University of the Pacific, Arthur A. Dugoni School of Dentistry -- Architectural review
This is a letter I wrote recently to Dr. Patrick J. Ferrillo
Jr., Dean of the University of the Pacific, Arthur A. Dugoni School of
Dentistry. It conveys my reaction to
their new clinic that opened in July at 155 5th St. in San Francisco.
Dear Dr. Ferrillo,
Yesterday I had the privilege of being treated as a patient
at your new clinic at 155 Fifth Street in San Francisco. I have been a patient at the University of
the Pacific Dental School for over twenty years, and your students and faculty
have done a marvel with my teeth for which I am very grateful.
However, my reason for writing today is that I was disturbed
and troubled by my experience yesterday, so much so, that I feel compelled to
write and share my thoughts and observations with you. My student dentist, (name omitted) and his
assistant, (name omitted) were excellent and showed great capability and
conscientiousness. This letter, though,
has nothing to do with their performance or my treatment as a dental
patient. It has, rather, to do with the
ambience and character of the new space where the clinic is now located.
My initial impression as I walked through was one of
sterility and impersonality. I don't
mean sterility in the sense of the absence of bacteria, but rather the absence
of human warmth and personality. This
initial impression grew and intensified throughout the afternoon.
The layout and arrangement of the new clinic has been
calculated in every consideration to minimize the interaction between the
student dentist and the patient. The
patient sits in a chair that is facing into the back of the cubicle, with the
student's workstation and computer directly behind
the patient. The result is that the
student is constantly talking to the back of the patient and the patient is
responding away from the dentist into empty space. The student may try to lean around the back
of the chair and the patient may try to twist his body on that uncomfortable
seat so they can see each other a little bit, as we did, but it is a very
awkward, uncomfortable, stilted way to conduct a conversation. And the effect is that it discourages the
patient and the dentist from talking to each other anymore than is absolutely
necessary, reducing personal interaction to an absolute minimum. I believe this was a deliberate, conscious
choice on the part of the interior designers.
I would not say that the layout of the space was thoughtless. On the contrary, I think it has been
carefully thought out under the guidance of the most perverse and misguided
values.
One positive thing I can say about the interior design is
that the cubicles are spacious. There is
plenty of room in those cubicles in contrast to the ones on Sacramento Street,
which were so cramped that the students could hardly move around the dental
chairs. It is too bad that you have made
such poor use of that generous spatial allotment. The student's computer is positioned on an
unmovable pavilion at the front of the cubicle that divides and partially
blocks the wide entranceway creating a closed in effect. Perhaps it was intended as a visual obstacle
to make it less easy to see in or out of the cubicle. But its immobility means that the student has
to do all of his work and analysis out of sight of the patient. The patient never sees what the student is
looking at.
At one point early on, my student presented me with a small
electronic tablet on which I was to sign my name to authorize charges. But the cord was too short. It wouldn't reach from the computer station
to the dental chair. I had to twist
awkwardly on the chair and reach around and the student did something I could
not see to get a little more length out of the cord so I could sign my
name. This is one example of the ridiculous
inconvenience of having the computer and related equipment on something that cannot move, and positioned so that the
patient in the chair is completely excluded from it.
When the instructor comes to discuss the case with the
student, the discussion takes place behind the patient with the patient facing
in the opposite direction being unable to participate or comprehend what is
being discussed. The patient is
effectively excluded from the deliberations on his own case. I think this was also a conscious, considered
decision in the design.
The height of the partitions between the cubicles is about
shoulder high effectively preventing anyone who is not standing up (and many
that are) from seeing anything else that is going on in the clinic. This underlines the sense of isolation that
the patient feels being positioned away from the dentist and his associates who
are working on him. In the Sacramento
Street clinic a person sitting upright in a chair could see all around the
clinic humming with activity. I always
enjoyed this and found it stimulating and interesting to watch: the people
coming and going, the diverse activities, the buzz of conversations, the
attractive female dental students. It
provides stimulation and a sense of inclusion and participation in a group
activity.
On your website you boast that the dental school, "is
renowned for its humanistic model of education.
Accentuating the positive, respecting the individual and empowering its
dedicated faculty to provide the best possible learning environment for every
dental student are among the school's primary goals." I had to laugh when I saw that. This new clinic makes a mockery of those
values. This new space is one of the
most inhuman, depersonalized environments I have ever seen in a medical
context.
This is all justified under the guise of preserving the
patient's privacy. What does that amount
to? Is it that you imagine that people
do not wish to be seen or have it known that they are being treated in your
clinic, like it's some pornographic book store?
