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 https://forallevents.com/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
