Interview with Dr. Victoria Sweet, May 19, 2014: Slow Medicine
by Mary Stein, Jul 30, 2014
What would it look like—an intimate, intuitive, deeply skilled medicine, focused on continuing care and observation of the patient, minus computers? It’s not a question that most of us can think about in any great detail these days. In her book God’s Hotel, Dr. Victoria Sweet writes about an unusual hospital where she found amazing insights to the question. Laguna Honda Hospital in San Francisco was, as far as anyone knows, the last almshouse, or Hotel-Dieu, in this country—a hospital for the sick and poor. Dr. Sweet took a position there, expecting it to be temporary, then stayed for more than twenty years in a place where she and other physicians could practice a different kind of medicine. They had little access to state-of-the-art medical equipment but all the time in the world to watch over patients with complicated and multiple sicknesses and injuries, and gradually to eliminate the obstructions to their healing. The hospital itself, with its open wards, was a powerful influence on the kind of medicine Victoria Sweet was able to practice. In a recent interview we started out talking about that.
Mary Stein: For years, as I drove past Laguna Honda Hospital several times a week, I’d glance up at it on its hilltop and take in that wide silhouette, the peach-colored walls, the tower and the tile roof. There was something gracious and attractive about the look of that building. And when I read in your book that the hospital’s traditional architecture had a big impact on the care of the patients, I wanted to hear more about that.
Victoria Sweet: All the patients in the old hospital have moved into the new place, and even though I’m not practicing there as a doc now, I talk to my friends who are still there. I go visit my old patients, so there's a sense of how things are different. I had the hypothesis in the book that the architecture of the old Laguna Honda was really important to the community of the place, the serendipity of the place. And now we actually have a comparison—looking at how things are there now, with these two beautiful new buildings—how does it all work?
It has basically confirmed what I wrote about seeing in the book. In the old place everything was very open—open wards, open hallways, open doors, open windows—for better or for worse! Air came through the place. If you wanted to shut the air off you didn't turn the air conditioner off. You closed the window. And one of the things they nailed us for was we had no air conditioning. But it's San Francisco! You don't need air conditioning. So everything was open in a lot of ways and inviting in a lot of ways. Basically the reason the Department of Justice made us rebuild was because of the open wards.
Mary: What’s it like in the new place?
Victoria: The new place is the opposite: it’s closed. There are these two big new buildings with eight floors, connected by a third building. Every patient has his or her own room, in a kind of a suite, and every three rooms have their own bathroom.
There are cameras all over and locks every place. There’s a patient who's very dear to me that I continue to visit and the last time I visited her I was thinking as I went to her how much space there was between us, between me parking the car and actually being face to face with her. I counted how many locked doors I had to go through to get to her. There were eleven! There were the front doors that you could just walk through. Then I had to get in the elevator, and get out on the second floor—that's another door. Then I walked through two or three corridor doors—the corridors all have doors—and then I had to go to another elevator, another door, go out another door, and then go up through another corridor. I counted them: eleven doors. That's a big commitment to make.
Mary: And in the old place?
Victoria: In the old place there weren't many doors and they were literally open. So you parked your car and then you'd go through an open door; the doors to the wards were open. The wards themselves were open, and even though the patients had privacy curtains, almost no one closed them. So there was maybe one door before you got to the patient. There was a free flow of people going in, people going out. And walking into the wards, you looked around; you had a sense of the community of the ward, just visually.
Mary: A community of patients? That’s interesting.
Victoria: There was even a community of smokers! They gathered around the group of vending machines and formed a certain community sitting in their wheelchairs, talking, gossiping, sharing.
Mary: Did they try to build that out of the new place?
Victoria: They made it illegal to smoke anywhere on campus, even if you’re outside! Which is not to say that I recommend smoking.
Mary: You mentioned the serendipity of the place. How did the architecture relate to that?
Victoria: It was another way the architecture created or allowed for meaning. For instance, I might be walking down those long open corridors thinking about the patient I’m on my way to see, and we would just meet. They were going someplace else and we would meet in that open place.
Mary: In the book there’s the patient you call Paul Bennett who was dying of terrible wounds from amputations that wouldn’t heal. You’d come to the end of what you could figure out to do for him. And you went out to the beach and walked there in the roar of the wind and waves praying for some help that you didn’t know how to find. And the very minute you were back at Laguna Honda you had a call from another physician who suggested a little-used treatment that actually worked and saved the man’s life.
