Slow Medicine

by Danielle Ofri
San Francisco Chronicle

(Review of “God’s Hotel” by Victoria Sweet)

I can’t tell you exactly when it happened, but sometime in the past two decades, the practice of medicine was insidiously morphed into the delivery of health care. If you aren’t sure of the difference between the two, then “God’s Hotel” is the book for you. It’s an engaging book that chronicles this fin-de-siecle phenomenon from the perspective of San Francisco’s Laguna Honda Hospital, the last almshouse in the United States.

Dr. Victoria Sweet, a general internist, came to Laguna Honda for a two-month stint more than 20 years ago and ended up staying. Laguna Honda was home to the patients who had nowhere else to go, who were too sick, too poor, too disenfranchised to make it on their own. The vast open wards housed more than a thousand patients, some for years. Laguna Honda was off the grid, and this, Sweet discovered, was to the benefit of the patients.

Unencumbered by HMOs and insurance companies, the doctors and nurses practiced a very old-fashioned type of medicine, “slow medicine,” as Sweet terms it. There was ample time for doctors and nurses to get to know their patients, and ample time for patients to convalesce. Many a written-off patient recovered within the comforting, unhurried arms of Laguna Honda.

Sweet realizes that the inefficiencies of this old-fashioned hospital – from the doctors who had time to fully research their patients’ complicated histories, to the nurse who knitted a handmade blanket for every charge on her ward, to the chicken that wandered regularly through the AIDS ward, bringing a spark of life to even the most demented patients – were actually its secret weapon. The inefficiencies were actually quite efficient, if your metric was healing patients.

Then arrived the consulting firm of “Dee and Tee, Health-Care Efficiency Experts.” Horrified by the rambling open wards and the old-school style of medicine, never mind the chicken, Dee and Tee quickly cut out excessive head nurses, consolidated departments, speeded up discharges and created committees, PowerPoint presentations and forms with 1,100 boxes. The consulting firm never consulted with any staff members who actually took care of patients, but they did stand to earn 10 percent of any savings engendered.

Thus Laguna Honda was rapidly schooled in the inefficiencies of efficiency, as patients without nurses grew sicker, and enthusiastically discharged patients spiraled downward, had multiple ER visits and were eventually readmitted to the hospital. Dee and Tee, of course, did not have to pony up for any additional costs the consultancy caused.

Over the course of Sweet’s 20 years as a staff physician, Laguna Honda made this painful transition from the practice of medicine to the delivery of health care, and it was the patients who suffered most, followed by their caregivers.

During this period, Sweet found solace in her doctoral studies of Hildegard of Bingen, the medieval healer, nun, mystic and composer. Hildegard’s pragmatic and thoughtful approach to medicine appealed to Sweet and even informed her own practice of medicine. Stymied by an oddly agitated patient who’d already been given a full diagnostic workup, Sweet had a What-Would-Hildegard-Do moment, and decided to simply sit with the patient.

She sat with the patient for a good long time, watching her, thinking about her, being in the moment with her. There was something frankly medieval about the patient’s twisting and writhing, as though she were trying to expel something, as though she were … poisoned.

Reviewing the chart, Sweet realized the woman was indeed being poisoned – by her own medications. A toxic brew of antidepressants, antipsychotics, pain meds and sedatives had led to serotonin syndrome. Sweet decreased the patient’s medications, and within hours the patient improved. She eventually stopped nearly all the medications, and the patient became well enough to go home.

Untangling the mass of medications that most patients arrived with became Sweet’s hallmark. She found that nearly all her patients could be relieved of a portion of their accrued medications. But this could only work in the setting of “slow medicine,” of having time to watch patients carefully over an extended period, of digging deep into the convoluted lives of these patients, of having time to “just sit” with each patient.

This, of course, is highly inefficient, if you are Dee and Tee. But it’s remarkably efficient if you are a patient and are interested in being cured, cared for and comforted.

You might not expect a book about San Francisco’s most downtrodden patients to be a page-turner, but it is. With its colorful cast of characters battling the tide of history, “God’s Hotel” is a remarkable journey into the essence of medicine.

In 1925, Dr. Francis Peabody told a graduating class of medical students that, “the secret of the care of the patient is in caring for the patient.” Simple, eh? If Peabody were practicing medicine today, he’d surely be consolidated with a midlevel provider to deliver health care with maximal quality indicators and operational excellence. Sigh …