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JENA: My mom, is a physician. She’s retired and she used to work in rehab medicine. She worked at this university in Richmond, Virginia for many years. And, that university invited me to go give a talk, at this place called Sheltering Arms Institute, So I go to this facility. And it looks almost like a Four Seasons meets a rehab hospital. I mean, the place was brand new. The ceilings were probably 30 or 40 feet tall. And I remember thinking to myself, I would never wanna leave this place if I needed to go to a rehab hospital because it was absolutely stunning. The patient floors had huge windows, lots of sunlight and it struck me how , the environment in which people receive care might matter.

KANFER: Because usually Bapu hospitals aren’t places anyone really wants to be.

That’s my producer Julie Kanfer and she’s right: most of us do not want to be in the hospital, even if it’s as beautiful and new as the Sheltering Arms Institute. But a lot of the time, hospitalizations can’t be avoided. More than 33 million times each year in the U.S. to be exact, according to data from 2020. And in those cases, maybe the slightest difference — a sunnier room, better-fitting gown, or softer pillow — could impact how you feel.

I’m Bapu Jena, and this is Freakonomics, M.D. Today on the show: Hospital amenities might make patients feel happy — but do they also make them feel better?

JENA: Here’s the problem, suppose you want to figure out whether going to a hospital with better amenities impacts your care and your outcomes in a positive way. The problem is that if you look at patients who go to fancy hospitals those hospitals are different than other hospitals in a lot of ways, and the patients who go there are probably very different. So you can’t really infer anything about the quality of medical care or the outcomes of patients in those two different settings by comparing great amenity versus no amenity hospitals. But there’s a couple of studies I thought were really interesting.

So one is a study that was published, about five years ago in the journal Environmental Health Insights. and it was titled “The Effects of Natural Daylight on Length of Hospital Stay.” The authors looked at their hospital system in Korea over about 15 years, and they looked at patients who were hospitalized and happened to be allocated to a bed that was next to a window or next to the door to enter into the room. And what they wanted to figure out was something very simple, which is what was the length of stay for people who happened to be placed in a bed that was near the window? Under the idea that, look, maybe you get more exposure to sunlight if you’re next to the window, and that might make you feel better as a patient and may reduce your length of stay.

KANFER: When you’re near the window, I think you also feel a little bit of a sense of privacy, which could promote maybe your mental health

JENA: So first of all, there’s a clear link between our mood and how we perceive symptoms, when it relates to our health. That’s clearly a possible explanation. The other one is a little bit more subtle, and I would describe it as follows, when you go into a patient’s room before you know anything about them as a clinician, you can get a sense of, how sick they might be just by looking at ’em. We call that the door test. You walk in the door and you just eyeball the person and you can get a sense, all right, is this person looking sick or not? But what these folks did, I mean, they looked at a lot of patients, about 40,000 patients who were near a bed and about 46,000 patients who were near the door. And what they found was the length of stay was shorter for those patients whose bed was near the window compared with near the door. Now I don’t know if you believe that as causal, I’ve got some thoughts as to what I might be concerned about.

If the mechanism is sunlight, what you should expect to see is that when people are in the hospital when it happens to be a really sunny week, there should be a reduction in length of stay for those beds that are near the window. But if it happens to be a really rainy week, then you would not expect to see any improvement or reduction in length of stay. I mean, maybe people value just having an outdoor view, even if it’s raining, but if it’s all about sunlight exposure and, feeling better because of that, you could use that variation in weather, which is totally random with respect to the patient to figure out well, is this window effect because of better sunlight? Or is this window effect because of what you’re describing, which is more privacy, being at the back end, of the room?

KANFER: I have one other thought though. Let’s say you’re next to the door and then the nurse, the doctor has to walk by you to get to the other patient. Wouldn’t it also suggest that the provider is maybe seeing the person more who’s near the door, getting more eyes on them? just to, to sort of flip it around a little bit.

