Evidence Based Design: How Good is the Evidence?

Evidence-based Design is one of the hottest topics in HealthCare Design these days. Everyone seems to be jumping on the bandwagon.

I'm a naturally skeptical person and, being from Missouri, my inclination is to say "show me." When I hear about  Evidence-based Design I ask:
"How good is the evidence?"
"What does evidence really mean?"

To help answer these questions, I asked a real researcher: Dr. Bernard Ewigman. He has conducted major research studies that have been published in the highly regarded New England Journal of Medicine.

"Here's the thing. There is evidence (like anything used in a courtroom is evidence) and there is evidence (as in "evidence based" medicine). An eyewitness to a crime provides "evidence".  The prosecution is therefore evidence based in this general sense.
However, in health care "evidence based" refers to measurable outcomes usually in randomized controlled trials for interventions, which I seriously doubt you will find for fine art.

I recommend that you use the more general meaning of evidence based rather than the evidence-based medicine meaning of evidence based.  Then you might have something to talk about, and you can disabuse others who are using "evidence based" as a marketing ploy (if there are others doing this).  Surveys or interviews of peoples experience in a hospital with fine art can then be described as evidence."

As we saw in the recent post on this blog Nature versus Virtual, there have a few randomized controlled trials done in HealthCare Design. But studies as rigorous as this are the exception. Because randomized controlled trials are so expensive, we can't expect the data to be excellent.

When I ask: "How good is the evidence for evidence based design" I will have to accept the answer: "Not perfect, but as good as we can get under the circumstances."

I asked Dr. Upali Nanda to comment on Dr. Ewigman's thoughts about evidence. Dr. Nanda is deeply involved in the field of research to find evidence on the impact of Art in healthcare. She was kind enough to email me this:

"Research on fine art is not at the point where it can afford an either/ or decision. It needs to balance both these facets of research. On one hand evidence based on medical outcomes makes the case for the role of Art in Healing. Healing is measurable by the physiological benefits to viewing art. For example reduction in cortisol levels, heart rate and blood pressure, upon viewing art, makes the case for how viewing art can reduce stress. Such studies, few and far between as they are, form the foundation for how we can claim that Art "can" Heal.

Questions about what kind, content or style of art are appropriate, are more involved. Having established an overall benefit of art, and certain genres of art, now other methods need to be employed to explore the nuances. It is not possible to do an outcomes study with 300 or even 30 images. The "choice" of appropriate stimuli (art) for an outcomes study can be based on surveys and other social science tools.

Also, there are other aspects of art-research such as effect on perception of pain, patient satisfaction, patient/ staff preferences,etc., which are in the realm of social science and warrant different tools. The research question here determines the appropriate evidence.

It is only when all levels of evidence work in tandem, and everyone commits to collecting evidence, at different levels of rigor as it may be, that a process or approach is termed evidence-based. Right at the onset of a study that is being undertaken, or reviewed, it is critical to understand the nature of the evidence, and the level of rigor, in order to avoid making over-reaching statements.

I agree that the analogy with Evidence-based Medicine can only be taken to a point- but it is an analogy that serves us in good stead today as we find our feet in a very young field. In time research on design and art, within the healthcare context, will find its own identity and vocabulary. Till such time it needs role-models, and research-models, alike."

Additional Note: Be sure to click the "comments" button below. The debate continues and gets more interesting. Dr. Ewigman concludes: 

"I find Dr. Nanda's reply quite thoughtful and it helps me understand the shift in paradigm in the fine arts field that is analogous to the shift in medicine; e.g. moving from a strictly authoritative and theory based approach to a more empirical basis for expertise."

Bernard Ewigman MD, MPH, is a Professor of Medicine and Chair of Family Medicine at the University of Chicago. He has also been my best friend since we met in Medical School 33 years ago.

Upali Nanda PhD is Vice President and Director of Research at American Art Resources. American Art Resources is the largest art consulting firm in the United States working exclusively with the healthcare industry. It is one of only two Art Consulting firm conducting original research on Evidence-based Design. The other firm is Aesthetics based in San Diego.

 

Comments

[Bernard Ewigman]

Thoughtful response from Dr. Nanda. What she says makes a lot of sense for the subject of research in art. However, like most who have borrowed the term "evidence based" from medicine, the usage of "evidence based" in this context is incoorrect. What Dr. Nanda describes for art is the nature of research in every field. Ones seeks evidence of varying levels of rigor and validity and integrates it as best as possible. There is nothing unique from an epistemiological point of view about the kind of research being described.

