Acknowledgments
First and foremost, I thank the patients, staff, and doctors of Laguna Honda Hospital, past, present, and, I think, future. I’ve used pseu-donyms to protect privacy, but you know who you are.
Nevertheless, here in the acknowledgments, in no particular order, I’d like to mention especially certain staff, patients, doctors, and mentors: Elizabeth Cutler, Paul Hendrickson, Monica Banchero, September Williams, Hosea Thomas, Ann Fricker, Larry Funk, Eric Jamison, George Brown, Guenter Risse, Jack and Wendy Pressman, Joan Cadden, Mary Anne Johnson, Craig Wilson, Grace Dammann, Thereso Berta, Johnnie Brooks, Phoebe Lim, Paul Brizendine, Chris Winkler, Brian Dolan, Julie Bresciani, Patrick Monette-Shaw, and Ellen Ficklen. Each one taught me some thing, and often many things, that changed me for the better.
Next I thank my first readers. Rebecca Moore, who freely gave her time and energy to this project, despite her own intense and demanding work. No one has been more passionate and concerned that this book be the absolute best it could be. Patricia Wick, whose critical reading and antipathy to adverbs, adjectives, and any hint of cant forced me to sculpt my prose; and Eleanor Sweet, whose laugh, and whose tears, are worth so much to me.
Others to thank include Oliver Sacks, who was just wonderful. Hearing from me, an unknown writer, he was immediately enthusiastic, generous, and emphatic that I must write this book, as was his assistant, Kate Edgar.
Many thanks to my agent, Mary Evans, who is at once warm and demanding, insightful and romantic, and has such very good ideas and instincts. Her input was crucial in the evolution of my book proposal into a real book.
Rebecca Saletan has been everything I could ask for in an editor: enthusiastic, supportive, wise with her critique, protective, and a lot of fun. Her assistant, Elaine Trevorrow, always came through. Publicity and marketing—Marilyn Ducksworth, Mih-ho Cha, Kate Stark, and their teams—have been great. Special thanks to Riverhead’s publisher, Geoff Kloske, for his belief in the book.
Others without whom God’s Hotel might not have come into being, and certainly not in the way it did, include Jennifer and Robert Leathers, who set the example of true hospitality for us all. I’d like especially to thank their sons, Jeff and Ed, and also Allison and Katie Wick for their excitement, curiosity, and fresh perspectives.
Who else? Glen Worthey and the other librarians at Stanford University Library. Meg Newman for being a wonderful physician. Dan Wick for his bravery under fire. Art Sweet for giving me his energy, his love of life, and some, at least, of his intrepidness.
And last, Jenny, for being a warm and loving partner, and for creating a stable, warm, and loving home with me for many years.
Notes
INTRODUCTION: HOW I CAME TO GOD’S HOTEL
Page 5. Hildegard of Bingen’s Medicine was not a great book: It really wasn’t. It was too presentist; it did not contextualize Hildegard’s medicine; it was more a book of medicine than a book of history; and yet, it was still worth reading. See Wighard Strehlow and Gottfried Hertzka, Hildegard of Bingen’s Medicine, trans. Karin Anderson Strehlow (Santa Fe, NM: Bear & Company, 1988).
Page 7. Laguna Honda, Dr. Major said, was probably the last almshouse in America: It’s hard to know for sure. Originally, Laguna Honda was the San Francisco Almshouse; and, according to the Centers for Medicare and Medicaid Services, it was the last hospital in the country with open wards, so perhaps that entitles it to be called the last almshouse in America. On the almshouse in America, see Charles Rosenberg, “Almshouse or Hospital: Reforming the Public Hospital,” in The Care of Strangers: The Rise of America’s Hospital System (Baltimore, MD: Johns Hopkins University Press, 1995); and David Wagner, The Poorhouse: America’s Forgotten Institution (Lanham, MD: Rowman & Littlefield Publishers, 2005).
