MJM MedTalks
MJM MedTalks (S02E04+05): Building Healthcare: How Architecture Influences Medicine

S02E04+05

Renée-Claude Bider1, Annmarie Adams1, Masha (Maryia) Samuel1, Vanessa Ross1, Samy Amghar1, Katherine Lan1, Esther SH Kang1, Khiran Arumugam1, Meryem K. Talbo1, Predrag Jovanovic1, Jan Pack1, Susan Joanne Wang1 for the McGill Journal of Medicine
Published online: July 31, 2024

1McGill University
mjm.med@mcgill.ca

Abstract

McGill Journal of Medicine (MJM) Podcast Series, MJM MedTalks, interviews members of the medical and health sciences community from McGill, and beyond to gain insights into their careers, research, advocacy, and more. This series aims to enhance knowledge sharing between experts and trainees in the medical field. In this episode, Renée-Claude Bider, a Master’s student in medical physics and Podcast Associate at the McGill Journal of Medicine, interviews Prof. Annmarie Adams, who is jointly appointed in McGill University's School of Architecture and the Department of Social Studies of Medicine. Dr. Annmarie Adams trained as an architect and architectural historian at UC Berkeley. Her research focuses on how medicine, gender, and architecture intersect. In the first part of their conversation, Bider and Prof. Adams discuss the history of hospital architecture, starting in the late 1800s and focusing on Montreal and Canadian institutions, including the Royal Victoria Hospital, Montreal Neurological Institute, Montreal General Hospital, The McGill University Health Centre (Montreal, Canada), Sick Kids (Toronto, Canada) and McMaster Children’s Hospital (Hamilton, Canada). In the second part of their conversation, Bider and Prof. Adams discuss the architecture of specialized healthcare spaces, such as long-term care homes, birthing suites, palliative care, and cancer centers. They end their conversation by discussing Prof. Adams' ongoing research into the life of influential physician Maude Abbott and advice for trainees in the medical field. A glossary of terms, a content overview, a list of relevant links and research articles, supplementary images from Prof. Adams’ collection, and a transcript of the interview are included in the show notes for this episode.

           

Content overview

Episode 1

Episode 2

Glossary

Links and papers

Websites:

Articles:

Supplementary Figures

Figure 1 Inkwell from Dr. Annmarie Adams Personal Collection depicting the Royal Victoria Hospital at its original site, dated approximately at the hospital’s opening,1893.


Figure 2 Montreal Star article from May 7th 1957 depicting daily activities at the Montreal Neurological Institute from Prof. Annmarie Adams’ personal collection.


Figure 3 Post card with a photo of the Royal Victoria Hospital at its original site from Prof. Annmarie Adams’ personal collection, date unknown.


Transcript


Episode 1

00:10 Renée-Claude Bider (RCB): Hello and welcome to a new installment of the McGill Journal of Medicine podcast series, MJM MedTalks, where we speak with members of the medical community here at McGill and beyond. I'm Renée-Claude Bider, a Master’s Student in Medical Physics and Podcast Associate here at the McGill Journal of Medicine. Today, I'll be speaking with Professor Annmarie Adams.

Professor Adams was trained as an architect and architectural historian, and is jointly appointed in McGill University’s School of Architecture and the Department of Social Studies of Medicine. She's author of “Architecture in the Family Way: Doctors, Houses and Women, 1870-1900”, “Medicine by Design: The Architect in the Modern Hospital, 1893-1943”, and coauthor of “Designing Women: Gender and the Architectural Profession”. Her research focuses on how medicine, gender and architecture intersect.

This is the first of my two-part conversation with Professor Adams, where we covered the history of Hospital architecture, design of other Healthcare spaces, such as long term care homes, the future of Hospital architecture and Professor Adams’ research on Maude Abbott. Professor Adams, welcome to the podcast, it's a pleasure to have you here today.

01:19 Prof. Annemarie Adams (AA): Thank you, I'm thrilled to be here.

1:21 RCB: So starting right off, coming across your work was the first time that I had heard about architectural history, let alone the architectural history of hospitals. So I'm curious to know how you found your way into the field.

01:33 AA: Well, I started as an undergraduate studying art history, and thought I'd be an art historian, but got super interested in becoming a professional architect, so went to graduate school to do a Master’s in Architecture, and then got really interested in architectural history from taking courses from a particular professor. And many many years later got interested in the history of Medicine and have moved in that direction. So it's sort of following my nose of things that interest me. I don't have any formal training at all in the history of medicine so I'm kind of delighted to find myself in a Department of Social Studies of Medicine as a self taught historian of medicine. I thought I would be a professional architect, I love design, I love arts, love the visual world so it seemed like the right place for me but I found myself drawn to research and to writing about architecture.

02:42 RCB: Were there moments you remember where you really went well, I think this is going to be my new path?

02:50 AA: Yes! Many moments! Many sort of intersections where I had to choose this way or that way, and I guess the most recent one that brings us together is in 2016 there was an opening in the Department of Social Studies of Medicine to be a chair, and I had already been at the School of Architecture for, let's see, 26 years and I thought moving half my position within the Faculty of Medicine, it was just such an exciting idea that I could stay, you know in the safety and security of a job at McGill that I love, but I could teach medical students and I could be with colleagues in anthropology, sociology and history and be inspired in a whole new way. It's really been an incredible experience the last 7 years.

03:46 RCB: It's definitely something I've seen in a few professors, this ability to reinvent yourself as your career goes along. That seems really exciting.

03:53 AA: Yeah and the kind of mobility that McGill has offered me, the support all along the way, but just this idea that I can move half myself to a different faculty at a pretty advanced stage in my career was just you know, I'm so grateful for that, I thank my lucky stars every day that I work here.

4:16 RCB: On the topic of that move towards medicine, there's an article you wrote with a line I thought was really interesting where you said that the histories of hospital, architecture and medical practice had rarely converged and I was interested in that perspective so I was wondering if you could expand a little on that.

