CHAPTER FOUR: THE MIRACULOUS HEALING OF TERRY BECKER
Page 81. He reminded me of an aphorism I loved: The classic article of Dr. Peabody’s is still worth reading; see Francis W. Peabody, MD, “The Care of the Patient,” Journal of the American Medical Association 88 (1927): 877–82. “Look out for all the little incidental things that you can do for his comfort. These, too, are part of the ‘care of the patient.’ … The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret in the care of the patient is in caring for the patient” (882).
Page 82. The good, the better, and the best doctor: From Swami Nikhilananda, The Gospel of Sri Ramakrishna (New York: Ramakrishna-Vivekananda Center, 1977). Ramakrishna compares the three types of gurus to three classes of doctors: “There are three classes of physicians. The physicians of one class feel the patient’s pulse and go away, merely prescribing medicine. As they leave the room they simply ask the patient to take the medicine. They are the poorest class of physicians…. There are physicians of another class, who prescribe medicine and ask the patient to take it. If the patient is unwilling to follow their directions, they reason with him. They are the mediocre physicians…. Lastly, there are physicians of the highest class. If the patient does not respond to their gentle persuasion, they even exert force upon him. If necessary, they press their knees on the patient’s chest and force the medicine down his throat” (469). I interpret “forcing the medicine down his throat” for the modern physician as walking to the pharmacy with the patient, waiting for the medication to be dispensed, and watching the patient swallow down his pills.
Page 83. The police department would deliver 2,356 wrapped presents: Christmas was a special time at the hospital, with a decorated tree and a special meal, although the impetus for the celebration did wax and wane over the decades. According to Miss Lester, it had waned almost completely by the late 1950s: “It was Christmas, and Mr. Moran, the administrator at the time, called me up. Let’s go sing Christmas carols to the patients, he said. So we did, just the two of us. We walked around all the wards and sang Christmas carols. Later the volunteers got involved, fund-raising for those presents, and then wrapping all of them, with the police department coming over to deliver them” (oral interview, December 12, 2007).
Page 86. My master’s thesis into an article for publication: For the article, see Victoria Sweet, “Hildegard of Bingen and the Greening of Medieval Medicine,” Bulletin of the History of Medicine 73 (1999): 381–403.
Page 92. The twenty-eighth time: I’m sorry to have to report that this is not hyperbole. When I reviewed Terry’s records, I counted twenty-eight emergency-room visits for the care of her open wound.
Page 95. My first job, therefore, as gardener-doctor: In the premodern era, the connections between gardening and doctoring were many, profound, and went both ways. Sometimes the doctor was thought of as a gardener, and sometimes the gardener was thought of as a doctor, whose medicine was laetamen (fertilizer)—the different types of fertilizers being analyzed just like medications as to their proportions of humors and of qualities. For a modern-day parallel, where the gardener is enjoined to be a good doctor of the soil, see Masanobu Fukuoka, The One-Straw Revolution: An Introduction to Natural Farming (Mapusa Goa, India: Other India Press, 1992).
Page 99. Physis: For a history of Nature, and mechanism and vitalism, see Max Neuburger, “A Historical Survey of the Concept of Nature,” Isis 154 (1944): 16–29, and Max Neuburger, The Doctrine of the Healing Power of Nature Throughout the Course of Time (from Hippocrates to the Middle of the Nineteenth Century), Linn J. Boyd, trans. (New York: 1932).
CHAPTER FIVE: SLOW MEDICINE
Page 103. Dr. Kay, our hospice director: I was impressed by Dr. Kay the first day I met him. It wasn’t just his clipped English accent, though I liked that, or his well-tailored suits, or his Harvard degree, or even that he was an oncologist, that most serious of medical specialties. I was impressed by his name tag. He came into our doctors’ office, sat down to use the computer, and introduced himself formally as he put out his hand.
“I’m Dr. Kay,” he said. “MD, CNA.”
I shook his hand. “CNA? Certified nursing assistant?”
“Yes,” he replied, leaning forward and showing his badge to me. “David Kay, MD, CNA. I just finished my training as a nursing assistant. It took me twenty years to realize how little I knew about nursing, and how important it was, especially in oncology, and especially here.”
“What do you mean?”
“You learn how to brush a patient’s teeth, which isn’t easy, especially if there are mouth sores or yeast. You learn how to turn a patient, how to make a bed, how to feed a patient, and how to give sips of water. It’s a lot of work, a skill, and an art. Doctors need to learn it.”
