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The idea of an almshouse may seem Dickensian, but one – Laguna Honda – operated in San Francisco until recently. It turns out there’s a lot modern doctors can learn from seemingly antiquated approaches to treating patients. We talk with a physician who practiced there about the benefits of ‘slow medicine’.
- Victoria Sweet, M.D. Physician, San Francisco’s Laguna Honda Hospital; associate clinical professor of medicine, University of California, San Francisco
Read An Excerpt###
Reprinted by arrangement with Riverhead, a member of Penguin Group (USA) Inc., from “God’s Hotel: A Doctor; A Hospital, and a Pilgrimage into the Heart of Medicine” by Victoria Sweet. Copyright © 2012 by Victoria Sweet.
MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show" connecting your neighborhood with the world. Later in the broadcast, artificially inseminating a panda at the National Zoo, but first, imagine a hospital where tall windows let in sunlight and ocean breezes, patients who don't pay a penny, tend potted plants in the greenhouse and let chickens sometimes wander through the AIDs ward.
MR. KOJO NNAMDISounds like an ideal place to convalesce and a health department's worse nightmare rolled into one. And while it may sound like a fictional setting, it's the very place where Victoria Sweet has treated patients for two decades. Laguna Honda, though technically a hospital, its mission is reminiscent of the almshouses that used to be found in nearly every U.S. county and Dr. Sweet thinks modern medicine has plenty of lessons to learn from the way things used to be done.
MR. KOJO NNAMDIVictoria Sweet has been a physician at San Francisco's Laguna Honda Hospital for more than 20 years. She's the author of the new book "God's Hotel: A Doctor, A Hospital and a Pilgrimage to the Heart of Medicine." Victoria Sweet, thank you for joining us.
DR. VICTORIA SWEETWell, thank you very much, Kojo. It's really an honor and pleasure.
NNAMDIThe honor and pleasure are also mine. 800-433-8850, you can have the honor of joining this conversation yourself, 800-433-8850 if you have questions or comments. If we're able to conjure an image of an almshouse, at all odds it comes straight out of a Dickens novel.
NNAMDIWhat is a modern almshouse and how different is it from what we might picture when I was growing up in the South American Caribbean nation of Guyana? There was an almshouse that later became known as The Ponds, which was probably its real name, but it used to be called just The Almshouse. And I suspect that after a while, people didn't think that was an appropriate name to call it. But what is a modern almshouse?
SWEETWell, why don't we start with what an almshouse is because my experience, Kojo, is anybody under my age, about, hasn't even heard the term...
SWEET..at all. And so I usually have to quote "alms for the poor, alms for the poor" from "Monty Python" and they start getting the picture. The almshouse goes way, way back to the Middle Ages. It was the way we used to take care of the sick poor before there was health insurance.
SWEETThere was an acute, county hospital usually and then a county almshouse in the United States in every county in the country up until really about the '50s. They were mandated by the county rules.
NNAMDISo the almshouse was invariably connected, related to the hospital?
SWEETYes. What happened, they originally go back to the medieval monks in medieval monasteries whose main obligation was prayer and taking care of the sick poor. And they took care of the sick poor in hospices, which is where we get our word hospital. And when the monks, particularly in England, were dissolved by Henry VIII, the counties took up that role and they also took up the architecture of the monastery, which is one of the reasons why the almshouses look so monastic very often, so what we think of as institutional.
SWEETAnd up until the '50s, every county in the country had a free county almshouse as well as a free county hospital.
NNAMDIYou did not intend to stay very long at the Laguna Honda. How did two months become 20 years?
SWEETWell, Laguna Honda cast a kind of spell. When I first got there my first day for my first interview, I had no idea what it would be like and it looked like a medieval monastery with long, open wards, a chapel, a greenhouse, an aviary, a barnyard, and a surgery suite. It was immense.
NNAMDIA throwback to the past?
SWEETReally, it was a throwback to the past and it actually originally was the San Francisco Almshouse, although the current incarnation, at the time I came in, was built in the '20s. But it was built along the Nightingale Plan and I ended up staying because I really fell in love with the place. The patients were fantastic. They were fascinating and it was a lovely place to practice medicine.
NNAMDIAs a young medical student, you set out, it is my understanding, to become a psychiatrist. What changed your mind?
SWEETTwo things changed my mind. I wanted to be psychiatrist because I had decided I wanted to follow the footsteps of Carl Jung, the psychiatrist.
