October 1, 2011
Bedside Manner 101
Stanford University’s new medical school, designed by NBBJ, places a premium on hands-on learning and the cultivation of “people skills” often sadly lacking in doctors everywhere.
Max Headroom—the patient on Bed 1 of the intensive care unit—is having a seizure. His chest rises and falls, his eyes blink open and closed, his entire body shakes against the backdrop of his hospital gurney. He can’t speak, can’t explain what’s going on, and you get the sense that what’s happening here is otherworldly, almost inhuman. It brings to mind the uncanny, the unheimlich. Watching a body go through the motions of illness and uncontrollability, seeing the fallibility of the human form, isn’t exactly what this writer expected to witness on a Wednesday morning in July. Which is why it’s a relief when Joseph Phillips turns Max off.
Max is one of about a dozen mannequins who live—for want of a better word—on the ground floor of the Li Ka Shing Center for Learning and Knowledge, a new $90 million medical building situated right at the edge of Stanford University’s Palo Alto, California, campus. Two other mannequins are called Lee Majors and Jaime Sommers; both were named by former students and staff members and are currently monitored and cared for (as well as acted out by) Phillips, whose life path led him here circuitously. The reason for the mannequins—originally developed by Dr. David Gaba, a professor of anesthesia and the associate dean for immersive and simulation-based learning at Stanford—is a new type of final exam, a new way for doctors to be tested across multiple types of patient engagement, and a new form of medical learning.
In recent months, there has been a surge of attention focused on medical schools, particularly on the absence of any sort of humanistic learning. Doctors are notorious for poor bedside manners, for a lack of social skills, and for the insensitive delivery of news like “your husband died” or “your wife has syphilis.” Schools across the country have been dealing with this issue on both the admissions end—the New York Times recently reported on the speed dating–style interviews that the Virginia Tech Carilion medical school uses to assess applicants—and more importantly, on the education side. People aren’t generally born attuned to the intricacies of delivering terrible news, and there’s no reason why anyone should expect doctors to be inherently more sensitive than anyone else just because they deal with death and its accompaniments on a regular basis. If anything, the discipline and detachment necessary for the deep, often brutal, and just as often dismal emergency room and surgery work that many of the graduates of Stanford’s medical school will go on to do can sometimes create an overcompensation, a sense of even greater disengagement.
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To that end, the Li Ka Shing Center is novel in that it trains the students psychologically as well as practically, the curriculum preparing them for a lifetime of failures as well as successes. Max Headroom’s home, a 28,000-square-foot model hospital, includes an eerily regular-looking waiting area, which is currently seeking more funding in order to be staffed; ten treatment rooms where doctors-in-training see “patients,” actors who’ve been coached by one of the Center’s two full-time drama staff; an acute-care room; an operating theater; a part-task training room for medical simulations; debriefing rooms; and a multiuse simulation room, the one in which Max had his seizure. As the Center’s director, Sandra Feaster, points out, “in the airline industry, you don’t fly without having done the training.” Astronauts never go into space without spending a significant amount of time flying in parabolic arcs and experiencing 30 seconds of weightlessness at a pop. Why should surgery, anesthesia, and the delivery of difficult medical news be at all different? The completeness of the simulation is crucial for the students. “You see a real doctor’s office with real equipment, and it’s really nice to be in that setting when you’re doing your standardized exam,” says third-year medical student Woody Chang. “When I practice at free clinics, I don’t get a bed or a chair to work with—all that equipment is taken care of here.”
Focused on standardizing and streamlining tasks, the Center’s teaching takes a comprehensive yet controlled approach, as does the building. From the basement filled with partial-task mannequins (on which to practice events as disparate as heart murmur recognition and episiotomies) and thawing vascularized chickens, to a greenroom for the actors who’ve been hired to play drug-addled surfer dudes with mysterious gastrointestinal distress and maybe a gnawed-off arm, the building aims to encompass the holistic experience of medicine and its training.
