God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine

by Victoria Sweet

  In her case, what saved money were an accurate diagnosis and the leisurely reevaluation of the patient. It wasn’t much—a simple physical examination and an old-fashioned X-ray—but it did take time, quite a bit of time, actually. A thorough exam takes me almost two hours, and my daily visits, while not lengthy, were not rushed, but they were what allowed me to see that Mrs. Muller was not demented, psychotic, or diabetic.

  Economists assume that this kind of care is expensive, but it is still cheaper than an MRI or even a routine lab panel, not counting the cost of keeping Mrs. Muller in the hospital for the rest of her life. I worked it out. At $120,000 per year for the average six years a patient lives at Laguna Honda, less the cost of Mrs. Muller’s resurgery (and not counting the cost for the care her retarded daughter would have required), an accurate diagnosis of Mrs. Muller saved the health-care system about $400,000.

  The case of Mrs. Muller got me to thinking. If doctors were going to be held accountable for costs, why shouldn’t we get some kind of credit for savings? To use for patients, for the kind of care that economists cut out as extravagances?

  What was happening was the opposite: No expense was spared for medications, tests, and procedures, but to make up for that, staff, food, and accoutrements were cut to the bone. The calculus being that the medications, lab tests, and procedures were necessities, but that staff with enough time to do their jobs were an expendable luxury.

  Doctors in particular. I was amazed at how expensive economists thought doctors were. They instituted many economic maneuvers—de-skilling medicine onto nurses and physician assistants; computerizing medical decision-making; substituting algorithms for thinking—because they assumed that doctors were such expensive commodities. And yet doctors were not expensive, at least, not the doctors I knew. We cost no more than the nurses, the middle managers, and the information technicians, alas. Adding up all the time I spent with Mrs. Muller, the cost of her accurate diagnosis was about the same as one MRI scan, wholesale.

  Economists did the same thing with the other remedies of premodern medicine—good food, quiet surroundings, and the little things—treating them as expensive luxuries and cutting them out of their calculations. At Laguna Honda, for instance, while most patients were on fifteen or even twenty daily medications, many of which they didn’t need, the budget for a patient’s daily meals had been pared down to seven dollars, which could supply only the basics.

  I began to wonder: Had economists ever applied their standard of evidence-based medicine to their own economic assumptions? Under what conditions, with which patients and which diseases was it cost-effective to trade good food, clean surroundings, and doctor time for medications, tests, and procedures? Especially ones that patients didn’t need?

  Although Mrs. Muller was an impressive example of Laguna Honda’s Slow Medicine, she wasn’t the only one. Almost every patient I admitted had incorrect or outmoded diagnoses and was taking medications for them, too. Medications that required regular blood tests; caused side effects that necessitated still more medications; and put the patient at risk for adverse reactions. Typically my patients came in taking fifteen to twenty-five medications, of which they ended up needing, usually, only six or seven.

  And medications, even the cheapest, were expensive. Adding in the cost of side effects, lab tests, adverse reactions, and the time pharmacists, doctors, and nurses needed to prepare, order, and administer them, each medication cost something like six or seven dollars a day. So Laguna Honda’s Slow Medicine, to the extent that it led to discontinuing ten or twelve unnecessary medications, was more efficient than efficient health care by at least seventy dollars per day.

  I thought about what I could buy for my patients with seventy dollars a day. Good food. Not just tasty food, but excellent, organic, and varied food. Good wine. Hildegardian medicinal ales for the anorexic and digestives for the dyspeptic. Acupuncture. Massage. We’d be rich with seventy dollars per day to spend on each of our patients.

  Over the next months, as I studied Hildegard’s medicine, my thinking evolved. Suddenly it occurred to me: Why not have a ward at the hospital where Laguna Honda’s Way of Slow Medicine could be tested for efficiency? Against the efficient health care of the economists? It would be easy to run a two-year experiment. All I would need would be a ward and an administrative dispensation from the forms and regulations raining down, along with a computer program to track the costs and savings incurred. I was pretty sure we’d end up in the black, and I knew just how I’d spend those savings.