CHAPTER ONE: FIRST YEARS
Page 12. The changes in medical financing of health maintenance organizations: In the 1970s a fundamental shift took place in medicine, engineered not by doctors but by economists. Taking the idea from the newly publicized medical payment system of the People’s Republic of China, where doctors got paid only when their patients stayed well, economists proposed that the best way to manage the ever-rising cost of medical care would be if doctors were paid preemptively, to maintain their patients’ health. Instead of getting paid for what they did when a patient got sick, doctors would get paid a fixed amount per patient per month, regardless of how sick or well a patient was during that month. It would be up to the doctors to manage their own budget, and, economists thought, doctors would simply have to learn to be efficient. They did learn, too. Since doctors have no control over the three determinants of health—people’s behaviors, luck, and genetics—they learned that the only way to manage their budgets was not to accept patients who were sick, unlucky, or genetically challenged. Some did this by placing their practice in an old Victorian house, on the third floor, with no elevator, neatly excluding the sick or disabled; others by advertising yoga and meditation, which would be of interest only to the healthy. Doctors also realized that the longer it took them to order a test or do a procedure, the more efficient it was for their budget. For a clear explanation on of how economists understand medicine and health care, see Sherman Folland, Allen C. Goodman, and Miron Stano, The Economics of Health and Health Care, 6th ed. (Upper Saddle River, NJ: Prentice Hall, 2009).
Page 12. (DRGs): The DRG—diagnosis-related group—was based on the same concept as health-management organizations, but applied to hospitals. In this scheme, hospitals would be paid a fixed amount per diagnosis, per patient, per hospitalization, regardless of how much or how little care a particular patient received. Hospitals’ incentives would then become, economists were sure, efficiency, and they were right. Cadres of middle managers were hired to make sure that doctors put the most remunerative diagnosis first on their list of discharge diagnoses (instead of the most important diagnosis), and that doctors discharged patients as soon as possible—and usually sooner. One unintended consequence: Patients were discharged when they were still sick, and often had to be readmitted for another hospitalization soon after. This was not efficient, and medical costs continued to increase. In the health-care act of 2010, this same model of paying a lump sum based on diagnosis was extended to home care and long-term care.
Page 15. There was a waiting list of more than two hundred patients: From Laguna Honda Hospital’s Annual Report, 1993.
Page 15. She showed me a sample of her previous day’s admission: A handwritten note sometimes takes longer than the cutting and pasting of electronic health records, but it has much more information. With our handwritten notes, I knew at a glance who it was who wrote the notes and just how much credence, therefore, to put into its conclusions.
Page 16. A microscope, with boxes of slides: The microscope, centrifuge, and slides would be the first things to go, when Laguna Honda was discovered by modern health-care efficiency. A new law required all “laboratories” to be certified, with annual inspections and policy-and-procedure manuals, and Dr. Major determined that, what with all the extra bureaucracy, it was more cost-effective to send our slides across the city to a laboratory. The microscope, centrifuge, and slides were taken away, and we were no longer able to examine our patients’ blood, urine, or sputum ourselves.
Page 24. It was never easy to track down a discharging doctor: It still isn’t. This should be one of the great advantages of the electronic health record: a clearly written discharge note by the actual discharging physician, with a readable name and accurate cell phone and beeper numbers. But the discharge note is often cut and pasted by a medical student with no knowledge of the patient, and the discharging doctor often randomly chosen by computer. For some reason, the cell phone and beeper numbers are never up to date.
CHAPTER TWO: THE LOVE OF HER LIFE
Page 37: “We’ll never have it this good”: It was no illusion of Dr. Jeffers’s that we would never have it so good. Laguna Honda at the time was a well-run place, as the typed two-page Annual
Report of 1992 made clear. The hospital easily passed its annual inspection. No services were cut, despite it being a recession year. The hospital had no influenza cases, a two-hundred-patient waiting list, and a new laundry system.
Page 42. Dr. Weitz explained its theory to us: For a thorough history of the “System of the Fours,” see Elizabeth Sears, The Ages of Man: Medieval Interpretations of the Life Cycle (Princeton, NJ: Princeton University Press, 1986). See also the diagram of the System of the Fours by Peter S. Baker in “Byrhtferth of Ramsey, De Concordia Mensium Atque Elementorum,” Victoria Sweet, ed., Rooted in the Earth, Rooted in the Sky: Hildegard of Bingen and Premodern Medicine (London: Routledge, 2006), 162.