Page 103. Miss Lester: I interviewed Miss Lester in December of 2007. I also interviewed some of Miss Lester’s staff, who were still working in her now ten-years-vacant office. Did they remember her? Of course! What did they remember? “Everything got done. She did it herself. Give her something in the morning, and it was done by three-thirty. She ran this place tight but—have a family problem, she just melted. She could come back tomorrow and run this place.” Silence. Then, “There would be a lot of people who wouldn’t be here anymore, if she did” (oral interview with staff, October 9, 2009).
Page 106. The Latin curare split into cure and care: Actually, the derivation is a little ambiguous. The Oxford Latin Dictionary defines curare to mean both care and cure, but The Oxford English Dictionary derives the English care from the Germanic cur, and the English cure from Latin cura. On the other hand, Carl Darling Buck, using Julius Pokorny’s etymology, seems to disagree, since he defines the Middle English cure as meaning care for and care as well as cure (307). See Carl Darling Buck, A Dictionary of Selected Synonyms in the Principal Indo-European Languages: A Contribution to the History of Ideas (Chicago: University of Chicago Press, 1965), 307.
Page 106. For more than a thousand years the nuns ran the Hôtel-Dieu: For this story, see Louis S. Greenbaum, “Nurses and Doctors in Conflict: Piety and Medicine in the Paris Hôtel-Dieu on the Eve of the French Revolution,” Clio Medical 13: 247–67. “For the first time, the full range of medical interventions admitting, examining, diagnosing, feeding, treating and discharge … were vested in the hands of physicians under whose direction the nurses of the Hôtel-Dieu were to serve [247]…. On May 6, 1789, all appeals exhausted, the prioress notified the administration that her nuns would physically prevent the entry of workmen into the St. Paul ward” (254).
Page 108. The Department of Justice arrived, and in its wake, still a second investigative agency, the Health Care Financing Administration: To summarize the gist of it: The DOJ arrived at the hospital in February 1997 to investigate violations of CRIPA (Civil Rights of Institutionalized Persons Act). Their findings were submitted May 6, 1998; a second findings letter was submitted April 1, 2003, and in May 2008 there was a settlement letter. As for HCFA, it investigated the hospital at the same time, and its letter came on June 8, 1998. Laguna Honda’s plan of correction, its letter said, was unacceptable. The hospital must decrease patients by 140 beds and add social dining by September 9, 1998, or face the withdrawal of Medicaid and Medicare reimbursement.
Page 108. Miss Lester quit—in protest, she told the newspapers: See David Tuller, “Director of Nursing Quits Laguna Honda / Abrupt Departure as Staff Dwindles,” San Francisco Chronicle, August 29, 1997. For Dr. Stein’s rebuttal, see the same article.
Page 109. Study done at the hospital: See J. S. Kayser-Jones, “Open-Ward Accommodations in a Long-Term Care Facility: The Elderly’s Point of View,” Gerontologist 26(1) (1986): 63–69. Its abstract explains: “A field study of r
esidents’ satisfaction with open ward accommodations revealed that 88% of the respondents preferred the open ward to any other type of room accommodation.”
Page 110. The eighteen-page DOJ letter ended: For the letter, see www.justice.gov/crt/about/spl/documents/laguna_honda_98_finding.pdf. I’ve summarized only the most important issues here. The letter was a tough one, and it must have been difficult for Dr. Stein and the mayor not to have felt attacked by it. We, the doctors, certainly felt attacked, and this even though the medical staff was off the hook—the DOJ acknowledged that the medical care at the hospital was excellent. I did recognize the hospital I knew in their letter, though. Patients did wander off; alcoholic patients did drink; unsafe smokers did sometimes smoke without supervision; drug abusers did occasionally succeed in using illicit drugs on campus. It was regrettably true that the violent, demented patients we admitted from the County continued to be demented and sometimes violent with us, and that the demented hoarders continued to hoard. It was all especially true after the dismissal of the head nurses, who had been that extra pair of hands and eyes that noted the patient about to wander off, that smelled the liquor, kept the peace, and filled in when an extra pair of hands was needed. The DOJ provided a long list of remedies, most of which were ultimately applied though they never did cure the patient.