  I had a name for the ward, the ecomedicine unit, or ECU. Ecomedicine because it would be an oikos—a self-sufficient system at the level of the body, the ward, and the world. The patient’s body would be an oikos because it would be envisioned not in isolation but as part of its environment. The ward would be an oikos because it would be in balance as a self-sufficient minihospital, with its own ecology within the larger ecology of the hospital and the world. The well-being of the staff would be taken into account as well as the well-being of whatever and whoever came into and left the ecomedicine unit: the plants and animals we ate, the stuff we used and threw away.

  The ECU would be ecologic in a fractal sense, with ecosystems from smallest to biggest, lowest to highest.

  I talked to Dr. Curtis about it. He would be the man to get the ecomedicine unit going.

  It was a great idea, he told me, but he’d already planned his next move, which would be to New Zealand. The surfing there was terrific, and the medical system well run. He was looking forward to the change.

  Then I told Larissa about my idea. Would she consider being the head nurse of the ecomedicine unit? Because a head nurse would be the first thing I would spend money on.

  Of course she would. My ideas, after all, were not so radical; Russia had never lost touch with premodern medicine the way America had. In Russia, she’d often prescribed herbal medicines as tinctures and saunas. They were slower than synthetic medicines but worked pretty well, with fewer side effects. But did I really think that with everything happening at the hospital, with all the new demands of the DOJ and HCFA and Ellen Mary, I would be allowed to start something so, so … counterrevolutionary?

  Dr. Major would help, I said. She would let me have an ecomedicine unit, I was certain.

  Hadn’t I heard? Dr. Major had resigned.

  Larissa was, as usual, well informed. After twelve years Dr. Major was leaving. No one knew why, but she was as frustrated as the rest of us with the ever-increasing number of middle managers and the ever-decreasing clinical staff. Without Dr. Major, I would never be able to get the necessary dispensation to start my ECU.

  It was just as well. It was time to write my PhD and a good time to take a break. I’d saved up enough money from Dr. Weitz’s fellowship to take a year off. Why not go to Europe to write it, where premodern medicine had been born but did not die? I would escape the hospital during its painful metamorphosis; and I could visit Hildegard’s monasteries and villages. I could study beautiful manuscripts in old libraries. And who knows? Perhaps I would never come back to the hospital or to medicine.

  Over the next months I prepared my exit and then went one last time to Dr. Major’s office. She was packing up. She was happy to hear about my plans for the future and happy to sign the form granting me a year’s leave of absence. Then I went back to our doctors’ office; said good-bye to Dr. Romero, Dr. Fintner, and Dr. Jeffers; took my white coat and stethoscope; and a short time later, got on a plane for Switzerland.

  Six

  DR. DIET, DR. QUIET, AND DR. MERRYMAN

  IT WAS EVENING when the jet landed in Switzerland.

  On the steps out of the plane it was foggy and cold, but inside the terminal it was bright, with posters touting the professionalism of a Swiss bank, the craftsmanship of a Swiss watch. How elegant everyone was! Slimmer than in the States, with shaped haircuts, gold around wrist and neck, and leather shoes. My train was just underneath the terminal, and in no time at all I was look
ing out a window at the dark lake and the lights across the lake, in France. It was all so different from the place I’d just left that it was as if I’d been dropped not simply onto a different continent with a different history but onto a different planet.

  I arrived just a few days before an important conference about Hildegard, to be held in her town of Bingen, Germany, and I settled into my flat as quickly as I could. The conference was going to cover all of Hildegard’s facets—her mysticism, her music, her art, and her medicine; and it was scheduled to take place exactly nine centuries after her birth in 1098, and to run through the anniversary of the day of her death on September 17.