Victoria: That’s it. That happened all the time. It seemed accidental at first, and then I started thinking it was serendipitous, that there was a meaning to running into somebody at the right time in the right place. It wasn’t just an accident, it was a meaningful coincidence.
Mary: And the architecture supported that, the openness of the place.
Victoria: That’s right. People formed groups, and that encouraged you to join them, or think about making your own group. It was sort of like “that’s what people do around here. They have little groups.” I remember one patient, who was brought to Laguna Honda by her husband because she was demented and he couldn’t take care of her any more. She was about 90. Now one of the striking things about the place was that people who came in with dementia, and were gradually getting worse and worse would get admitted to Laguna Honda and they wouldn’t go downhill anymore. They would stay about the same. I noticed it with patients with other diseases too—Parkinson’s disease or even ALS, Lou Gehrig’s disease. They would just stop going downhill. And this patient was one of them. She was at Laguna Honda for years! Her husband would take the bus every day and bring her lunch, and they would sit together at a little table in that big open space with the big windows. He was in his mid 90s, a thin, vigorous guy, and she was demented, but not any more demented than when he brought her in. Sometimes I’d sit down and have a little chit-chat with them. This went on for years.
Mary: The whole social atmosphere sounds like part of the treatment.
Victoria: Just having people be able to freely come and go! I went to speak to the architects about this when they were designing the new hospital. I tried to explain to them that when you’re acutely ill and are taken to the hospital, you don't want an open ward. You’re in the hospital for a couple of days and of course you want your privacy, a private room. But if you’re sick for weeks, months, years, you don’t want a private room with eleven doors between you and everybody else. The architects had a hard time wrapping their minds around that, that there was something salutary about being in an open ward and watching the world go by. There’s maybe somebody visiting a patient across from you and they see you and come over and talk to you, bring you something. It’s all gone now. Everybody is in these beautiful little private rooms.
Mary: You wrote in the book that, when you first came to Laguna Honda, there was a head nurse on each ward, watching everything that went on from her station in the middle of the ward. There’s something interesting about that kind of watchfulness, keeping all these people and their activities and their caretakers in view all the time.
Victoria: Florence Nightingale is the one who came up with the Laguna Honda-style hospital. When I realized that, I went back and read her Notes on Hospitals. She'd worked as a nurse during the Crimean War when there were thousands of English dead—not from getting shot but from getting dysentery and typhus in the terrible hospitals with their warrens of rooms. She decided that the problem causing deaths was the architecture of the hospitals. After the war she went around Europe, looking at hospitals, and she came up with the design that was the model for hospitals for more than a century. Laguna Honda was a Nightingale hospital. There were 30 beds in each open ward, with a head nurse. Why 30? Because, Nightingale said, that’s the most that one person can see at once and keep track of.
Mary: You’ve made a deep study of medieval medicine—the kind that Hildegard of Bingen practiced back in the 12th century. That kind of medicine has such an open feel to it—with its emphasis on the natural world, tending the patient as a plant in a garden among many other plants. There seems to be a connection to Laguna Honda right there.
Victoria: There is a connection. Because the Hotel Dieu, which was the God’s Hotel of Paris at the time, was a very old hospital that was still there when Nightingale was making her tour of hospitals in the 1850s. Most of the hospitals in Europe had these big open wards.
Nightingale did recognize that some people did need a private space, and so she designed her hospital to have a few private and semiprivate rooms, and so we had some of them at Laguna Honda. But most people didn’t want a private room, even when it was available. Too lonely, they would tell me.
Mary: What happened to the patients at the old Laguna Honda?
Victoria: Everyone moved to the new hospital about three and a half years ago. When I go back now, the new place is beautiful and quiet and well kept, and you have to give Administration credit for that. But it feels so empty. Before, in the old place, you’d walk in and it was open, people were smoking, someone was seeing his wife, and the nurses were coming and going—and doctors, relatives, and ambulances. It was lively.
Mary: In the book you quote the saying that “the secret in caring for the patient is caring for the patient.” It took me a while to realize that this caring was more than a sympathetic emotional attitude. You write about the doctor who actually went out and bought shoes for his patient who was ready to be discharged, but had been waiting two months for the requisition to go through. And you describe other acts of caring, like smoothing out the bedclothes to ease a wound, or bringing little gifts.