04:30 AA: I think what I meant is that very few people study the history of the profession of architecture and the profession of Medicine. So I'm just one of the unusual people who are interested in that and what I have worked on, is what I call designer doctors, doctors who believe they know a lot about architecture and make major decisions about hospital architecture. And that's one of the reasons I wanted to teach medical students because I thought if they just had a tiny little bit of architectural education and they went on to positions of leadership where they made decisions about the built environment, even if they remembered that there was a field that they could study before they made a quick decision, it would be worth it. So that's what I meant. Architecture and medicine are quite unusual as professions, because both insist that their students know about the history of the profession. Like if you study dentistry, you don't take a course in the history of dentistry that I know of, or even in Engineering. Law might be an exception, but Medicine and architecture are quite insistent that the history of the profession shapes the profession today. And I think sharing that is one of the reasons it's easy to study both of them.

05:54 RCB: I guess the hope would be that you're not repeating past mistakes or you're learning from the history?

06:01 AA: Yeah, and just learning the kind of richness of how people operated in the past that it might not be as simple as you might, you know, learn from a quick Google or Wikipedia. That there, I mean for the med students, I really, in my course on medicine and architecture that I teach in med four, I really always hope that I'll whet their appetites and that this will just be the beginning and I'll just open their eyes so when they travel or see different hospitals they'll think about them in an educated way.

06:34 RCB: On that topic, I'd love to go through the history of some of the, I guess, major hospitals in Montreal. And thought the Royal Victoria would be an interesting place to start. So I work at the MUHC and I come through the Royal Victoria doors everyday, but the history of the Royal Victoria is much more rich than that. And its previous edition, which was in downtown Montreal to my understanding, is a very good example of some of the architecture we're seeing in hospitals in the1900s. And maybe if you could paint a picture of what the Royal Victoria looked like at the time?

07:11 AA: Sure, well you know the Royal Victoria Hospital is one of my favorite topics in the entire world, and I've been kind of obsessed with it since I arrived here in 1990, and I had no idea when I started working on it that it would be, the site would be abandoned and that a new hospital would be constructed so that has added a layer to it, but what I have written about the Royal Vic, the former Royal Victoria Hospital that is, is that it is a virtual encyclopedia of Canadian hospital architecture, because they the hospital almost always, or maybe I can even say, always hired the very best hospital architects, and so every additional pavilion or renovation represented a kind of cutting edge idea, concept of hospital design at that time, and the site itself, which is on the southern flanks of Mount Royal, just above the main campus of McGill, as a consequent is really layered if we see the original building of 1893, which is a classic example of the hospital type called the pavilion plan that features nightingale wards named after nursing reformer Florence Nightingale. And turrets, high rise turrets, which were actually toilets which were a particularly Scottish feature and in many ways, the 1893 building set the tone for many public buildings in Montréal, through it’s kind of Scottish style and it is a very close replica of the Royal infirmary in Edinburgh, a direct pays homage to the Scottish medical tradition and right away as soon as it opened, the hospital renovated, pavilions grew in a very seemingly chaotic way and with each pavilion, the circulation through the site changed so much so that by 2015 many users thought it was, you know, unfixable, that a new hospital was the better, a better idea. So after the pavilion type, we have what’s called the block plan and you can see that in Ross Memorial pavilion at the Royal Vic and the women's pavilion which instead of open wards that had 30 or so patients you would have smaller rooms along double loaded corridors like a hotel plan today. And of course surgery and other key aspects of the Hospital changed at the same time and then by the post-war World War II era, we see the construction of tower hospitals, so high rise modernist, very undecorated tower hospitals, high rise hospitals that in many ways, pay homage to office building architecture, so with each layer at the Royal Vic, the hospital also made associations with other building types. So you could say the 1893 building was like an old castle of course, it looks like the Scottish hospital of 23 years earlier. The block hospitals look like nobel civic buildings like town halls or libraries, schools. And then the office buildings really emphasize the idea that the hospital is a modern efficient corporation. And they’re almost always white, and they function as kind of backdrops, almost curtains to the Victorian hospital, so it’s just an incredible ensemble.

11:04 RCB: Circling back first to the Royal Victoria and sort of the original pavilion design, was that design linked to the philosophies we had around medicine at the time? How did that design emerge?

11:17 AA: Yes, so although it was designed in 1893, a full 23 years after the date we considered 1870 the development of the germ theory, it actually does connect to earlier theories of disease, basically the miasma theory, which suggested that bad air, bad smelling air in particular, was a carrier of disease. So the medical philosophy was that each patient in a bed could be protected or almost like flushed by cold fresh air all the time, and that would stop the spread of contagion and have a healing effect. So in the Nightingale Wards, those held about 32 patients and the rhythm of the ward would be patient, window, patient, window. And the windows were always open, luckily for us. There was a tradition of always taking Christmas photos at the Royal Vic in the wards, so we know on December 25th, which is usually pretty chilly, all the windows were open almost every year, so that's the kind of place it was, but the pavilion plan and the Nightingale Ward was also really good for surveillance. So a couple of nurses could oversee the entire ward from a special station at the foot of the room and also the wards would open up towards the south with great views of Montreal and the Saint Lawrence and beyond, so it was quite a glorious kind of architecture too.

12:55 RCB: Well, so that brings me to a few of my other questions, one of them being, so you describe the architecture sort of castle-like, and I was wondering how social class came to play in the attitude around hospitals, or the architecture of hospitals. Is there a role there?

13:10 AA: Yes, absolutely there's always a role for social class in hospital architecture. But at this time the architecture- I should have said the hospital was designed by a very well known, well respected British hospital specialist, Henry Saxon Snell, who designed hospitals all over the British empire so getting Snell was a coup first of all. The idea, the concept of designing a hospital that looks like a castle, looks like, draws on aristocratic architectural traditions, express the message that the hospital would take care of everyone, no matter their financial or religious or any other background. So everybody was welcome at these hospitals and the tradition of paying patients came much later, in numbers, so it was a, it looked like buildings in England, like workhouses or orphanages or schools that were associated with social reform and with taking care of working class families. It's debatable whether they were good or bad places, but in any case the hospital was part of that world of design and it didn't, I mean, that really good architecture doesn't need signage, it’s design expressed that care taking role. And so the changing of those associations from the pavilion plant to the block plant in the tower, also function to express the changing care types offered in the hospital.