CHAPTER THREE: THE VISIT OF DEE AND TEE, HEALTH-CARE EFFICIENCY EXPERTS
Page 56. The consulting firm of Dee and Tee: You can’t blame the city. The state had recently passed a law requiring that county health departments compete with private health-care providers, and the city, therefore, had to come up with an “enterprise solution.” Later, I learned that our city’s system was by no means Dee and Tee’s only opportunity to reengineer a hospital. At about the same time as our Laguna Honda experience, Dee and Tee was brought in to help the finances of Beth Israel-Deaconess Medical Center in Boston. For the results, which paralleled our experience at Laguna Honda, see Dana Beth Weinberg, Code Green: Money-Driven Hospitals and the Dismantling of Nursing (Ithaca, NY: Cornell University Press, 2003). She writes, “For the most part, frontline employees’ input was unsolicited; they did not participate in the task forces or meetings [40]…. Overlooking the therapeutic value of nurses’ relationships with patients, administrators insisted that the hospital could not afford to indulge nurses with the luxury of getting to know their patients [179]…. The very restructuring strategies that [the hospital], following trends in the hospital industry, adopted to solve its problems were themselves a problem [183]…. In fact, there is some evidence that trying to wring greater productivity out of employees increased the hospital costs [186].”
Page 57. Looking at the payroll, especially at the laundry: Laundry was one of our oldest departments. It was down in the basement, spread out across the length of a long ward, and every floor above it had a large metal basket affixed to the wall and leading to a chute in the basement. A hundred years ago the laundry had been staffed by patients to help pay for their own care. It was still a pleasant place, its wooden shelves filled with stacks of clean-smelling, starched sheets, gowns, and white coats. Laundry did all the hospital’s laundry, and actually made a profit for the city because it also did the laundry for many other hospitals. All day long, vans pulled up to deliver dirty laundry and take away the newly cleaned. It was a busy place, but not cost-effective, and Dee and Tee calculated that it would make more sense to contract out the laundry services. The city agreed, and Dee and Tee was awarded their 10 percent of savings for the first two years. But it did not share in the increased costs of their plan, which ended up being considerable because the laundry workers continued to work for the city; the city no longer received reimbursement for doing the laundry of other hospitals; and it still had to pay for its own laundry, including the additional expense of transporting it to outside contractors.
Page 58. The closing of the state mental hospitals: For a history, see “Politics of Deinstitutionalization” in Steve M. Gillon, That’s Not What We Meant to Do: Reform and Its Unintended Consequences in Twentieth-Century America (New York: W. W. Norton & Company, 2000). According to Gillon, it was the Community Mental Health Act of 1963 that crippled state mental hospitals. Crafted by Robert Felix, MD, it was a reaction to the conditions of state mental hospitals, revealed in a Life magazine article, “Bedlam,” in 1946, and the 1948 film The Snake Pit, in conjunction with the development of thorazine in 1952. President Kennedy submitted a reform package, and Dr. Felix promised community mental-health centers in lieu of state hospitals. In addition, in order to encourage discharges from mental hospitals, Medicaid decided it would no longer reimburse states for treating patients in mental hospitals, but would reimburse them for treating patients in a facility “not designed solely for the treatment of mental illness.” What happened? Only 768 of the 2,000 promised community centers ever materialized, but mental patients were discharged from the state hospitals anyway. The population of mental patients fell from 504,600 in 1963 to 138,000 in 1980, and many went to the streets or to nursing homes. By 1977, 87 percent of the 1.3 million patients in nursing homes had a diagnosis of chronic mental illness (Gillon, 103). At Laguna Honda, about one-third of my patients had a serious mental illness. Later, Dr. Felix admitted that closing the state mental hospitals was the worst mistake he ever made.
Page 60. He thought he was a vending machine: Jimmy’s psychosis is not uncommon. For instance, see Dr. Swait Pawa and others, “Zinc Toxicity from Massive and Prolonged Coin Ingestion in an Adult,” American Journal of the Medical Sciences 336(5) (November 2008): 430–33, which describes a thirty-eight-year-old schizophrenic who ate coins. See also Dr. Daniel R. Bennett and others, “Zinc Toxicity Following Massive Coin Ingestion,” American Journal of Forensic Medicine and Pathology 18(2) (June 1997): 148–53.
