Unlike Professor Doctor Weitz, however, Jack was not a physician. Instead of going to medical school, he’d gone straight to graduate school for a PhD in the history of science. This was no longer unusual; there was a whole new generation of medical historians who had PhDs but not MDs. They were scholars, but not doctors, and they studied medicine from the point of view of the patient, not the doctor. Indeed, they were skeptical of the doctor’s point of view. They interpreted medical professionalization as simple power politics, and, though few, they had an outsized effect on the health-care policy decisions of the 1980s and 1990s. The closure of the state mental hospitals, for instance, was based on research by a PhD graduate student about the negative effects of institutionalization on mental patients. Jack was young and energetic, and we became friends instantly. He talked fast and laughed often, and was Professor Doctor Weitz’s polar opposite. Together the two of them made a good, if truncated, team for my research.
My master’s thesis was to be a prelude to my PhD, and the question Jack and Dr. Weitz wanted me to answer with it was: What was the context of Hildegard’s medicine? That is, who else was practicing medicine in the twelfth century? How were they trained? What medications did they use? What theories did they hold? Their idea was that I would apply what we already knew about premodern medicine to Hildegard, and then apply what I learned about Hildegard’s medicine to fill out our understanding of premodern medicine. No one had ever done that. Instead, Hildegard’s medicine was dismissed by historians as simply an example of saintly medicine, based only on faith and prayer. No one had tried to use it as a way to understand premodern medicine, or use premodern medicine as a way to understand it.
I started by researching the kind of medicine practiced around Hildegard in twelfth-century Germany. I learned that there were many kinds of practitioners—monks, university-educated doctors, herbalists, and Jewish doctors. Each had a different way of learning medicine—as an apprentice, at a university, through family and friends—and each had his own medical texts, in German, Latin, or Hebrew. Many of these texts survived, and I studied them. All of them, I was surprised to discover, although written in different languages and coming from different traditions, were similar. Each had a simple, practical structure. First, a short explanation of the System of the Fours; next, an explanation of the humoral body; last, a series of herbal prescriptions for the maladies of the body, in order, from head to toe.
When I compared Hildegard’s text, Causae et Curae, to them, it was not different. It was structured just like the others, and was practical, relying on medications, not on prayer. Hildegard did have her own way of looking at things, and she did include some things that the other texts did not include—a technique for bleeding a patient; a method for moxibustion. She even had a section on taking care of farm animals, which I found rather whimsical, particularly her herbal prescription for headache in mules. But on the whole, Hildegard’s medicine simply reflected the usual practice of medicine in the twelfth century.
I wrote up my thesis; Jack and Dr. Weitz approved it, and they advanced me to the doctoral level.
My PhD, I decided, would be a much deeper exploration of Hildegard’s medicine. I would immerse myself into her life, education and medical training, into her context, and, finally, into her practice of medicine, which I wanted to understand thoroughly, as if it were mine.
Dr. Weitz advised me that my plan was quite ambitious. It would take me years. I might even have to spend some time in Europe, studying medieval medical manuscripts in the old libraries.
That would be fine with me, I told him. I enjoyed my every-other-day alternation between practicing medicine in the hospital and exploring Hildegard’s medicine in the library. Each illuminated the other. It would be good for me to have an alternative world anyway, since, with the report of Dee and Tee, the going at Laguna Honda was beginning, but just beginning, to get the tiniest bit rocky.
It was Kathleen who told me that Dee and Tee had finished their investigation and, after six months, were leaving.
Kathleen was one of our Irish-Catholic nurses. Redheaded with pale, delicate skin and clear blue eyes, she had an honest, almost naive face. As an Irish-Catholic, she belonged to the oldest sect of the hospital’s nurses, which reached back in a continuous line to the nurses of the city’s almshouse of 1862, and further back to the nuns who took care of the almshouse patient before it was called an almshouse, when it was still the hospice of the Middle Ages.
I liked Kathleen. She was a good nurse—attentive and careful, with a strong work ethic and a willing pair of hands. Also, conforming to two out of the three of the traditional requirements for a nun, she was obedient and stable, though, being married, not chaste. She had trained as a student nurse with us; and then, after her RN degree, stayed on in the admitting ward. Over the years she would rise in the nursing hierarchy from floor nurse to charge nurse to head nurse, and finally to nursing supervisor, although never into the august region of assistant nursing director.
We ran into each other in the hallway, and Kathleen pulled me into the linen closet and shut the door.
There was a reason for this: The director of nursing, Miss Lester, did not approve of fraternization between nurse and doctor. Evolving friendships, confidences, even the usual caretaking of nurse for doctor—making coffee, hanging up white coats—she viewed askance. Nurses seen to be too friendly with the doctors would find themselves mysteriously transferred to a different ward and a nighttime schedule, and all the nurses except for Larissa took account of this.