14:49 RCB: Super interesting, and then my other question from there was so you mentioned these views of the mountain and the river. So the Royal Victoria and actually the MUHC today seemed to be a little bit separated from the city itself, and I was wondering where that influence came from, of having the hospital separated versus very much integrated in the city.

15:13 AA: Yes, so in 1893, that sight on Mont Royal was a little bit removed from industrializing Montreal. So it was also very important to have a site with good air. So the elevation of the site was thought to offer better air. And I’ve actually done a study of the air with my colleague Sal[maan] Craig right now, we're doing a much more sophisticated study of how the air moved but in really basic terms, the air was drawn in via inlets from the East Side of the hospital - facing where the Montreal Neurological Institute is now - was heated in the basement rose up through tubes in the greystone walls, and then was dispersed among the patients, and then the batter in principle, including the breath, the vitiated air of the patients was sucked back down, then it was shot up a ventilating tower that's still there on the East Side and spread all over Montreal [haha]. So it's kind of a building that many hospitals do this actually, make patients for themselves make users you know spread illness in a big picture way, but very interesting that the Montreal reservoir was right across the street on Pine and was open, you know where our playing fields are now, Rutherford Park. So underneath the playing fields it's still a water reservoir, but there was always this question on whether the hospital would pollute the water or the water would pollute the hospital. They've always been in tension.

16:53 RCB: I'm really impressed though by how well thought out or how much thought got put into that air system.

17:00 AA: Oh yeah, well Snell I mean, hospital designers usually specialize in ventilation and it's enjoyed a comeback with Covid. But yes, Snell had strong opinions about how much fresh air was needed per patient, etc. And I think the nurses who worked at the hospital were quite expert at regulating the, as we call it, the HVAC system, the heating, ventilation and air conditioning of the wards.

17:28 RCB: I do want to open up a conversation a little bit to other Montreal hospitals and one that you mentioned just now was the Montreal Neurological Institute or the MNI, so the MNI was a joint vision between Doctor Wilder Penfield and Robert McDonald was the architect, and from my understanding there was quite a bit of collaboration there that maybe joins into your mention of how doctors often have an opinion on the architecture, and I was wondering if you tell us a little bit about that collaboration.

17:58 AA: Sure, yes, Wilder Penfield was absolutely involved in every detail of the design of the Montreal Neurological Institute, including its construction on the East Side of University across from the Royal Vic, but I should say first that there was a design for a Neurological Department on the other side, on the Royal Vic side done by Robert McDonald and so that's how he ended up getting the job for the new building. He had already worked on a less ambitious building, but in the building we have now looks quite a bit like McDonald's first scheme for the Neurology Department at the Royal Vic, so everything about, and it was funded by the Rockefeller Foundation which made it quite distinctive. Everything about the Montreal Neuro passed by Penfield's desk. He was quite involved in the design, especially the design of OR 1, the surgical suite I've written quite a bit about which is still active today and is a very unusual arrangement of galley seating, so sloped seating like you might have in a stadium, very small number of them, that which gives viewers this almost aerial view of the surgical procedures and then under the seats, there was a camera that was aimed at a mirror just above the patient, and so those images shot by the camera would give the viewer exactly the same view as the surgeons. And there was a microphone allowing people in the gallery to speak to Penfield. There was buzzer on the wall allowing Penfield and other surgeons to alert people in the building when something interesting was uncovered, and of course many of the patient’s were awake during Penfield’s revolutionary surgeries, so I can imagine being a very dynamic and high sensory environment and I been lucky enough to watch two surgeries now showing the surgery, showing the architecture in action, which is exhilarating for me as a historian.

20:14 RCB: Do you think it still performs in the way that Penfield, sort of envisioned his OR to perform?

20:21 AA: Well yes, of course it has many more technologies in it than in Penfield’s days, so there’s big monitors and scanning and the camera has been replaced, but I think that idea of having a kind of bird's eye view on the- the surgery is exactly what Penfield envisioned.

20:42 RCB: So my understanding was that Penfield had been interested in architecture for some time and really thought that the architecture could I guess empower the physicians and the students in that space to be more maybe ambitious in their work and I wonder if there was any other example of that in in the building of places where he envisioned the architecture to have an effect on the medical practice?

21:05 AA: Yes, the other major public space that I’ve written about in the building is a lobby, which is highly usual because there’s no admitting desk or registration, it's almost like a gallery it’s still intact today with its original art deco furniture, each piece modeled on some particular aspect of the brain. It's incredible that you can go in and sit on that bench and enjoy the radiators and the lamps and the decorations still today. And then there, the wall freeze, the upper freeze has names of famous neurologists and other scientists and doctors that Penfield admired. And after he died they changed the order of them and added Penfield to it so it's not in its original order. And then there’s this copy of a neoclassical statue from Paris which is - oh I forget the actual name of it - Science Unveiling- Art Unveiling Science - sorry, I don't remember the name of it but she's veiled and she's removing her veil and Penfield was pretty obsessed with that statue and carried a photo of it in his wallet, apparently for most of his life, so he was quite involved in getting the copy made in Paris and having it shipped to Montreal. There's correspondence about, you know, how white should the skin be, and how high should the base be, every detail was of interest to him.

22:40 RCB: Maybe more broadly in the case of the architecture of the building, so it was also the work of Robert McDonald, who had previously designed other hospitals, as you mentioned so does the MNI sort of fit into the traditional hospital buildings at the time, or was it something new?

23:00 AA: No, it fits into the context of other neurological hospitals at the time. It was actually pretty conservative as a design and it's really only OR one that makes it so different than other hospitals. But Penfield, MacDonald and other doctors at the Neuro traveled around mostly in the US and looked at OR configurations, made detailed notes on them, so that's really interesting, too, that they did sort of field work, before they made decisions.