Victoria: The way we talk about patient care in our society is almost the opposite of what’s actually happening. It’s almost like the less we care in any way for the patient the more people talk about the patient, the “consumer” of health care.
What was actually meant by that saying was that caring meant doing the little things for them; it’s the little things that establish that relationship between you and the patient, not some abstract “love for your neighbor.” It’s doing something actual and physical for this neighbor.
works: And it seemed like part of what made that possible was seeing other doctors doing it in the open ward. So you couldn’t say, “Oh, doctors don’t do that.” They were doing it and you saw them doing it.
Victoria: That’s right. I came in to Medicine with many “boxes." As a woman of my generation, it took me a long time to not worry about being mistaken for a nurse. So I made sure to wear my white coat! I got to the point, though, eventually, that it didn’t matter anymore; I felt confident enough to step out of that box. I began seeing what some of my friends the docs were doing. I’d say, “Where are you going?” “Oh, I’m bringing in this coat for Mr. so and so. You know, my husband doesn’t use it any more.” Or, “Where you going with Mr. Lanza? “Oh, I’m taking him to the opera. He’s such a music lover, and it’s the one thing he wanted to do before he dies.” I just couldn’t imagine that people were like that! But at Laguna Honda I could see that they were like that, and it rubbed off on me.
Mary: One of my daughters is a home health nurse. She’s a good listener, able to draw her patients out when they need to talk, and she takes the time for that. She says that in some ways it feels like she is fulfilling the old role of a doctor making house calls.
Victoria: I think there were doctors like that in the old days and some nurses, too. Not everyone, though. It's a matter of temperament.
Mary: And how does this kind of “slow medicine,” spending time with your patients, affect your ability to figure out what’s going on with a patient physically?
Victoria: It’s huge. I don’t call it health care by the way. I don’t go along with the role of the doctor as “health care provider.” I couldn’t “provide” health care if I tried. I don’t even know what that means. My role is to figure out if someone is sick and then how sick they are. In a way that’s the main thing a doctor does—if a doctor is really good at figuring out whether you are sick or not, that’s actually the most important thing! Because if you're not sick then nothing much needs to be done. On the other hand if you are sick, how sick? Are you acutely sick? How emergent is it? How fast do we have to be? In medical school you learn what to pay attention to.
So in sitting with a patient, or in seeing a person more than once, you can keep asking yourself that question, is he sick or not? How sick? You have someone with a fever and a cough and you aren’t sure, because they could have pneumonia, or is it just a cold? If you’re in an emergency room you do everything immediately—x-ray, CT, labs. At Laguna Honda, those were difficult to arrange, but I did have time. So I could see the patient, and then if I weren't sure how sick, how emergent, how acute the situation was, I could go back and see them again. That kind of repeated observation is amazingly efficient; it saves a lot of money.
Mary: Sounds like taking a snapshot compared to being able to take a moving picture over time. I was struck by the complicated multiple diseases and injuries that you treated at Laguna Honda with this “slow medicine”—watching and adjusting what was needed from day to day. Maybe that’s not “health care,” but it certainly sounds like healing.
Victoria: It was an amazing learning experience. I had no idea when I walked in for the first time. I went there because it looked convenient for what I wanted to do, which was to get a PhD. I wanted to practice medicine, but I didn’t want to practice full time, and I didn’t want to have an office, didn’t need a big paycheck. I wanted to come in only three days a week and have interesting patients. So it was convenient, and I took the job, and then it took me a long time to go, like, “Wow! This place is remarkable!” The set up and the people—the doctors and nurses, the administration, the director of nursing—it was just a fantastic place.
Mary: It was touching to read about Miss Lester, the director of nursing there for more than forty years, who saw every single patient every day, making the rounds of all 38 wards every morning.
Victoria: She knew that just being seen looking around at every thing every day made a difference in the way the patients were cared for. It kept everyone on their toes, looking through her eyes at what they themselves were doing.
Mary: It’s hard to imagine how that kind of observation would work in the new hospital with private rooms.
Victoria: In the new hospital it’s harder. The nurses are responsible for the minute-by-minute care of the patients, and in the old hospital, on those open wards, they could just look up and call for help if they needed it. Now nobody can hear them, the doors are closed. Plus, in terms of communication, the computer has replaced every other thing, so everything’s on a computer and the nurses and therapists and doctors spend a lot, a lot!, of their time in front of those screens.
