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Sledge, George W. Jr., MD

doi: 10.1097/01.COT.0000431870.46036.38




One of my favorite pictures of Winston Churchill shows him, in profile, surveying the ruins of the House of Commons. That storied building, the “Mother of Parliaments,” had been destroyed in the last great German air raid on London in 1941. Churchill was there to survey and pay tribute to the building that had nurtured his political career. The building was, in a very real sense, what the Western allies were fighting for: a place where political discourse, not a dictator's whim, decided human events.

The House of Commons was dominated by two design elements. First, it was an oblong where the parties literally faced each other. Second, it was cramped, with insufficient room for all the elected parliamentarians, and with no desks for individual members.

The Nazi bombs offered a choice: recreate the old, or build something “modern,” less cramped, more “functional,” with all the modern amenities. Churchill never seriously considered the second option. There was, he thought, magic in the old structure, with the seating arrangements forcing one to address one's political foes, the tight space creating excitement and political conversation. Anyone who has ever seen debates in the House of Commons, and then contrasted them with the empty spaces (I refer to the building, not the politicians) one sees on C-Span will appreciate Churchill's analysis.

As he told Parliament (in a statement much beloved by architects), “We shape our buildings, and then our buildings shape us.”

It is a quote I often consider when passing by buildings great and small. Buildings send messages, often obvious ones: a Chartres cathedral, aspiring to the heavens; a Parthenon, simultaneously glorifying human reason and the free citizens of Athens; or the massive Stalinist architecture of the 1940s and '50s as ugly in form as the tyranny it represented, with its “your individuality means nothing to the State” message.

At a somewhat lesser level, consider courtrooms. Hollywood courtrooms are often glorious, but their current counterparts, of the sort one sees regularly on second-rate reality TV, are as sordid as the crimes. The majesty of the law seems somehow less majestic in low-ceilinged, fluorescent-lit, faux-wood paneled modern courts. I'm sure they are less costly to build, but does anyone really care about these structures?

Is this worship of form just romantic nonsense? Or do our buildings really shape us? The question is pertinent to science and medicine. Consider research facilities. If one believes that one can design an environment that fosters creativity, then why would we not want do so? If proper building design improved research productivity by 20 percent, then the indirect costs from research grants would pay for the cost of just about any structure in short order.

Of course, research buildings don't exist just to foster creativity. They are also there to carry out the physical act of experimentation, and that physical act imposes real design constraints. Creativity and experimentation are two different, if related goals: consider Princeton's Institute for Advanced Study and the Lawrence-Livermore laboratories and you get some idea of what I am talking about. But let's focus on the creativity part, on the assumption that you can always find a structure to actualize a great idea.

Steve Jobs famously believed in the mysterious alchemy created through building design, and both Pixar and Apple headquarters are exemplars of this concept.

The Pixar campus has a great atrium space at its center, acting as a central hub for unplanned encounters. The atrium houses mailboxes, cafeterias, workout rooms, and restrooms. It forces employees to come together. And it is attractive, with Jobs' usual concern for aesthetic design: a place you want to work, rather than one you have to. It also has sculptures recounting Pixar's successful movies, reminding employees why they work.

Bear in mind that Steve Jobs did not believe in the mystical powers of distributed networks, but rather in the socializing values created through proximity and the personal touch. Jobs, like Churchill, believed that we shape our buildings, and afterwards they shape us.

But is it true? The House of Commons and Pixar are pretty good anecdotal evidence supporting the hypothesis, but in the end just anecdotes. The hypothesis is, I suppose, testable. Take two groups of equally well-trained knowledge workers and randomly allocate them to a “control” building designed by low budget bean counters, or to a Jobs-type building environment. Come back five years later and measure outputs (patents, animated movies, scientific citations, or whatever) and compare. No one, to my knowledge, has conducted the experiment.

Instead we have what might be considered, if architects were oncologists, a series of underpowered Phase II trials of buildings. And a fair number of them, including the Salk Institute and Stanford's Clark Center, as well as numerous attempts scattered through many industries.

It is difficult to imagine a scenario in which putting mediocre investigators into great buildings will turn them into great investigators. Similarly, if you tore down Pixar's campus and put its talented animators into a warehouse in downtown Fresno, they would still be likely to outperform. Great scientists would still publish in Nature or the New England Journal of Medicine even when placed in a mediocre building (most do already, after all). Social engineering (of which the “our buildings shape us” argument is a subset) has very real limits. Leadership (which creates a different sort of environment), resources, and talent all matter.

Nevertheless, it is equally hard to imagine that we couldn't do better, couldn't be more creative, if we fostered interaction, and one way of fostering interaction clearly involves one's physical environment.

Unfortunately, because space is always at a premium, the “touchy-feely” aspects embodied by the Pixar atrium are often jettisoned in our unquenchable thirst for bench space and maximal office footprint. The standard way universities allocate space (X dollars of indirect costs = Y dollars of square footage) actively undercuts this sort of intellectual agora.

Buildings can shape us in other ways. I have spent a fair amount of time at the National Academy of Sciences' Keck Building in Washington, D.C., doing committee work the past two years, and have come to be charmed by the place. The building itself is not beautiful, nor even particularly functional, but it has a lobby that others could well emulate. Carved into the marble are emblems of scientific success: formulas, engravings of Darwin's finches, the original x-ray crystallography for DNA.



Every time you walk through the door, you are reminded of the great scientists who helped create the modern world. Does that matter to the people who work at Keck? I don't have a clue. But it is wonderful nevertheless. And I hope someone will help me with the equation.

Hospitals appear to be a special case. They are, by necessity, utilitarian. They are usually built by accretion over time, with little logic. Can they be designed to foster high-class medical care? There are certainly design firms that think so.

Bad design certainly can cause massive problems. I knew a hospital where the architects, new at the job, made the doors to patient rooms quite narrow, forgetting that hospital rooms have full-bodied hospital beds. At enormous cost the hospital special-ordered beds that would fit through the doors. Sometimes we shape our buildings and they drive us crazy. But how about good design?

As with research buildings, hospitals (and clinics) have purpose. That purpose, simply put, is to take in sick people and send out healthy people. That purpose, by general consent, has two sub-purposes: health care should be skillful (i.e., it should deliver effective care efficiently) and it should be compassionate (i.e., it should emulate the great tradition described in the Oath of Hippocrates).

Can we shape hospitals in ways that shape us to be skillful and compassionate?

I don't know. I have certainly seen designs that are more or less efficient, depending on where one places the ER or the radiology suites or the lab. But efficiency is only one aspect of skill, and it need not be the least bit compassionate, other than in the sense that a short length of stay exposes patients to fewer nosocomial infections and less hospital food.

A solitary focus on efficiency may even thwart the development of caring teams. Teamwork and creative care are the provenance, not of the building, but of the employees who walk the halls.

There's a wonderful sight gag in the Marx brothers' A Night in Casablanca, where Harpo (the one who never speaks) is leaning against a wall (see the clip on YouTube at An officious busybody accosts him. “Say, what do you think you're doing, holding up the building?” Harpo happily nods yes. “Come on!” says the official, pulling Harpo out of the way. The wall promptly falls down.

We shape our buildings, and then our buildings shape us, but like Harpo it is we that keep the walls from falling down.

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