Outside the admitting ward, it was not quiet. There were a lot of politics.
First, there was Proposition D.
The Committee to Save Laguna Honda had come up with a strategy to prevent Dr. Stein from turning the hospital into a psychiatric facility—Proposition D, a ballot measure sponsored by a second, related group, San Franciscans for Laguna Honda. Proposition D would rezone the hospital as a “special use zone,” its special use being that it would care only for the chronically ill and never for the psychiatrically disabled, drug-abusing homeless. It was a clever strategy, but it had two problems. In order to fund the campaign, the committee took money from the Builders’ Association and had agreed that the proposition would also allow the building of for-profit residential care facilities on city lands. Second, if the proposition passed, the zoning administrator, not the doctors or the hospital, would henceforth have the last say on admissions.
The mayor and Dr. Stein took advantage of these flaws. In their arguments they said that Proposition D was “probably the most poorly drafted proposition” in the city’s history. It would put the zoning administrator in charge of admissions, allow residential care facilities everywhere in the city, and require Laguna Honda to discharge hundreds of its Alzheimer’s patients.
The committee tried to defend the measure, but they ended up simply attacking the mayor and Dr. Stein. The mayor was “deceptive” and “despicable,” they wrote. Dr. Stein was driven not by the needs of patients but only by his budget. Sister Miriam lost her temper once again and declared that voting against Proposition D would be actually “immoral.” Even I was not convinced by these ad hominem attacks, and Proposition D went down to defeat three to one.
To their credit, Dr. Stein and the mayor did not immediately retaliate against Sister Miriam, Dr. Kay, Dr. Romero, and the rest of the committee for the attacks against themselves. Nor was it a full rout on the patient-admission front. Perhaps Dr. Stein was chastened. But whatever the reason, we were no longer getting the psychotic, drug-abusing criminals that Dr. Romero had tried so hard to stop from being admitted. Most likely, Dr. Stein had a longer-term retributory plan in mind. I think, as a matter of fact, he did. Certainly the next years would prove difficult for Sister Miriam, Dr. Kay, and Dr. Romero.
The next thing that happened was the Chambers class-action lawsuit against the city. It alleged that by keeping patients at Laguna Honda, the city violated the civil rights of the disabled.
If this sounds familiar, it was. Chambers v. City and County of San Francisco was a continuation of Davis. Davis had won its demand that the city review every Laguna Honda patient for discharge and inform them of community alternatives. Chambers went three steps further. It demanded that the city provide those community alternatives to any patient who wanted to be discharged; that the city cut the new Laguna Honda by one-third; and that the hospital change its mission from long-term care to short-term rehabilitative care.
To find the six patient-plaintiffs for Chambers, the lawyers strolled around the hospital for months, putting up flyers and encouraging patients to join their suit. Most of the patients didn’t want to leave the hospital, the lawyers discovered, but eventually they found six who did. Two were not, perhaps, the best choices for a case alleging the hospital’s failure to discharge patients because they had already been discharged from Laguna Honda twice. The family of the third patient opposed his discharge and fought his inclusion as a plaintiff. But the other three plaintiffs were good examples of patients who could have been discharged if we had money enough for housing and the panoply of services each one needed.
Because Chambers was right: Disabled patients are best cared for at home. And if money were no object, every patient at Laguna Honda could have been discharged. But money was an object. The lawyers for Chambers argued that caring for our patients at home would be less expensive than in the hospital, but their calculations worked out only because they estimated the cost of the patients’ medical care at zero. Yet it was precisely their medical problems that brought patients to Laguna Honda in the first place, and it was their medical problems that made them so complicated, so expensive, and so difficult to discharge. And although Laguna Honda was expensive, it was still cost-effective, because with our daily doctor visits, careful nursing, and open wards, it was rare for a patient to get so sick that he needed to be admitted to the County.