  Just knowing those birth and death dates is a lot to know about a medieval person. In the twelfth century there were no bureaus for the registering of birth, death, copyrights, or anything else. But Hildegard took care to mention dates in her writings and to preserve her work for the future. She kept copies of the hundreds of letters she wrote to popes and archbishops, kings and queens; and she made sure that her writings were preserved in a single volume, which has survived to this day. She even wrote a kind of autobiography. So that one of the most unusual things about Hildegard is how much we do know about her, given that she was not a king, a queen, or a pope.

  She was born in Bermersheim, a tiny village in the southwest hills of Germany, and her family was well-to-do and devout. Two of her sisters also became nuns, and two brothers, monks. At eight, she was sent away to be schooled by a distant cousin, Jutta; four years later, she, Jutta, and Jutta’s three other students were admitted to the formerly all-male monastery of Disibodenberg. This was remarkable because it meant that Hildegard would be exposed to the richer, more complex culture of monks.

  After Jutta died, Hildegard took over as the head of the women’s side of Disibodenberg. At forty-two, she began her first book, Scivias, which described and interpreted the spiritual visions she’d had since she was a girl. This was bold. Although the Church was the most powerful institution in Europe at the time, it was threatened by rising dissent. And authors who claimed independent insight into God’s intentions, which was what Hildegard claimed with her visions, were not necessarily embraced. Sometimes they were brought to trial as heretics, imprisoned, and even executed. Hildegard, however, was able to convince first her abbot, then her archbishop, and finally the pope that her visions were from God and not the Devil, and they permitted and even encouraged her to keep writing.

  Then, at fifty, she decided to leave the monastery of Disibodenberg and build her own monastery in Bingen. This was another bold move. Nuns and monks were expected to spend their lives in their original monastery, and her abbot forbade her to leave. Hildegard took to her bed with a serious, though undefined illness that lasted for months. Eventually her abbot gave in, and she made a miraculous recovery. She left for Bingen, taking most of the other nuns with her, along with their dowries of money and land. In Bingen she built a new monastery on the Rupertsberg hill.

  There she spent the rest of her life. Over the next thirty years, she wrote two additional books of visions and composed more than seventy Gregorian chants. For the dedication of her monastery in 1152, she wrote the first musical drama of Europe, the Ordo Virtutum, which her nuns produced and sang, dressed in the scandalous costumes that Hildegard had designed for the occasion. In her seventies, she began to preach in towns across Germany, going out on four separate tours. She wrote many other works, including saints’ lives, her interpretation of the Benedictine Rule, and medical and herbal texts, and she also built a second monastery for the many women who wanted to join her.

  She lived through a fascinating time in Europe, the so-called Twelfth-Century Renaissance, when the West became intrigued by the Arabic culture it had discovered during the First Crusade and began importing, translating, and imitating Arabic music, medicine, astronomy, literature, and technology. In effect, Hildegard lived through a cultural revolution, and perhaps her biggest accomplishment was dying in her sleep at the age of eighty-one, in the monastery she had built, with her legacy and writings intact.

  The conference was going to cover everything.

  In addition to the conference, I wanted to see the village where she was born and what was left of her monasteries at Bingen and Disibodenberg. So as soon as I’d settled in my flat, I took the train to Bingen, and on the Sunday afternoon before the conference, I set off exploring.

  There wasn’t much left of the twelfth century in Bingen, I discovered pretty quickly. It was a forlorn little town on the edge of the Rhine, with a train running right through its center. There were a few structures that Hildegard would have known: Klopp Castle, which would have overlooked her monastery; Saint Martin’s church, whose monks did not like her very much; a Roman bridge she would have used; but even they had all been destroyed and rebuilt many times. Her monastery was gone, destroyed during the Thirty Years’ War, although I’d heard that there was one piece of it still standing, preserved inside a real-estate office.

