Thursday, August 2, 2012

"God's Hotel" by Victoria Sweet


Update, August 20, 2012: For an insight into which direction Big Medicine may be moving, see Atul Gawande's article "Big Med" in last week's New Yorker. (As of this writing it's not behind a pay wall but that may change.)

I am a person who believes in using numbers to understand and manage programs, and who regularly asserts with some confidence that anything can be measured. And that those measurements can be put to work constructively. So it was with an increasing sense of discomfiture that I read Victoria Sweet's wonderful memoir, "God's Hotel." Sweet, a doctor and medical historian, worked at Laguna Honda Hospital as it made a difficult transition from hospital to modern health care facility. When Sweet first started working there Laguna Honda was one of the very few descendants remaining in the United States of 18th and 19th century almshouses that provided care for the chronically disabled. It had open wards and lots of nursing care, almost no computers, and very few departments - doctors, not techs or specialists, read the x-rays they had ordered. By the time she ends her book, several investigations, lawsuits, and one Ph.D. later, it had become a modern facility with private rooms and many administrative staff including utilization managers, but fewer nurses. What happened at Laguna Honda is only one small ripple of a much larger wave social changes playing out in the country, but seeing the jolting as doctors and patients moved from backwater to modern medical center is instructive.

Sweet pairs the story of the hospital's move forward into her own explorations back in time, into the world of premodern medicine, or medicine as it had been practiced for most of history through the end of the 19th century. Her particular focus was Hildegard of Bingen, a 12th century mystic and author of various medical texts. Working at Laguna Honda, Sweet learns the virtues of caring for the whole person, the body, and also what she thinks of as the anima, the force that animates the body (in the premodern sense). "Even when there is nothing to do for a patient, there is something to do," she says. Her example is a new pair of glasses. Along the way, Sweet explores the history and development of hospitals, from medieval monastery hospices for the poor through de-institutionalization to our modern tertiary care centers. Sweet argues that the old system had some virtues that have been lost in the transition.

And what are those virtues? Things that we all think we need more of: time, peace and quiet in which to heal, good food, and, well, sex. Medieval thinkers tried to keep the humors in the body in balance, and as she learns more, Sweet expands the metaphor. If you think of the body as a plant, the immediate environment is the garden, and the garden and plant contribute to each other's equilibrium. After finishing her doctoral work, Sweet celebrated by following the medieval pilgrimage route from Le Puy to Santiago de Compostela. Along the way, Sweet thought about her often difficult patients. Her lessons are several: hospitals are open to those in need. As a doctor, she provided care. Following the pilgrimage route, Sweet became the stranger experiencing hospitality. This will come in useful, as eventually everyone, including doctors and hospital visitors, will become a patient.

Sweet brings her garden metaphor into work with her. Laguna Honda provided care for the indigent, the homeless, people with complex triple diagnoses of mental illness, drug addiction, and the complex medical problem that had landed them in the hospital. Often, patients had no home to go to. Sometimes they had partners or street friends who took advantage of them; they smoked and drank illicitly even at Laguna Honda. These were not model patients; they were not easy ones. But the hospital allowed doctors lots of time, time to sit and reflect, to spend time with each patient, which Sweet explains often gave her the time to find a diagnosis lurking among all the information in the chart. Time also gave patients time to heal. But time is the one thing that modern medicine doesn't allow, at least time in the hospital: it's too expensive. Unfortunately, and this is where things become uncomfortable for the analyst, time was one of the first things to be eliminated. Face-to-face contact was another victim, replaced by paperwork: forms, procedures, policies.

And forms, procedures, and policies all have their place, as does aggregating data about individuals. The changes were hard on everyone; as Sweet puts it, "the practice of medicine had become the delivery of health care." It's hard to argue with that conclusion. But I think there is some place for worrying about outcomes. There's a difference between counting units of service for their own sake, and counting something  -- the output -- as it contributes toward an outcome you are seeking. It's possible that at least some of the work Sweet describes was about outputs, without outcomes. Second, there's no use in developing outcome measures without thinking about the context in which the work is taking place. Some of the patients discharged under the new managed utilization regime returned, sicker than before. Others were never heard of again.

Everyone who has ever been a patient, or known one, should read this book. At the moment, administrators are in control of hospitals, but perhaps the pendulum will swing again. Taking the long view, I will give Sweet the last word:
It was true that medicine and nursing and administration had always been at odds . . . but then I remembered what Florence Nightingale had written about the struggle between medicine and nursing and administration. That struggle was irresolvable and should not be resolved, she said, because it was in the patients' best interest. If medicine ever won control of the hospital, too much would be practiced on the patient; if administration, too little; if nursing, medical progress would be curtailed in the interest of the spiritual and emotional care of the patient.

There's a nice slideshow of images from the old Laguna Honda hospital here.

Image above via http://jsri.jp/English/ojo/2008/sanfran/zenhospice.html

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