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Is Time The Missing Component In Health Care?


I'm Michel Martin and this is TELL ME MORE from NPR News. Now, we turn to the story of a doctor with a very unique experience in medicine. More than 20 years ago, Dr. Victoria Sweet began working at San Francisco's Laguna Honda Hospital. It was an almshouse or what they French call God's hotel. It was meant to care for the sick poor or all the people that didn't quite fit in anywhere else in the city's health care system.

Now, you might think a job like that, dealing with the sickest of the sick, people with nowhere else to go, might be one of the most depressing places you'd ever want to be, but Dr. Sweet found it was exactly the opposite and, in fact, offered a window into a type of health care that most Americans can only dream about.

She chronicles her two decades at Laguna Honda in a recently released memoir, "God's Hotel: A Doctor, a Hospital and a Pilgrimage to the Heart of Medicine," and Dr. Victoria Sweet joins us now.

Welcome. Thank you so much for joining us.

DR. VICTORIA SWEET: Well, thank you, Michel, for having me.

MARTIN: Can I just start out by asking you to tell us a little bit about what an almshouse is and why you wanted to work there?

SWEET: Well, I got there accidentally, really. I had been practicing medicine for several years and I had decided to go back and get my PhD in medical history and Laguna Honda was the only place that would let me practice medicine part time.

It was originally called the San Francisco Almshouse and the almshouses were how we used to take care of the sick poor before there was health insurance. The concept goes all the way back to the Middle Ages and the way it used to work was that the counties were responsible for their own sick poor. There would be county hospital for the acutely ill and a county almshouse for everyone else.

It used to be that almost every county in the country had this system, but over the last 50 years, most of them have disappeared. I think that Laguna Honda's probably the only almshouse left in the country, although it does call itself a hospital and renamed itself a hospital in the '60s.

MARTIN: It's hard for me to describe just exactly what makes this place so different. So could you just give us just a couple of examples where people who may have a recent experience with a hospital or a regular hospital will understand what we're trying to talk about here?

SWEET: Well, first of all, was the way it looked. So I got there 20 years ago and when I first saw it I was totally nonplussed, Michel. It was high on the hill, overlooking the ocean and it looked like a medieval Romanesque monastery. It had peach-colored walls, a red tiled roof, a bell tower and turrets.

The last rendition was built in the 1920s and it was built on this very old-fashioned - called Nightingale model, long, open wards that go all the way back to the Middle Ages when the monks took care of the poor for free. A surgery suite, which looked like the operating room where Humphrey Bogart had his face redone in "Man Without a Face." We had an old-fashioned library, you know, facing north, long windows. There was a chapel with wooden pews, stained glass windows, stations of the cross along the walls.

So, inside, it encapsulated the whole history of medicine and particularly the history that goes back to when taking care of the sick poor was considered the vocation of the monks and nuns of the Middle Ages.

MARTIN: You tell a really interesting story about the role that the head nurse played and you described just what these folks did and just the things that other people would see as inefficient, how you came to see as being fundamental to a kind of really profound and total care for the person. And I want you to just tell me about the head nurse who knitted.

SWEET: I ended up calling that the efficiency of inefficiency. So the way the hospital was set up was on the Florence Nightingale plan. Florence Nightingale studied hospitals in the 1860s. In the same year that Laguna Honda was founded, Florence Nightingale wrote her note on hospitals and she talks about that the best way to construct a hospital was as mini hospitals and each mini hospital would be a long, open ward with one head nurse at the end of each ward.

One head nurse could always monitor all 30 patients at the same time and what that meant was the head nurse felt totally responsible for everything that went on in that ward.

The head nurse who knit had been in her ward for a long time and had things so perfectly organized that she would sit at the front of the ward and knit. She had made a vow to knit blankets for every single patient on her ward and she was about halfway through when I got there.

Of course, from the health care efficiency point of view, a head nurse who knit was about the most inefficient thing you could imagine, but in fact, I realized over the years, it was very efficient. Because she was sitting there observing everybody all the time, I walked in with a sense of somebody really in charge, of somebody noticing everything, knowing everything.

So having that head nurse prevented many, many expensive hospitalizations and that would be one example of how - sorry.

MARTIN: But it was also the fact that each person was cared for in a particular way...

...many, many expensive hospitalizations, and that would be one example of how...

But it was also...

SWEET: Sorry.

MARTIN: ...the fact that each person was cared for in a particular way.

SWEET: Well...