In contrast, evidence based medicine is a different way of thinking about evidence and research. Not only are the methods of assessing the validity of individual research studies explicit and replicable, in evidence based medicine the methods of integrating evidence and research are also explicit and replicable. Unless Dr.Nandi simply has not described this distinction for evidence based fine art and I have missed it, then the usage of evidence based is incorrectly borrowed from medicine. It simply does not mean the same thing, and, to those of us who teach, practice and do research in evidence based medicine, it is a misuse of the term.

David Sackett, one of the pioneers in evidence based medicine and one of the authors of key textbooks in EBM, has denounced the term "evidence based" in a prominent editorial and vowed never again to have anything to do with EBM because of this misappropriation and abuse (from his perspective). EB This and That has proliferated on the coattails of EBM to the pont that the understanding of the uniqjue power and value of EBM has been completely diluted in his view.

I don't think it is possible to either educate or control other fields that adopt this terminology. There is no patent, copyright or trademark on the label evidence based. Gordan Guyatt at McMaster coined it 20 years ago when the faculty objected to his proposal of "scientific" medicine as a name for the new approach. They felt that by implication other types of research (such as the kind Dr.Nandi describes), would be considered "non-scientific". They were more accepting of the implication that other research was not 'evidence based' according to this new and unprecedented meaning.

I can understand why other fields are picking it up, even it is has nothing to do with the principals and methodology of EBM. "Evidence based fine art" has a nice ring to it. It sounds newer, sexier and more meaningful than "fine art resaerch". But Dr. Nanda's description of it bears no particular commonality to EBM. Most researchers in medicine, most physicians and most health care administrators don't understand this distinction either. It is probably not a big deal to anyone except people like Drs. Sackett and Guyatt. The biggest risk in my mind is that for those who have some grasp of what EBM means, they may mistakenly attribute that meaning to other fields that apply the EB label. For example, I might assume that for evidence based fine art the methods of systematic searching of the research literature, explicit measures of quality would be applied for inclusion and exclusion of reseasrch studies, step by step critical appraisal of each study completed, rules and statistics for using qualitiative versus quantitative data for integration, designation of levels of evidence, and determination of strength of recommendation would all adopted and applied. Of course, I would not actually assume that because of all of the fields that I have seen adopt "evidence based" none have actually done this. They have simply done research as usual and adopted the name, not the methodology.

[hdomke]

Cassie,
Pretty funny! Hah!
Art for the Prevention of Illness.
I love it!
Makes me laugh.

[Upali Nanda]

I agree with Dr. Ewigman about most of his concerns. It is true that evidence-based is an over-used, and often abused, term. It is also true that evidence (from medical outcomes) is different from evidence from self-reports, surveys and interviews. The latter constitutes evidence in a general, broader sense, and is less rigorous (but sometimes more insightful) than the former. At the end of the day, why this compulsion to don the robes of "evidence-based" rather than simply claim to do research, which is after all equally respectable, and has a long established history?

Perhaps the answer is in the history of the professions themselves. One of the similarities between medicine and design, two seemingly distinct and different fields, is the traditional deference to the expert. Traditionally, the medical expert/ doctor's word was gospel, and his/her judgment based on the unique combination of information, knowledge and experience was rarely questioned. When Evidence-based Medicine came along it demoted ex cathedra statements of the "medical expert" to the least valid form of evidence. All "experts" are now expected to reference their pronouncements to scientific studies. (From Wikipedia.org)

The field of design has faced a similar situation (and still is). The designer is the expert, and makes decisions based on training and intuition. similar to the traditional medical practitioner, the decisions of the designer take place in a highly efficient black-box, and the final pronouncement is what clients receive. In healthcare today, the danger of doing this is being established. Outcome studies now show that the physical and visual environments have a measurable impact on health outcomes and good design for healthcare is one that is linked to good health, not just good aesthetics. Given this perspective, it is no longer sufficient to refer to the unsubstantiated claims of the "expert", but rather to place the onus on the expert to justify their decisions based on sound studies.

Thus, in keeping with the philosophy of EBM, the borrowing of the term "evidence-based" is to demote the statements of the "design expert", who has traditionally been answerable only to the clients demands and his/her own creativity, to the least valid form of evidence, and design experts too are now expected to reference their pronouncements to scientific studies.

But what constitutes scientific evidence in the Design/Art fields? The issue of methodology is admittedly trickier, and neither the methods of assessing validity, nor the methods of integrating evidence into design decisions are firmly in place in order to be explicit and replicable.