23:29 RCB: On that topic I guess, Penfield was very involved in this process and you mentioned that doctors often have opinions maybe on the architecture of their buildings, but is it common to have a physician advise on these kinds of projects? Or was this different?

23:43 AA: Yeah, not quite to the detail that Penfield did. Penfield had amazing power that sometimes manifested in spatial ways, and an example is the overhead bridge over University that linked to the Royal Vic, you probably know that bridge. Such a bridge is actually illegal in Montreal. We don't have any other overhead bridges, but he demanded it and it was quite controversial at the time. He, you know, kind of threatened to leave if he wouldn't, if he didn't get his way sometimes and McGill went to great lengths to make sure he stayed as he was so important to the Neuro. I mean the Neuro really is so shaped around his vision of an interdisciplinary Neurological Institute and Hospital.

24:35 RCB: And in many ways, you sort of survive the test of time in that regard, which is exciting. Sort of transitioning forward in hospital architecture so you mentioned that we move towards these more office-like hospitals. And I guess maybe the Montreal General is an example of that, and that's still around in Montreal. So what motivated the shift towards that more, that more office building-like design in our hospitals?

25:00 AA: Well, it happened of course in many building types. In architectural history, we call it the international style that really developed earlier in Europe, but arrived in a full fledged form by the post-war era and it was this really idea developed after World War One, but then more fully developed in the ensuing decades that modernism, modern life, sort of pure, abstract, undecorated composition. And I think for medicine what it meant is this association with modern corporations and modern businesses that used particular technologies and you know high, high levels of organization to make work efficient, and that's the hospital interior that we see on soap operas and movies that have the nursing station right across from the elevator and double- wide double loaded corridors with railings along them. It's what hospital architects after about 1980 work against that they don't want their hospital to look at anything like those buildings, I mean the whole generations of hospital architects, like in most arts, rebel against the, the work of the generation that they were trained in- so in- by 1980 we see a really strong critique of those buildings as sterile, and uncaring and institutional, which always- it always strikes me that how- of course they're institutional they are institutions, but that takes on a really negative connotation around that time. And so today, and since about 1980 long term care, or any care buildings, you'll often hear the architects say well, our design is the opposite of an institution. And what that often means is that it's homier, that it's cozier, that it sort of fakes being a domestic building.

27:17 RCB: Well, could we also link that shift maybe to the transition from a paternalistic view of medicine to something that's more patient focused?

27:25 AA: Yes, it is clearly associated with the rise of so-called patient centered care so that the - the building itself responds to the needs of the patient, more than the needs of the staff. So in the MUHC, for example, the offices aren't, you know so fabulous for staff so often many of them are windowless and very small whereas some of those same people probably the older ones had had offices in the Royal Vic and and other Montreal hospitals that had you know spectacular views and were big and gorgeous. Anyway that's - you've got it, you put your finger on it. That's the exact change.

28:07 RCB: And I guess they would also link to hospitals, which I don't know that we have a good example of in Montreal, but of these sort of atrium hospitals?

28:15 AA: Yeah we don't have an atrium hospital, but if you just see them as sort of mall hospitals, then the MUHC would be a good example, not so much the CHUM because it is a high rise. But there are many parts of the new MUHC that look like big box stores and rely on the kind of circulation systems that we associate with commercial architecture. But the idea of not doing an atrium hospital was interesting because most new hospitals, urban hospitals after 1980 are organized around an atrium, which of course is such clear wayfinding, almost every building type after 1980 turns into an atrium. In my class, I call it atrium-itis that libraries, airports, university buildings, they just all adopted atrium style arrangements after that time. So it's kind of, people know how to ambulate in those spaces. I call it the mall crawl. They sort of walk at a different speed and it puts you in kind of a passive zombie state, almost like I sometimes feel when I'm watching TV, that that's the state, the state of kind of compassivity that the atrium is supposed to give you.

29:38 RCB: And I guess the atrium also, I think you mentioned somewhere, can help normalize experiences of the hospital?

29:48 AA: Yes yeah, that's one of the big ideas behind the atrium. We worked on Sick Kids in Toronto from that perspective. So a young patient going for, you know a scary treatment, a cancer treatment or something might find arriving at a hospital that looks like a mall or a hotel, looks like some place that he or she has just been in a fun capacity, can make it seem more normal, but you know, I have some problems with that because I find, I always find it unethical when architecture deceives users. But I've been a critic of the Dementia Village, which is a new architectural form for the housing of patients with Alzheimer's that sort of fools them into thinking that they're in their childhood homes. It's like it's sort of Disney-style, Truman Show architecture. And I understand, I understand very well that it's the best that we have, it allows people to roam freely on a site that's basically walled, and allows them to feel like they're out shopping or catching their bus stops where there are buses that never come and I just ethically, I find that really problematic.

31:13 RCB: I'd love to delve into this a bit more and will be continuing your conversation on long term care homes in the second part of this episode, along with discussing the future of hospital design and Professor Adams’ research on physician Maude Abbott. This podcast was edited and produced by MJM's podcast team. If you've enjoyed my conversation with professor Adams so far, reach out to us on Twitter or Instagram @McGillJMed and be sure to listen to part two.


Episode 2

00:13 RCB: Hello and welcome back to the McGill Journal of Medicine podcast series, MJM MedTalks where we speak with members of the medical community here, at McGill and beyond,I'm Renée-Claude Bider, a Master's student in Medical Physics and Podcast Associate here at the McGill Journal of Medicine. This is the 2nd part of my conversation with Professor Anne Marie Adams, who is jointly appointed in McGill University School of Architecture and the Department of Social Studies of Medicine. In the first part of this conversation, we discussed the history of architecture and began our conversation on the architecture of long term care homes, such as the new Dementia Villages made to imitate a neighborhood while staying enclosed.