Mary: And there’s no time for the patient?
Mary: Recently I read an article about what are called physician helpers, who are there in the room with the physician and the patient and take care of filling out the forms on the computer, so that the physician can spend more time with the patient.
Victoria: In a way it's a good idea. But what does it do to your relationship with the patient? When you walk in with someone else, there’s another person there all the time, and if somebody is really going to confide in you, they may need more privacy.
Mary: The article said they checked on the time involved with and without the helper, and it turned out that with a physician helper, the doctor could actually spend a little less time with the patient—saving money! Which sounded like the important thing, as it so often is. I know you have some ideas about an ecomedicine unit in which you could practice “slow medicine” of the kind you practiced at Laguna Honda—with the idea of showing that it would get better results for the patient and also save money.
Victoria: That’s tucked away in the back of my head for now because the book’s been getting a huge amount of attention. I’ve even gotten a Guggenheim fellowship! And it’s been a learning experience, these last two years since the book came out. It’s been fascinating because every time I give a talk I also learn from the audience what's going on in their hospital or university or group. I do have the ecomedicine project tucked away as something I want to do, but I’m waiting for things to sort themselves out. There are some very interesting things going on these days. For instance, one way doctors have figured out how to get their time back with patients is by making their practices a retainer or direct patient care or concierge practice. People pay something per month--depending on the number of patients in the practice: anywhere from $50 to $300 per month, and anywhere from 600 to 200 patients in their practices. Instead of the 2500 patients that the primary care doctor is somehow supposed to take care of. Better for everyone and cheaper: the data is coming out that such practices have 30 percent fewer ER visits, 15 percent fewer hospitalizations and, of course, fewer tests and way fewer medications. So I think that’s going to be what happens in the next few years to give doctors back their time with patients.
Mary: That’s interesting. The eco-medicine unit sounded interesting, too.
Victoria: My original idea was to have an eco-hospital; the “eco” part being from the Greek oikos which in ancient Greece meant a household that grew its own food and, up to a point, was self-contained. The idea came when I visited a friend of mine who had set up an eco-village in Ithaca. She designed it as a way to get away from the suburb as not a very good way for people to live, just as the private rooms at Laguna Honda aren’t very good for the long term. In the Eco village you take the same amount of land as you would for a suburban development and the same amount of money and the same number of people, but instead of everybody having their individual space, with dead-end streets and speed bumps and private lawns and lawnmowers—you build something that’s almost like a medieval village. As when I visited it I thought great! But an eco-village should also have an eco-hospital! That’s how I came up with the idea of an eco-hospital at Laguna Honda. You could take one of those old open wards, use the Nightingale approach and make a mini-hospital, and prove that it would be cheaper. You give doctors and nurses back their time, and the patients would, of course, do better off their unnecessary medications, and without those unnecessary tests. You could take the money you'd save and spend it on massage, and acupuncture and organic food and medicinal wines.
Mary: The idea of using the money saved to provide the patients with better food fits in with the medieval trio you mention in your book—Dr. Diet, Dr. Quiet, and Dr. Merryman—nourishing and delicious food, quiet conditions, and suitable enjoyment—even a glass of wine with meals.
Victoria: Well, the ecomedicine unit is still tucked away in the back of my head. The old building is still sitting there—it’s too expensive to tear it down—and I would love to get my hands on it.
Mary: “Slow medicine” really goes back to medieval medicine, doesn’t it? You write about how people back then saw human beings as more like plants, with innate powers of growth and self-healing. That was the metaphor—that we’re not like machines to fix, but more like growing plants to be tended. That came home to me recently when a friend of mine, a man in his upper seventies, had an angiogram to open an artery that was blocked. And though that artery was 100 percent closed, three small bridging arteries had developed that detoured around the blockage and let just enough blood through to keep him alive. And I thought, that’s what Hildegard of Bingen knew, what she called viriditas—greenness, the body’s ability to heal itself.
Victoria: Yes. Studies show that 30 per cent of the time a placebo works as well as the medicine they’re testing. People get better about a third of the time, no matter what they’re given.
Mary: It’s pretty ironic—considering all the well-advertised new medicines with dozens of side effects.
