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  • >>female presenter: Welcome to Authors at Google. I'm Rebecca Moore, and I'm privileged

  • to introduce our speaker Dr. Victoria Sweet. I was going to talk about her new book, God's

  • Hotel: a Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine. The book launched

  • just one month ago. I think, as Googlers, we can relate to working long and hard on

  • something, maybe for more than a year. You're passionate about it, you launch it, and then

  • you wait with some trepidation to see what's going to happen. Well, the great news is that

  • God's Hotel is taking off like a rocket ship. We're very privileged to have Dr. Sweet with

  • us here to talk about it. In its first week, it made it onto the San Francisco Chronicle

  • Best Sellers list. Two days ago, it was just reviewed by the New York Times' Science Times,

  • who called it "transcendent and a tour de force." Congratulations on that.

  • Dr. Sweet is both a physician and a prize-winning historian with a Ph. D. in history and social

  • medicine. She's also associate clinical professor of medicine at UC San Francisco, and I'm personally

  • happy to say that she studied mathematics and Greek at Stanford University. Go Stanford.

  • [laughter] There will be time for Q&A at the end, and

  • Victoria will sign books for those of you who would like them. Finally, just on a personal

  • note, I've known Victoria for many, many years. She has always been someone who was comfortable

  • taking the road less traveled. I think, now, with God's Hotel, she's created a whole new

  • road to a place and time that few of us even knew existed. And now she's here to tell us

  • about it. Please welcome Dr. Victoria Sweet.

  • [applause]

  • >>Victoria Sweet: Is that microphone working? Well, thank you very much, Rebecca. Thank

  • you all for being here today. Thanks Google for letting me speak here.

  • Laguna Honda Hospital was like no hospital I had ever seen or even imagined. I got there

  • kinda accidentally. I had decided to go back to school to get my Ph. D. in medical history

  • after I had been practicing medicine for many years. Laguna Honda was the only place that

  • would let me practice medicine part time. So I went over for my interview. When I saw

  • it for the first time, I was nonplussed. It was high on a hill, overlooking the ocean,

  • and it looked like a medieval, Romanesque monastery. It had peach colored walls, a red

  • tiled roof, a bell tower, and turrets. After my interview, the medical director took

  • me out to show me around. She showed me the long, open wards that go all the way back

  • to when monks took care of the sick poor in the monasteries for free. When went upstairs

  • and she showed me the surgery suite, which looks like where Humphrey Bogart had his face

  • redone in "Man Without a Face." We walked past the old-fashioned beauty salon with its

  • steel helmet hairdryers. She showed me the library, the auditorium, and the chapel, which

  • was really more like a small church with polished wooden pews, stained glass windows, and the

  • stations of the cross along the walls. Then we went out and she showed me the gardens.

  • Turned out that Laguna Honda had been the almshouse for the city, and it was on 62 acres.

  • It is still on 62 acres of land in the middle of San Francisco. The gardens are extensive.

  • She showed me the greenhouse, the aviary, and the little barnyard. So the patients could

  • pot plants, watch chickens hatch from eggs, and even see animals, even if they were bed-bound.

  • Then we walked back to her office, and she offered me the job. I didn't know. I wasn't

  • sure. I told her I would come for two months, but I stayed for 20 years. Turned out to be

  • a wonderful place to practice medicine. Part of that was the place itself. The place was

  • a great place to practice medicine in terms of its spaciousness, kinda ramshackle. But

  • what really made it incredible were the patients, because it turns out that Laguna Honda was

  • the original almshouse for the city. That was how we used to take care of the sick poor.