So, as we just discussed the architecture of long term care homes, often centres around the illusion of homeliness, I was wondering if you could speak to whether that was an efficient way to approach long term care. Do you think that illusion works for patients?

01:04 AA: It's so hard for me to answer because it seems like patients and their families really like that. So I realize that my opinion as an architect and architectural historian is different than theirs. I think it’s maybe okay to have those domestic touches in long term care because it is a residence, even though you probably, you don't live there that long, I mean most patients don't live there that long. But to have those touches in a hospital for me is really problematic. So we saw it mostly in birthing centers, which suddenly became, you know, had flowered wallpaper and rocking chairs and posters, and we're supposed to look like your grandmother's living room, but, it makes a bit more sense in residential buildings. So yeah, domestic associations have always had this soothing, calming effect, particularly because they’re not institutional, but there are so many problems with that, first of all, home environments are not happy environments for everybody, so it projects this, kind of assumption that everybody has a nice, cozy, middle class home that they, that they associate with the space, and also of course it’s somebody else’s choices for the domestic associations, it’s not your home, so how to designers choose things that appeal to everyone? What is the, sort of, universal home? And in a multicultural city like Montreal, it’s just, there’s so many ways of configuring a home. So you just end up with this big stew of meaningless associations.

02:54 RCB: I think that's a fascinating point but I also want to circle back to your previous- or what you mentioned about birthing suites being also domesticated and I- could you expand a little bit on why you find that problematic?

03:11 AA: Well, first of all there's a long tradition of any design for women being homey. So I sometimes call it big house syndrome. So even when we have, like the nursing school, Wilson Hall on McGill's campus was the only building, really, for mostly female student body. It's brick! it's the only brick building, it's the only one that looks like a house. It's empty now, but there are lots of examples like that, but the Royal Victoria College too, you know, very housey looking. So, in many ways it claimed the birthing center as part of that tradition, but also what I really don't like about it is that it's fake. It's not a house and it's projecting that it's a house. So maybe you could get away with it, making it more hotel-like. But to really suggest, I mean I gave birth in the centennial pavilion of the old Royal Vic, which was new at the time, was built for the centennial, so I guess that's 1993. I gave birth there in 1999, 96 and 99. So I was in this, you know, room, waiting, that looked like somebody’s living room, had posters of Venice on the wall and a rocking chair, and, anyway then when it turned out I needed to have a cesarean, somebody like, pushed a button and all these things sort of went away! And the oak, I remember this so clearly, the oak cabinet opened up and all the machines, all the technologies that were needed for the, you know, relatively minor surgery were right there. So it was like a film set, it was so superficial, I mean I already knew that but I witnessed how quickly it could be wished away when it became purely symbolic.

05:12 RCB: And a patient would read that dishonesty, would you say?

05:16 AA: Well, I actually I don't think so, I think patients don't read the dishonesty and they, that they like it. They think it's nice and comforting, so I accept that. But I always teach the architecture students to, you know, think more deeply about it, even if they have to do those things. I just don't think it's honest. I think we should develop birthing centers and other architecture or contemporary women that maybe have a way of looking that we haven't even thought of but that aren't so hooked to the home and the parlor in this old fashioned idea of what home is.

05:58 RCB: Well I think that's a really valid point and also for myself, having interacted with say long term care spaces before I find that they often read as kind of soulless, because there is an illusion of personal connection to something that ultimately has no personal connection to me or to the family member I might be with. And also I haven't really thought about birthing centers, speaking to the tradition of linking women to the home, but absolutely see that now.

06:29 AA: Yeah, I mean to just argue the other side, I was studying an important long term care home in Toronto that had these, what are they called? Memory boxes or something? Like this sort of a glass case and the resident is invited to put important things on display. And usually it's like the women all have wedding photos and little statues and things… Anyway I thought that was a bit, I wasn't, I didn't really understand why that was so important, but then a couple of the people that work there told me there had been a study done that showed that staff members actually spent longer with the residents who have those memory boxes because they tend to see them more as, like real people with histories and did they give them things to talk about and then it made sense to me. So I'm open to learning more about how it works, but from the people who work there.

07:30 RCB: Maybe as a side note from that, so that was backed up by research and what would be the role of these sort of researched-informed design decisions? Do they come up a lot in our hospital and long term care home designs, or do we base ourselves much more off of what we think would help?

07:55 AA: Well, no, there is a very strong subfield of architecture, called evidence-based design, which is very much based on evidence-based medicine, and is centered in a couple of really big health care design programs in the US. I'm quite a critic of those pro-, of that way of design thinking, because, I think there's so much good architecture that touches the soul that would not be captured by evidence-based design decision making. So I've come to understand that EBD as it's called is a way to convince doctors and scientists of particular design decisions, and I don't mind that, I mean it's kind of, things like, you know a study that shows yellow is the most common calming color, so ER waiting room should be yellow, so doctors aren't going to believe that until you show them the study. So that’s fine, it's just when the whole hospital is based on evidence-based design, I fear that we won't have the kind of poetic notes that really fine architecture has.

09:15 RCB: Well, maybe on the topic of those poetic notes, I guess the blueprint we have for these hospice, palliative, or long term care homes, we said is it's a homeliness but I was reading about the Maggie’s Centres, which are day centers for cancer patients, who maybe touch more those poetic notes so I was wondering if you could maybe talk a little bit about that and more broadly these maybe more innovative designs for these kinds of spaces.

09:49 AA: Yeah, Maggie Centres are great examples, they're small scale day centers that don't have much therapeutic programming, but are places that take care of the patients in other ways. They're named after Maggie Jencks and Charles Jencks, her husband who’s a very famous architectural critic and theorist. He was so well connected with the world's star, we call them “starchitects”, star architects, that he convinced a group of them to design them, I think pro bono but in any case, they made quite a splash because they were designed by these star architects, and they're often on hospital sites like off in the corner of a site. And unfortunately we haven't, we don't have Maggie’s Centres in North America. I have investigated a little bit to see if we could get one in Montreal, and I didn't get too far because of regulations around health care employees have to work in spaces that are fully publicly funded as I understand it, in any case they are based on this idea of kitchenism, which is, you know the welcoming atmosphere of a house kitchen where you'd go and have tea and relax, and they have that kind of furniture, but they aren't in like kitschy house, inspired ways. They are spectacular contemporary architecture. So I've been to a couple of them, and I have a few students studying them right now, and they've made a big difference because they show people what good design can do.