SWEETI liked the way he approached mental illness, especially the really severe mental illness of schizophrenia as having a meaning, the hallucinations as having a meaning. And I started medical school and I actually did a year of psychiatry, but I realized during that year that I actually didn't believe Jung's formulation having seen a lot of schizophrenics. They seemed to have more of a brain disease than a mental disease and I could go into more detail, but I won't.
SWEETAt any rate, at the same time, I really loved the physical examination, seeing patients, figuring out what was wrong with them, with their bodies. And I found there was a lot more psychology in that than I'd expected so I ended up becoming an internist.
NNAMDIWell, we're about to enter what started you in a way looking back, pre-modern Western medicine included many treatments now considered obsolete, those involving leeches and bloodletting among them. But you think we can learn a lot from the way medicine used to be practiced. When did things change and why did they change so completely?
SWEETThat's a great question. I do think we can learn a lot and I think we also, at the same time, have to realize what a treasure our modern medicine is. Up until the late 19th century, there was a different way of looking at the body. It was more as a plant rather than a machine and the doctor was more like a gardener than a mechanic. And what that meant was doctors didn't look at an ill patient and ask themselves what's wrong. How can I fix it?
SWEETThey stepped back from their patient and put the patient back in his or her environment and thought, what's created this state of ill health and what can I do to improve the environment around the patient because the intrinsic belief in the pre-modern era, before the late 19th century, was that human beings had a natural power of healing within them like plants do.
SWEETAnd if we could just fortify that natural power of healing and remove what was in its way, people would get better. Then in the 19th century, late 19th century, the whole industrialization of our environment took place with the advent of really marvelous machines. And that model was also applied to medicine very successfully with the body as a machine and the doctor as a mechanic for acute illnesses, for things that happened suddenly, so a stroke, a heart attack, car accident, appendix.
SWEETWe do a great job of what I sometimes call in the book, fast medicine. But once the patient is over their car accident, their appendectomy, their chemotherapy and their heart attack, applying fast medicine is not the way to go is what I learned at Laguna Honda. Having a slow medicine approach of getting everything out of the way of the patient's natural power of healing is wonderful for rehabilitation and I think of that as a slow medicine approach.
NNAMDI800-433-8850 is our number. If you have a question or comment for Victoria Sweet, you can call us. Do you think medical care has become too rushed or too impersonal? Give us a call, tell us why, 800-433-8850. Send us a tweet at kojoshow, email to email@example.com or go to our website, kojoshow.org, and join the conversation there.
NNAMDIWe're talking with Victoria Sweet. She has been a physician at San Francisco's Laguna Honda Hospital for more than 20 years. She's the author of the new book "God's Hotel: A Doctor, A Hospital and Pilgrimage to the Heart of Medicine." Many of us have had the frustrating experience of waiting an hour or two to get, oh, six minutes of face time with our doctor. Can people really get good care in that short of period of time?
SWEETWell, that's a loaded question for me, Kojo.
SWEETYes, I'm going to say this. I think for certain problems, they can get adequate care in six minutes. I could describe what I mean by that, but for long-term problems, complex problems, difficult diagnostic problems, no.
NNAMDIWhat do you mean by the term slow medicine?
SWEETIt's a great question because other doctors are using the same term, but in a very different way.
NNAMDISeems to be a growing movement.
SWEETYes, and I think the people that, they're using it in a different way from the way I'm using it so I want to make that clear. I forget actually the name of the doctor who is using it to mean, I think, the equivalent of palliative care in the elderly and the aged, going slow when we have nothing to. There's nothing really to do, not applying the technology of the modern world to someone whose life expectancy is six months, going slow in that sense.
SWEETThat's not what I mean by slow medicine. I mean a different way of looking at the patient number one, where the doctor does have enough time with anybody, not just with somebody who is elderly, that the doctor has enough time to do a good job because one of the things I learned at Laguna Honda that so impressed me and if I have to summarize what I learned, it would be that medicine is personal. That it's the personal relationship between doctor and patient and when it's personal, it works and it cannot be personal in six minutes. That's impossible.
NNAMDIWell, I want you to give us a few examples of what you're talking about. In addition to feeling hurried, patients sometimes feel as though their doctors forget that well, I'm a person. Could you tell us the story of Miss Todd and what you learned from Miss Todd (sp?) ?
SWEETShall I read this, Kojo?
NNAMDIYes, go ahead.
