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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.
>>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
until it was even with the rest of the skin, and then just as petals push against the constriction
of the bud and open it, the scab flaked off and there was pink skin underneath. That awful
crater filled in from bottom to top and from side to side. It took a long time. It took
two and a half years. But we were in no hurry, and neither was she. [pause]
Terry changed the way I practiced medicine. After that, I not only looked at patients
with the eye of the modern doctor, focusing in on what was wrong with the patient and
how I could fix it, I also stepped back and looked at the patient in the context of his
environment and asked myself, "Is there something I can do to encourage this patient's viriditas?
Is there something I can do to remove what's in the way?"
What I found was that this kind of slow medicine worked very well for patients with slow diseases,
diseases that were long in developing, chronic diseases, for which medicine had no really
good treatment. I began to think of it as slow medicine as opposed to the fast medicine
that I also use, which works so well for fast diseases: heart attacks, appendicitis, cancer,
but doesn't work so well after the heart attack, the appendectomy, the chemotherapy. [pause]
Then, about halfway through my time at Laguna Honda, things started to change. There was
a big push to turn the old fashioned hospital into a modern health care facility. There
was a lot of battles, politics, and struggles, especially between the director of public
health, whom I call Dr. Stein in the book, and the doctors, nurses, and administrators
of Laguna Honda. Finally, one day, Dr. Stein had had enough. He replaced the medical director,
the nursing director, and the executive administrator all at once with his own picks. They were
to come over to the hospital and transform the hospital into a modern facility.
The name of the new executive administrator, I call Mr. Conley. This is what happened.
[pause] Mr. Conley was a bluff, hearty fellow with an energetic, gravely voice, red hair,
and red beard. He reminded me of the youngish Henry VIII around the time he fell in love
with Anne Boleyn. 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 health care and rehabilitation
facility. 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: email, printing, all the laboratory
data, all the 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
email, however. So instead of sitting in his re-redecorated administration wing and shooting
out electronic missives, Mr. Conley had to scribble his messages of pieces of paper,
and when they were important, 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 praying. 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 resident. Perhaps Laguna Honda was a hospital, and not a health care and
rehabilitation facility. 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 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 be fatal. Mr. Conley changed after that. Not so much
his decisions, which came down from above, [pause] [knocking sound] but the way he felt
about his decisions, because he knew the patients now. He knew how his decisions would affect
them. What I learned from that is that it wasn't only medicine that had to be personal.
Administration has to be personal, too. [pause] Over the past 20 years, I've watched medicine--
the pendulum of health care swing from the personal to the efficient, and I have been
amazed by how inefficient that efficient health care has turned out to be. Healthcare costs
keep rising astronomically every year. Patients, doctors, and even economists are more and
more frustrated. Nobody seems to know what to do. So let me end with showing you what
happened when modern, efficient health care landed at Laguna Honda. [pause]
What I did is I put together a graph over the 20 years I was at Laguna Honda. As cost-cutting
measures, the patients were gradually whittled down by about 40%, from 1178 to 780. The doctors
were also whittled down, from about 32 to 9, about by 80%. The clinical staff was whittled
down by about 30%. But the budget kept rising. What's more, the total staff stayed the same.
Why was that? We kept having more and more administration and management. [pause] In
fact, by the time I left, the day I left I looked around and realized that there were
more quality assurance managers at Laguna Honda than there were doctors. That was pretty
scary. What does all this new management do? It's
hard to know for sure, but the one thing there are more of at Laguna Honda today than when
I started there is forms. When I first got to Laguna Honda, there were two forms of one
page each. The day before I left, I took out a random chart, opened it up, and counted.
There were 43 forms, and most of them were three, five, ten pages long.
I made a rather complicated scribbled graph of this, but I think it's worthwhile looking
at it. I don't have little pointers, so you just have to follow me, but you can see the
patients in the blue in the middle are going down, down, down, down. The doctors, the physicians,
in the black, going down, down, down. The budget, that blue line that just goes up.
And the forms, which is the red line, going way up. I've actually pulled this out to,
assuming that the present trends continue, in 2024, if they continue, there will be no
patients at Laguna Honda, [laughter], two physicians, 1400 FTE and a budget of 280 million
dollars. I think it's time for us to all work together
to give that pendulum of health care a nudge backwards, towards the inefficient, the human,
and the personal. Thank you very much.
