It almost always annoys me when someone who isn't a professional writer produces a great book, but Victoria Sweet has written the best non-fiction book I've read this year and all I wanted to do when I finished reading it was to meet her and congratulate her and ask her a lot of questions.
So I did.
Something happened at the start of that conversation that made me realize why her book dazzled me ---- the qualities that make her a great doctor are the same qualities that make her book so powerful, original and relevant.
She heard me. She paid attention. She made me her patient.
Before I asked my first question, I mentioned a health issue. When she returned to San Francisco, she wrote me: "Now that you've let me know you haven't been feeling well, you need to make sure to let me know that/when you are feeling better and the meds are kicking in. Otherwise, I worry."
You want a doctor who has infinite time for you? Who cares -- as a person -- how you fare? Who uses not just the tools of current medicine but learns Latin so she can scour 11th century texts to learn the wisdom of pre-modern medicine?
For 20 years, to get that kind of doctor, you went to Laguna Honda Hospital in San Francisco.
To an almshouse -- a facility that provides medical and spiritual care to the poorest of the poor.
"God's Hotel" -- the term comes from the Hôtel-Dieu, the French charity hospitals of the Middle Ages -- is four books in one. Because it reads as much like a memoir as a chronicle of daily life in an unusual hospital, it's the story of Victoria Sweet, who came to Laguna Honda on a part-time basis for two months, stayed two decades and, along the way, staged a successful "twenty year escape from health care." It's the story of her patients, many of them "Bad Boys and Bad Girls," and how treating them with dignity either sweetened their days or, on occasion, turned their lives around. It's an intellectual adventure story; a doctor follows an insight and reconnects with a way of practicing medicine that's almost totally forgotten. And it's the story of clueless government bureaucrats and "efficiency experts" whose apparent goals are to transform an adequate facility into a dysfunctional one.
It is, I suspect, this last thread that will resonate with most readers. We are not, most of us, poor. In the main, we are healthy. It's not likely we'll embark on a treasure hunt for obscure knowledge. But heartless bureaucrats -- yeah, we've met a few.
Laguna Honda did not, as legally required, deliver mail on Saturdays. The daily menus were not translated into Chinese. There was peeling paint. Dust. And -- horrors -- drug and alcohol abuse among the patients.
How to fix all that? Thin out the medical staff, add administrators. Bring in consultants who earn 10 percent of any savings they produce. Decide to tear down the old hospital and build a new one. Make sure the architects never talk to patients or doctors, so when it's finished there is no place to put the wheelchairs.
Infuriating stuff. And yet that's not what you feel at the end. What you leave with is, oddly, a sense of celebration. For a very long time, a gang of renegades got away with practicing medicine the way it should be: sitting with patients, watching, listening, often doing nothing more than being present. And then Victoria Sweet, a candidate for sainthood, wrote a book that is a beacon in the darkness.
JK: Give me three adjectives you'd use to describe your patients -- the poor.
VS: I don't think of them as poor. I don't know why I don't. They just didn't seem "poor," although they mostly didn't have money. But they were the bottom one tenth of one percent of our society; they were the ones who fell through the holes in the safety net, and they were always two standard deviations from the mean. Any mean.
JK: You write: "The diagnosis is written on the body." You write: "The secret in the care of the patient is the care of the patient." What other home truths have you picked up that you weren't taught in med school?
VS: One is from a book that many doctors have read, The House of God -- "In an emergency, the first pulse to take is your own." And then "the efficiency of inefficiency." Which means: do the thing in front of you first. The secret in caring for the patient sometimes is doing the little things. In Latin, there is no distinction between caring and curing -- "curare" means both. In that way, doctors can learn a lot from nurses; I know I did.
JK: You write enthusiastically about the "tincture of time"-- not an idea most of us are familiar with.
VS: This was the secret ingredient of pre-modern medicine. The old doctors had observed that almost everything gets better over time if you are able to remove or fix the initial problem -- the infection, the appendix, broken bone. The body wants to heal -- let it, help it. It's what I've come to call "Slow Medicine," as opposed to the Fast Medicine that works so well to remove the appendix, open the blocked coronary artery or shrink the cancer, but which doesn't work so well after the appendectomy, the operation, or the chemotherapy. That's when patients need time, rest, and Dr. Diet, Dr. Quiet and Dr. Merryman.
JK: Many of us know Hildegard von Bingen as a composer and mystic. For you, her importance is as a healer with insight into a concept called "viriditas." Explain, please.