Consequently, I got to know the linen closets on many of the wards quite well. I liked them, especially the linen closet on the admitting ward. It was a little smaller than the doctors’ office, and it, too, had a long window at its far end. Wooden shelves lined its walls, on which were stacked the white towels, white sheets, and white cotton blankets our patients used. The linen closet was always sweet-smelling and heated, so that the towels, sheets, and blankets started out, at least, warm and clean. The linen closet was also private.
“Did you hear?” Kathleen asked. “Dee and Tee left yesterday.”
“Really! You know, they never talked to us doctors,” I told her.
“Well, they never talked to us nurses either.”
“What have you heard?”
“Well. They didn’t like us very much. They didn’t like the building—the open wards, the open windows, the open spaces. But they know they can’t do much about that until it’s replaced. So their main recommendation is going to be to cut the number of head nurses in half.”
“How are they going to do that?” I asked.
“They’re going to change the title of head nurse to nurse manager and give each nurse manager two wards instead of one. She’ll carry a beeper and have to supervise both!”
She looked to me for indignation. I didn’t know what to say. It didn’t seem like such a bad idea. Cutting one-half of the head nurses would save a lot of money, and, at the time, I didn’t know much about what the head nurses actually did. On the admitting ward, our head nurse was certainly very busy, what with our thirty-six sick patients, our four or five daily admissions, and our four or five daily discharges, and I couldn’t imagine her with two wards to run.
I also knew that the head nurses made up the caring structure of the hospital, just as the wards made up its physical structure. Each head nurse was responsible for her own ward, and this went all the way back to the medieval monastery. The earliest monastic infirmary was built like a church, with an altar at the end and patients in beds along the walls, under windows; a monk or nun infirmarian was in charge.
After the Middle Ages, other organizational structures for the hospital and the almshouse were tried, but when Florence Nightingale wrote her Notes on Hospitals in the middle of the nineteenth century, she favored the medieval. Hospitals should be made up of individual wards she called “pavilions.” Each ward, she advised, should have thirty or so patients, with beds set up along the long w
alls and a solarium at its far end. Each ward should be independent of all the others and capable of acting like a small hospital within the larger. Most important, each ward should have its own head nurse; she would sit at the front, observing and being observed by all thirty patients at once. The head nurse would be in charge of the ward; one head nurse, one ward.
Nightingale’s recommendations were why our wards were structured as they were, each with about thirty beds, a solarium at the far end, and a head nurse at the other; and they were why the head nurse was in charge of her own ward, which was architecturally and in fact a minihospital inside the larger one.
In my visits to other wards I was always struck by how, despite their architectural similarity, each ward had its own character—cheerful or somber, quiet or noisy, social or lonely. Each ward was decorated individually and had its own kind of patient, too; each seemed like its own neighborhood within the village of the hospital. But, until that conversation with Kathleen in the linen closet, I’d never stopped to think about how much, or whether, this individuality depended on the head nurse. All I knew for sure is that when I went to a ward, the head nurse was always sitting in her chair at the glassed-in nursing station, and from there she monitored her ward, both patients and staff. She also answered the phones, tidied the charts, talked to the families, and helped the nurses, if they were busy, with whatever they had to do. Still, cutting the number of head nurses by 50 percent would save a lot of money, and, though I didn’t tell Kathleen, I wasn’t sure whether it was a good idea or not.
When Dee and Tee’s report came out some months later, Kathleen turned out to be right.
Dee and Tee had been taken aback by their time at Laguna Honda, the report said. They’d been stunned by the immensity of the aged facility and its inefficiencies of space; by its wide, tiled corridors and its long, open windows; by its legless smokers congregating in the hall and drinking out of brown paper bags. They’d been appalled by the time the therapists wasted in taking care of the aviary, the greenhouse, and the barnyard; by the live-in priest, by the resident nun, and by the podiatry students who lived in an unused wing.
Above all, the report said, they’d been amazed by the anachronistic presence of a head nurse on every one of the hospital’s thirty-eight wards. As far as they could tell, this head nurse did nothing but sit most of the day in her chair in the nursing station. She answered the phone, to be sure, and kept the charts tidy; now and again she went out and inspected a patient with one of her nurses. Also, she made coffee, kept the TV room and lounge neat, organized patients’ birthday parties, and, in general, did whatever needed to be done. It was a pleasant job, Dee and Tee observed, helpful, no doubt, but one hundred years after Frederick Taylor’s description of scientific management, and in a time of tightening health-care budgets, such a use of a skilled RN was excessive. They’d even seen one head nurse whose only task was knitting. That’s right, a head nurse who, as far as they could tell, spent all day in her chair at the head of her ward, doing nothing except knitting blankets and booties for her patients.
So their main recommendation was to change the nursing structure at Laguna Honda. The job of head nurse should be eliminated. Instead, a new nurse manager position should be created, where each nurse manager would be responsible for two wards instead of one. She would no longer answer the phones, tidy the charts, or help out with patient care. Rather she would manage the staff. And managing meant instituting the fastest, most efficient way of providing care.
