Victoria Sweet, MD, PhD, spent 20 years tending to patients at San Francisco’s old Laguna Honda Hospital, the last remaining almshouse in America. With gardens, open walkways and windows, and occasional chickens wandering the wards, the mission-style hospital was a throwback to a time when doctors had plentiful time to work with long-term patients.
Last year, Dr. Sweet published God’s Hotel: A Doctor, A Hospital, and a Pilgrimage to the Heart of Medicine, a compelling account of her growth as a healer. Her search for the "heart" of medicine leads her to Hildegard of Bingen, the 12th century German mystic and theologian who was also an influential medical practitioner. By studying Hildegard's writing, traveling to the site of her monastery, and brewing her medicinal beers, Dr. Sweet uncovers the surprisingly holistic roots of Western medicine, gaining a metaphor that guides her work at Laguna Honda.
God's Hotel abounds with tender sketches of patients, the charming yet unlucky (or self-destructive) characters who landed Laguna Honda after they were plucked from the streets or discharged from more “efficient” health care centers. In telling their stories, Dr. Sweet argues for a “slow medicine” that depends less on technology and more on the careful attention of doctors and nurses.
Her plea becomes all the more poignant as she watches efficiency consultants transform Laguna Honda into a modern health care facility, losing much of the time-tested wisdom of the old hospital.
You write about viewing the body not only as a machine to be repaired — the modernist view — but also as a garden to be tended — a much older metaphor. How did you develop that understanding?
I started reading Hildegard of Bingen, who wrote often about "viriditas," from the Latin "viridas," which means green. The religious-minded Hildegard readers saw that concept as something spiritual, akin to godliness. But when I read her medical book, it became clear she thought of it as something physical, something real.
For her, viriditas referred to the green sap of plants — that was her metaphor for the life force of humans. It's very similar to the naturopathic vis medicatrix naturae, the healing power of nature. I tracked the usage of “viriditas” outside of Hildegard all the way back to Theophrastus, a Greek writer in the fourth century B.C., who wrote about health as a balance between the four fundamental humors. Those are related to the other "fours" of pre-modern medicine — earth, water, air and fire. In that way it's very similar to ayurvedic or Chinese medicine. And the word "humor" comes from the Greek word for sap. So the fundamental understanding of the body in Western culture was not as a cellular machine but as a plant.
I applied this approach to some of my patients at Laguna Honda. They were perfect for it because they were there for a long time, and most were not acutely sick but were there with chronic illness. So I had time to think of them both as machines and as plants. Over time I began to integrate those two ways of looking at the body into my practice.
For many years, the garden metaphor thrived at Laguna Honda, with its gardens, open units, chickens visiting the bedridden, and generous timeframes for patients to recover. How did that model come to be?
Laguna Honda was founded in the 1860s when San Francisco wrote its city charter. It represents the way we took care of the sick poor before there was health insurance. Because we did used to take care of the sick poor — they weren't out in the streets with their appendixes needing operations. Every county in the country used to have a free almshouse. It was often on the outskirts of a city, with a farm. The county hospital was for the acutely ill, and the almshouse was for everyone you didn't know what to do with — the chronically ill, those who needed more care or rehab, those who weren't going to get better, lunatics (as they called them), and the homeless.
The concept goes back to the Middle Ages, when monks and nuns took care of the sick poor for free as part of their calling. That's how I got the title for my book, because in French and Latin, the name almshouse is Hotel Dieu, or God's Hotel. The idea built into Western culture is that all of us have an obligation to take care of the sick poor. Those are the values that Laguna Honda maintained. It even looks like a medieval monastery, with arches and turrets and open windows.
But gradually the almshouses were closed, starting in the 1950s. The Left thought they were too institutional and the Right thought they were too expensive.
You tell wonderful stories about a nurse who hand-knits blankets to show patients on her ward they’re cared for and a doctor who buys a patient a pair of shoes to end a bureaucratic runaround. Your idea of the “efficiency of inefficiency” seems central to the book. How can we bring that perspective into the public conversation on health care?