JENA: If you’re getting more eyes on the patient you might expect that they would do better because there are just more eyes on them. But it could be the opposite, right? Like the more you look under the cover, the more you find? And so you might see someone who otherwise would’ve been totally fine, but you respond to what you’re seeing and say, all right, I need to do this. I need to order this test. I need to ask another physician to see them. They would’ve been totally fine if you waited 10 minutes, but because you’re constantly observing them, you feel like you need to act. There are two other things actually that I just thought about. One is that, again, trying to understand why is it that patients who are near the door would have a longer length of stay in the hospital than people who are near the window. This might not be totally random. The operating hypothesis of the authors of the study is that people who are near the windows are basically the same as people who are near the door. But the people who are near the door might be put there because they’re sicker. Why? Because the nurses say, I wanna keep my eyes on this person. When I walk by that room, I wanna be able to quickly see how the person in bed one is doing. And I put that patient there specifically because I’m a little bit more concerned about them. So that could explain why the patients who are near the door, , do worse in some sense, why they stay in the hospital longer.

KANFER: That’s such a good point and not something that a regular person like me would think of.

JENA: Oh yeah. Regular person like you. Okay, Julie. I don’t know. Like my sense is yes, it could be causal. Maybe there is some benefit of being further away from the door because you get exposure to sunlight. I think you could test that directly by looking at whether or not that effect is true on both sunny days and non-sunny days. I just wanna point out, there was another study from 1996 in the Journal of Affective Disorders, which looked specifically at patients with depression. And so they looked at whether or not patients were in rooms that were, very bright and sunny versus ones that were not, again, under the assumption that the patients are pretty similar in these two different areas. And they found that the length of stay in people with depression in sunny rooms was about two and a half days less. So about 17 days versus 19.5 days. It’s a little bit of a different methodology here. We’re not worried about people being selectively placed in sunny rooms for a particular reason. So that arguably is a little bit more credible in getting at the causal effect.

KANFER: Well, and also it’s looking at, psychological illness. Maybe it could be more causal with someone who has a mental health problem, because we know about things like seasonal affective disorder and the light therapies that people are given in those cases.

After the break, how else could you try to measure the health effects of sunlight, or being near the window, or any other environmental factors in medicine? I’m Bapu Jena, and this is Freakonomics, M.D.

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Aside from my visit to the Sheltering Arms Institute in Richmond, there’s another reason Julie and I got interested in how the environment inside a hospital or a doctor’s office could influence patient outcomes. Earlier this year, the New York Times published a piece by Jancee Dunn called, “How Would You Redesign Your Doctor’s Office?” In it, Dunn writes about the changes some physicians are making to their offices with patients top of mind. Things like better lighting, more plants, and warmer exam rooms. It makes me wonder whether variables like these matter for patient outcomes, but also, if we might reframe the way we think about their potential value.

JENA: There is this movement in behavioral economics, to nudge people’s behaviors using really small, cheap interventions that have substantive impacts their health outcomes. Now, you could imagine here that something as simple as changing the quality of the hospital gowns that people wear, switching from those plastic crunchy pillows to more proper pillows, very simple things like that might certainly affect the experience of people in the hospital. But the question is, would it also have an impact on things like the length of stay? Which, by the way, is not just a cost issue. It’s not that it’s costlier to keep people in the hospital longer, but the longer people are in the hospital, the more likely they are to get things like hospital acquired infections. So if you could change this built environment in an easy way to get people out of the hospital faster, that would be a really, I think, important, innovation to think about.

KANFER: You mentioned the pillows, but it makes me think of, just anything that would make the patient feel good, that could foster healing, could improve commitment to a recovery plan or improve outcomes, reduce readmission rates.

JENA: I’ll tell you one thing that will never change, and that’s the food quality —.

KANFER: That’s not true. I don’t think that’s true. I worked at a hospital, not doing medical care, but for a long time and they improved the cafeteria and everybody was happy.

JENA: Can I share two more ideas with you though? (JK^Please.) So first is if you actually thought that there is a biological effect of being exposed to sun in the hospital versus being a couple of beds down and not being exposed to sun, you could look at this with existing data in a number of different ways. So for example, if you’re in a hospital system, there will certainly be an electronic health record system, and you could look at things like blood pressure measurements, heart rate. You could look at blood tests that are drawn. look at things like the white blood cell count. You could look at measures of blood sugar or glycemic control. You might look at measures of inflammation and you could see whether or not the patients who are exposed to more sunlight actually have better lab values or better blood pressure or heart rate, measurements.