SWEETI met Miss Todd, a little preamble, I met Miss Todd towards the end of my first years at Laguna Honda when I realized I wasn't leaving after two months or even two years. I was just fascinated and I was going to stay. I had already learned a lot, but she taught me something very particular that I never forgot.
SWEET"Toward the end of those first years, there was one patient in particular, a terrible patient, she wasn't even my patient. She was Dr. Romero's patient, but her bed was between two of my patients' beds and I passed her every day. She had a horrible disease and a horrible disease at Laguna Honda was really horrible.
SWEETMiss Todd was 35 years old. She had cancer. Her cancer was brain cancer and what made it horrible was that it was just behind her right eye and it had grown in spite of surgery and radiation right out of her eye. The surgeon had removed the eye and sewn the eyelid down over the cancer, but the cancer was still growing.
SWEETMiss Todd had never been beautiful, but what with the radiation which had caused her hair to fall out, the steroids which had caused her face to balloon and the sewn eyelid which had started to bulge, she was now very hard to look at, yet she was pleasant and quiet. She always smiled as I passed her by.
SWEETEventually, we were on speaking terms with a quick hello and how are you from me to her and from her to me. I got used to her deformity, although only by blocking out in some way my experience of her experience. One day I finally braved my reluctance and stopped by her bed, full stop. We looked at each other. She at me, white-coated, rushed, a bit disheveled. I looked only at her left eye.
SWEETIs there anything I can do for you, I asked her, after we talked a bit. Yes, she replied, there is. I really don't like the food they're giving me. It's all cut up and bland. Do you think it could be changed? And another thing, could you arrange for me to visit the eye doctor? I need a new pair of glasses.
SWEETI was and am to this day floored by her response. I was and am awestruck by such equanimity. She wanted not euthanasia or a miraculous cure, stronger pain medications or a second opinion, but different food, a pair of glasses. She said nothing about her terrible misfortune. She was calm, matter of fact. Somehow she'd accepted her fate and it was the small things, the little daily things that were important to her."
NNAMDIYou did change her diet and you did get her new glasses.
NNAMDIWe're talking with Victoria Sweet, who has been a physician at San Francisco's Laguna Honda Hospital for more than 20 years. Her new book is called "God's Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine." She's also explaining what she means by slow medicine. And we're taking your calls at 800-433-8850. If you have already called, stay on the line, we will get to your call. If you've tried to find a doctor who will spend more time with you, we want to know if you have had any luck, 800-433-8850. If you're a health care provider, give us a call and let us know if you find the idea of slow medicine appealing. You can send email to firstname.lastname@example.org. I'm Kojo Nnamdi.
NNAMDIWelcome back, we're talking with Victoria Sweet. She's been a physician at San Francisco's Laguna Honda Hospital for more than 20 years. She's the author of the book "God's Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine." The title intrigues me. Why "God's Hotel?"
SWEETWell, the reason it's called "God's Hotel" is that's what we used to call hospitals for the sick poor back in the middle ages. They were called Domus Dei, House of God. And in French, a hospital like Laguna Honda is still called God's Hotel, in French, a Hôtel Dieu.
NNAMDISure is. Laguna Honda is a different place now than when you started there. Have changes made, in the name of efficiency, well, have they been, well, efficient?
SWEETWell, that is a wonderful question. Not in the sense that health care economists would like. No, they haven't been efficient. And what the health care economists mean by efficient is cost effective. We now spend more money per patient, way more money, and see many fewer patients. It takes doctors about 50 percent longer to see a patient when they have to use electronic health records. For instance, at Laguna Honda, although our budget's gone way up, we see a third fewer patients than we used to.
NNAMDIThen you used to see before?
SWEETYeah, yeah. Q.E.D.
NNAMDIHow could that be in the name of efficiency?
SWEETWell, that is just a wonderful question. And we probably need a lot of time to discuss it. You know, I sat down at some point, well, not some point, two years ago while I was writing this book and I read the health care act.
NNAMDIYes. I know you did. All 900...
NNAMDI...pages of it.
SWEETYes, all 900 single-spaced pages of it.
NNAMDII know you did.
SWEETAnd I can tell you why it's -- what exactly happened at Laguna Honda and what's likely to happen elsewhere.
NNAMDICan you tell me right now?
SWEETI can tell you if I talk really quickly.
