but i'd like to shift the</b> <b>topic a little bit for</b> <b>the benefit of our students</b> <b>uh i don't know but three or four doctors</b> <b>who are also architects</b> <b>meaning physician architects</b> <b>could you trace what led you down that</b> <b>path some of your</b> <b>frustrations which you have expressed a</b> <b>little bit and what you see as</b> <b>possibilities because you may be</b> <b>interviewing for projects</b> <b>along with our students and you have a</b> <b>certain advantage with</b> <b>those credentials uh could you</b> <b>talk about the bigger picture of being uh</b> <b>so uh unique and</b> <b>thank you for being unique</b> <b>we're all unique but in different ways no</b> <b>thanks right you're asking</b> <b>for another lecture this is</b> <b>a whole other topic uh but yeah so um</b> <b>there's not many who've done both</b> <b>architecture and medicine</b> <b>this particular combination it is a</b> <b>little bit insane uh the</b> <b>amount of studying i did and</b> <b>rigorous programs i i think a lot about</b> <b>that because a lot of</b> <b>people approach me and feel</b> <b>free to reach out if you're thinking</b> <b>about certain things but</b> <b>i get a lot of emails not</b> <b>really from the architects but mostly</b> <b>from the clinicians medical</b> <b>students medical residents</b> <b>saying i want design backgrounds i maybe</b> <b>i should go to</b> <b>architecture school i said wait</b> <b>hold on um the same way architecture</b> <b>students will say well i</b> <b>want some health care training</b> <b>should i go to medical school so i think</b> <b>you know i've done a deep</b> <b>dive into each profession but i</b> <b>have been thinking a lot about the way</b> <b>our world is going in terms</b> <b>of hybrid knowledge sets and</b> <b>you don't know that you really need to be</b> <b>an architect if you're</b> <b>a doctor and want some</b> <b>design knowledge what the clinicians seem</b> <b>to want is some language</b> <b>right they want to understand</b> <b>what we do they want to have a little bit</b> <b>of knowledge around it</b> <b>but they don't necessarily</b> <b>want to spend eight ten years certifying</b> <b>but they want to be able to</b> <b>discuss with us and integrate</b> <b>and i think in the future what we'll</b> <b>start to see is more hybrid programs</b> <b>fellowships courses that</b> <b>integrate the two fields together a lot</b> <b>of people ask me you know i'm a i'm a</b> <b>physician can i work</b> <b>in an architect's office how do i do that</b> <b>there's not very good</b> <b>frameworks i think for that right</b> <b>now we're still sort of sorting out how</b> <b>we integrate two fields</b> <b>together but certainly</b> <b>from your standpoint you are in a design</b> <b>field many architects will say well</b> <b>should i go to medical</b> <b>school if you really want to treat</b> <b>patients and you really want</b> <b>to spend eight to ten years</b> <b>studying and doing your practical</b> <b>residency sure do that um but i don't</b> <b>think you necessarily have</b> <b>to there are interesting options to look</b> <b>at masters of public</b> <b>health and integrate that</b> <b>with architectural training and also</b> <b>health care administration it would be</b> <b>great if people who ran</b> <b>hospitals knew a little about</b> <b>architecture and design it might be very</b> <b>beneficial so i think</b> <b>there's lots of different avenues um i</b> <b>certainly didn't plan this i</b> <b>have a great slide somewhere</b> <b>on how twisty and turny the path was you</b> <b>never know where your career</b> <b>is going to go and in medicine</b> <b>you probably know but after medical</b> <b>school you apply for a</b> <b>residency position a sort of</b> <b>internship and actually you don't really</b> <b>get to pick you rank your</b> <b>choices and then the computer</b> <b>spits out a decision and you are in a</b> <b>binding contract and you</b> <b>have to go and many people find</b> <b>that very traumatic families are torn</b> <b>apart they think their life is over</b> <b>because they match to</b> <b>boston not new york san francisco not</b> <b>texas but in looking back i</b> <b>always tell them these things</b> <b>really happen for a reason and at the end</b> <b>of their residencies they always call</b> <b>back and say you know</b> <b>i ended up in the right place where i was</b> <b>supposed to be and i</b> <b>was supposed to meet these</b> <b>particular patients and have these</b> <b>relationships and done this</b> <b>in my career so i guess i know</b> <b>there's a lot of anxiety sometimes or</b> <b>uncertainty where many of you are in</b> <b>undergraduate or graduate</b> <b>studies but i really do think that you're</b> <b>on this path for a reason</b> <b>and what you should do is just</b> <b>take these as learning situations you</b> <b>know there was a an</b> <b>instance where i met a patient who</b> <b>uh made a big impact on me and i emailed</b> <b>kirk hamilton that night</b> <b>from the icu and i said kirk</b> <b>this happened today and it was really</b> <b>interesting and i'm super</b> <b>motivated by it but it's only one</b> <b>patient it's only a little story what am</b> <b>i going to do with this</b> <b>anecdote and i remember kirk wrote</b> <b>back saying sure it's an n of one this is</b> <b>not a research study it's</b> <b>one person and they said one</b> <b>thing to you but it's made an impact and</b> <b>you can take what they've</b> <b>said and create studies and</b> <b>research and drive change just from that</b> <b>one anecdote and that kind</b> <b>of always stuck with me that</b> <b>nothing is too small and i would</b> <b>encourage you to keep little</b> <b>journals and when something</b> <b>is interesting you see something you're</b> <b>doing a tour of a hospital</b> <b>or something gets set in class</b> <b>that you want to remember just write it</b> <b>down i'm older now i forget things</b> <b>already um so i have to</b> <b>write them down but keeping these little</b> <b>journals along the way</b> <b>actually yielded research projects</b> <b>um