I am sympathetic to the concern that the term "Evidence-based" is bandwagon that everyone wants to get on. It is perhaps most frustrating to sense this about the field as a researcher, because it reduces the credibility of any work being done. I can empathize with David Sacketts temptation to renounce the term- It is becoming a label that is placed indiscriminately, and exploited unashamedly.

But the solution is not to abandon the term, rather it is to create yardsticks for each of the fields that adheres to the Evidence-Based philosophy, and seeks to get answerability, transparency and tangibility, to decisions that can effect Health and Well-being.

I must defer to Dr. Ewigman's experience in Evidence-based Medicine, and agree that careful usage of the term "Evidence-Based" is essential. The work of experts such as Dr. Roger Ulrich, Dr. Richard Coss, Dr. Yvonna Clearwater, and others who have contributed to the small but significant evidence-base on appropriate image content based on physiological outcomes and forms the foundation of the Evidence based Art initiative. Dr. Ulrich's article on Evidence-based Environmental Design, and the section on positive distractions, is a good insight into the rigor of this foundation: http://muhc-healing.mcgill.ca/english/Speakers/ulrich_p.html

If we return to Evidence-based Medicine for a moment, and refer to the definition by the Centre for Evidence-Based Medicine, "Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."

This definition is generic, and is applicable to all the fields that make a commitment to improving patient (and staff) experience in a healthcare environment. To be conscientous, explicit, and judicious, is an issue of professional culture more than simply research. I know that the opening of a research department in an healthcare art firm is in itself a step that Kathy Hathorn and jack Reichenthal have made towards changing this culture.

At the end of the day, however, Applicability, does not ensure appropriate application and I am glad that there is a healthy environment of debate on whether Evidence-based Design and Evidence-based Art is indeed "Evidence-based" or more Evidence-blaséd.

[Bernard Ewigman]

I find Dr. Nanda's reply quite thoughtful and it helps me understand the shift in paradigm in the fine arts field that is analogous to the shift in medicine; e.g. moving from a strictly authoritative and theory based approach to a more empirical basis for expertise.

The point about the definition of EBM is well taken. It is sufficiently general to encompass a broad range of methodologies and standards of evidence, as Dr. Nanda points out. Finally, it is worth remembering that "imitation is the highest form of flattery", (to quote someone unknown to me), which should be a source of solace for the David Sacketts' of the world.

[John P. Eberhard]

I think Upali did a great job on your blog page saying what can be said about "evidenced based" concepts.

At another place on your blog you say the following:

How odd that this art (most painting by recent MFA graduates) is so inappropriate for use in Hospitals and Medical Clinics. Evidence-based Design (if we can believe what has been learned so far) argues against this High Art because High Art is difficult and ambiguous.

There is more than being "difficult and ambiguous" -- we would still have to ask why this was so, if we are going to be speaking from the viewpoint of neuroscience. At the risk of oversimplifying a difficult subject let me suggest the following.

Perception (in this case the visual processes of being aware of a painting, paying attention to the painting, and recognizing something in the painting) of images on the wall of a hospital when experienced by the "average" person -- i.e., one that was not educated in high art -- will not normally be capable of being "understood". This leads to it being difficult and ambiguous. It is not understood because when our brains undertake the perceptual process of recognition they search our memories for previous examples to which we can compare what we are seeing at the moment. If what we are seeing is "novel" -- our memory has no stored images that can be comfortably associated with the image we are observing -- we will likely reject what we are seeing as inappropriate to be considered "art" or simply negative (we have no past memories that are supportive of the image we are perceiving).

This contrasts sharply with our brain processes is perceiving a photograph of a bird. We will immediately have a classification "bird" stored in our memory to which we can reference the image at which we are looking. We may not be able to say what kind of bird it is (unless we are trained in bird watching) but we probably can relate it to a bird group we have experienced before. It the bird is beautifully photographed (as yours are) the brain has a further positive response --- not only do we recognize the object portrayed in the photograph, but we are likely to have an innate response to good proportion and color of any object. Very young children, who are just beginning to draw, normally place their drawing on the paper they are using in a way that is well related to the edges of the paper. This seemed to provide some evidence for an innate sense of proportion.

[Charisse Oland]

Dr Nanda refers to the healing value of art with evidence based on medical outcomes, such as lowering blood pressure, etc. Skeptics will likely point to fact that very ill people in hospitals will need much more than art to heal. Art alone will likely not cure illness. Others who understand a multfacited approach to healing including medical treatments and physcho-social supports which impact physiology, will value the contribution of art as an important aspect of recovery. Hats off to those who see the bigger picture and are diligently doing research, like all respected medical professionals, to demonstrate the benefit of healing arts.

[Acceltcop]

When you go out to buy, don't show your silver.

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