Letter From the Editor

Bruce D. Cheson, MD

Clinical Advances in Hematology & Oncology

February 2014, Volume 12, Issue 2


It described the way we should want to practice medicine. That was the basic conclusion we reached during the most recent meeting of our hematology-oncology book club. The selected volume was an excellent read entitled God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine by physician Victoria Sweet. “God’s hotel” is a translation of Hôtel-Dieu, a type of charitable hospital from the Middle Ages.

The author of this nonfiction journey within a journey started off as a young physician who took a position at Laguna Honda Hospital in San Francisco, California, intending to be there part-time for a few months so that she could pursue her doctorate. She ended up remaining for 20 years. She was writing a thesis on the history of medicine, with a focus on Hildegard of Bingen, a medieval poet, physician, and abbess who practiced a form of alternative medicine that was highly successful in her day. It was not the herbal “eye of newt” sort of medieval medicine, but one that focused on both the body and the spirit of the patient. Sweet successfully brought this attention to both body and spirit to the care of her patients.

Laguna Honda was the last remaining almshouse in the United States, situated on 60 acres of land with an ocean view. It served as a virtual home to 1178 patients who were the poorest of the poor. The hospital had limited technology—the most sophisticated piece of equipment was an x-ray machine—and sparse resources. Nevertheless, the people who worked there were blessed with the most important of treasures: time. The clinicians had time to spend with their patients and to understand them. With this often came the opportunity to diagnose conditions that had been missed by the local county hospital that had “dumped” them.

Several patients in particular struck our group. One was a woman who had been deemed mentally ill for years, but who had a miraculous recovery when Sweet realized that what she really needed was a pair of glasses. Another patient with communication difficulties had been written off as demented by previous doctors, when in fact she had been suffering from a painful dislocated hip. Once her hip was repaired, a relatively normal person emerged. Not all the patients could be success stories; many had a history of mental illness or substance abuse. The staff did remarkably well, however, given the resources and the challenging patient population.

When I asked my group what impressed them most about the story, it was that Sweet had been able to practice medicine in a manner we are not able to. The way we practice medicine today is inconsistent with the reasons we all became doctors to begin with. Our hours are consumed by learning modules, unending forms for everything, electronic medical records, and reporting to a bureaucratic structure that values the dollar over the patient. At Laguna Honda, patients stayed until they were better. For example, one patient had a severe, life-threatening pressure sore that took years to finally heal, but finally did because the staff had the time and interest to help. Nowadays, physicians are rewarded for how quickly patients can be discharged from the hospital; ready or not, there they go! Another reason why Laguna Honda worked well was the sense of community, which was bolstered by open wards that gave the patients a sense of belonging. A couple even met, courted, and had their wedding there while still inpatients!

The Laguna Honda system began to unravel after a new administrative structure was imposed on it that transformed a highly functional system into one that was unworkable. The downfall started with halving the number of nurses, the cornerstone of patient care.

The book came to an end after many of the patients and staff had been moved to a nearby, brand-new structure designed by administrators with neither a sense of history nor an understanding of what was needed for patient care. The rooms were private, the wards were carpeted, and there was no convenient closet space or room for wheelchairs: a lovely facade that was not functional.

The members of our book group agreed that the major problem with everything from patient care to clinical research is the layers upon layers of structure that prevents function. If only the administrators—whether they be in hospitals or in government agencies—would take the time to get involved, to see what is really going on and what is needed, the patients would be better off. Administrators are where they are because of who they are, however, so things are unlikely to improve. We have become victims of efficiency. Those who suffer most are our patients, whom we entered this profession to serve.

Until next month . . .

Bruce D. Cheson, MD