The other thing that this made me think of is a study that we tried to do a few years ago. I’ve been interested in this idea of whether or not first impressions matter. Right? Like, that’s a common phrase that we talk about, but how do you study it? And I had this idea: Look at patients who go to a doctor for the first visit. And look at instances in which they see that doctor on a really rainy day versus a beautiful day. Under the hypothesis that if you see the doctor after you just ran through the parking lot soaked, what you bring to that visit might be very different than if you were able to stroll into that doctor’s visit, in sunny day, 70 degree weather and looking at whether or not those patients had a differential rate of coming back to that doctor based on whether or not it was sunny or rainy during that day. And we don’t find any evidence of that. So that’s not to say that first impressions don’t matter, but it got me thinking about how things like the environment might affect our perception as patients of the care that we receive.

KANFER: It also makes you think of how the doctors and nurses and everyone who works in the hospital might feel about working in a better environment. Would you think that working in a hospital that was really nicely maintained that clearly there was a dedication to keeping facilities at a certain level not just the equipment and the important technology that’s required for patient care, but also just painting the walls, cleaning the floors. Is there any research looking at how keeping an environment well-lit and well maintained could impact how the staff performs?

JENA: That’s a good question. I could certainly imagine that being in an environment that is just nicer could impact healthcare worker perceptions of work. Where I thought you were gonna go is take it back to this window thing because it just made me think of another explanation for this study finding. When I go into a patient’s room and their bed is near the window, if it’s really beautiful outside, I typically spend a little bit longer there talking with the patient, in part because I’m, you know, kind of soaking up the sun and enjoying the view. And so it could be that patients who are closer to the window, they actually get more engagement from the healthcare provider because the provider wants to spend more time in that area. So that’s another mechanism by which there could be this quote, unquote, “window effect”.

KANFER: What do we do with all of this? We think there might be something there with the sun. There’s been movements in medicine to improve the experience in these sort of built environment ways. So, what can we do?

JENA: I’d say there probably could be health effects from building up better amenities. As an economist, I’m thinking about what are the costs of doing all that stuff and what are the benefits. The costs are very easy to measure, like you can figure out how much it costs to get better pillows, better gowns, better food, et cetera. It’s harder to quantify what the benefits are cause the benefits could be something as simple but important as patient experience. But does patient experience ultimately matter enough to justify those costs? Maybe, maybe not from the hospital’s perspective. And the other thing, which is where I think we could see more evidence is, is there any way in which this could actually impact health outcomes? It’s plausible that for certain conditions you might see health benefits.

That’s it for today’s show but I’m curious: have you been in a situation where the place you were getting care was really nice, or nicer than you expected? How’d it make you feel? Let us know! Send an email to BAPU at Freakonomics dot com. That’s B-A-P-U at Freakonomics dot com. I want to thank my producer Julie Kanfer for joining me today, and thanks to you, of course, for listening. Coming up next week: We try really hard to improve health care quality in the U.S. And yet, the evidence suggests we’re still not doing such a great job. There are a lot of potential solutions out there but what if we just … paid people more? That’s next week on Freakonomics, M.D.

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Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and People I (Mostly) Admire. All our shows are produced by Stitcher and Renbud Radio. You can find us on Twitter at @drbapupod. This episode was produced by Julie Kanfer and mixed by Eleanor Osborne, with help from Jasmin Klinger. Lyric Bowditch is our production associate. Our executive team is Neal Carruth, Gabriel Roth, and Stephen Dubner. Original music composed by Luis Guerra. If you like this show or any other show in the Freakonomics Radio Network, please recommend it to your family and friends. That’s the best way to support the podcasts you love. As always, thanks for listening.

JENA: I remember one time walking out with the resident physicians and I said, you know, I think that it’s important to bring levity to the patient encounter. And one of the residents said, “Bapu, have you ever thought that they’re laughing because you’re the attending and they feel like they have to laugh at your joke?” I was like, “Oh, yeah. I did not think about that until now but thank you for putting that in my head.”

KANFER: Well, I don’t want you to worry cuz I don’t feel pressure to laugh at your jokes.

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