MARTIN: I mean that they had their own blanket, they had their own booties.

SWEET: That's right.

MARTIN: And it was just, it wasn't just the blanket, it was kind of the metaphor of the care that literally enveloped each person as an individual.

SWEET: That's lovely, Michel. I didn't quite come out and say that in exact that way but that was true, and every time I see them, I think about her, I think about the care, the organization, the attention that she gave to them and it kind of straightens my spine a bit - if you see what I mean.

MARTIN: Mm-hmm. If you're just joining us, you're listening to TELL ME MORE from NPR News. I am speaking with doctor and author Dr. Victoria Sweet. We're talking about her new memoir, "God's Hotel: A Doctor, A Hospital, And A Pilgrimage To The Heart Of Medicine." You know, getting to the heart of medicine piece, one of the reasons you went there is you wanted to pursue a doctorate in pre-modern medicine.

SWEET: Yes. Exactly. Mm-hmm.

MARTIN: And you started to kind of think about medicine in a different way, as you dug into really been very roots of the thing. And I want you to tell the remarkable story about Terry Becker - was one of your patients.

SWEET: Mm-hmm.

MARTIN: She was a sex worker, a heroine addict, homeless, and you started to apply kind of what you were thinking about both from being at Laguna Honda and your own studies to her. Could you just talk a little bit about that?

SWEET: I had gone back to study particularly the medicine of Hildegard of Bingen, who was a 12th-century non-mystic visionary composer, but also, as it turned out, a medical practitioner. And she'd written a book on her medicine and instead of being the eye of newt, tongue of frog medicine I'd expected, it was a medicine for real patients with real diseases that I could recognize. Hildegard thought of the body as more of a plant than a machine and the doctor as more of a gardener than a mechanic. What's the difference? Well, someone has to fix a broken machine, but a plant can heal itself. So Hildegard had this idea that just as a plant has its own greening power to grow, so did human beings. We had a natural healing power.

And I thought a lot about this, and with Terry Becker I applied Hildegard's idea of sort of looking at the body of my patients more as if I was a gardener, and asking myself not what can I do to fix them but what can I do to remove what's in the way of their own natural healing power. What happened with Terry Becker is that in addition to her own self-generated medical problems with her drug use, etcetera, she had developed a rare viral disease which had left her paralyzed from the neck down. And usually it gets considerably better over time. Terry had originally come to Laguna Honda, she'd gotten a little bit better, she'd gone back on the street, she gone back and forth many times, and during one of her episodes on the street she developed a bedsore. It got bigger and bigger, she didn't get it treated. Finally she came in with the most hugest hole in her body, really, I'd ever seen. It was...

MARTIN: It was one of those things that I'm not even going to ask you to describe here.

SWEET: All right.

MARTIN: Because I'm not sure everybody could handle hearing...


MARTIN: ...the seriousness of her bedsores, which sounds so simple but it's just so profound. Let me just help a little bit here. She was in and out of the health care system. She had something like 20 ER visits, including a number of surgeries. You could say that she was kind of an extreme case of what people think of as kind of hospital care, you know, cure at all cost, then discharged.

SWEET: Mm-hmm.

MARTIN: But you had a different approach, and it took what? Just tell us a little bit, just a little bit, if you could, and how long it took.

SWEET: Well, what I realized is that there was not anything to do from the point of view of modern medicine for her. It was too big an open wound to graft, and that I was going to have to let it heal naturally. And I thought about what Hildegard would do in that case. And what I realized what she would do was not do something to, Terry, but remove what was in the way. So extra medicine she didn't need, the nicotine she smoked, crumpled bedclothes, bad mattress, all that, sort of move that out of the way and let her own natural healing power do its magic. It took two and a half years. But during that time, I watched as this open wound healed in gradually. And at the same time, because of Laguna Honda's sort of spirit, everything else about Terry healed too. She gave up smoking. She got in touch with her family. And at the end of two and a half years, not only was for bedsore completely healed, but she herself was healed. As far as I know, never went back to the streets again.

MARTIN: It is only one of the many profound stories that you tell in this book. But it does raise some really serious questions, which is like how much it costs to kind of cycle her in and out of hospitals, getting a lot of really intensive care. But then you think to yourself, OK, two and a half years in the hospital, even a hospital like Laguna Honda, which is run as low-tech a way as we can do in modern medicine in the United States, and you sort of say to yourself, OK, what really makes more sense? But is it even possible to envision a way that more people could get the kind of care that she got? Can you?

