Wednesday, August 1, 2012

The Virtue of Patience With Patients


What do you call a doctor who for decades cares for the destitute, demoralized and demented, patients who often care little for themselves, in a medical anachronism fast giving way to politics and bean counting? You might call her blessed. She probably would.
Welcome to God’s Hotel, Victoria Sweet's loving and powerful story of a San Francisco hospital  where whisky bottles litter the grounds, patients smoke in the halls, "Bad Girls and Bad Boys" find private corners to do private things, and one nurse's shift consists pretty much of knitting blankets. (Don’t underestimate knitting. Sweet doesn’t.)
The list is long of perfectly sound reasons for a mayor or federal department to step in and change the way things are done at Laguna Honda. That they do so, as Sweet eloquently writes in a manner more insightful than wistful, is truly sad.
I was drawn to this book for its combination of medicine and religious faith, and by Sweet's apparent ability to practice both without compromise or apology.
If aspects of the hero archetype apply,  it is fitting. Medicine was a redirection for Sweet, initially drawn toward psychology by Carl Jung, and she can seem a healer from another time -- which, AIDS patients and MRIs notwithstanding, she sort of is. While practicing medicine at Laguna Honda at the close of the 20th Century and start of the 21st, Sweet worked on a doctorate in medical history, with a particular emphasis on the 12th Century nun Hildegard of Bingen. Hildegard was a poet and writer of liturgical music. She was also a mystic, a botanist, an influential theologian and a medical practitioner.
Hildegard is no med school icon, and maybe that's as it should be. And yet Sweet places Hildegard within the historic sweep of medicine's evolution, and shines a particularly bright light on the role of time in healing. Along the way, she comes to question accepted contemporary thinking about the doctor-patient relationship.
"I'd accepted the teaching that a good doctor does not get too close to his patient," Sweet writes. "He or she does not jump into the mix, but keeps some distance, watches for the 'counter-transference,' but does not get drawn in. There is much truth in that wisdom passed down by generations of doctors. The Hippocratic physician does not fall in love with his patients, or in hate either. He keeps their secrets no matter how heinous; he does not have dinner with his patients, or buy them presents. He remains 'other' to their lives, their families, their neuroses. It is a good ground rule. For a patient to turn to someone kind but distant, caring but calm, wise but not attached, is important, is necessary. But it requires that the doctor maintain a certain distance, and this means not quite being yourself. ... and it was not something I wanted to give up any longer. I didn't want to reestablish distance; I didn't want to be a Hippocratic physician; with my patients, I wanted to be myself. Whether that was possible for a doctor, I didn't yet know."
Along this path of discovery, time, good food and joy become as important to Sweet's philosophy of healing as any diagnostic tool at her disposal. In comparing then and now -- the centuries of premodern medicine little more than a curiosity in the scientific and technological present -- Sweet seems intent on finding the baby that has been thrown out with the bath water.
Sweet is endlessly forgiving of her patients, and knows them and loves them deeply. Only such a person could perceive a place such as as Laguna Honda in San Francisco, what might have been America's last almshouse, with the affection Sweet shows.
Catholic enough to follow the footsteps in pilgrimmage of a 12th Century nun/healer, Sweet also is Zen enough to sit in the dark with a perplexing patient, agitated and agonized, see this person acting as if poisoned, and find a diagnosis in the act of sitting “like a mental state of knitting.” What had seemed an inexplicable symptom of dementia was in fact a toxic reaction to a cocktail of medications.
Sweet begins regularly to sit with patients, "and something, somehow, would happen. It would become clear what, if anything, was wrong with the patient and what, if anything, I could do about it."
Pain comes in great variety, from the physical to the existential, and Sweet strives to understand and distinguish them. This is a valuable skill, especially with a patient no longer able to communicate what’s wrong in any way but physically.
"The demented men of E6 gave me pause,” Sweet writes. “They weren't all there, and they weren't all not there either. They were demented, but not de-souled or de-spirited. ... I learned a lot about sensibility, feeling and will from those demented men of E6.”
And, she writes, “I wondered how many of those I called Bad Boys and Bad Girls were, in reality, spiritually thirsty and spiritually sick. Perhaps they were the most sensitive, the most easily hurt of all my patients, the most tortured by the human fate of knowing we are going to die."
So forgiving is Sweet that Miss Lester, a nurse as disdainful and distrustful of doctors as she is devoted to her patients, is portrayed as a lost treasure.
"Miss Lester was right to be suspicious of the medical profession,” Sweet writes and reflects on medicine’s centuries-old power struggles. “Ever since the duties of the monk infirmarian had been split between doctor and nurse, and the Latin curare split into cure and care, there'd been a battle going on for control. Who would be in command of the hospital? Doctor or nurse? Whose model  of curare would triumph? Cure or care? And this battle was joined at the French Revolution, when the doctors tried to wrest control of the Hotel-Dieu in Paris from its nursing nuns.”
At Laguna Honda, patients often are victims of their own behavior, and Sweet doesn't sugar-coat this. The patience they require is that of, well, a saint.
Over time, Sweet watches her profession transition from physician to health-care provider. GIven a tour of the new Laguna Honda building, she asks where is the doctors' office? There seems to have been an oversight, and the cost-containment strategy bans new patients but keeps the mayor's PR consultants on the payroll.
Sweet values efficiency, if not in hospital administration, then in her prose. She is a wonderful story teller and gifted at human insight, a nice skill in a writer, even better in a physician.
God's Hotel left me wondering whether an MRI would have shown Dr. Sweet anything more than she learned sitting quietly in the dark with a writhing patient. I wondered, too, whether a caring society can afford NOT to pay a nurse to sit, watch and knit.
And as efficiency came to seem, not a cure, but a disease, I was left with this sad impression:  In caring for the poor and sickly, this apparently isn’t a good time.
"God's Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine," by Victoria Sweet (Riverhead; $27.95).

(This blog post published originally at paulcmclean.wordpress.com)

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