Page 63. He had the right to refuse psychiatric medications: For what happened to the mentally ill after the Mental Health Bar became concerned with their rights, see Rael Jean Isaac and Virginia C. Armat, Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill (New York: The Free Press, 1992), especially chapter seven: “From the Right to Treatment to the Right to Refuse Treatment” (142–60).
Page 64. When the first effective treatment for mental illness was discovered: For a history of lobotomy, see Jack D. Pressman, Last Resort: Psychosurgery and the Limits of Medicine (Cambridge, UK: Cambridge University Press, 1998). On thorazine, see Isaac and Armat, Madness in the Streets, “Psychoactive Drugs, The Last Domino” (221–46). Many of our ideas about the coercive effects of treating mental illness come from the psychiatrist Thomas Szasz, cofounder and chairman of the American Association for the Abolition of Involuntary Mental Hospitalization. For instance, see Thomas Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (New York: HarperCollins Publishers, 1974). Dr. Szasz did not believe that there was such a thing as mental illness. Instead, he wrote, “[P]sychiatric diagnoses are stigmatizing labels…. Those whose behavior makes others suffer and about whom others complain are usually classified as ‘psychotic.’ … If there is no mental illness there can be no hospitalization, treatment, or cure for it…. There is no ethical, moral, or legal justification for involuntary psychiatric intervention. They are crimes against humanity” (267–68).
Page 68. Based on research by a PhD graduate student: This was Erving Goffman, who wrote the influential Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (Chicago: Aldine Publishing Company, 1961). His ideas came out of his one year of fieldwork where he posed as a student of recreation and community life at a large mental hospital. As he admitted, he “came to the hospital with no great respect for the discipline of psychiatry” (x), and his year in one did not change his mind.
Page 70. The traditional requirements for a nun: The three requirements were: stability, obedience, and chastity. Nurses were originally nuns and monks; as the French for nurse—infirmier from infirmarian—shows. To this day, nurses are called “sisters” in England.
Page 71. Florence Nightingale wrote her Notes on Hospitals: What a woman she was! For a good biography, see Mark Bostridge, Florence Nightingale: The Making of an Icon (New York: Farrar, Straus & Giroux, 2008). Born in 1820, she lived until 1910, and her life, therefore, spanned the Victorian era. Never married and educated at home, at twenty-seven Nightingale experienced a call from God, and would have entered a monastery, probably, had she been Catholic. But she was Protestant, so she decided, instead, “to devote herself to works of charity in hospitals and elsewhere, as Catholic sisters do” (85). Eventually, she trained as a nurse in Germany and bought its str
ict system back to England, instituting the ideals and practices of nursing we take for granted today. Her Notes on Nursing is still a worthwhile read; see Florence Nightingale, Notes on Nursing: What it is, and What it is not (New York: D. Appleton and Company, 1860). During the Crimean War, she worked in army hospitals, and realized that the most important attributes of a hospital were cleanliness, fresh air, and quiet. She toured hospitals throughout Europe and then wrote up her ideal hospital in Notes on Hospitals, also fascinating reading. See Florence Nightingale, Notes on Hospitals, third ed. (London: Longman, Roberts, and Green, 1863). She begins the book with the unfortunately still pertinent line: “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. It is quite necessary, nevertheless, to lay down such a principle.” In view of Dee and Tee’s recommendations about the head nurses and their consequences, her observation is astute: “Practically a nurse can really supervise only as many persons as she can see from one point” (114). Laguna Honda, with its open wards, solariums, wide corridors, and floor-to-ceiling windows, was built on this Nightingale plan.
Page 72. Dee and Tee’s report: I was able to find the executive summary of the report, but not the full report, even from the librarian of the Dee and Tee library. For a copy of the executive report and a summary of the full report, see http://cityofsf.net/site/courts_page.asp?id=3972. It is contained in the Civil Grand Jury Reports, 1995–1996, IX; the Dee and Tee executive report is Appendix G.
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 37