Or do you think people might feel self conscious or embarrassed should
someone see them laid back in a dental chair with their mouth open being worked
on by the student dentists? This is a
very minimal inconvenience and should not drive the design of the entire
clinic. The feeling of self
consciousness or embarrassment is a signal that one is not alone. It is impossible to feel self conscious when
one is alone. In order to eliminate the
feeling of self consciousness, of being vulnerable in the gaze of another
person, it is necessary to eliminate all sense of connection, to create a sense
of solitude, which is exactly what you have done. It is a great price to pay to remedy a most
unobtrusive problem, if it can even be called a problem. I would just call it a phenomenon, a
condition of the experience of being in a teaching clinic. It should be seen as benign since it
underlines the sense of participating in a communal activity. It creates a sense of inclusion and mitigates
whatever indignity one might feel by virtue of the fact that we are all subject
to the same conditions and we all share a common experience in this place.
The elevation of "patient privacy," to a paramount
value, I don't see as benevolent. I see
it as another instance of the dehumanization and depersonalization that is
increasingly pervading society in our architecture and our public space. "Privacy" is interpreted to mean
minimizing interpersonal contact by structuring the physical environment to
make it as difficult as possible. This
new dental clinic is a paradigmatic example of that trend.
However negative these effects that I have pointed out are
on the patient, the most insidious and detrimental impact of this architectural
misdirection is the impact it has on the students and on their relationship
with their patients, and most importantly, on their attitude toward their patients.
Throughout the afternoon I pointed out to my student dentist the things
that I saw wrong with the way the clinic and the cubicle space was laid
out. His attitude was "Well, that
may be, but these are the conditions that are given and we have to make the
best of them." At the end of the
day, when his assistant walked me to the escalators she asked me what I thought
of the new clinic. When I explained to
her exactly what I thought about it, she probably wished she hadn't asked. But she could understand my point of view,
but again, she is reconciled to a circumstance about which she can do
nothing.
So what is going to happen is that students, and faculty
alike, are simply going to accept this
as the given conditions in which they must work. And they will make the best of it, of
course. But they will fail to perceive
the impact that this is going to have on their interactions with their patients
and on their relationships with their patients -- if there are to be any relationships. These conditions discourage the formation of
"relationships." The patient
becomes an impersonal "object" to be worked on. The whole atmosphere becomes
depersonalized. The students will accept
this as "normal." They will be
conditioned to expect things to be this way.
It won't be taught. It won't be
pointed out. It will just be absorbed the way one breathes poisoned air. This is the most far reaching and malignant
impact that this architectural affront will have as long as this clinic
exists. It affects the many thousands of
people who will be treated in this clinic in the coming years, but it will
extend beyond the clinic and affect the character and practice of dentistry in
the United States more broadly by virtue of the students who will be
acculturated to this impersonal style of relating to their patients. This is a public issue that goes well beyond
my personal case and even beyond the clinic.
If I were in your position I would fire the people from the
university who were on the design committee for this clinic, and sue the
architectural firm that realized the design and layout of this clinic for
creating a brutal, oppressive atmosphere for the students and faculty to work
in and for the patients to be treated.
There are three things you can do to fix that place,
although it would be expensive. But I
think the expense would be worth it and would create a permanent improvement in
the ambience of that clinic for every single person who comes through it or
works in it.
1. The dental chairs
need to be turned 180 degrees, so they are facing out toward the entrance of the cubicle rather than toward the back
wall.
2. The computer and
all of the related equipment needs to be on a mobile stand that the student can
move as he needs to, instead of being in a rigid, fixed location. It should be closer to the patient and
visible to the patient.
3. The height of the partitions
between the cubicles should be about half of what they are now, giving anyone
sitting up in a chair a full view of the entire clinic. This would not enable people to see patients
who are prone and being worked on. It
would simply create a panorama of visual interest and a sense of inclusion,
rather than isolation.
Since this issue is of public interest rather than my
personal medical case, I decided to post this letter on my blog where the world
can see it http://forallevents.info/reviews/.
I think it is important for people to resist the depersonalization that
is taking place more and more in our public spaces and our architecture, and the
first step in resistance is to point out what is happening. So that is why I am writing to you and that
is why I am posting this in a public forum that others may perceive and be inspired
to speak out and voice their opposition to the creeping dehumanization that is
affecting all of us, and to prompt the University of the Pacific to live up to
the humanistic values that it professes.
Sincerely,
Michael
Ferguson