SWEETOkay. Well, basically, health care economists, for the last 20 years, have approached the question why is health care so expensive? And their fundamental answer is that doctors are expensive. And that anything they can do to get doctors out of the equation will save money. And that is not a correct hypothesis, the last 20 years shows us. I am not expensive. I am cheap. I am sorry to tell your listeners in the sense that if I have enough time to carefully examine a patient, I can often figure out what they have without ordering, let's say, an MRI. If I spend an hour with a patient, it costs the county of San Francisco $100 for that hour. If I have only six minutes and have to send that patient for an MRI...
SWEET...it costs the county of San Francisco $1,800. So it's not even -- it's not efficient not to have doctors have as much time as they need for patients.
NNAMDIWell, you certainly did that in a very short period of time.
NNAMDIBecause we do have a lot of callers waiting. But I'd like to start with an email from Dawson. "Today's doctors appear to be trained only to treat symptoms and or perform surgery, not heal patients of disease. But what is most troubling is that they don't even seem interested in actually healing patients and are routinely dismissive of a holistic approach to medicine, including the potential impact of dietary changes. In addition, they're comfortable shrugging off patient questions with responses like I don't know, they didn't cover that in medical school. For the most part, they are not true professionals, but technicians." Do you think that doctors have increasingly been turned into technicians?
SWEETYou know, I can't speak for all doctors. I think that, you know, I teach medical students every year and this particular years of medical students, which I got in September, where the most darling people. They were bright, they were wide-eyed, they were so enthusiastic. And we went over the physical exam. They get a huge introduction to exactly what the writer of the email was regretting. And then what happens after they get out of my little hot little hands, they go into the rest of their training and they're taught all the things you need to -- all the scientific medicine and technological medicine which we need.
SWEETWe need to have doctors who are good technicians. But by the time they've done all that, they've never had a chance to really experience what it's like to have enough time with patients. So I think it's kind of -- I have to answer, yes, to what the caller says. But I don't think it's an impossible situation to reverse with the doctors we have today.
NNAMDIOn to the telephones. Now, you can put your headphones on. And we'll start with Joy in Rockville, Md. Joy, you're on the air. Go ahead, please.
JOYYes, I just think that you're talking about changing the values in this society. And what are the chances of real education of people so they can take care of themselves more? I mean, nobody cares about anything except very short term issues. Until that's different, it's not going to change. And also, did you say electronic records use is much -- the cost is much greater or other?
JOYI thought so. Yeah, I had that idea before. And this is terrible and nobody is saying that, you know. It just, you know, we have the wrong values.
NNAMDIVictoria Sweet is saying it. Care to comment on what Joy...
SWEETJoy, well, two things. The electronic health record story is very interesting because that whole movement was put into place with the promise and the expectation that it would be more efficient in the way the health care economists mean efficiency. But nobody ever tested it until last six -- six months ago, Stanford's University came out with a study where they actually tested it and found that doctors are having to spend between 30 and 50 percent more time filling out their electronic health records then they used to scribbling notes. And everybody knows that actually. It's kind of a disaster and guess where that time comes from, it comes out of the 10 minutes that the doctor has to spend with you. It's now down to seven minutes.
NNAMDIThank you very much for your call, Joy. We move onto Claire in Washington, D.C. Claire, your turn.
CLAIREHi, Kojo. Great show today. I just wanted to comment that this idea of slow medicine. I think really kind of resonates with the rising numbers that we see in the home birth midwifery community where you have a group of women who are really drawn to having a relationship with their health care provider that's not about the six minutes.
CLAIREAnd the Paraview research shows that when somebody can take time with them, especially during labor, to really be with them, not for just coming and going, their stress levels go down and their positive outcomes in labor and delivery go dramatically up. And the ParaView research also shows that it is not only as safe, but more safe for low risk mothers to actually go with midwifery than with the six minute care of the occasional obstetrician.
NNAMDICare to comment?
SWEETIt's great actually. That's a very interesting comment. And I think that would be one way of looking at that. Again, just from an economic point of view as an example of how in-fact this approach isn't just nicer and sweeter and more holistic in all those, you know, touchy-feely things that economists don't like, but is actually cheaper. And that gets back to Joy's comment about needing a whole value change. The kind of exciting thing I learned at Laguna Honda is, I'm not sure we do need a value change.
SWEETLet's meet health care economics orthodoxy upfront. Let's meet them on the level of money. If it's cheaper to do midwifery for your normal delivery and you get better outcomes, than there's absolutely -- we don't have to have any value change, we can just show -- just scientifically, there it is. It's cheaper to do it this way. Why don't we do it this way?