The lawyers for Chambers also argued that Laguna Honda was big, old, and old-fashioned. Which was true. But with its faults, it had its virtues. In fact, its faults were its virtues. Its very bigness, oldness, and old-fashionedness provided play in the city’s health-care system. At Laguna Honda we knew we could always find a place for someone with no other place to go.
So we all worried about Chambers, although the mayor and Dr. Stein seemed sanguine about its demands and settled the suit without a fight. The board of supervisors agreed to provide whatever money was needed so that any patient who wanted to leave the hospital could leave. It also provided funds for still another new program, the “Diversion and Community Integration Program,” to monitor admissions and discharges. And last, it cut the new Laguna Honda by one-third.
No one knew how much this Chambers settlement would end up costing. Rumor had it that discharging the lead plaintiff alone came to $78,000 per year, not including his medical care or housing. But Dr. Stein seemed happy about it. And in his next budget, he cut out of the settlement the position of Dr. Kay’s hospice chaplain, which Sister Miriam had instituted so long ago and was still so very proud of.
During all of this—my return to the admitting ward, Proposition D, Chambers—Rosalind and I continued our pilgrimage to Santiago de Compostela.
The third section of the pilgrimage goes over the Pyrenees and halfway across Spain. That walk was even more varied than the first two, and there were many more pilgrims. What I took back to the hospital that third year was the day we got ahead of “our group.”
Not that we had a formal group. Rosalind and I traveled as the two of us; nevertheless, groups formed, just as they had for Chaucer at the inn of The Canterbury Tales. Because, starting out from the same place every day, most people walk about the same distance—a kilometer every fifteen minutes, or about two miles an hour. Some walk quickly, arrive at their destination early, and take a siesta or drink a beer. Others take their time, though they still arrive at the same destination by the end of the day. So groups naturally form: the two Americans, the French singers, the flirtatious divorcée, the talkative Spaniards, the friendly Dane, the two serious Germans.
But that particular day we somehow got ahead of “our” group—a whole day ahead, though we didn’t know it. That evening we went out for dinner, sat down at a table, and ordered. As we waited for our meal, I noticed that right next to us, at the next table, were two other American women—pilgrims just about our age. They even looked kind of like us. Then I sat back in my chair and looked around. Sure enough. Over there were the two somber German pilgrims, engaged in their serious discussion, except they were not our serious German pilgrims. There was the French singing group—true, they were Belgian and they didn’t sing but played recorders, but still. Way in the back was a dour Norwegian, taking the place of our friendly Dane. And the little group of Spaniards, talking loudly, just not our Spaniards.
It was uncanny. It was a whole group of pilgrims traveling together, just like our group of pilgrims, but not our group of pilgrims. All the time I’d thought we were unique, walking on the pilgrim path; I thought it was our pilgrim path, walked by us for the first time, opening its adventures, stumbles, and stones for the first time—to us. But no. Ahead of us, all the time, was a near-identical group, and, doubtless, behind us, too. For lo and behold, there “they”—that is, “we”—were, in the restaurant that night, a version of ourselves and our group. Unaware that just one day’s walk behind them were their adequate replacements. And, two days ahead of them, and two days behind them, too.
That is what I brought back to the
hospital that year.
I’d already begun to realize something like that. On the admitting ward, I’d noticed there was a way in which my patients were almost, if not quite, interchangeable. I always had a kind of “group,” it seemed: two Bad Boys, one Bad Girl, one querulous old woman, one stroked-out Chinese, one aging hobo, one new and miscellaneous. But after that third year of the pilgrimage, I began to see that it was also true about the nurses and the doctors and everyone else at the hospital. My group, individual as each of its members was—Dr. Jeffers, Dr. Fintner, Dr. Romero, Dr. Kay, Larissa, Christina, Mr. Conley, even Dr. S.—was not unique. After us, as before us, would assemble some other group, with our approximate equivalents. It might be in a different building, in a new Laguna Honda, even in a different century, but such a group would arise; the nature of the hospital required it.