>>male#1: I had a question about the bad girl patient.
>>Sweet: Yes.
>>male#1: What exactly was it that helped her to turn around her life and break free
of her abusive, exploitive boyfriend?
>>Sweet: Yeah, yeah.
>>male#1: Is it about the care she received, or was it something that she just had reached
a point where she knew it was either death or completely transform her life? Any idea?
>>Sweet: It's a great question. Can everybody hear that? Good. Okay, great. I think that's
a beautiful question, actually, to ask. I ask myself that a lot. I think there are two
things. That last time, Terry was way at the end of the ward, and she had a very special
nursing assistant named Connie. I noticed that Connie's patients always got better.
It was just something about Connie. She was also kinda trapped because she was on that
gurney lying down, face down, for weeks. I just think she had some kind of change of
heart. It was really a very mysterious change of heart, but that was her true healing. In
fact, the name of this chapter I called the Miraculous Healing of Terry Becker. And that,
what you put your finger on, is exactly the miracle, that she made that decision. I don't
really know why, but I do know that decision stayed made, and that once she was healed,
and not only was she healed of her bedsore, but by the time the bedsore was healed, everything
else about her was healed. We'd found her family, which hadn't seen her in 10 or 12
years. Her family wanted to have her back home with them. We had a patient gift fund
at Laguna Honda, so we could get the money together to send her back home. She'd fattened
up. She had a whole personality change, from irritable, frustrated, and kinda mean, to
kind and grateful. She was like a completely different person. I know that she went back
to her home and stayed. She never went back on the streets.
>>female #1: Going off from this last slide, what do we do to make that happen?
>>Sweet: You know, I don't know quite the answer to that, except I am getting so much
attention for this book and these ideas. I feel a little bit like the kid in The Emperor's
New Clothes. I'm like, "But there are just no clothes here. I mean, come on, people.
Like, medicine is personal? Is that the most unbelievably smart thing you've ever heard?
No! It's like, hello! So I'm getting this kind of reaction from people. I think it's
going to make a change, I almost think just by thinking about this, recognizing it. I
think it's going to change anyway, because, fortunately, we live in a capitalist country.
The fact is, not only is it-- It is in fact more efficient, it saves money, when the doctor
has enough time to do a good job, get the right diagnosis, take you off the medications
you don't need. It saves money. I think once the capitalist health systems realizes that
it's cheaper to give doctors enough time to see patients, than it is to whittle us down
so that we just have to order a whole bunch of tests, it will change on its own, I do
believe. I just think there's kind of a will out there, because the doctors, they'll love
what I'm saying here, and the patients, everybody. It's like a trip.
>>male #2: I'm curious, did Terry have substance issues, and was becoming sober [clears throat]
part of her recovery?
>>Sweet: Absolutely. Absolutely. But as you probably know, making that decision to become
sober. It really was-- When she went in that room, I can remember
right now, we were all just cringing. This had happened over and over again. We were
just sure Mike and she would be rolling out together. And when I saw-- It still gives
me shivers. When I saw Mike walk out of that-- The door opened, he walks out, and he's by
himself. And I remember him walking out the ward, we had swinging doors, and he went through
the doors and they swing shut. Then Terry rolled herself out of that room back to her
bed. I was like, "Wow. Something happened there." And then, of course, she did give
up smoking. Once she gave up smoking, everything sort of fell into place. But why, I don't
know. I don't really know. Yes.
>>male #3: With the popularity of your book, have the decision makers at any of the medical
facilities reached out to you to learn how they can reproduce the success of your experience?
>>Sweet: I'm starting to get a few things like that. [pause] But it's really just starting.
I'm getting invitations to talk at different places. I've had a few, but I'm actually wanting
to get like Washington-level, because they have-- huh?
>>male #3: inaudible
>>Sweet: [scoffs] I don't know, what about the surgeon emperor or something. [laughter]
Really powerful, you know? Yes.
>>female #2: When I look at the medical profession here, and actually, I should just add a footnote:
my mother is actually currently in hospital. She's been in for a couple weeks, and probably
be in another week. But I feel very comfortable about that--
>>Sweet: Is she here, or in Italy?
