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June 1&15, 2013 BOOKLIST
Find more The Booklist Interview
Victoria Sweet is a physician and an associate clinical professor of medicine at the University of California–San Francisco who holds a PhD in history and social medicine. She is also a writer of exceptional power, poised to enter the realm of Oliver Sacks and other compelling doctor-writers who have radically altered our perception of health, illness, and medicine.
Sweet’s intensely affecting, enlightening first book, God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine, both recounts her adventurous quest for understanding the body and the life force, medicine and healing, and tells the resounding story of a unique community, the Laguna Honda Hospital in San Francisco, where Sweet has worked for more than two decades.
Did you want to be a writer early on? If so, did you plan to make writing part of your medical practice?
Sweet: I’ve always written some, but it was being a doctor that made me into a writer. Doctoring, especially the “workup”—the written account of the history, the physical examination, and the test results—requires a lot of writing, and the more I wrote those workups, the better writer I became. Nowadays, with electronic medical records, young doctors cut and paste everyone else’s words, but the traditional workup is handwritten and, at best, a work of observation, intelligence, and good storytelling.
Doctoring is similar to writing in that it requires the observing of physical details, intuiting a backstory from what is “not there,” reading emotions, and finding the thread of logic in a bunch of different impressions, thoughts, feelings, and facts.
Have you been inspired by other medical doctors who write?
Sweet: I wasn’t exactly inspired by their writing, but the fact that William Carlos Williams, and A. J. Cronin were physicians and also managed to be great writers was important to me. As far as inspiration, it would have to be Naomi Rachel Remen. Her Kitchen Table Wisdom (1996) blew my socks off. Oliver Sacks, for his breadth, and the way he weaves patient stories together with medical facts, scientific ideas, and history. Jung, of course, especially his Memories, Dreams, Reflections. Chekhov, especially “Ward Six.”
When I decided to write God’s Hotel, I read every doctor-writer I could find, to see how they did it, including Jerome Groopman, Pauline Chen, Abraham Verghese, Christine Montross, and Atul Gawande.
Did you keep journals during the years you chronicle in God’s Hotel?
Sweet: I didn’t keep a journal. I had notebooks for my PhD work, but it just didn’t occur to me to write about my patients until those bulldozers appeared. Fortunately, a doctor’s training really helps one’s memory. Most of my doctor friends can recall in detail stories of patients from years ago, including their relevant blood tests and X-rays. I think we can recall these details because medicine often happens in a state of heightened awareness.
I don’t write every day, deliberately. When something wants to be written, I don’t think about it much, until I write it. I let it bat around; I let it smoke and smolder; then I try to catch it when it starts to flicker.
You’ve done phenomenal research. Can you share any thoughts about libraries?
Sweet: I love libraries, especially university libraries, and especially Stanford’s, which I visit almost every day. They are so individual and so quiet, with their particular smell of books, paper, and just a bit of mold. Getting to read manuscripts at Paris’ Bibliothèque Nationale, in the eighteenth-century reading room, with its long oak table and a trolley piled with ninth-, tenth-, and eleventh-century manuscripts, was unforgettable.
Perhaps the most interesting library I’ve visited, though not the fanciest, is the Warburg Library in London. Abby Warburg was the eldest son of the Warburg banking family, but he fell in love with books. He sold his birthright to his younger brother in exchange for the right to buy any book he wanted for the rest of his life. His brother later said that it was the worst deal he ever made. Eventually, Warburg had so many books that he had to move his family into the house next door.
What makes that library fascinating is that he didn’t agree with any of the existing filing systems, and he came up with his own: one which put books that would be important to have next to one another, next to one another. So, for instance, in the medieval science section, he has alchemy next to gardening next to cooking next to cosmology. And when I was working in the Warburg Library, I found this idiosyncratic filing system not only convenient but also provocative. It caused ideas about gardening and medicine, cooking and chemistry, to link up in my mind, naturally. Warburg’s organization was thoughtful, literally.
How have your love of language and your etymological inquiries helped you understand Western medicine and Hildegard of Bingen’s Way of Medicine in particular?
Sweet: Etymology helped me understand that hospital and hospitality are related, and the fact that their root, hospes, means both “guest” and “host” pointed me to what is missing from modern medicine. Health, wellness, and wholeness all come from the same root, and this shows that they are practically the same thing.
Etymology was particularly important with Hildegard. Her special word for the natural power of healing was viriditas, “greenness” or “greening,” from the Latin viridis (“green”). Going deep into the etymology and history of viriditas turned out to be my key to premodern medicine, which saw the body not as a machine to be fixed but as a garden to be tended, and the doctor not as a mechanic but as a gardener.
Will doctors insist on spending more time with patients and less time on the computer filling in forms? Do you detect desire for change?
Sweet: Doctors are pretty fed up. Most every medical journal has an article every week by some such fed-up doctor as well as an article by some economist, suggesting just one more form.
A number of doctors are turning to so-called concierge, or boutique, medicine. It’s a bit like community-sponsored agriculture. The docs accept 300 patients or so into their practice; the patients pay a monthly or yearly fee. The docs can do a fantastic job with that number of patients: full physical exams, seeing patients the same day in their offices, attending them in the hospital, even scrubbing in on surgeries. Since the fees are upfront and set, the docs have no billing department. Everyone seems quite happy with the setup. So it seems too good to be true.
Certainly, while I’ve been at Laguna Honda, things have gotten more and more bureaucratic and less and less efficient, though in the name of efficiency. When I started there, a typical patient’s chart had just one form; by the time we moved to the new hospital, each chart had 43 forms, some many pages long. And how often those forms interfered with efficiency! There was the patient who stayed for an extra two months while he waited for the form allowing his new shoes to be approved. There was the form that was so complicated that an additional 38 nurses had to be hired just to fill them out.
Then there was the blissful two months when the computers crashed, and we found out just how much more time we could spend with our patients.
What lessons learned from working with the “sick poor” can be applied to our overall health-care system?
Sweet: Because it was off the radar, God’s Hotel (Laguna Honda Hospital in San Francisco) allowed me to learn and then to practice what I now call slow medicine, as opposed to fast medicine. Slow medicine is just taking time to talk to and examine and even reexamine a patient; to call other doctors; to go over lab tests and X-rays; to think about and muse over a diagnosis; to discontinue medications that are, perhaps, no longer needed; to try a new medication—but carefully.
Let’s take our time, instead of changing everything all at once, in a crisis mode—which is what, I am sorry to say—the Affordable Care Act tries to do. Let’s sit back and focus first on what it is we do adequately, on what is working. Let’s make a list—which is what I would do with a patient—of what needs to be done, in order of importance, and then come up with the simplest, cleverest solution for each one.
Where I would start would be to re-create a simple safety net for all: say, a free hospital and a free almshouse in every county, so that no one would face bankruptcy if they got sick, and everyone would have some place to go.