Victoria: That’s right. Before Reagan was president, the government used to do the studies on new drugs. But Reagan said, “Why should we spend the money to test the drugs? Let the drug companies do the drug trials.” What he didn’t realize was if they did that we’d never get a full report on the results. And that’s what’s happened in the last thirty years. Every time a new drug comes out, I read what the side effects are and how many people really get better, and I add in the side effects and the adverse reactions. When you do that, and subtract out the placebo effect, not many new medications make a difference.
Mary: In addition to being deeply interested in medieval medicine and the medieval attitude toward the body, you’ve observed the medieval custom of pilgrimage. Over several years you and a friend made the ancient pilgrimage—1200 miles long—from southern France to Santiago de Compostela in Spain. You write that you were surprised to see how deep the practice of walking day after day went, how it taught you about being in the present moment. Whether it was raining or cold, whether there was stony terrain, tough hills to climb, or maybe the sun was shining, there was happiness in just being there, whatever the conditions. That interested me.
Victoria: There is something about walking long distances, not in a hurry, being outside all day long, eating in a little place and walking by a river. You meet somebody and talk; some one invites you into their kitchen.
Mary: It sounds a bit like meeting somebody in the corridors of Laguna Honda.
Victoria: We divided the 1,200 mile pilgrimage into four sections of 300 miles per year. And after my friend and I did the first section and went back the second year, we met some of the same people we’d met on the first part of the pilgrimage. Nobody uses last names and they don’t talk about who they are, or “what do you do,” nobody talks about that. You meet somebody, you don’t even know their first names a lot of the time.
Mary: In the fourth and final year of your pilgrimage you walked beyond Santiago de Compostela, where the pilgrimage ended, to a place called Finisterre—land’s end. You write that it interested you to go and stand at that outermost place, on the Atlantic shore, where the unknown began for people in the Middle Ages. They didn’t know there was a whole continent out there waiting to be discovered. They assumed there’d be India, but they were mistaken. It was something else, completely different.
Victoria: You never know what’s out there, what’s going to happen next, what’s going to retroactively change how you think about it now.
Mary: And over and over you speak of waiting for that sort of event or still unknown answer to appear, as it so often did when you were sitting with patients at Laguna Honda. In the book you compare that sort of quiet waiting to being in Swiss railway station—the Swiss being incredibly punctual--where you have total confidence that the train will come. It’s a helpful image.
Victoria: You’re sitting, not doing anything; that quality is just part of your practice. Time is stretched. You don’t have to be in a rush. The other day I was in New York and talking to someone who liked the idea of slowness.” And her life was so rushed! She was always doing five things at once. She said she’d love to try slowness, but no matter how fast she did things, she was always behind. And I said to her, “You know, the faster you go, the faster time goes. And the slower you go, the more time stretches out. Try not doing anything for an hour. Then just try doing one thing in an hour. There’s a different sense of time.”
Mary: In the book, as you observe the struggles and changes that were happening at Laguna Honda, you describe the mixed qualities in just about all the players—the bureaucrats and the investigators and the changing guard of administrators. Each person is a mix, not all good and not all bad. Sometimes they’ll be doing something that looks reprehensible and at another point they seem to be really trying, and you report that, too. It felt rather objective.
Victoria: I learned that on the pilgrimage. There was one year, one day, when we had walked so fast that somehow we'd caught up a whole day, but we didn't know it. And when we went for dinner that night, and looked around the restaurant, we realized that it was a different group of pilgrims than the group that we'd been casually traveling with. Yet though they were different, there was a way in which they were the same--the roles were the same, but filled by different people. And that's what I eventually realized also at Laguna Honda. We were all pilgrims on the pilgrimage of life and our roles were almost interchangeable: this life I was playing doctor, and you were playing patient; next life it would be different. So in my role as doctor I had my definite opinions of your decisions as administrator, or for that matter, as patient. At the same time, I knew the roles were contingent, and the decisions went with the role, not with the person. So perhaps that gave me a little, hmm, perhaps not objectivity, but distance. You might put anybody in charge of the hospital at a particular moment, and maybe they could make a little bit better decision, but fundamentally, because they were in that role, they were making the decisions they made; it wasn’t ad hominem. I think that’s part of it. You’re the interviewer and I’m the interviewee, but somehow we could just switch—opposites could just switch. There are these roles to be played.
works: As if we’re all on pilgrimage?
Victoria: Yes, that’s it.