Bringing it to the public discussion has not been as difficult as I thought. The book has received a huge amount of interest. It's being translated into Chinese, Korean, Japanese and many other languages. I think it hit a wave of interest in this way of thinking, a wave that's cresting just now. In some ways it's a pushback against an efficiency model that has become too extreme.
As a society, we have to be concerned with value and the cost of medicine. What you seem to be critiquing is an overly narrow definition of “cost.” Skimping on doctor time and discharging patients as quickly as possible is not actually cheaper in the long run.
There's a group at Harvard with the phrase "Do what's right for the patient and cost control will follow." I wish I'd thought of that. That's what the "efficiency of inefficiency” model is about. Where I challenge the efficiency model is not saying we shouldn't pay attention to cost. But the question is how we do that. If you do what's right for the patient, it will be cost effective. The doctor who goes out and buys a patient a pair of shoes instead of filling out 25 different forms — that's cost-effective.
The more we focused on cost and tried to come up with shenanigans for controlling costs, the more expensive it's been. At Laguna Honda, our budget rose every year, we take in fewer and fewer patients, and we have fewer and fewer doctors. But we have more and more management and forms. Seventy percent of doctor time is now spent on the computer.
You note that the health economists who wanted to modernize Laguna Honda viewed drugs, equipment and diagnostic tests as necessities, yet they saw ample staff as an expendable luxury. How do we reclaim the role of human relationships in medicine?
It's important to challenge the assumptions of economists. It's not that I'm a bleeding heart and they're the tough fiscal-minded ones. They're incorrect on the fiscal level. Doctors are not expensive compared to a test that a patient doesn't need. A classic example is an MRI for back pain, which costs $2,000, but not everyone needs it. How do I tell which patients need one? By examining them thoroughly and usually having them come back a couple times. If I have the time to do that, two out of three patients don't need the test. An Institute of Medicine study found the same thing. There's plenty of savings to be found.
How can integrative practitioners like naturopaths, acupuncturists, nutritionists and exercise therapists contribute to a more complete system of medicine?
Honestly, I'll understand that better when I visit Bastyr this spring. I'm really looking forward to seeing how you integrate the Western model of medicine into your education and seeing how much clinical training your students receive. I think of the machine and garden metaphors like eyesight. When you use two eyes, the images merge and you get a three-dimensional view. It's not an either/or question. I use the body-as-machine view first, because some things are clear to fix. But if not, you nurture the vis medicatrix naturae, or Hildegard’s viriditas.
What have you been doing since the original Laguna Honda closed at the end of the book?
I imagined that I would be back practicing medicine at the new facility, but I haven’t returned yet because I've been floored by the response to this book. I've been getting invitations to talk from all over the world.
My next goal is to do an experiment by running a short-term care ward that gives doctors and nurses as much time as they want with patients. It would be a place to get a second opinion; to have a thorough exam and get the right diagnosis and treatment; to have medications thinned; to get the patient in the best possible state. I call it an ecomedicine unit because we would prefer natural treatments over synthetic ones. We would provide organic food, fresh air and sunlight instead of prepared food, air conditioning and artificial light. After a two-year pilot project, we would compare medical outcomes along with patient and family satisfaction, staff health and morale, and cost. I’m confident it would be more “efficient” than conventional care.
What can medical education — either conventional or natural medicine — do to restore a more humane system of health care?
Medical schools are interesting. I teach at the University of California, San Francisco, and these things we're talking about are espoused as principles. We say "patient comes first” and yada yada. We say the right things in schools and residences and even in hospitals. And yet it's completely undercut by what actually happens — who gets promoted, who chairs the departments, who gets the grant money, who has the power. I'm not sure what to do about that.
There is a lot of energy around what we're talking about — bringing back this forgotten side of Western medicine and having the two sides function together. There is a lot of energy around giving doctors back their time and not doing everything through labs, electronics and virtual communication. But the money and the power haven’t supported that.
That’s why I want to build something separate and show that slow medicine works. Because I believe we could build another system in this country and show that it works. If it’s better and cheaper, people will follow it.