Book Review: God's Hotel by Victoria Sweet

God's Hotel: A Doctor, A Hospital, and a Pilgrimage to the Heart of Medicine. Victoria Sweet. Riverhead Books (2012). 372 pages. Genre: Memoir.

First Lines:  "It was my first autopsy, my first day in the clinical clerkship of medical school called pathology.

Of course, I had seen and even taken apart dead bodies before, in the first months of medical school, but those had been bodies that were clearly ex-bodies."

Summary:  When Victoria Sweet first entered medical school she intended to pursue psychiatry.  After two years of medical school a student begins practicing what they have learned on real patients.  She found she loved the process of taking the patient's "history", the actual process of examining the patient and noticing what clues the condition had written on the body and then analyzing the facts and coming to a conclusion which is a diagnosis and plan for treatment.  When she finished medical school she realized that psychiatry "had changed since Jung" and this was a bad thing in her mind.  So, she practiced medicine in a country clinic.  

Ever since that first autopsy in medical school she wondered about the invisible force that made a body alive and when it left made the body dead.  While practicing medicine she continued to research.  It was during this research that she discovered a book about a German nun's medical practice in the Middle Ages.  This is how she began to learn about "premodern medicine".  She discovered that, unlike modern medicine, "The body was not imagined as a machine nor disease as a mechanical breakdown."  This was thrilling and she wanted to learn more. So she began looking for a position that would allow her to practice medicine while also pursuing a doctorate in the history of medicine.  

This led her to Laguna Honda Hospital in San Francisco.  

"Laguna Honda was an almshouse, she explained as we started, or, as the French called it, an Hotel-Dieu - God's Hotel - a kind of hospital from the Middle Ages that evolved as a way of taking care of those who couldn't take care of themselves."

There was a time in our history when every county had an almshouse.  Laguna Honda was the last almshouse in America.  Dr. Sweet was hired as a part-time physician and this book is the story of the years she spent there.

My thoughts:  What a fascinating book!  Victoria Sweet is an amazing storyteller and that made this book hard to put down.  

As she tells the story of her time at Laguna Honda we are introduced to some of the doctors and nurses she works with as well as some of her patients.  As in a great work of fiction, I fell in love with many of them.  

While working at the hospital she is also pursuing a doctorate in medical history and it is interesting to follow her on this journey which eventually takes her to Switzerland for a year.  Along the way she shares with the reader what she is learning. 

Many changes begin to take place at Laguna Honda.  The Department of Justice is sent to do a review.  After months of investigation and pages of reports, the DOJ found Laguna Honda to be inefficient, unsafe and lacking privacy.  Changes would need to be made.  Dr. Sweet thought about these things as she made her rounds.  It may be true that things were inefficient, but sometimes that inefficiency was actually more efficient than the so called efficient methods and often saved more money.

For example, there is the case of Mrs. Muller.  She became Dr. Sweet's patient when she was brought in to Laguna Honda because she just couldn't manage anymore.  Eight months ago she had broken her hip.  She had had surgery to replace the hip and was sent home.  However, after the surgery she became delirious.  Her workup showed no acute medical problems, so her doctors concluded that she had undiagnosed Alzheimer's disease that was causing the psychosis and started her on an antipsychotic medication.  She was also found to have diabetes and put on medication for that.  She remained confused even though she was on the antipsychotic medication and became withdrawn and unable to manage her diabetes.  She complained that her hip hurt.  All of these things are what brought her to Laguna Honda.  