My patients and I and the doctors and nurses and administrators were just as accidental a group as a group of pilgrims on their way.
I found that to be a very relaxing thought. It meant I was off the hook. If I weren’t the perfect Dr. S. this time—well, eventually someone would come along who would be.
It also meant that the parts we were playing were, in some sense, parts; as if this time, I’ll be doctor and you’ll be patient; next time, we’ll switch. And so, after that third section of the pilgrimage, I began to look much more closely into the faces and eyes of my patients and the janitors and the nurses and the bus drivers. Which parts were they playing? I wondered. And I found they were looking back at me in the same searching, intimate way.
In the meantime, Mr. Conley, our new executive administrator, was trying to figure out how he could implement Chambers, especially its requirement that the new Laguna Honda be one-third smaller.
How was he going to do that? The obvious thing would be to stop admissions and just let the census dwindle down to 780, which would take more than a year. But there was a long waiting list of patients, and he would be pressured to admit them. It would play hell with his budget, too, which was based on revenues for 1,030 patients, not for 780. Plus, he would have to lay off staff and that would be tricky, because it wasn’t like whole wards would be emptied; each ward would just dwindle.
So Mr. Conley decided to do nothing. He would wait until the new facility opened. Then he would transfer the sickest 780 patients over, and leave the other 250 patients at the old facility, from which they would gradually be discharged. Of course, that would mean keeping two hospitals, two kitchens, and two policy-and-procedure manuals going at the same time, and he couldn’t imagine how it would all work out, but he couldn’t come up with any other possibility.
Now, Mr. Conley was a bluff, hearty fellow, with an energetic, gravelly voice, red hair, and a red beard. He reminded me of the youngish Henry VIII around the time he fell in love with Anne Boleyn, and he was, as they said in the Middle Ages, Dr. Stein’s Man. His orders were to change Laguna Honda from an old-fashioned almshouse to a modern healthcare and rehabilitation facility, and he had been warned by Dr. Stein about the obstructions he would face—the balky doctors, the obstreperous nun, the ex-director of nursing. Mr. Conley was prepared. But Mr. Conley, with the best will in the world, eventually made a fatal mistake—he stepped out of the administration wing and met the patients of Laguna Honda.
I don’t know how it happened, but I suppose it had to do with the crashing of our computers—every computer in the hospital, and everything about them—e-mail, printing, all the laboratory data, all the MDS forms. The computers went down and stayed down for months. It was fortunate that the hospital was as big and sloppy as it was, because not everything was on those computers. Most of us still had our books; the telephones were still plugged into the walls; we still had our wooden mailboxes, overhead paging, and clocks.
There was no e-mail, however, and so instead of sitting in his re-redecorated administration wing and shooting out electronic missives, Mr. Conley had to scribble his messages on pieces of paper and, when they were important and confidential, deliver them himself. Huffing and puffing the whole long length of the hospital, himself praying that the elevator would start and not stop midway, himself passing the tattooed smokers in Harmony Park—like the rest of us, Mr. Conley fell under Laguna Honda’s spell. He began to say hello to the patients he passed. He began to know some of them. He began to visit them in their rooms and on the open wards. And he softened. He got a bit confused. Perhaps there were patients at Laguna Honda and not simply “residents.” Perhaps Laguna Honda was a hospital and not a health-care and rehabilitation facility.
And so, even after the computers were fixed, which took four months—and I was surprised at how much less work I had while they were down, even including telephoning the lab for my lab results—Mr. Conley continued to step out of the administration wing and visit the patients. Not with Miss Lester’s compressed mouth and eagle eye, but still, he sat on beds; he talked; he listened; and he learned about the hospital from the patients’ point of view.
Which would prove to be fatal.
No, Mr. Conley was not a lucky man. At least not as far as Laguna Honda was concerned and especially not as far as this particular time went.