11:37 RCB: And then, so I guess it's maybe the idea of the hearth, without the homeliness that we attached to it. So, a gathering space and a calming space, but not a space that has to be linked to our visual cues for home?

11:54 AA: Yeah, like the kitchen or the kitchenism in a Maggie Centre is quite large, you wouldn't think it was a kitchen in a bungalow. So it takes the idea of the kitchen as a gathering place, but that's in a whole new context. I mean it really is a new building type which is so exciting. But Frank Gehry, Zaha Hadid, Rem Koolhaas, they've all designed Maggie’s Centres.

12:27 RCB: Without verging on evidence-based design, do we know what the effectiveness of the centers are on patients?

12:28 AA: Well, I don't think we have, I don't think we have measurements of their therapeutic efficacy but they, the kind of reviews of them are very, very positive. I mean people go there on a daily basis and they meet other patients, and there they have classes or they have other things associated with wellness. They're pretty remarkable places.

12:55 RCB: I think it's a fascinating and sort of refreshing take on how we can address these later stages of life and spaces to have these later stages of life in. And then the other example of that that I was sort of surprised by was you mentioned that some of the more innovative long-term care homes were commissioned by groups of nuns, so I think there's an example of this in Toronto? And I was wondering if you could talk a little bit about what makes those briefs, those architectural briefs unique?

13:31 AA: Well I don't think the brief that the architect received would have been unique. It's really in the creativity of the architectural firm approaching it, so the one that you mentioned is by Shim-Sutcliffe, and they're an outstanding architectural firm, possibly counted as best architects, Bridget Shim. So the design itself is an almost snake-like addition to a Victorian convent, which basically just looks like an old house and it's along a ravine, it's all glass, it's spectacular. It reminds me of the work of the Finnish architect Alvar Aalto in the early 20th century that often did those curved buildings. So, I mean I was as surprised as you are that maybe the two best buildings for long term care in the last little while in Canada are both for nuns, so nuns continue to be pretty sharp architectural clients. And I mean they, it's not like they picked firms that are associated with Catholic institutions. They just picked really good architects, which is a good thing to do. [laughter]

14:53 RCB: So that brings me to one of my broader questions I have which is, hospital architecture to my understanding is limited to a few firms that sort of specialize in it, and that seems to maybe stagnate the progress that we see in hospital architecture. So I wonder what would be your take on what are ways that we could push innovation in these spaces?

15:16 AA: Well, I have written that I think if we opened up hospital commissions to non-specialist firms, we might get more ideas, but the problem of course is that hospital programs are so complicated and there’s so much based on what needs to be next to what on adjacencies, as it’s called. So you save a lot of time by having a firm that already knows all that. But in any case, it has been a pattern in the last few years where major hospital commissions to go to a non-specialist, and what they do to get around that is just hire some of the people from the non-specialist firm to move to their firm, so it appears that they are non-specialists, but all of them will admit that they had to add staff that had some specialist knowledge. But it’s a kind of hybrid solution.

16:11 RCB: Are there some examples of Modern hospitals? We talked about modern longcare care homes but modern hospitals that maybe overcome those challenges to do something that's new and innovative?

16:25 AA: Sure, there are lots of really good hospitals opening around the world right now, but within Canada, there hasn't been a hospital that kind of put us on the world map at the same level of these other designs, since McMaster, McMaster in the 1970s really was a different kind of hospital building, it changed the course of hospital architecture. And there hasn't been another one of those in Canada.

16:56 RCB: Maybe as a side note, I find that fascinating, so I went to McMaster, it's where I did my undergrad, so I'm very familiar with that hospital. But my understanding is that it had a very different approach to the architecture that was maybe seemingly more sustainable, that had a vision of the future of the hospital and kept it flexible?

17:17 AA: Absolutely that was the big idea, and it also was a very close partnership talking about designer doctors between the physician administrator, John Evans and the architect Eberhard Zeidler. And there was something about the magic of their partnership too I think that led to this really innovative building. That is of course really rough concrete, but is a modular design so that any department could change functions almost overnight and the way the architecture worked was that every 2nd floor held all the technology. So it was kind of like a sandwich and it's what's called the interstitial floor, the floor that you can't gain access to - although I got to go in it recently, one of the thrills of my life - held all the technology. So that meant that the plan itself could be completely open.

18:16 RCB: Well, as someone who’s walked past that hospital a lot, from the outside, I guess what’s sort of jarring about it, is it's almost an exoskeleton. Like, you really see the bones of the structure from the outside, which is very cool, and very different from a lot of the hospitals we see.

18:35 AA: Yeah, of course it's huge, which is off putting for many people and it's also confusing inside because every place looks like another so they had to develop a colour coded system of wayfinding, which many hospitals use. So that you could follow, you know the red arrows to your appointment etcetera, and because it was so deep, the floor plate is like a giant concrete monster. It has these window wells and courtyards that pierce the concrete frame and allow a little bit of wayfinding and natural light into the deep spaces, but now it's been changed. It's the Children's Hospital and it was just, even though the loading, the engineering was done so that additional floors could be loaded, and that's why the staircases stick up in this funny way, it was decided not to add to it, so it was never, it didn't fulfill its own dream, but it's a it's a really interesting building there. There hasn't been another game changing building like that in Canada.

19:42 RCB: Do you think we have hope for some other game changing hospitals in our future?