Page 114. Vision Three of her first book, Scivias: For excellent colored reproductions of many of Hildegard’s illuminations, see Matthew Fox, Illuminations of Hildegard of Bingen (Santa Fe, NM: Bear & Company, 2002).
Page 126. How expensive economists thought doctors were: For instance, economists often suggest replacing MDs with mid-level providers as a cost-saving measure. Yet the math doesn’t work out, at least in our city, where midlevel providers often earn as much as physicians, while carrying half the caseload.
Page 128. Where Laguna Honda’s Way of Slow Medicine could be tested for efficiency: It is in the measuring of the “efficiency” of hospitals and doctors where the devil is really in the details. For instance, in acute hospitals economists often use mortality rates or readmission rates as a measure of efficiency, which is not the same thing at all as measuring success at diagnosis and treatment. In Britain, the National Institute for Health and Clinical Excellence (acronym, NICE) measures efficiency using the QALY (cost per Quality-Adjusted Life Year), where 1 is perfect health, and 0 is death. NICE defines treatments as cost-effective if their incremental cost-effectiveness ratio is £20,000 or less per QALY. “The Quality Adjusted Life Year (QALY) has been created to combine the quantity and quality of life. The basic idea of a QALY is straightforward. It takes one year of perfect health-life expectancy to be worth 1, but regards one year of less than perfect life expectancy as less than 1. Thus an intervention which results in a patient living for an additional four years rather than dying within one year, but where quality of life fell from 1 to 0.6 on the continuum will generate: 4 years extra life @ 0.6 quality of life values 2.4 less 1 year @ reduced quality (1—0.6) 0.4; QALYs generated by the intervention 2.0.” See the article, “QALY,” at http://www.medicine.ox.ac.uk/bandolier/booth/glossary/QALY.html. (I have condensed, slightly, the explanation of the calculations.)
Page 128. The ecomedicine unit: We did three studies at Laguna Honda to see if some of the medications that patients arrived with could be discontinued. We found that they could be discontinued 90 percent of the time. Several years later a formal study was published that looked at a similar issue; it found that 50 percent of medications could be discontinued without adverse effects and with improvement in health and well-being. See Doron Garfinkel and Derelie Mangin, “Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults: Addressing Polypharmacy,” Archive of Internal Medicine 170(18) (2010): 1648–54. The figure for the money spent on patients’ meals comes from an oral interview I had with Steve Konefklatt, director of food services, on November 23, 2009. In addition to seven dollars for the food itself, he had eighteen dollars per patient, per day, to spend on its preparation and service, he told me.
CHAPTER SIX: DR. DIET, DR. QUIET, AND DR. MERRYMAN
Page 130. An important conference about Hildegard: This was the “Hildegard von Bingen in ihrem historischen Umfeld: Internationaler wissenschaftlicher Kongress zum 900 jährigen Jubiläum, 13–19. September 1998, Bingen am Rhein.” Many of the conference papers were later published in Alfred Haverkamp and Alexander Reverchon, eds., Hildegard Von Bingen in ihrem historischen Umfeld: Internationaler Wissenschaftlicher Kongress zum 900 Jährigen Jubiläum, 13–19 September 1998, Bingen Am Rhein (Mainz, Germany: Philipp von Zabern, 2000).
Page 131. She even wrote a kind of autobiography: What Hildegard wrote was an autobiographical letter to an inquiring admirer, and this letter, and information in other letters were pulled together into a Life of Hildegard (the Vita Hildegardis)—by her monk secretaries, Godfrey and Theodorich, probably with her help. However, since the Life was written with a particular viewpoint—namely getting Hildegard declared a saint—it highlights the religious, spiritual, and miraculous aspects of her life. But there are many other sources for her biography, including the hundreds of letters she wrote, and even an eyewitness report made by a Papal Inquisition sent to Rupertsberg in 1232 to interview her nuns. Much work has been done on Hildegard, and today there are many biographies; see chapter one in my book Rooted in the Earth, Rooted in the Sky: Hildegard of Bingen and Premodern Medicine (New York: Routledge, 2006), or see Sabina Flanagan, Hildegard of Bingen: A Visionary Life, 2nd ed. (New York: Routledge, 1998).