Let’s start at the beginning: the entrance. When Dean Dr. Philip Pizzo, then at Harvard, first visited the campus, he asked his taxi driver to drop him off at the front door of the medical building. Expecting an easy response, Dr. Pizzo instead received a baffled look. It was a moment that stuck with him, and when he started searching for architects to help him design this new center, he remembered that lack of a front door. That became the centerpiece of what he wanted. “I was hoping to not only create a front door that would provide a sense of place, but also anchor the Li Ka Shing Center in a footprint that will help transform the medical school from a mix of unrelated buildings to the beginning of an integrated campus,” he says.
The door, designed by the architecture firm NBBJ under the leadership of Seattle-based Richard Dallam and San Francisco–based Todd Bloch, succeeds in providing a sense of integration with the rest of the campus. Two walkways, Academic Walk and Foundations Walk, intersect, cradling the rectangular footprint of the Li Ka Shing Center. The Academic Walk axis is patterned like a sidewalk (and students do, in fact, adhere almost rigidly to the delineations), and features a low wall engraved with notable Stanford medical discoveries. Foundations Walk intersects Academic Walk, leading toward the front door, and offering a timeline of Stanford-specific scientific discoveries that revolutionized the fields of medicine, science, and technology. The kicker comes with the overlap of the two walks and the two worlds that they embody, for it should come as no surprise that a significant number of crucial discoveries originated at Stanford.
This power of accumulated knowledge is expressed architecturally throughout the building. An overhanging roof, made of red Prodema wood and metal, juts out from the school to create a penumbra of influence, but it is over the entrance, sliced open with two rectangular slits, that the humanity begins. As Dallam explains, the carefully demarcated oculi are there to give “sun and time registration,” a way of inviting external reality into the often bizarre chronometry of the medical world (70 hours on call, a 36-hour internship shift). Louvers shade the windows around the building, and on the front and back of the building, limestone from France provides visual interpolation and a sense of exterior readability. Access to the building is crucial—Nobel laureates, who may be older than the young buck students who otherwise occupy the Center, need to be able to come for second-floor terrace dinners, and so on—and Dean Pizzo’s rhetoric of the accessibility and recognizability of a “front door” is extended throughout.
Inside, the five floors each demonstrate a different approach to learning. The first floor opens up into an airy café—crowds of students, some dressed in scrubs and some in street clothes, are sitting at tables, unaware that the architects responsible for their classrooms are sitting among them—while two fully wired, theater-style lecture rooms offer a more traditional learning environment. It’s hard not to think of the operating theaters of the 19th century, when doctors routinely practiced on cadavers—or patients!—in front of rows of bleachers occupied by would-be doctors. In contrast, these theaters are updated, with comfortable seats and desks on which students can rest their mandatory iPads.
This technological awareness is complemented by germ awareness. The classrooms on the second floor—whose hallways are lined with a curious collection of modern-art posters (think Klimt, Klee, Mondrian, and Warhol)—are filled with students learning about asthma symptoms and treatments and are furnished with, in one case, three bottles of Purell, two of Clorox, and two boxes of hand wipes. On the third floor, administrative offices and a board-room occupy a corner of the building. As Dallam points out, Dean Pizzo wanted to be involved, but not controlling, which is why his office sits in the back corner, near a boardroom, rather than at the top.
The top floor is where the true student focus comes through, and only students have access to it. Central to the fourth floor is the student lounge, which features table tennis and foosball tables, a kitchen, and a small computer center. A copy of The Clinical Practice of Emergency Medicine lies on top of a low bookshelf, its title partially obscured by well-loved Ping-Pong paddles, while a corkboard advertises events like a “Neuroscience Happy Hour!” or an immunology barbecue. Doors lead to a wraparound porch, where the overhanging roof is once again punctured by a skylight that draws in just enough bright California sunshine. An exercise room overlooks—for now—a power plant and the
Li Ka Shing Center’s other neighbors. Dallam points out that the vista from the exercise room is good for more than just daydreaming. “You see people walking,” he says. “So you’re sequestered, but you get mental and emotional relief.” This visibility of people, he says, is all part of the empathy training, a reminder that the practice of medicine is, fundamentally, for people. Like Max, and like you.