19:45 AA: Yeah, I'm always, I’m always hoping, but you know the choice of architect is really a key thing. And unfortunately many medical boards think that the hospital will be whatever they're thinking and the architect will just realize their plans, and that's really not the way it works. But there is a move, this might interest you, in European cities for hospitals to be more integrated into the city, so for there to be less of a threshold between non-hospital and hospital, so for example, in Zurich and other cities that size where you can, the new hospital was right on the campus and apparently you can see into many of the spaces just as a student walking by, and there also places where you cut through the hospital as a kind of shortcut, so that, too, is a way of kind of normalizing medical care that I think is quite interesting. And of course these hospitals are smaller, just when we have these two giant hospitals, the trend now is to have smaller hospitals in Europe.

20:59 RCB: And more integrated. This actually touches on one last point that I had over hospital architecture overall which is, you sometimes draw comparisons between hospital design and city design, and I wonder if you could maybe speak to how that comparison might help us understand the design of our hospitals.

21:19 AA: Well there are many, many parallels between urban planning and hospital design because hospitals, many hospitals are so huge so it’s just a way of conceptualizing hospitals to have, for example, zoning. You could think of the various departments of the hospital as zones of the city, and also to, circulation is one of the most important features of hospitals, not only that people know where they’re going but also just to have the space for the equipment to circulate, and for everything that needs to happen to move, mobility all the time, 24 hours a day, and so you think of it the grid of corridors as like a city grid with major thoroughfares and minor thoroughfares, actually the MUHC to say something good about it, has quite an innovative Emergency Department that has separated, I’m sure you know this, separated circulation of staff and patients, and as I understand it that has led to efficiencies because staff members are able to focus and not be interrupted and not be distracted, I guess, by things that don't help them. They have been able to see more people in a certain amount of time. And the Jewish also has a really interesting configuration of waiting spaces. I've never been to the Jewish ER, but I often have students who write about that. In my course on medicine and architecture that I teach to med four, I invite the students for their assignment to critique a healthcare space that they've worked in as a healthcare provider and they, the clincher is they have to draw the floor plan of it. So I teach them how to draw a floor plan, properly, and most of them, you know these very accomplished students who know how to do so many things, they've never drawn a floor plan and they say that it's made them just think differently about noticing heights of windows and proportions of rooms and I’ve heard from some of them many years later that they thought that was a really good assignment.

23:34 RCB: I find that interesting, just because as someone who started working in the hospital, my perspective, my interaction with the space changed so much as I went from interacting with hospitals as a patient to interacting with the hospital as a, you know, a staff member, and I imagine that's another new perspective to add on how you're interacting with the space.

23:54 AA: Yes, my dream is to find from the former Royal Victoria, the journal of a cleaner or a janitor to get his or her perspective on all the spaces and I think I might- I might find it someday. But I'm really interested in how different groups perceive hospital space differently. You know I also work on Houses and Health, so those are my two- because I started out studying houses, my PhD dissertation that you mentioned “Architecture in the Family Way” was on houses and doctors, it's never really left me that link between hospitals and houses and the tensions, and the problems and how long term care deals with death too is a really interesting concept whether it's hidden or whether it's up front and of course there has been this tendency to hide it. Which is, when you make a place, it looks like a house, there's not going to be an obvious place to remove dead bodies from the building, so.

25:00 RCB: Well, it is also interesting because long term care homes ultimately are there for that last step of life so are very much embroiled with death and how we deal with death and so, to ultimately resolve that with hiding it is a maybe, speaks to how we're approaching death as a society in general.

25:18 AA: Yeah, so palliative care is a huge step for that.

25:25 RCB: And I guess it also will, I imagine change a lot with the rise in medically assisted dying, which sort of is going to revolutionize our relationship with death.

25:36 AA: Yes! Well, I’ve been trying to convince Master’s students in architecture, design students to take it on because we don't have a building for that and they could invent a building type. I understand many people just do it at home or in the hospital. Is that correct?

25:50 RCB: Yeah, that's also my understanding. I only know I think there's one organization that offers a third space, and I've also heard of some services in funeral homes, which is, I think a very interesting juxtaposition.

26:05 AA: That must be terrible to go there, anyway.

26:09 RCB: Yeah, so to me it seems like there's a real opening there for, as you say, a new kind of space.

26:15 AA: Yeah, but funeral homes also are like fake houses, it's another soothing example of domestic references and daycares too, we don't have a proper building type for daycares. I mean, what are daycares? Are they kindergartens, are they houses um, and it suffers from a lot of house hype.

26:36 RCB: I just want to finish this off by maybe talking about your new project on Maude Abbott, you’re writing a book. So maybe, for the listeners out there, Maude Abbott was one of the earliest female doctors in Canada and she was a faculty member at McGill before McGill allowed women to practice medicine, to attend their program in medicine. She's a curator of the McGill Pathological Museum. She's the co-founder of the International Association of Medical Museums, the Founder of Medical Women in Canada. She's a very important character in Medical History, but seems like maybe a bit of a departure from your architectural work, so I was wondering how you got interested.

