Abstract
D. Kirk Hamilton, FAIA, FACHA
I have recently been reading Atul Gawande's outstanding books, Complications: A Surgeons Notes on an Imperfect Science (2002) and Better: A Surgeon's Notes on Performance (2007). Gawande is the surgeon at Brigham and Women's Hospital in Boston who writes so well that he has been named a MacArthur Fellow and who has collaborated on high-profile editorials with the likes of Don Berwick of the Institute for Healthcare Improvement. He doesn't say much about design of the facilities in which he works, but I was struck by a passage in the final chapter of Complications.
The core predicament of medicine—the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of a society that pays the bills they run up so vexing—is uncertainty. (Gawande, 2002, p. 229)
Uncertainty is equally difficult for designers coping with the gravity of their decisions. I have told my colleagues, clients, and students that in my opinion there is no absolutely conclusive information; a designer will never have all the relevant data he or she wishes to have to make key project decisions with certainty.
A bit later Gawande adds: “Decisions in medicine are supposed to rest on concrete observations and hard evidence” (p. 232). After sharing a riveting story of one woman's case where there is much uncertainty and an absence of clear evidence to guide the surgeon's decision, he returns to the consideration of medical decision making.
Overall, physician compliance with various evidence-based guidelines ranges from over 80 percent of patients in some parts of the country to less than 20 percent in others. Much of medicine still lacks the basic organization and commitment to make sure we do what we know to do.
But spend almost any amount of time with doctors and patients, and you will find that the larger, starker, and more painful difficulty is the still abundant uncertainty that exists over what should be done in many situations. The gray zones in medicine are considerable…. (p. 236)
In the absence of algorithms and evidence about what to do, you learn in medicine to make decisions by feel. You count on experience and judgment. And it is hard not to be troubled by this. (p. 237)
Gawande goes on to describe what I interpret to mean medical best-practice decisions in these “gray zones” based on the physician's observations, interpretations, and experience. The design professions don't yet have analogous measures for compliance with evidence-based concepts, but it would be fair to say that at this point in time, there is a low level of professional agreement about concepts that purport to be founded on research and a still lower level of their purposeful application to contemporary projects. As in Gawande's comment about medicine, it appears that healthcare design also “lacks the basic organization and commitment to make sure we do what we know to do.” Furthermore, just as he has declared medicine to be fraught with uncertainty, I believe design is also a realm of “abundant uncertainty” where we must rely on best practice based on the designer's observations, interpretations, and experience.
I believe design professionals have the same need to turn to best practice as physicians do. Designers often must strive to make the best possible decisions on the basis of partial and incomplete information. Many who read language advocating an evidenced-based model for design, such as appears in my own editorials, are concerned that there is not sufficient credible evidence to make the majority of design decisions on healthcare projects; thus, they are inevitably faced with uncertainty. Although it is true that our field lacks much at the beginning of a broader push for rigor, I hope these design professionals recognize that where certainty is unavailable, the majority of project decisions can be made on the basis of recognized best practice. Where a design hypothesis is involved, one cannot expect to be certain until a project is completed and measurements have been reported. Even then the findings may not be conclusive. My belief is that evidence-based projects will continue to be founded largely on best practice, with a smaller number of key decisions made according to the rigorous application of critically interpreted research findings.
It must be said, of course, that architecture is not medicine, and it need not try to be. The spark of innovation lies within the creative process, and creativity is prized by all design professionals. Erich Fromm has said, “…the willingness to let go of all ‘certainties’ and illusions—requires courage and faith” (1959, p. 53). He went on to say that “Without courage and faith, creativity is impossible…” (1959, p. 54). Thus, it would seem, creativity requires the courage to let go of certainty. Let us then not ask too much of our budding exploration of designs that attempt to make critical decisions on the basis of the best available evidence. We must remain cautiously uncertain.