articles grant applications you never</b> <b>know when you'll go</b> <b>back and read this stuff so</b> <b>for me that was very helpful advice kind</b> <b>of keep track even if</b> <b>they're small little stories or</b> <b>little things people say wonderful thank</b> <b>you so much so gonna try we</b> <b>have uh two more questions so</b> <b>let's cover them very quick</b> <b>okay</b> <b>i was just gonna say i think by the way</b> <b>thank you for your presentation</b> <b>i was gonna say i think there might be a</b> <b>comment in the zoom chat</b> <b>oh to look at perhaps you're right thanks</b> <b>um yeah i agree with i agree with her</b> <b>definitely thank you</b> <b>you're saying i'm samos um i'm a master</b> <b>of architecture student here at texas anm</b> <b>thanks so much for being here and this</b> <b>has been a really great presentation</b> <b>my question for you and i kind of feel</b> <b>like i might know a little</b> <b>bit of the answer just from</b> <b>what you've been touching on but um i</b> <b>actually i wanted to ask you</b> <b>about um the health or health</b> <b>design being seen as a medical</b> <b>intervention and if you've seen with your</b> <b>work in the industry if</b> <b>it's been or if there is like a lot of</b> <b>pushback on that and um an</b> <b>additional question of how you</b> <b>think that this concept of health care</b> <b>design as a medical</b> <b>intervention becoming more mainstream</b> <b>and widely implemented good questions two</b> <b>questions uh i have to</b> <b>think about those answers</b> <b>complicated uh pushback you know i think</b> <b>what's pretty cool about</b> <b>this industry in this profession</b> <b>is it's changed so rapidly i think even</b> <b>george will agree that in</b> <b>just a few years i'd say even</b> <b>two decades there's been a huge amount of</b> <b>growth and change and</b> <b>interest you know the other day i</b> <b>was giving a lecture at the university of</b> <b>toronto in ontario to</b> <b>undergrads like just starting out</b> <b>their architecture and they were asking</b> <b>questions about nursing</b> <b>homes i didn't even know nursing</b> <b>homes existed when i was in undergrad i</b> <b>didn't even care like i</b> <b>feel like where you guys are at</b> <b>now there's just so much insight to</b> <b>global health issues and other topics</b> <b>that it's pretty exciting</b> <b>and so i think this field is changing</b> <b>super fast and it's sort of like the</b> <b>world is your oyster you</b> <b>can change it how you want i think the</b> <b>people who are in it are</b> <b>people who want change who want you</b> <b>to come with new ideas it's a type of</b> <b>profession that is moldable</b> <b>and malleable to what we need in</b> <b>the future right since even covid the</b> <b>pandemic we've shifted our</b> <b>thinking as architects and</b> <b>healthcare design and so now like</b> <b>resiliency is a topic in firms and they</b> <b>have whole departments</b> <b>to talk about it pandemic preparedness so</b> <b>um it's always ebbing</b> <b>and flowing and changing</b> <b>uh i think in terms of pushback i love</b> <b>academia so i wear the</b> <b>academic hat and i love it i love</b> <b>just talking to my academic friends on</b> <b>the weekends and writing papers and then</b> <b>i go to my day job i'm</b> <b>like oh profits and dollar signs i can't</b> <b>stand it right like i'll</b> <b>talk about look at the evidence</b> <b>if we just change the light bulb you know</b> <b>20 people are not going to</b> <b>fall and then yeah but it's going</b> <b>to cost us too much 1200 bucks to change</b> <b>the bulb i'm like oh can't</b> <b>deal with it so the pushback i</b> <b>think is really on the industry side and</b> <b>the finance side trying to</b> <b>convince clients you don't</b> <b>have to convince the architects and your</b> <b>peers convincing health</b> <b>systems that if you spend a</b> <b>dollar today even though it's 50 cents</b> <b>more to buy that bulb it's</b> <b>going to have huge benefits</b> <b>later and this concept of return on</b> <b>investment is just something that i think</b> <b>architecture you know</b> <b>maybe because it's somewhat intangible i</b> <b>don't know what it is but</b> <b>it's just very hard to convince</b> <b>people that good design doesn't have to</b> <b>cost more and has huge</b> <b>benefits not just today or tomorrow</b> <b>but in 50 years time because whatever</b> <b>nursing homes we're building</b> <b>today that i'm doing this week</b> <b>we're all going to be in them right we're</b> <b>going to live in them so we</b> <b>should have motivation to do it</b> <b>right um so i think that answered some of</b> <b>your question but uh it's</b> <b>pretty exciting i don't know</b> <b>where this field is going to go in the</b> <b>next decade or two but it certainly</b> <b>changed a ton you know when</b> <b>i was in medical school i'm not going to</b> <b>say the year because i feel</b> <b>kind of old today but um the</b> <b>social determinants of health were not</b> <b>something we really talked</b> <b>about right we even had a course</b> <b>called the community health determinants</b> <b>and people made fun of it</b> <b>and didn't go they thought</b> <b>why are we talking about diet and</b> <b>socioeconomic status and where people</b> <b>live what does it matter</b> <b>we want to go to the surgical rotation</b> <b>and now this is super accepted</b> <b>right the social determinants</b> <b>of health no one would second guess you</b> <b>if you brought this up as</b> <b>an important factor in public</b> <b>health it's ingrained in everybody the</b> <b>physical determinants of</b> <b>health what we do is just on the</b> <b>cusp of being recognized now the pandemic</b> <b>i think pushed that needle a little bit</b> <b>to make us see that built spaces matter</b> <b>but it's still early days</b> <b>not fully there yet to be fully</b> <b>accepted thank you so much thank you for</b> <b>the great questions thank you</b> <b>so much dr diana anderson for</b> <b>joining us really really greatly</b> <b>appreciate it thanks everybody</b> <b>so</b>