Dr. Sweet always started by meeting with a new patient.  That way she could examine them for herself regardless of what the chart might say.  She expected Mrs. Muller to be withdrawn and confused, but when she greeted her, she got a "Good afternoon" in response.  She knew her name, where she was, the date and what was wrong with her.  An Alzheimer's patient would not necessarily be able to tell her these things.  As she continued the physical examination, she couldn't find any of the subtle signs of diabetes.  On examining her hip, she found very restricted range of motion which is unusual 6 months after surgery.  After taking an x-ray she discovered that Mrs. Muller's new hip was dislocated which is what was causing her pain and lack in range of motion.  She scheduled surgery to put the hip back in place.  After this she seemed better, more relaxed.  Once her hip healed from the surgery, Dr. Sweet discontinued the pain medication.  Mrs. Muller became brighter and stronger.  In a few more weeks, Dr. Sweet wondered if she was really demented or psychotic.  She decided to try taking her off of the antipsychotic medication.  This process takes several weeks of tapering the medication.  Mrs. Muller got brighter and stronger each day.  She asked if she could go to physical therapy and learn to walk again.  After 3 months she was doing quite well and Dr. Sweet revisited her diabetes diagnosis.  She didn't see any physical signs of long-term diabetes and so decided to gradually taper her off of the insulin to see what would happen.  Nothing happened.  She was fine without the insulin.  Mrs. Muller did eventually go home.

Dr. Sweet's point was that at Laguna Honda they had time to do this type of thing.  Also, the doctors weren't specialized and were able to look at all the angles.  The efficiency of the health-care system meant that they wanted to take care of the problem in the quickest way possible.  There was no time to observe and wait.  Also it meant, for example, that the physical therapist only worked on physical therapy and didn't try to figure out why Mrs. Muller's range of motion was limited, the nurses gave her insulin, but didn't question whether she needed it or not.  They didn't work together to make sure the patient was whole, they didn't have time.  So, if she would have come to Laguna Honda first, where they were inefficient and able to just observe a patient for a while, they could have saved so much time, discomfort and money.

Another example of inefficiency was Miss Lester.  She had been the director of nursing for thirty-six years.  She had accepted the position right after she got out of the army.  She ran the hospital with a firm hand and an underlying softness.  But if something needed typed, Miss Lester typed it, she answered the telephone, she made calls and she spoke with patients and family members.  Every morning at 6:30 am she met the nursing supervisor of the night and the nursing supervisor of the morn.  Together they went to see every patient in the hospital, all 1,178 of them.  This took approximately 3 hours every single day.  Miss Lester knew everything about every patient and was able to give orders to each head nurse.  In this way Miss Lester gave her patients the very best care and was able to instruct her nurses in providing what was necessary.  

Dr. Sweet began to refer to this process of observing a patient, sitting with them, trying things as Slow Medicine.  

After she finishes her doctorate in medical history, Dr. Sweet takes a pilgrimage.  She decided on the medieval pilgrimage to Santiago de Compostela in Spain.  Because of her work schedule she would need to divide the pilgrimage into four sections and complete them in four years.  The story of each pilgrimage is short and interspersed into whatever was going on at that time in the hospital.

I thoroughly enjoyed this book and highly recommend it.  

Quotes:

"It used to be that all doctors knew Latin.  For centuries, medical books were written in Latin; medical terms were derived from Latin; and, most important, in the days before science, the knowledge of Latin differentiated the physician from the traditional healer."

"Instead it was the Christian monastery of the Middle Ages that originated the hospital system we know today.  In the monastery, caring for the sick was the foremost Christian duty, and each monastery had, therefore, a hospice for taking care of the sick poor and an infirmary for taking care of the sick monks."

"She was expected to die of liver failure, and soon.  Her crime was alcohol.  Now, the liver can tolerate many years of drinking; unlike the brain, heart, or limbs, under the right conditions the liver can regenerate and reconstruct itself."

"There'd been the shutting down of most of the almshouses in the country; then the phasing out of most of the free county hospitals; and, last but not least, the closing of the state mental hospitals.  The closing of the state mental hospitals was particularly disastrous, the result of an unwitting but agreeable collusion of the Left and Right; the Left being convinced that institutionalization of any kind was harmful, and the Right, that institutionalization of any kind was expensive."

"And it made me wonder whether fun, although inefficient, might actually be therapeutic and, therefore, efficient."

"This being Laguna Honda, however, I had the time to wait and see - for family and friends to show up and fill me in on the details; for Mr. Tam to get better or worse or stay the same; for a trial of medications to treat his possible depression, Alzheimer's, Parkinson's.  In short, for Slow Medicine to do its job."