NNAMDIThank you very much for your call, Claire. We move on now to Lisa in Washington, D.C. Lisa, you're on the air. Go ahead, please.
LISAHi, Kojo. I have a question about the idea of membership doctors' offices and searching for a primary care physician (word?) . I've noticed that the doctors that have the best reviews tend to be a part of these memberships. Doctors offices where you have to pay a monthly fee and I just wanted to get Dr. Sweet's opinion on whether that's really a patients best opportunity to get good health care anymore.
SWEETGreat question. I've been looking into that quite a bit because I think it is and I say this from having quite a few doctors who are doing that, throwing up their hands and saying, you know, I want to do a good job and I cannot do a good job with a 2,000 patient panel. I can do a great job with 250 patients. And in order to support my, you know, middle class lifestyle, I need to charge those patients a $180 or $200 a month and then we're done. Because when a doctor does that, he doesn't -- you're not, as his patient, supporting a huge back office. The docs I know out in California who are doing that are wonderful doctors. They are thrilled with being able to do a good job and the patients I know are thrilled.
NNAMDIIn an ideal world -- and thank you very much for your call, Lisa. In an ideal world, it's my understanding, you would like to see alms houses return on a national scale. Is that a model that you think is sustainable or supportable today?
SWEETWell, these are all wonderful questions and fun to think about. I think we need a safety net. One of the things about the health care act was, it supposed to do something about the 35 or 50 million or 23 million or however many million Americans don't have health insurance. And it does help about 12 million of them. But if every single rule and law and regulation in the new health care act is passed, according to the CBO, we're still going to have 23 million Americans without health insurance. So we need a safety net. We need a place where people can go regardless.
SWEETAnd I look at the old model, which actually was a tend model, it wasn't just an alms house. There would be a free county hospital and a free county alms house, which is what we used to have, which meant anybody could go and they would not be perfect. They would be a two-tiered system. But we know that, at least, everybody would have someplace to go if they were down and out on their luck or had no insurance. Is that sustainable? I think if we have 96 percent of Americans have private health insurance and we're talking about what we're going to do with the other four percent, I think it's sustainable and come to San Francisco, we still have it.
NNAMDIFinally, here is Ian in Alexandria, Va. Ian, you're on the air. Go ahead, please.
IANYes, sir, thank you. I am a disabled veteran. I've been out for a little over two years now. And working with the V.A. is literally like pulling teeth. I've had a dizziness issue for the past three years and I'm basically the one that has to take the initiative of figuring out what's wrong with me. And I've gone through the V.A., I've gone through private doctors, I've tried a holistic approach, everything. And with the V.A., it seems that you're the one that actually has to make the appointments and kind of lead the doctor.
SWEETWhat's your name?
IANMy name is Ian.
SWEETIan, I just want to say, Ian, I'm so sorry to hear this.
IANAnd it's not fun.
NNAMDI...you feel, Ian, that there should be a system there that is more accommodating, the kind of slow medicine that Victoria Sweet has been advocating so that you can really get to know your doctor and vice versa?
IANI believe that's definitely true. I've know -- actually my doctor isn't a doctor, she's a physician's assistant. And I think it's a little bit more difficult knowing that, you know, they're basically -- they haven't received that full training yet and they basically are thrown right from college into the V.A.
NNAMDISounds like you're in a difficult situation. Victoria Sweet, sounds like a typical case that would call for what you call slow medicine.
SWEETWell, I don't know exactly Ian's basic problem, but my heart goes out to him, really. And I think you should keep pushing, Ian, to the extent that you can. The squeaky wheel gets the grease at the V.A. I did a year's training there. And that's who gets listened to so speak up, push.
NNAMDII was about to say, should patients expect to take the lead on their own cases?
SWEETThey shouldn’t, but sometimes they have to. And having a support system around you, if you've got a significant other or somebody that can help you get through that system, that is really the best thing to do because that's kind of how the V.A. works. Don't tell anybody I told you.
NNAMDIVictoria Sweet is a physician. She's been a physician at San Francisco's Laguna Honda Hospital for more than 20 years. Her new book is called "God's Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine." Victoria Sweet, thank you so much for joining us.
SWEETThank you, Kojo.
NNAMDIGoing to take a short break. When we come back, artificially inseminating a panda at the National Zoo happened yesterday. Did you follow it on Twitter? You might want to listen afterward. I'm Kojo Nnamdi.
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