Wednesday, January 1, 2014

God’s Hotel

God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine
Victoria Sweet (2012, Riverhead Books)

    When Victoria Sweet was hired at San Francisco’s Laguna Honda Hospital, she planned to stay two months; she wound up working there for twenty years. God’s Hotel is, in part, the story of how she changed, as her understanding of the practice of medicine deepened and ripened. She also made time to study the history of medicine, as it was practiced by medieval monastics who ran hospices and infirmaries; she wrote a PhD thesis on Hildegard of Bingen, and walked an ancient pilgrim road.

    Laguna Honda was the right home for Sweet because it was possible there for her to be a scholar at the same time she was a doctor, with periods of half-time work and leaves of absence. In this, she replicated some of the pre-modern medicine she was studying, from the time when “medicine had not been a full-time profession but a craft, transmitted through families and learned as an apprentice. Most practitioners, therefore, were not only doctors, but doctors and something else.” That something else might be a scholar, like Sweet, or perhaps an herbalist, a farmer, or a barber. “For the patient, it meant that doctors had more than one point of reference; for the doctor, he or she had time to think about other things in other ways.”

    Sweet’s study of pre-modern medicine was particularly fitting because Laguna Hospital was one of the last places in the US delivering medical care on the ancient model of the monastic almshouse, from which European hospitals developed in the Middle Ages. Combining infirmary, hospice, and shelter, the almshouse served as God’s Hotel, the place of last resort for people who were sick or dying, and poor. Nowadays that includes homeless people, drug addicts, and the former inhabitants of mental institutions. San Francisco had, and has, plenty of such people: even though Laguna Honda operated at a capacity of 1178 patients, there was always a waiting list.

    That was partly, of course, because there wasn’t a particularly speedy turnover of patients. People with dementia, AIDS, cancer, or liver disease could stay until they either got better or died, which might take a long time. Sweet appreciated the chance to practice Slow Medicine, learning to get out of the way of the patients’ own healing processes. Sometimes she is diagnosing, and figuring out an intervention she can make with modern tools; other times, she is reducing medications, or doing her own lab work, or simply sitting with a patient, listening to the silence for a course of action, or non-action, as Hildegard might have done.

    These are mostly hopeful stories, but they are happening in the context of the slow-motion death of the almshouse, which has no place in the imagination of the modern health-care system. With its extravagant use of space, its greenhouse and farmyard from the days when work was part of the patients’ therapy, and its open wards, Laguna Honda was a relic of a by-gone era. Standards have changed, for good and ill.

    Toward the end of the book, these changing standards are physically realized in the erection of a shiny new building right next door, but the old, slow ways have been under siege for a while, at the hands of consultants, city politicians, and medical administrators. The dissolution of Laguna Honda sheds light on how it had worked for so long. Though Sweet treads fairly lightly on the personalities of those who dismantled it, ‘ham-handed’ is not too strong a word.

    The consultants, for example, had a hard time with the sight of head nurses keeping watch over their wards, not apparently doing anything. It looked inefficient, but they were missing the long view. “After the head nurses were cut in half, there were more illnesses and sick days among the staff; there were more injuries, more disabilities, and earlier retirements. Among the patients, there were more falls, more bedsores, more fights, and more tears. And this, in the broader scheme of things–even of economics–is not efficient.”

    Though bean-counting high-tech medicine may seem to have won, God’s Hotel is evidence that these things are cyclical. In addition to a masterful work of medical history and civic anthropology, Sweet has written a manifesto for a return to human-centered medicine, based on a relationship of care as well as knowledge.

    May the day come soon!

1 January 2014