SWEET: Well, I think there's really two parts to that question. One is, is there some kind of limit that we should place to people's going back and forth in a hospital or getting two and a half years of treatment? I think I as a citizen have a right to ask that question and answer the question, but as a doctor I don't.

MARTIN: Mm-hmm.

SWEET: If we're going to take care of somebody who shows up at every ER, like Terry, then it was definitely less expensive to take care of her at Laguna Honda and have her heal and never go back on the streets than it was to let her go back and forth.

MARTIN: But Laguna Honda itself has changed, hasn't it?

SWEET: Yes, it has, and during the years I was there, there was a whole movement to either close it down, like all the other (unintelligible) has been closed down, or rebuild it as a modern health care and rehabilitation facility. The citizens of San Francisco were very generous, they passed a huge bond to rebuild it, and it was finally rebuilt and the patients were moved in about two years ago to a very beautiful, very modern facility that looks like the most modern hospital you can imagine - private rooms, halogen lights. But it has a very different sense about it from the old Laguna Honda.

MARTIN: But is it possible, and I understand that you're saying that this is - you're not really a policy person, you're writing about what you saw and what you thought about.

SWEET: Mm-hmm.

MARTIN: But do you think it is possible to practice the kind of slow medicine that you found so effective?

SWEET: Yes. Well, I do. I draw a distinction now, Michel, between fast medicine and slow medicine - like fast food and slow food. And fast food is great when you have a very, you know, you need to eat something. Fast medicine is wonderful for acute diseases. Slow medicine - as meaning the doctor has enough time to do a good job with the patient. Where we've been headed the last 20 years, both at Laguna Honda and out in the country, is this idea that doctors were very expensive. So there's been a whole movement to cut the time patients can spend with doctors, doctors can spend with patients, trying to de-skill what doctors do onto machines, onto computers, onto nurses, onto protocols, onto paradigms. And that is a very expensive way to go because doctors compared to lab tests and MRIs are cheap. For me to do a good job and have enough time with the patient, I'm not expensive. And the slow medicine piece, I do believe, is efficient and can be applied across the country.

MARTIN: Do you think anybody's listening to you? I mean interestingly enough, we've spent tremendous amounts of time over the last couple of years talking about what health care should look like in this country. Do you think anybody's listening to you?

SWEET: Oh, it's been fascinating. I'm getting emails from all over the country - from doctors, nurses, patients, health care economists, administrators, everybody. I think there's a real need and a sense the time is right to do that. But the really fascinating thing is there's a kind of (unintelligible) experiment going on that is not called slow medicine. It's got an unfortunate name of boutique or concierge medicine.

But there are doctors dropping out and saying I can't take care of 2,000 patients. I can't do a good job when I have seven minutes to spend with the patient. They're refusing to take insurance and they're getting an upfront monthly payment from patients 150 to 200 dollars a month, and for that they can decrease their panel of patients to 250 patients, and in return for that they can spend as much time as they want with you.

MARTIN: With all due respect, Doctor, I don't know what parts of the country you're talking about, but I know where I live boutique and concierges are exactly the right terms because...

SWEET: Mm-hmm. Mm-hmm.

MARTIN: ...they're so expensive. The only people who can afford to access services like those are CEOs, celebrities, you know, people with inherited wealth. I mean it's just, that is just not something accessible to most people. So is that an answer?

SWEET: Well, there's two things, Michel.

MARTIN: I mean...

SWEET: Well, here's the thing. First of all, I know out here in California and I know specific docs and that is what they charge. I've heard anywhere between $150 a month to $600 a month. I call it an experiment because what I think it will show is that we could take and see how much a doctor saves. If I have an hour to spend with the patient and I cost $100 and during that hour I can determine the patient doesn't need an MRI scan, I've saved the system $1,700. So what we can do in a year is go and look at those concierge practices and those boutique practices - no matter how much they cost - and see whether they'd save money in the end, because if they do save the money in the end because a doctor has enough time to spend with the patient, we can apply that model even for patients that are poor.

MARTIN: Victoria Sweet is the author of the recently released memoir "God's Hotel: A Doctor, A Hospital, And A Pilgrimage To The Heart Of Medicine." She is a physician, as she said. She also has a doctorate in history and social medicine, and she's a clinical professor of medicine at the University of California, San Francisco. We caught up with her in Stanford, California.

Dr. Sweet, thank you so much for speaking with us.

SWEET: Thank you so much, Michel. Transcript provided by NPR, Copyright NPR.

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