This would require a significant use of resources in order to retrain the remaining head nurses—many hours and days would be spent in education and training meetings. But in the end, Dee and Tee were sure, this would produce a tighter ship. And, for certain, it would save a lot of money right away—nineteen salaries, amounting to about two million dollars a year, of which Dee and Tee, as per their contract, would receive 10 percent.
Although the full report was never released, a ripple of disturbance went through the hospital. Soon after, one-half of the head nurses were cut. They weren’t actually laid off, though, but simply reassigned to other administrative positions. The other half were given a beeper, two wards, a new title, and considerable training in the principles of scientific management. As for their former duties—those were not reassigned. They would be done by whoever had the free time to do them.
It was a lesson in the inefficiency of efficiency. And the best way to explain that is to tell you about the head nurse who knit. Because Dee and Tee had been correct; there was a head nurse who sat at the head of her ward and knit all day.
I’d first run into the results of her industry on one of my days covering the hospital when, on the way through the wide hall to another ward, I passed two little ladies sitting outside of their ward. They had been wheeled there so that they could have a porchlike view of the passing world, and they looked almost identical, with white hair, small bodies, and quiet manner. What made me stop were their blankets. The lady on the left was wrapped in a thick, hand-knit white and blue blanket; and the lady on the right had a hand-knit white and purple blanket tucked around her.
When I got back to the admitting ward, I asked Larissa about the blankets, and she told me that the head nurse of their ward had vowed to knit blankets and booties for each of her thirty-six charges. I should go take a look. So I walked back to that ward.
It was a little-old-lady ward, with thirty-six little old ladies—white-haired, tiny, and old—and sure enough, almost every one was wrapped in or had on her bed a hand-knit blanket: white and green, white and red, white and yellow. And there was the head nurse, sitting in her chair in the nursing station, answering the phone, fussing with the charts, observing her charges, and knitting one of the few blankets remaining to be done.
I’ve thought a lot about those blankets since the disappearance of the head nurses and their well-run neighborhoods of wards. About what the blankets meant and what they signified. And here’s the thing: The blankets made me sit up and take notice. Made me pay attention. Marked out that head nurse as especially attentive, especially present, especially caring. It put me and everyone else on notice.
It’s not that the ladies for whom they were knitted appreciated them or even noticed them. Who did notice was—everyone else. Visiting family noticed. Looking down the center aisle, they saw two rows of little white-haired ladies—their mothers, great-aunts, and sisters—each lady bundled up in a bright, many-colored, hand-knit blanket. They also saw that each had makeup on, and her hair done and her nails polished, by the nurses who knew that, down at the end of the ward, was the head nurse, knitting. The Russian ambulance drivers noticed, when they rushed onto the ward to pick up one of the ladies, that each was wrapped in a colorful identifying blanket. They also noticed the head nurse, sitting in the nursing station, answering the phones, arranging the charts, and directing them to the correct patient. Even the doctors noticed. The blankets put us all on notice that this was a head nurse who cared.
Those knitted blankets lasted for years, through many other investigations, and every time I passed a little lady wrapped in one, I thought about that head nurse, about her vow, and about Dee and Tee. And about efficiency. Because those blankets signified even more than attention and caring. The click of that head nurse’s knitting needles was the meditative click of—nothing more to be done. Although it had seemed to Dee and Tee that the head nurse did nothing except knit, that nothing was the nothing that, as the Tao says, the Superior Man does when everything that was supposed to be done has been done.
We did get used to the new system eventually. The remaining staff learned to answer the phones, tidy the charts, talk to families, help the doctors, survey the ward, and support one another at the same time as they were looking on the computer or filling out the forms that the new nurse managers created. But the new system had a cost. It was stressful. After the head nurses were cut in half, there were more illnesses and more sick days among the staff; there were more injuries, more di
sabilities, and earlier retirements. Among the patients, there were more falls, more bedsores, more fights, and more tears. And this, in the broader scheme of things—even of economics—is not efficient.
It was not unlike the closing of the state mental hospitals, which had also seemed at the time so efficient and so cost-effective on paper. And was efficient and cost-effective—on paper. Just not in the real world, where good budgeting intentions will be cut; ideals will be compromised; and where, sometimes, what has no place in the Excel spreadsheet is the key to what makes a system, even a hospital, work.
The report of Dee and Tee taught me not only the lesson of the inefficiency of efficiency. It also taught me the lesson of the efficiency of inefficiency.
Because it wasn’t just the tasks of the head nurse that fell by the wayside with Dee and Tee’s recommendations. It wasn’t even their watchful re-creation of neighborhoods within the village of the hospital. It was the time they had, the unassigned time, that not only belonged to them but spread itself to all the staff—doctors included. That unassigned time, as inefficient as it seemed to Dee and Tee, turned out to be one of the secret ingredients of Laguna Honda. With the elimination of the head nurses, so economical on paper, some of that extra time was also eliminated, and with it, some of the mental space to focus and to care. There was, I discovered, a connection between inefficiency and good care, and it was epitomized by one of my heroes, the handsome Dr. Curtis.
Four
THE MIRACULOUS HEALING OF TERRY BECKER
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 8