Friday, February 13, 2009

Kitsch and Kundera and the Hospital Atrium

This link (via KevinMD) from the Freakonomics blog highlights the beautification phenomenon sweeping American hospitals. Here's what I'm talking about: You walk into a renovated hospital atrium and you have to pause because your breath get sucked right out of your essence; you gaze up at 50 foot ceilings and brass rail fittings and sparkling waxed floors and luminescent lights and 30 footer Christmas trees decorated with gold limned angels and red gleaming placards proclaiming area businesses who have donated a certain minimum and the hi-def muzak and nice looking people in Prada and Brooks Brothers bustling around and Starbucks just to your right and your little old granny is tucked away in a wood floored, heavily lacquered expansive room with a private bathroom and the butler, er orderly, arrives ringing a little silver bell to announce the hour of feeding, Wolfgang Puck platters and a half carafe of red wine (tannins exemplary examples of underutilized natural health products, according to the brochure that accompanies admission) and massage/spa options depending on your insurance and a botanical garden wedged between the parking garage and the boiler room with brick lined paths and rhododendrons and hyacinths and guide books for the horticulturally inclined. This is the new trend. This is the modern American hospital. Part utilitarian bastion of higher medical provision; part weekend getaway spa package. And the latter, alas, has become just as important as the former in terms of how we assess our "hospital experience". According to the article cited, "Hospitals as Hotels":
From the patient perspective, hospital quality therefore embodies amenities as well as clinical quality. We also find that a one-standard-deviation increase in amenities raises a hospital’s demand by 38.4 percent on average, whereas demand is substantially less responsive to clinical quality as measured by pneumonia mortality.

You see, this is how our hospitals respond to economic stress; by building bigger parking garages and painting the walls and replacing old carpeting with fake wood flooring and making the rooms WiFi accessible and constructing fabulous new "wound care centers" or "wellness gyms" and putting in a bunch of gigantic indoor vegetation in the well-lit main atrium and assigning each patient a personal masseuse. (Maybe not the last one). Meanwhile, the unglamorous aspects of a hospital are neglected. Laparoscopic equipment from the mid nineties aren't upgraded but million dollar DaVinci Robots are purchased. At one of the hospitals I cover, employees received a standardized mass email from the Director informing them that there would be no raises this year because of "economic turmoil". Moreover, families were informed that "sitters" (usually a nurse's aide who sits with a patient {typically an older, possibly demented patient who needs to be watched during the night lest he/she yank out all his/her IV's and tubings}) would now only be provided at an additional cost to the patient, i.e. either sit with grandpa overnight yourself or fork over some cash. Meanwhile, a massive construction project is ongoing (in response to a rival hospital system's plan to construct a new hospital on the east side, aiming to cut into that lucrative east suburban Cleveland insurance coin) with new OR's and more parking and an expanded ER on the docket.

There is a word for what is happening in suburban and tertiary care American hospitals and it is kitsch. Kitsch is the forgotten other disease afflicting the American soul right now (the other being unbridled irony) and its effects are just as insidious, just as damaging. Kitsch is the aesthetic ideal of the soggy, weighted-down heart. It is the apotheosis of dripping sentimentality. It is the enemy of subtle beauty and nuanced aesthetic worth. Kitsch is Thomas Kinkade paintings and Yanni soundscapes and Nicholas Sparks novels and "This is my country" pickup truck ad campaigns and patriotic American flag lapels and faux Irish pubs in strip malls and the miniaturized versions of Paris and New York and Egypt on the Las Vegas strip. Kitsch lulls us into the misapprehension that we're participating in something cultural and sophisticated. Our hearts are warmed by the fact that, yes, we too can appreciate "culture", just like everyone else and it's right there, mass produced, easily accessible and understandable, not elitist and obscure like so much of what is considered high brow and cosmopolitan. Why slog through Joyce's Ulysses when you can have intelligent discussions in your weekly book club on the relative merit and artistic value of The Devil Wears Prada? Why buy a bunch of unglamorous wheelchairs for patient transport that no one ever sees or appreciates when you can budget instead for brand new carpeting in the front atrium? Kitsch is reassuring because of its widespread appeal. Look, everyone else is doing it. I'm not alone, you think. But it is this very popularity and pervasiveness that makes it so dangerous (and unconscionably profitable). Kitsch may masquerade as real art and capture the mass public's imagination but deep down, it knows better. Deep down, kitsch is an unscrupulous scam, capitalizing on our collective longing for order and meaning and uncomplicated beauty. Which, I think, is sort of sad and melancholy.

Milan Kundera talks about the totalitarian aspects of kitsch in his great novel "The Unbearable Lightness of Being". He describes kitsch as the "total denial of shit". For example, the Soviet May Day parades were a rebuke to anyone who dared to claim that the communist system was going to hell. The massed crowds and the orderly marching and the smiling apparatchiks and the patriotic hymns were proof, don't you see, that all was well behind the Iron Curtain. In another passage, he describes a Czech emigree in America with her lover, and they watch children scrambling through a sunny field. The American says, "now that's what I call happiness", and he smiles the same glazed, self-satisfied smile of the Communist honchos of the May Day parades. What does he mean by that phrase and that smile? Kundera replies:
How did the senator know that children meant happiness? Could he see into their souls? What if, the moment they were out of sight, three of them jumped the fourth and began beating him up?
The senator had only one argument in his favor: his feeling. When the heart speaks, the mind finds it indecent to object. In the realm of kitsch, the dictatorship of the heart reigns supreme.
The feeling induced by kitsch must be a kind the multitude can share. Kitsch may not, therefore, depend on an unusual situation; it must derive from the basic images people have engraved in their memories: the ungrateful daughter, the neglected father, children running on grass, the motherland betrayed, first love.
Kitsch causes two tears to flow in quick succession. The first tear says: How nice to see children running on the grass!
The second tear says: How nice to be moved, together with all mankind, by children running on the grass!
It is the second tear that makes kitsch kitsch.
The brotherhood of man on earth will be possible only on a base of kitsch...