Page 132. She wrote two additional books of visions: These are the Book of the Rewards of Life (Liber Vitae Meritorum) and the Book of Divine Works (Liber Divinorum Operum). Several illuminated copies of the Liber Divinorum Operum still exist, although none from Hildegard’s own scriptorium. The costumes she designed for her nuns to wear in her play were white robes, gold rings, and long, white, silk veils topped by golden crowns, with angels and a lamb worked into them. Rumor had it that her nuns also wore these costumes on holidays, which Hildegard did not deny: “It is true that a woman who is married should not show her hair, nor decorate herself with crowns of gold … but this isn’t the case for virgins, who are not ordered to cover their hair, just as it is quite proper for them to dress in white” (Epistola CXVI, Patrologia Latina, vol. 197: 1116, cols. 336 C and D). For a fascinating interpretation of the play in the context of Hildegard’s own life, see Gunilla Iversen, “O Virginitas, in Regali Thalamo Stas; New Light on the Ordo Virtutum: Hildegard, Richardis, and the Order of the Virtues,” in The Dramatic Tradition of the Middle Ages, Clifford Davidson, ed. (Brooklyn: AMS Press, 2005), 63–78.
Page 133. The Hildegard Haus: When I was there, the Hildegard Haus was growing many of the medicinal herbs recommended by Hildegard, including, in addition to those I’ve listed: hyssop, bertram, wormwood, thistle, fennel, parsley, mauve, lily, lettuce, achillea, arnica, hop, salvia, and fig.
Page 137. Unknown Language was the most mysterious: The Wiesbaden library has a copy of the Riesencodex—the collection of Hildegard’s works made in her own scriptorium—on its website; see http://www.hlb-wiesbaden.de/index.php?p=202. It includes Unknown Language. See also, Sarah L. Higley, Hildegard of Bingen’s Unknown Language: An Edition, Translation, and Discussion (New York: Palgrave MacMillan, 2007).
Page 140. Slowly I began to understand Hildegard’s methodus medendi: Hildegard does not provide a how-to manual of her method; I have inferred it from her description of disease states. For instance, the fact that she uses the color of the face, the tone of the skin, or the brightness of the eyes to describe a condition suggests that she observed the face and eyes, and touched the skin. For what she would have done in taking a pulse, I have combined her descriptions of different pulses with what we know about the premodern method of taking a pulse. For example, see Faith Wallis, “Signs and Senses: Diagnosis and Prognosis in Early Medieval Pulse and Urine Texts,” in The Year 1000: Medical Practice at the End of the
First Millennium, Peregrine Horden, ed. (Oxford, UK: Society for the Social History of Medicine, 2000), 265–78. Of course, the Chinese use the pulse in diagnosis as well; for a comparison of the traditions, see Shigehisa Kuriyama, “Varieties of Haptic Experience: A Comparative Study of Greek and Chinese Pulse Diagnosis” (PhD diss., Harvard University, 1986).
Page 142. Dr. Diet, Dr. Quiet, and Dr. Merryman: The Latin is Si tibi deficient medici, medici tibi fiant. Hæc tria: mens laeta, requies, moderata diæta. Mens laeta was rendered as “Dr. Merryman,” although I’m not sure that is quite right. A merryman was a jester, a buffoon, a clown who performed at horse shows and circuses—a Patch Adams, perhaps. Mens laeta was more of a joyous spirit, a cheerful heart, a light mind, so it might be better understood as Dr. Lightheartedness, Dr. What-Me-Worry?, Dr. I’m-Rooted-in-Life-and-It’s-Just-Flowing-Through-Me-Unimpeded-by-Worry-Irritability-or-Sadness.
Page 148. First, every Swiss citizen had to buy basic health insurance: For more on the Swiss system, see Uwe E. Reinhardt, PhD, “The Swiss Health System: Regulated Competition Without Managed Care,” The Journal of the American Medical Association 292(10) (2004): 1227–31. Reinhardt argues that the Swiss system is “superior, more cost-effective, and more equitable” (1227), but economists cannot agree on exactly why. Some think it is because the Swiss system is more price-transparent, with more consumer control; Reinhardt suggests that it is due to “pervasive government regulation” of insurers, drug prices, and markets. What was interesting to me about the system was the absence of lawyers—in terms of malpractice, of regulation, and of oversight—and that the power of medical decision making seemed to be still in the hands of physicians and patients. Most important, though, was the medieval regime of the Swiss. They ate and drank moderately, walked a lot, and had real vacations: They had not forgotten Dr. Diet, Dr. Quiet, and Dr. Merryman.
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 38