I picked up a book the other day that filled me with nostalgia, a yearning for a return to the way medicine used to be practiced 30 or more years ago.
Yes, I’m probably guilty of looking at the past through rose-colored glasses, but reading God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine by Victoria Sweet, MD, reminded me of the era before “bureaucratic medicine” when doctors and nurses had more time and more autonomy to deliver the slow medicine or patient-centered care she describes.
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Twenty-plus years ago, newly released from residency, Dr. Sweet was looking for a position that would allow her to work flexible hours and continue studying towards her PhD.
She found the perfect job at San Francisco’s Laguna Honda Hospital, a huge chronic care facility and America’s last “almshouse.” The almshouses were built to complement the county hospital system, and were modeled after the medieval European Hotel-Dieu, houses of God, that were run by nuns and gave refuge to those who couldn’t take care of themselves.
Laguna Honda’s patients included the chronically ill and disabled, those suffering from terminal disease, substance abuse, mental illness, dementia, or just old age. In other words, Laguna Honda’s doctors and nurses took care of almost anything and everything, and they were given an amazing amount of latitude in which to do what they thought best.
“I marveled and I was thankful. Laguna Honda was off the radar screen. Tucked away in that tiny office, over the hill and far away from HMOs and insurance companies, I was going to be able to practice medicine the way I’d been taught, the way I’d learned, and the way I wanted.”
Dr. Sweet shares dozens of moving stories of the patients she cared for over her twenty years. Many suffered from what she called “triple diagnoses”: complex medical problems, mental illness and substance abuse.
Typically, today, these difficult patients are treated for an acute illness at a large county hospital and then released back into the community, for better or for worse. (Who knows? Follow up of these patients is notoriously difficult.)
But in her early years at Laguna Honda, Dr. Sweet had the luxury of time. Some patients stayed for months or even years, and she appreciated being able to observe patients over a long period time, to get to know them, their friends and family, to see which treatments worked and which didn’t as she attempted to heal their bodies and minds.
Simple measures often had a profound healing effect—buying a new pair of shoes for a patient, or making sure a favorite food was served, or wrapping a patient warmly in a blanket hand knit by a head nurse.
She quotes an early 20th century physician: “The secret in the care of the patient is in caring for the patient.” Indeed.
Laguna Honda had a sense of community; doctors, nurses, and patients all worked towards one goal—the caring for and healing of the patient.
Individuals with such complex medical and psychological issues don’t get better on an insurance company’s time schedule. It takes however long it takes.
That’s slow medicine; that’s the tincture of time. As Dr. Sweet notes, it’s slow and probably inefficient, but it’s low effort and low cost and it works.
Sadly, today’s medicine is all about efficiency. And it’s more about maximizing corporate reimbursement and revenue than providing better patient care.
During the latter part of her twenty years, Dr. Sweet experienced the “chaos of change.”
Laguna Honda had flown under the radar for years, but eventually government agencies, advised by academic health care specialists (they had PhDs, but no practical experience), took notice.
Higher-paying nurses’ jobs were cut, and those left were moved into administration offices away from the patients’ beds. More middle management jobs were created while direct patient care jobs were eliminated. Forms, committees and training courses were required, all taking staff away from patient care.
Many jobs no longer fell under any one’s job description, such as answering the phone, filing, and talking to patients’ families.
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The shifting of budgets and staff seemed to save money,
“But the new system had a cost. It was stressful. After the head nurses were cut in half, there were more illnesses and more 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.”
In 2010 a gleaming new Laguna Honda hospital opened, replacing the old but charming and spacious building that had housed caring staff and healing patients for almost 150 years. The end of an era.
Dr. Sweet stood witness to an inauspicious change in the delivery of health care. Will the grassroots movement to return to slow medicine take root and lead us back to patient-centered care? I hope so, but I am not holding my breath.