VS: "Viriditas" means green. Hildegard used it to signify the greening power of plants. Her idea was that just as plants have a natural power of healing and growing, so too do patients; that the body is more like a plant, and the doctor, therefore, is more like a gardener, whose job is to remove what is in the way of the patient's natural ability to heal; to nourish and fortify it.
Hildegard didn't depend on numbers as we do. In that sense she was subjective, which is not to say that she didn't have measures. She took pulse and evaluated blood and urine; but it was more subjective and perhaps less repeatable than our own. Although I sometimes think that our measurements too are more subjective than we realize.
JK: In an election year, health care is a significant issue. I suspect you could -- with pleasure -- design an ideal health care system for America.
VS: Yes. And it's practical: Let people buy it.
JK: You mean single payer?
VS: No! Calling it single payer was a big mistake. If you sell it as single payer, most people won't want it. So let's just say that we'll let people buy into Medicare. Because, amazingly, it seems that the government has been able to create a remarkably good system, all things considered.
Most patients are satisfied with it, according to studies. Most doctors are satisfied with it, too. By that I mean, many doctors prefer to accept Medicare patients over patients who have insurance; apparently Medicare has less bureaucracy (!) and is more straightforward about what and how much it will pay. Of course, at this point, Medicare is starting to pay so little that many doctors can't afford to take it either.
The way it could work would to just let people buy into Medicare. I'm not an economist, but if you take Medicare's budget and divide it by the number of patients it serves, I think it comes out to cost about $700 per month per person. So if someone wants to pay $700 per month for a Medicare card, why not let them? It would be a wash for the government. (If you don't earn enough? The government kicks in $350.) That seems like a lot of money, but even Kaiser, our HMO in California, charges more than $600 for individual coverage.
A second piece of the plan would be to reinstate what we had in the old days, where every county had a free hospital and a free almshouse. They weren't fancy and they weren't equal but they were adequate, and they provided a place where anyone could go, no questions asked, to get care. Even if they were rich! If we had that, at least people without insurance wouldn't have to worry that they would go bankrupt if they got sick.
JK: At Laguna Honda, were you often annoyed by patients who wasted your time?
VS: It wasn't the patients. It was the administrators. But I don't think it's correct to say that the administrators were annoying -- it really was the bureaucracy that they were required to institute that was annoying. As people, the administrators at the hospital were by and large thoughtful and caring people. By and large, of course. I don't want to set up a personal ad hominem dichotomy.
JK: Would it have been better if the Department of Justice had not interfered with a patient-centered institution that didn't satisfy every modern code?
VS: In the '70s, young, idealistic lawyers at the DOJ had a mission: close snakepits. By the '80s, they had closed most mental hospitals. The plan was to move patients to small halfway houses. But then there were budget cuts, and the halfway houses never happened -- patients were put out on the street. Now the government has turned its attention to the last of the almshouses and state hospitals and are methodically trying to shut them down, too. I'm into adequate, not perfect.
JK: You write that, in 3 years, the government forced Laguna Honda to discharge 139 patients -- at a cost of $46,000 per discharge.
VS: I had to pull that data myself. And when I asked, "Why are you spending so much time trying to discharge a patient who's been comatose for 10 years?" I got a blank look.
JK: Where were you in the administrative battle for the survival of Laguna Honda as a traditional almshouse?
VS: A group of passionate people fought the changes. I'm not an adversarial person by temperament, so I didn't. As a doctor in charge of patients, you have to choose between seeing a patient or going to a meeting. In the long term, it's probably better to go to the meeting. But doctors are really co-patients -- we don't know what else to be.
JK: In the pre-modern period, you write, there was a concept called the Turn of the Wheel of Fortune. "Each of us is attached to that wheel, which is Time, and sooner or later we will go down, and sooner or later we will come up." Right now, where are you on the Wheel?
VS: We have no idea where we are on the Wheel of Fortune -- that's the point. We are at the top of the world: rich, handsome, healthy. And one day we wake up and there are lymph nodes growing out of our neck and we have cancer. We turn a corner and are smashed to bits. And vice versa: we are a cook's helper at Laguna Honda, and we win the lottery. We go backpacking, and we eat a can of tuna, and we are dead. So I have no idea where I'm on the Wheel of Fortune. All I do know is that at the moment, this is a wonderful and satisfying time in my life. We'll see how long it lasts.
Cross-posted from HeadButler.com
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