  • That's how we used to take care of the sick poor before there was health insurance. There

  • would be a free county hospital and a free county almshouse. The acutely ill would be

  • taken care of in the free county almshouse-- county hospital. And then, if they needed

  • additional care or nobody new what else to do with them, they were transferred to the

  • almshouse. It used to be that every county in the country had a free county hospital

  • and a free county almshouse, and that was how we took care of the sick poor. Starting

  • in the '50s, the almshouses across the United States were closed, and many of the county

  • hospitals, except for San Francisco, which still has its county hospital and still has

  • its almshouse, albeit now called a hospital. So the patients, as you can imagine, are the

  • bottom 0.1% of the population. What I've found is that they were two standard deviations

  • from the mean. Any mean. They were the tallest and the shortest, the fattest and the thinnest,

  • the nicest and the meanest, of any patients I ever had. They had every disease, too. They

  • taught me a tremendous amount about medicine and health care, cure and caring, efficiency

  • and inefficiency. The two months went by, and then a year or

  • two, and I really didn't notice that the years had gone by or that I was learning a lot from

  • the patients until I got to my patient, Mrs. Todd. [pause] Ms. Todd was 35 years old. She

  • had cancer. Her cancer was brain cancer. What made it horrible was that it was just behind

  • her right eye, and it had grown, in spite of surgery and radiation, right out of her

  • eye. The surgeons had removed the eye and sewn the eyelid down over the cancer, but

  • the cancer was still growing. Ms. Todd had never been beautiful, but what with the radiation,

  • which had caused her hair to fall out, the steroids, which had caused her face to balloon,

  • and the sewn eyelid, she was very hard to look at. Yet she was pleasant and quiet. She

  • always smiled as I passed her by. Eventually, we were on speaking terms, with a quick "Hello"

  • and "How are you?" from me to her and from her to me. I got used to her deformity, although

  • only by blocking out, in some way, my experience of her experience.

  • One day, I finally braved my reluctance and stopped by her bed, full stop. We looked at

  • each other. She at me: white coated and rushed, a bit disheveled. I looked only at her left

  • eye. "Is there anything I can do for you?" I asked her after we talked a bit. "Yes,"

  • she replied, "there is. I really don't like the food they're giving me. It's all cut up

  • and bland. Do you think it could be changed? And another thing. Could you arrange for me

  • to visit the eye doctor? I need a new pair of glasses." I was, and am to this day, floored

  • by her response. I was, and am, awestruck by such equanimity. She wanted, not euthanasia

  • or a miraculous cure, stronger pain medication, or a second opinion, but different food, a

  • pair of glasses. She said nothing about her terrible misfortune. She was calm, matter-of-fact.

  • Somehow, she'd accepted her fate. It was the small things, the little daily things, that

  • were important to her. We did change her diet, and we did get her new glasses. Not long after,

  • she moved to another ward, and there she died peacefully, 18 months later.

  • Ms. Todd capped my experience of those first years of Laguna Honda. She summarized it and

  • hinted at what I would be learning later. Even when there's nothing to do for a patient,

  • no cancer to discover, no paradoxical pulse to take, there is still something to do. It

  • doesn't have to be life saving, grandiose, and heroic. It can be as simple as a pair

  • of glasses or a different diet. In fact, it usually is. [pause] [clattering]

  • I learned a tremendous amount from the patients at Laguna Honda. If I had to summarize what

  • I learned in one sentence, it would be that the practice of medicine is a personal relationship

  • between doctor and patient. And when it's personal, it works. The best way, the easiest

  • way I can explain what I mean is to tell you the story of Dr. Curtis and the case of the

  • missing shoes. [pause] I learned a lot from Dr. Curtis, but it was in the case of the

  • missing shoes that he taught me the most about care and caring, time and inefficiency.

  • On this particular day, I met him by accident in the wide-windowed corridor that ran the

  • length of the hospital and connected all the wards. He was in a hurry. "Where was he going?"

  • I asked. "Back to the rehabilitation ward," he said, where he was covering for a few weeks.

  • The rehabilitation ward was its own mini hospital within Laguna Honda. It admitted the patients

  • with the milder strokes and the less traumatic head injuries, most of whom would recover

  • and be discharged back to their homes, if they had them. Although its patients, too,

  • were often without friends, money, or health insurance, like the admitting ward, it had

  • its own physicians to admit, examine, and discharge its patients. This month, Dr. Curtis

  • was one of them. He'd just returned from outside the hospital, he told me, and was heading

  • back to a patient who, having been rehabilitated after a stroke, had been ready for discharge

  • for months. Every day, when Dr. Curtis made his rounds, checking on the 36 patients on

  • the ward, this patient was still there, still zipping around in his wheelchair, still going

  • to therapy. Finally, Dr. Curtis said, "I asked him why, since he was able to walk, he was

  • still here. Why was he still in the wheelchair? Why hadn't he been discharged?" "No shoes,

  • doc. They ordered me special shoes, but they're waiting for Medicaid to approve them." "How

  • long have they been waiting?" Dr. Curtis asked. "Three months." Dr. Curtis thought a bit.

