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Second Chances

June 5, 2013

Another extraordinary book.  Victoria Sweet – “God’s Hotel”.  It’s about her work in a facility in, I believe, San Francisco.  It’s also about her work in medieval medical history, and how that study informs her work today.  Laguna Honda is sort of a rehab facility or chronic care facility but is basically a dumping ground for the poor, the old, the indigent, the drug addict.

Dr. Sweet has a couple of things in common with Dr. Paul Farmer, about whom I wrote last week.  First, she has a world view that sees every single human as just as valuable and deserving of treatment as every other, regardless of what they have done or how much they contribute or don’t contribute to society.  A lot of people SAY they believe this but these two REALLY DO believe it.  My father is a bit like this as well.  It is so easy and so natural to write off the drug addict after the 5th hospital admission for a drug-related problem.  It is so easy to look at the obese diabetic and judge him as less worthy of care because of what he puts in his mouth.  Dr. Sweet does not see things this way. She will treat the drug addict just as aggressively the 5th time as the first.  Expensive?  Yes.  Frustrating?  Of course.  Cost-effective?  Nope.  A true expression of what being a doctor is?  Absolutely.

The second is the focus on the individual.  Just as Dr. Farmer will walk 7 hours to see one TB patient and consider that a job well done, Dr. Sweet will treat a drug-addicted prostitute with a bed sore for 2 1/2 years until the wound is healed and consider that time well spent.  Dr. Sweet calls it TIME.  Unlimited and unpressured time.  The pre-modern medical practitioners understood this, maybe in part because they couldn’t intervene much anyway: given time, a body will heal itself.  Also given the right surroundings.  Isn’t it extraordinary that today the hospital setting is the environment in which we think people should get better when in fact it is the least therapeutic environment you can think of?  For example, Dr. Sweet points out the simple fact of the therapeutic value of good food.  Healthy, fresh, tasty, well-made food.  Dr. Farmer says the same thing:  yes the patient has tuberculosis, but his real problem is he’s hungry.  But what do we feed people in the hospital or even in rehab facilities?  Either nothing or a “diet” deemed suitable, but nothing fresh and nothing that encourages appetite.  Such a simple thing.

Doctors are under pressure to be more cost-effective and efficient, to move patients along faster and do more with less time.  I think doctors and nurses should be the last people to have to consider these things.  Their focus should  be on the individual.  It is not the doctor’s job to dole out “care” in a cost-effective way.  It’s her job to care for the patient in front of her, in every way that patient needs help.  Not the most expensive care or the recommended treatment or the latest thing, but what the patient needs.  Another example:  Dr. Sweet tried to discharge someone but he had no shoes.  Shoes had been ordered from central supply but the order had gotten lost.  He was still cheerfully waiting for shoes.  She went out and bought him a pair of shoes.  He went home.  It’s not efficient.  You have to get in your car, go to the local mall, buy the shoes, come back, try them on the patient, etc etc.  Takes longer than writing out a requisition for shoes.  You have to pay for the shoes yourself; you can’t be reimbursed by your insurance company.  You might pay more for the shoes than the insurance company would have contracted them for.  But it’s what the patient needed.  Time and care for the individual.  That’s what medicine used to be.

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