>>female #2: because she's not in America, she's in Italy. So I think she's going to
be fine. [laughter] Well, I mean that seriously, because, anyway. I mean, a lot of that's the
talk you're giving here. But one of the issues in America that I see that's very different
is everybody seems to want a quick pill fix-it thing, and if they don't get a quick fix-it,
they go to the legal system. So one of the issues that I keep thinking comes up around
medicine, why it is the way it is in this country, is a lot around malpractice, financial
covering your ass, a bunch of stuff like that. If you switch into being more inefficient
and human, the doctors are going to have to spend more time with their patients--
>>Sweet: Absolutely.
>>female #2: which means fewer patients. The whole equation in this country is in one direction,
and all of this-- Of course there's that other piece, that all too many doctors seem to be
focused on the money, and not so much on the caring. That's the stereotype that I see around.
All these pieces play in to an equation, as you were describing, that's around money and
efficiency and this and that and forms. About covering your ass and covering your pocketbook.
I'd like to know more about, you know.
>>Sweet: Well, there are alternatives. To me, what we need in this country is an experiment.
In a way, Laguna Honda for me was an experiment. I have many, many cases where it's quite clear
that the Laguna Honda treatment-- Terry is a perfect example. You can say, "Two and a
half years in the hospital, that's huge." But before she'd been in the hospital, she'd
been going back and forth, getting $100,000 operations. Back and forth. You could say,
"Why treat her at all?" and that's a different discussion. But if we're going to take care
of people, then I was quite sure, from what I saw at Laguna Honda, that it was cheaper
the Laguna Honda way: to take the time. I can give you a very practical example. Doctors
are cheap. One of the things that's happened in this country is the economists, when they
were trying to cut costs, they assumed doctors were really expensive, so they've been de-skilling
doctoring onto nursing and nursing onto dadadadada. But in fact, doctors are quite cheap. I'll
make $100 an hour. If I spend an hour with the patient, and that hour allows me not to
get an $1800 MRI, we're way ahead of the game. So I think one place to start is to just have
a model and show that, because if they show that Kaiser and HMOs, then everybody's going
to go, "Well, that's way cheap. We'll just give doctors back their time. That is cheaper."
In terms of malpractice, of course there's all that, and it's complicated, but I will
say this: that the malpractice, what they say is that you do not actually get sued as
a physician when you make a mistake. You get sued when the patient feels you didn't care
about them. I have found that to be the case so far. I really have. I think a lot of the
malpractice issue is a little bit of a covering. I think we could do this. I think what's going
to happen, it actually is happening. While I was writing this book-- This is actually
happening, because what's happening is doctors are saying they can't take it any more and
they're doing this concierge whatever, boutique whatever kind of stupid name they've got for
it. This idea that it's more like CSA, like Community Sponsored Agriculture, where you
pay upfront, you pay $100 a month or $150 a month and the doctor gets his patients upfront.
Instead of having to have 1000 patients to pay his bills, he doesn't need any back office
because he gets paid upfront. He can have 250 patients, and with those 250 patients,
he has all the time in the world to take care of them. So that's actually an experiment
that's a hidden experiment that's going on right now. It's very interesting. The patients
are thrilled, the doctors are thrilled. It's very interesting
>>male #4: I really admit that I may not know the facts correctly in this, but I understand
that there's something of a shortage of doctors. If doctors are inexpensive, then we should
have more of them. Is there something we should be doing to foster more doctors being out
there so we can have more slow medicine?
>>Sweet: Well, that's a complicated question. You don't know, and I don't really know, but
I think there's two pieces of it. The shortage is in what they like to call primary care
doctors. I'm an internist. I'm like the front person to take care of you. And there seems
to be a shortage. Why? I don't want to do it. I don't want to get an unbelievably complicated
patient and have ten minutes to spend with the patient, of which I spend three minutes
on the computer, seven minutes-- You can't do it. So what you're having is doctors are
not going into primary care. They're going into subspecialties. And if I had a kid who's
going into medicine, I would tell them, "Do not do what I did. You get yourself a nice
little specialty where you can do a good job, and you can have a satisfying practice." So
I think there's plenty of doctors, but they're not going into primary care. That's one thing.
The second thing is my generation of doctors are dropping out of the system like flies.
We don't want to. We love taking care of patients. I think if we could take care of patients
the way we wanted, I think it's a little bit-- That's my sense, is there's probably plenty
of doctors, but shifting who does what is more the issue than educating more docs.


Authors@Google: Dr. Victoria Sweet, "God's Hotel"

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Yuan Jui Yu 發佈於 2015 年 4 月 16 日
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