27:20 AA: Yes well, it may seem like a departure, but I took on the Maude Abbott book project as a way of answering questions that have been haunting me since my dissertation. So when I studied, it was, I studied British houses, health, hygiene, feminism. I never really used real women, I just used advice literature. Everything was kind of idealized and abstracted so with Maude Abbott, I felt I had this chance to study the same questions but with a real woman and because she's pretty famous, a lot of things she touched, her archives are well protected and organized, and I knew I had a lot to look at but what I wanted to do was offer a different kind of story of Maude Abbott. There’re quite a, there's a handful of books on her, and they all say the same thing, they all tell the story of her being rejected by McGill and apparently being forced into museum work etcetera so. What I wanted to do was offer a more positive story of her life and that is to use my architectural background to look at her life through 10 spaces. So she was obsessed with the decimal system. It was the way she organized the medical museum and it became a kind of template for medical museums around the world, because the decimal system, of course is, infinitely extendable. So I decided to go with 10. It’s a bit random, but makes sense for her, and to choose 10 spaces that she inhabited, and to study her agency in her own life so it's her story is always told as if she didn't have any agency or decision making power at all that she was like like a fan girl of William Osler and that he shaped her career. I don't believe any of that and so one of the spaces I study, for example, is Osler’s House in Oxford that she stayed in for three weeks. So I have this 300 page manuscript I've been working on it for 10 years. I just never think it's good enough or ready enough to submit but I'm hoping it'll be ready soon. And my funding, my SSHRC funding is going to run out in March so that might be a good deadline to just submit it, so it's called Maude Abbott: A Life in 10 spaces. It's not at all about the obstacle she faced. It's about what she did. And I think and as I put this in my funding application that reading this version of her life will be much more inspiring to young generations who are kind of tired of hearing about the hardship of the earlier generations, and they are much more interested in knowing what these women accomplished. So that's what it is! And I've also used archives far outside of Montreal. Most of the other books are just based on the archives that are here. And in true feminist research, I actually recognize my own subjectivity, in the spaces I study and so I'm quite affected by my, I was the only woman in the School of Architecture for 23 years so I had a, that experience resonated with Maude Abbott’s experience in Medicine and I've written a little bit about that in the conclusion, and I've discovered some things that just seemed like nobody else has ever seen. Published two papers from it already, maybe you've seen one of them was about her friendships with two famous doctors and another one was just about the need for a new book.

31:10 RCB: On that topic I guess it sounds like it’s really an interesting, an interesting project, and was there anything you found surprising in that research, did anything stand out to you as you were going through that really maybe was missed by previous works?

31:26 AA: Well yes, many things. There are many things mentioned in other books that seem to have no historical evidence. So, I think they were published in the first biography which came out just after she died and then everyone just repeated it without ever looking for the evidence. So it kind of hurts me every time I read those things because there's no footnote to them and I know they probably didn't really happen. So yeah, my book is kind of revisionist in that way.

32:06 RCB: And I guess this speaks more broadly to maybe a lack of research in these women in medicine and in architecture, and a lack of recognition of their effect on the course of medicine and architecture, which we didn't speak a lot about about the effective gender in the area today. But I wonder if you could maybe give us a little bit of an insight on what we're missing when we're excluding women from that narrative?

32:36 AA: Well, architecture is very far behind medicine in terms of the number of women. The numbers are kind of depressing, but we probably have somewhere in the twenties like 23 percent or 25 percent of registered architects are women. So it's pretty far behind. And there are even fewer women profs. So women, there aren't that many feminist researchers of architecture. So I've been trying to change all that with my work and my courses, I'm teaching a course on feminism and architecture now, which isn't just about women architects but it's about how you can approach any space and critique it from a feminist perspective. So hospitals are great examples of that. Yesterday, we did schools where the students went up to the black board and recalled with incredible detail their first schools that they attended, you know as a child you remember so much, and drew floor plans of the school. So that kind of work is restorative and feminist and makes students realize that their knowledge matters. Not just the knowledge of famous researchers are architects, and of course that’s a very feminist position, that idea of situated knowledge or standpoint theory. So then my book is you know, that's really what it's about too, it's sort of me and Maude, you know in the book. But, I don't know, I've just got to get working on it and finish it. Oh yeah, and the other thing about the obsession with 10 is that there are exactly 100 images which Maude Abbott would love so, each chapter has 10 images and there are 10 chapters. So it's a kind of system of understanding her life. It's using her system to understand her life, to explain it, but also what's feminist about it is that it's porous that, it's obvious I could have taken another space or studied it another way. So it's just showing that you can understand someone's life from multiple perspectives.

35:01 RCB: It's very far out I think in terms of the conversations that we have in science, and the conversations we have in science around feminism are very different from these conversations. So I really appreciate your point of view on that.

35:15 AA: Okay, great! Well, I hope people like you will read it.

35:20 RCB: Yeah, and I'm certainly looking forward to reading it. And just sort of closing off my broad question to yo u would be, having studied the history of the architecture of hospitals. Do you think there are any lessons that we could take from that history and bring forward into our future work?

35:35 AA: Yes, I think we need to acknowledge mistakes. And also to recognize that there are many stakeholders in the design of hospitals, not just doctors and architects, but many other people and we have to have ways of understanding their perspectives so all of that is still to be documented. I mean beyond, you know, focus groups and things like were just developed in the 1960s. So I think most of the really good new research on hospitals actually incorporates the history of emotions and the importance of the senses, all of these researchers with these interests are focusing on the hospital now which is so great!

36:32 RCB: I so appreciate our conversation today and in our MedTalk series, we always end with a question to our guests about any advice that they have for our trainees in health and medical sciences, and I think you come with a very different perspective than a lot of our guests. I'm curious to hear what your answer to that would be.

36:51 AA: Well mine would be to just keep your eyes open to think about why places look the way they do. To remember that everything in the hospital environment is designed. It's not random, and that someone has decided that it should be that way and to try to figure out how those decisions were made, and if you care about it, a lot to participate in the redesign of those places. But you know when you, as doctors when you travel, I'd love to say every city has hospitals you can visit and the big H tells you where they are. They're not even hard to find, I’m one of the few people who goes to visit hospitals when I travel. But I know that as part of your work you would be visiting other places and to just take the architecture in as part of the package that you know, I actually believe architecture shapes medicine. I don't believe medicine shapes architecture, that it's so clear. So you have to understand that dynamic.

37:56 RCB: Fantastic. I've found our conversation so insightful today. So thank you so much for taking the time to join me. And yeah, thank you so much. It's been a pleasure speaking with you.

38:08 AA: Yeah, thank you very much, I loved talking to you too.

38:12 RCB: Thank you for joining us on another episode of MJM MedTalks. In the show notes with this episode, you'll find a transcript, any of the papers we've referenced today as well as additional images of the buildings we spoke about and artifacts from Professor Adam's collection. This podcast was edited and produced by MJM’s Podcast Team. If you've enjoyed my conversation with professor Adams, reach out to us on Twitter or Instagram @McGillJMed and be sure to listen to our other episodes.



Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License .