When I discovered Hildegard of Bingen, a medieval nun who practised medicine, I was stunned by her sensible treatments – I had thought it was all just eye of newt and tongue of frog in those days. I’m a physician, but I also decided to do a PhD on Hildegard. That’s how I ended up at Laguna Honda, a very unusual hospital in San Francisco: it was the only place I could get a part-time position as a doctor so I could study.
The original hospital was built in 1862 as the San Francisco Almshouse. It was a sprawling place that admitted anybody who needed care for more than a few weeks. That’s the essence of the almshouse, which also goes back to the Middle Ages. In a sense it’s what Laguna Honda still was when I arrived there 20 years ago. It even looked like a medieval monastery, with bell tower, turrets, a church and long open wards.
I started out on the admitting ward. Every day was like the curtain rising on a new play. I would end up having a fantastic laugh at least once, having a cry once and getting really pissed off at least once. In America we have a phrase, “over the hill to the poorhouse”, and Laguna Honda really was over the hill to the poorhouse – there’s a hill separating the hospital from the city. We were left alone and I could practise medicine the way I wanted to, and try different things.
That’s how I came up with the idea of slow medicine. It’s all about giving doctors time to do a good job. In America, a doctor typically has 10 minutes to see a patient. Doctors order lots of tests because they don’t have the time to do a full examination, talk to the family, call previous doctors and go over records. I would spend up to two hours on a new admission. Laguna Honda took in the bottom 1 per cent and its patients were the tallest and shortest, the fattest and thinnest, the meanest and the nicest of any patients I ever had. They had every disease, too. We had cases so rare that only 20 had ever been found.
Because my approach is time-costly, it’s considered inefficient. But many diseases can be diagnosed just by examining the body – treating incorrect diagnoses isn’t cheap either.
One of my patients, Mrs M, crystallised slow medicine for me. She was 78 and had been fine until she fell and broke her hip. It was repaired but she didn’t recover. She complained of constant pain and wouldn’t walk; her visiting nurses thought she was demented and psychotic; and she was diagnosed with diabetes. She didn’t seem demented when I admitted her, though. When I examined her hip, it just didn’t feel right. So, I ordered an X-ray that first day. It turned out her hip was dislocated. Once it was fixed, she didn’t need pain medications. Then it became clear she didn’t need her anti-psychotic medications, either. She started walking. And since she had none of the physical signs of long-term diabetes, I took her off her insulin, too. After six months, she went home.
It costs $120,000 for a patient to stay at Laguna Honda for a year – and the average stay for a patient diagnosed with end-stage dementia like Mrs M is six years. Despite the costs of her treatment and the services she needed to live at home, I calculated that in this case slow medicine saved the system around $400,000.
I took a sabbatical to write about Laguna Honda. While I’ve been away, the hospital has moved into a new modern building and there are efficiency experts everywhere. We’ll see how that works out. What I’d like to do next is set up a clinic that tests slow medicine and assesses how it stacks up financially. Is inefficiency more efficient than efficiency? I think it is.
“God’s Hotel”, by Victoria Sweet, is published on April 26 by Riverhead Books