  • "What size shoe do you wear?" "Size 9." Dr. Curtis reflected for a while. He thought about

  • his duties, his other patients, the charts he had to dictate, the quality assurance forms

  • he had to fill out. Then he left the hospital, got in his car, and drove to Wal-Mart, where

  • he bought a pair of size 9 running shoes for $16.99. He'd just come back with the shoes

  • and was going over to the ward to put them on the patient and write the discharge orders.

  • "Was he planning to submit his receipt for reimbursement?" I asked. He laughed.

  • As I watched him hurry back to the rehabilitation ward, I wondered. Why had Dr. Curtis done

  • this, and why hadn't anyone else? It was a simple thing to do, but it never would have

  • occurred to me to do it. I would've been frustrated with the shoe delay, of course, and I would

  • have filled out a second or even a third Medicaid form. I might even have written Medicaid,

  • or braved its phone tree to complain about the time that pair of shoes was taking. But

  • it would never have occurred to me to go to Wal-Mart and buy the patient's shoes. I had

  • too much to do, too many forms to fill out, too many other patients to see. It would have

  • meant crossing an inefficiency boundary. And yet, Dr. Curtis got in his car without much

  • questioning and was hurrying back to the ward with the shoes to put them on the patient

  • himself. He reminded me of an aphorism I loved but

  • had never understood. "The secret in the care of the patient is in caring for the patient."

  • I'd always assumed that mean caring about the patient, loving or at least liking the

  • patient, but when I saw Dr. Curtis rushing off to put shoes on a patient he barely knew,

  • I thought there must be more to it than that. So I tracked down the quote and found it in

  • a talk by Dr. Francis Peabody to the graduating medical class of Harvard in 1927. Turned out

  • that Dr. Peabody didn't mean caring about a patient, but caring for a patient, which

  • he explained meant doing the little things, the little personal things that nurses usually

  • do: adjusting a patient's bedclothes, giving him sips of water. That took time, Dr. Peabody

  • admitted, and wasn't perhaps the most efficient way for doctors to spend their time, but it

  • was worth it, he told his students, because that kind of time costly caring was what created

  • the personal relationship between patient and doctor. And that relationship was the

  • secret of healing. [pause] In the meantime-- [pause] In the meantime,

  • I'd started my Ph. D. in medical history. I was studying the medical writings of Hildegard

  • of Bingen. Hildegard was a 12th century German nun. She was also a visionary, a mystic, a

  • composer, and, as it turned out, a medical practitioner. She'd written a book about medicine.

  • It was fascinating. There was not the "eye of newt, toe of frog" medicine I expected

  • from a medieval medical text. It was real medicine from real patients with real diseases

  • that I could recognize. But it was based on a completely different idea of the body than

  • our mechanical model. Hildegard's idea was that the body was more like a plant than a

  • machine. And the doctor more like a gardener than a mechanic. What's the difference? The

  • difference is that someone has to fix a broken machine. [pause] But a plant can heal itself.

  • [pause] Hildegard called the power of a plant to heal

  • itself its viriditas, its greening power, from the Latin "viridis", meaning "green."

  • She thought that human beings also had viriditas, a natural power of healing, and that the doctor,

  • therefore, should be more like a gardener cultivating that viriditas, removing obstructions

  • to it, nourishing it, than like a mechanic. I didn't really understand what Hildegard

  • meant by viriditas until my patient Terry Becker. Terry Becker was one of my bad girls.

  • Actually, the New York Times called her the "worst girl" and I thought that was actually

  • a good way to put it. She was homeless and lived on the street with her boyfriend, Mike.

  • She smoked and drank and used drugs. One day, she woke up paralyzed from the neck down.