Can you see how this kind of attitude is dripping with a lazy smugness? It is a refusal to acknowledge anything that detracts from the Platonic Ideal of the Whole, a refusal to look under the covers at the seamy underside of our complex reality. Kitsch demands conformity to Universal Truth and Beauty, whatever that means. It simplifies and softens rough edges and buries anything unsavory beneath a veneer of polish and gleam. Theodore Adorno puts it this way: "Kitsch or sugary trash is the beautiful minus its ugly counterpart". And there's the rub; kitsch does prick at something hopeful inside us, fuzzily arousing vague feelings of love and nostalgia for something that we can't, or dont have the intellectual courage, to try to define for ourselves. It defines the essence of what it means to be human, but in simplistic, juvenile terms. And we allow it, for a variety of reasons. That's the tragedy.

Kitsch seeps into our souls because it's easy and eliminates the need for critical analysis. It decides for us what we require, what is important. And so now we have the American hospital; clean, sparkling, almost luxurious. You will eat well and get exercise and return to a higher state of wellness than that which necessitated your admittance. Commit to this paradigm. Support this investment of dollars and public resources. Ignore the actuality. Ignore the smell of shit and melena and vomit and the corpsish spectres lingering down in the ICU's and the blood and pus soaked bandages and the late night delirium old people moaning, street names and ex-girlfriends from the Prohibition-era, and the mediciney smell of gauze and gowns and sharing a room with a stranger in a moment of absolute vulnerability separated by a thin drape and not eating when you want and waiting and waiting for the nurse to bring your pain meds when you really need it. None of that gets addressed. But at least the atrium is awe inspiring and the meals are world class and there's a piano that plays on Thursday evenings and when you wonder about the weather outside you can simply check via your complementary WiFi account. Make a commercial about those things. Come to our hospital! You won't want to leave! The rest is edited out of existence. And sadly, that's apparently just the way we want it.....


rlbates said...

I wish you could hear me clapping. I agree whole heartedly.

Anonymous said...

Really, really good stuff. Thanks for the think on a Saturday morning. It's good to be reminded that life is complex. I wish thinking were sexier. More people might do it.

Anonymous said...

Nice job putting that into words. When I try I often just end up incoherent with anger and disbelief.

Anonymous said...

Another home run.

Anonymous said...

I want my Hospital to SMELL like a know, like a Prison.


Anonymous said...

There's nothing like hearing Marlene Dietrich, in an interview long ago, utter the word 'Kitsch' in regards to an old film of hers. It gave the word a veneer of classiness.

The hospital at the U. of Pennsylvania has long had a marble, 2 story high atrium. Breathtaking.

But just try to get a copy of your medical records from the hospital. A breathtakingly fruitless endeavor.

Anonymous said...

2008 was the year of breast cancer treatment for myself. I was treated at a huge cancer center which was connected to a fancy hospital with atriums all over the place. I had to be admitted to the fancy place because of complications from chemo. It was a total nightmare. We think the problem was that the fancy place was understaffed. For my surgery, I had to go to a smaller hospital a few miles away from the fancy one because of scheduling difficulties. The smaller hospital was a dump. Probably hasn't been renovated in 30 years. They had to kick me out because I didn't want to leave. It was like staying in a 5 star hotel. Hopefully, this is all over for me but if not, I've learned that fancy doesn't mean good.

Victor Lazaron said...

This is a wonderful post. I used to be able to write like this myself, before med school, research, and especially residency took most of that out of me - my wife refers to it as "back when you were interesting". I am delighted to see someone get through it all and stay interesting. What's your secret?

Unknown said...


I think you're dead on with a lot of your criticism of society, and more importantly you're clever throughout.

A couple of thoughts:
What about the dignification of the patient process? I'm all for it if a prison-cell hospital appearance is directly linked with better outcomes, but otherwise a positive environment really can do a lot to aid healing.

You're still totally right that Kitsch is valued higher than medical outcome statistics, which is insane. Like, batpooloco. But the investments you find offensive later in the blog, the additional OR, bigger facility, things that increase demand, don't seem to be driven by our kitschfascination.

I think they're driven by the fact that we're a profit-driven healthcare industry. So long as private, profit-motivated groups make the decisions about hospital investments and policies, things that will increase the bottom line will win out.

Anonymous said...

Have you read Benjamin's article on Dream Kitsch. A useful rejoinder perhaps.

Anonymous said...

This is a trend that goes across the country. Maybe it makes economic sense to the hospital---and so ultimately helps provide more money for real concerns, but it is smarmy, and worse, reveals real problems with our society. I feel that if people really cared, doctors, nurses, administrators, the public, about the fact that there are so many people without insurance we'd just work to cover them all. Beds would be bunked, halls filled with stretchers and people working free overtime, with extras going instead to the care of your neighbor with pneumonia and no insurance.
Instead people feel ok about staying in a hospital room like at the Ritz while their neighbor has nothing, or economic ruin if they get sick. This reveals a perversity in our country.