  It took me a while but I did find the office, which was closed, it being Sunday. I went around to the back anyway and climbed down through weeds to see if I could see inside. The blinds in the back were up and I put my head against the window. There was just enough light for me to make out polished cement floors, recessed halogen lighting, and sleek modern desks. After a while I got used to the darkness and then, suddenly, eerily, I saw it, coming out of the shadows—an immense arch, made of the huge white stone blocks they used in the twelfth century, curving from one end of the office to the other. That was all that was left of Hildegard’s monastery: of the church, cloister, dormitory, refectory, scriptorium, hospice, and infirmary that she had, so radically, with such finesse, managed to build against all odds.

  The conference was being held at the Hildegard Haus in the hills behind Bingen, and it wasn’t fancy, just a few buildings with folding chairs. But planted all around were beds of the medicinal herbs that Hildegard had prescribed—sage and lavender, poppy, rosemary, borage, and many others—and there was a little Hildegard store selling Hildegard statues and calendars and books.

  The talks were in the mornings and the afternoons, with lunch in between so the participants could mix and mingle. But they did not mix and mingle. They were too different. Because, as I gradually realized, there were two kinds of Hildegardians, and they did not see eye to eye. There were the scholars who gave the talks—serious, precise, and pale—and there were the enthusiasts who listened to them—Birkenstock-shod, amulet-wearing, and confident. While the scholars focused on the details of Hildegard’s life, the enthusiasts were enthralled by the big picture, by the medieval woman who composed such grandiose music, painted such remarkable paintings, envisioned such marvelous visions, and brought a new kind of medicine to the modern West. Which was how they saw her medicine—not as an example of premodern medicine but as something new and brilliant. Thin and bright-eyed, the enthusiasts clustered together during lunch at the round dining tables, exchanging medicinal recipes and business cards for their Hildegard spas and Hildegard retreats.

  It was no accident that there were two such different kinds of Hildegardians, because there were two Hildegards—the Hildegard who came out in her theology, letters, and autobiography, and the Hildegard who came out in her medicine. And the conference participants did not mix and mingle because these two Hildegards were seemingly irreconcilable. The Hildegard of the former was a nun who almost never left her monastery. Shy and devout, she lived a strict Benedictine life, with periods of prayer interspersed with rest and work.

  The Hildegard who came out in her medicine was completely different. She knew about the body—all about the body—and gave prescriptions for everything that body was heir to: headache, toothache, earache; coughs, colds, and cancers; also for infertility, childbirth, and impotence—things no nun should know about. Even her tone was different: Unlike the mystical Hildegard, who was light-filled, abstract, and not of this world, the medical Hildegard was down-to-earth, forthri
ght, and practical.

  It was hard to reconcile the two of them. Most scholars left her medicine alone and concentrated on her theology, letters, music, and art. Other scholars questioned the authenticity of the medical writings ascribed to Hildegard, since all we know about her medicine came from two books, Causae et Curae and Physica, that surfaced only after her death. None of this, however, bothered the Hildegard enthusiasts. For them, her medicine was authentic, unique, and a gift from God to us moderns. It was the revelation of a spiritual medicine, and they took it at face value, planting her herbs, compounding her prescriptions, and drinking her potions.

  I found myself somewhere in between. It was hard for me to imagine how the saintly Hildegard could have written—could have known and cared about!—all the symptoms and earthy problems of Causae et Curae. Yet there they were, and there seemed to be nearly as much evidence for the one Hildegard as for the other. During her life, Hildegard was known as much for being a healer as a mystic; the style of the Latin in Causae et Curae and Physica was the same as in her mystical writing; and in her theology, medicine was one of her main metaphors.

  What finally would decide me was a puzzling but indisputable work by Hildegard, the Lingua Ignota (Unknown Language). It would reassure me that hard as it might be to accept that Hildegard was both a saintly mystic and a medical practitioner, that was our problem, not hers.

  After the conference I went back to Lausanne in Switzerland, and I settled down in my flat that overlooked the lake. My study was white and quiet, especially when it was snowing, which it did a lot that year. All I had in it was a white trestle table, a blue chair, piles of books and papers, and a computer.