  • She went to the county hospital, and they discovered that she had a rare viral disease

  • called transverse myelitis, that has no treatment but does tend to get better over time. They

  • sent her over to Laguna Honda. She was on rehabilitation, and she did pretty well. She

  • started to get better for about the first two weeks. But then the first of the month

  • rolled around, when the homeless in San Francisco get paid, get welfare cash. Mike, her cute

  • boyfriend, showed up, and out they went. She disappeared for about a year. Later, I found

  • out that during that year, she'd been seen in the emergency room at County 28 times,

  • and had 3 long admissions to the County. Each time, just as she was getting better, going

  • out on the streets. During that time, she developed a bedsore. Mike also robbed her

  • and beat her up. She went back and forth to the County getting very expensive operations

  • to cover the bedsore with a skin graft every time she went out. Finally, the bedsore was

  • too big to graft. County didn't know what to do, and they sent her over to Laguna Honda

  • for treatment. [pause] [clattering] When I examined her, I was really quite shocked.

  • She didn't look-- She looked pretty sick. She was only 37. She looked like she was in

  • her 50s at least. It was the bedsore that really shocked me. It was the worst I'd ever

  • seen. It was huge, enormous, and deep. It went from the middle of her back all the way

  • down to her tail bone, and it spanned both of her sitz bones. The skin was completely

  • gone, of course, but so were the fat and the muscles that covered the spine. In their place

  • was an unidentifiable mass of decayed and decaying and infected tissue from the failed

  • skin grafts. At the bottom of this wide, deep hole, I could see bone: Terry's spine. Terry's

  • bedsore was scary. She had no protection. Everything delicate and crucial in her body--

  • bones, kidneys, spinal cord-- was exposed and vulnerable to an environment full of germs.

  • Giving antibiotics to try to prevent infection wouldn't work because the bacteria would get

  • resistant to them. The bedsore really was too big to graft, even if the surgeons agreed.

  • It would have to heal on its own, and that would take years. In the meantime, what chance

  • did Terry have of not getting an overwhelming infection that would kill her?

  • I walked back to our little doctors' office and sat down at my rickety desk. I stared

  • for quite a while at the wooden shelf on which was Mrs. McCoy's robust plant, now grown all

  • over the wall. The bedsore was a catastrophe, and possibly the end of Miss Terry Becker.

  • The second time with the patient, I thought about Hildegard. I asked myself, "What would

  • Hildegard do? How would she treat Terry Becker's huge and open wound?" What she would do, I

  • suddenly saw, was remove obstructions to Terry's viriditas, because if nothing was in its way,

  • then viriditas would heal her wound as surely as a plant will grow green. "What was in its

  • way?" I asked myself. The massive dead tissue was in its way and needed to be removed. Any

  • pressure on Terry's body from wrinkled bedclothes, to hard mattresses, was in its way and had

  • to be removed. Dirt, unkemptness, stale clothes, unnecessary medications, fear, depression,

  • all were in its way. My first job, therefore, as gardener doctor

  • was not to make a brilliant diagnosis or give any magical medication, but remove obstructions

  • to Terry's own viriditas. It was quite amazing how fast Hildegard's prescription worked.

  • Within a few weeks, I began to see signs of healing deep within Terry's wound. There was

  • no infection. Deep down, at the base of the wound, is it my imagination? There was a smooth

  • and pink glistening which was starting to cover and protect the spine. But then the

  • first of the month rolled around, and Mike showed up. He was still pretty cute, still

  • wearing his tight Levi's, still walking with a flirtatious though constrained strut. The

  • nurses made him wait in the smoking room. Terry wheeled herself on her gurney, face

  • down, back covered, the whole length of the ward. Then she rolled into the smoking room.

  • They were in there a long time. Then the door opened, and Mike came out and left. Terry

  • had thrown him out. She told him never to come back. Then she stopped smoking, so her

  • appetite improved and she gained weight. Without nicotine constricting her blood vessels, the

  • tiny new arteries and veins at the base of her bedsore could absorb the vitamins and

  • protein she was eating, and the hole in her backside began to fill in.

  • Since I did not check the bedsore daily, but only once a week, its progress seemed as magical

  • to me as one of those time lapse movies they showed us in school, where a plant grows from

  • a seed in a matter of minutes. Terry's wound began to look like a huge scab. The scab thickened