Almost immediately after Chambers was filed, and while the computers were still down, Mrs. Han fell to her death from a second- or possibly third-story window, and no one knew how. She was demented, to be sure, and one afternoon she was more agitated than usual, wandering around her ward and trying to get out of the hospital to visit her family. The nurses put her to bed and gave her a sedative. Mrs. Han fell asleep, and they went about their other tasks. But a few hours later when they returned to check on her, her bed was empty. They found her bracelet on the ledge of an open window and her body two, or possibly three, stories below. She was dead.
Naturally, the state began an investigation.
Next, The Wall Street Journal contacted Mr. Conley. It was doing a piece on the anachronism of old-fashioned institutions like Laguna Honda and was sending out a reporter to interview him. The very same week, the Department of Justice arrived and handed him five pages of questions to answer about the status of their minimal remedial measures. And then came a TV journalist with coifed hair and jutting jaw, to interview him on camera about Mrs. Han’s death and the several investigations taking place.
Now, Mr. Conley was a nice man and a marine engineer, but in that interview he was out of his depth. When the reporter asked him how it happened that such a confused, restless woman as Mrs. Han, who was trying to get out of the hospital, had been left alone long enough to get out the window, Mr. Conley kind of put his foot in it.
“She was clearly supervised,” he answered.
“Oh, come on, Mr. Conley,” the reporter said. “She was supervised to the point she went out a third-floor window?”
“It wasn’t a third-floor window,” Mr. Conley corrected.
What was he going to do to prevent further incidents?
“I think you improve staffing,” he replied. “You look at your procedures, you look at your quality measures, and you stay focused on them; you try not to get distracted by external factors.”
The reporter followed up by interviewing a former Laguna Honda doctor, who told him that Mrs. Han’s death had everything to do with the mayor’s budget cuts to the hospital. Mrs. Han needed someone to sit and watch her, which she hadn’t had. Had a sitter been with her, she would not have gone out that window. But sitters were expensive, the doctor pointed out, and Mr. Conley had all but cut them from his budget.
Then the reporter tried to get the mayor’s response to this accusation. He sent in a request for an interview; he telephoned; and finally he waylaid the mayor coming out of a meeting. Did the mayor agree that his budget cuts had caused the death of a patient?
The mayor, who was just as well-coifed as the reporter, had no comment.
But right after that, Mr. Conley’s luck changed. One hundred thousand dollars turned up in his budget, earmarked for hiring a public relations fir
m to “support the hospital’s journey from institution to community.” Also, he had a new position to fill, a director of government and community relations, to “handle negative publicity and improve Laguna Honda’s community and media relations.” Mr. Conley did not have to look far for either one. For our first public relations firm, he selected the firm that the mayor used. For our first director of government and community relations, he hired the mayor’s spokesman, Adrian Serf. Also, at Dr. Stein’s request, he hired back Dr. Dan as assistant medical director, to help him out with all the new paperwork, questions, and decisions.
It was more and more difficult for us to take care of patients. With the computers down for so long, I had to depend even more than before on my physical examination and on Hildegard’s methodus medendi, and with the investigators, the media, the articles, and the press all so confident that our big old almshouse was not the wave of the future, it was easy to get demoralized.
Eventually, however, things seemed to settle down. Perhaps we were getting used to the changes. The hospital passed its next licensing and certification review; the computers came back online; and the new Laguna Honda finally began to emerge from the filled-in valley.
It had been so quiet over there for so many years. I’d gotten used to the parade of trucks up and down the hill, arriving with dirt, leaving with dirt; the wire fences; the tree removals; the swaths of earth replacing meadows. And so I was surprised one day to see real buildings, with steel girders and glass walls, rising out of the dirt. Suddenly—there was the Link Building, green-glassed and handsome, just as the architects had shown us years before. There was the South Building next to it, square and tall and wrapped in white. There was no East Building because Chambers had eliminated it; and construction of the West Building was delayed until Clarendon Hall could be demolished. Nevertheless, it was interesting. Sudden. Disconcerting.
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 28