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View From the Other Side of the Stethoscope

As an internist and cancer survivor, Wendy S. Harpham, MD, FACP, offers a unique perspective on oncology practices.

Friday, April 5, 2019

Checking Out God's Hotel

Assuming your patients' physical improvement is possible, how do you see yourself facilitating that healing? Surely you don't envision realigning four humors, as did healers in premodern times. Do you believe you're nursing a life force separate from the physical body? Your answers matter, because your understanding of illness and healing guides your care of patients.

In God's Hotel: A Doctor, A Hospital, and a Pilgrimage to the Heart of Medicine, Victoria Sweet uses deftly painted patient vignettes as scaffolding for a provocative discussion of clinicians' role in healing. The book opens with Sweet's disappointment as a third-year medical student watching the conclusion of the autopsy of one of her patients. "I'd expected (we'd find) some thing that was, well, ineradicably Mr. Baker, something the pathologist's (electric) saw could not open and destroy."

It wasn't until years later that Sweet realized modern medicine had no language for a patient's "life force," and premodern medicine did. Ancient terms such as "spiritus" and "anima" referenced "something present in the living body but missing from the corpse." Rest assured, God's Hotel is not a treatise about the soul or religion. This is the story of Sweet's earnest attempt as a scientist to reconcile the mysteries of healing so she could optimize her ability to help patients.

Sweet's efforts began informally while working in a rural private practice, and they continued with a stretch as the director of a community clinic. Then Sweet took a road less traveled, working for decades as a primary care physician at Laguna Honda, America's last almshouse. On the wards, she relished the slower pace and autonomy that long-retired physicians fondly recall and young physicians can only imagine. The gifts of Laguna Honda—its unconventional floor plan, a head nurse who knitted blankets for patients, and enough time to just sit and watch a patient—highlighted elements of the healing arts now threatened by technology-rich, rushed patient care.

What separates God's Hotel from other vignette-heavy clinician memoirs is Sweet's expertise as a PhD in history and social medicine. She learned German and Medieval Latin to explore original texts on the work of Hildegard, a 12th century German practitioner of premodern medicine (as well as a nun, mystic, and theologian). Sweet's academic effort was motivated by her desire as a clinician to find insights from a time when healers believed in viriditas—"the power of humans to grow, to give birth, and to heal."

Whenever diagnosing and treating patients, Sweet turned to the medical truths revealed by science and technology to inform her prescriptions. At the same time, she feared modern medicine's mechanistic approach suffered from rejecting (or ignoring) the notion of a life force. In Hildegard's writings, Sweet found ideas that opened opportunities to foster healing—and humanism—in modern medicine.

Here's an example. As the admitting physician, Sweet assessed Terry Baker, a heroin addict and prostitute with transverse myelitis and a massive inoperable decubitus. Facing "a catastrophe, and possibly the end of Ms. Terry Baker," Sweet tried a Hildegardian approach to healing by "removing all obstructions to Terry's own viriditas."

Please stay with me, here. As expected in a book like this, Terry makes a remarkable recovery, her vast wound healing by secondary intention, thanks to repeated debridement and proper dressing, healthful nutrition, rest, physical therapy, and her quitting smoking. And tincture of time: two and a half years of expert and compassionate care at Laguna Honda.

You could argue that Terry would have recovered had she received the same care from a physician who'd never heard of Hildegard but prescribed the same therapies. I agree. That argument, however, misses the point: Without a premodern concept of viriditas, Sweet likely would have been less persistent and holistic with the many little efforts she took to facilitate Terry's healing.

It's easy to get misled when you read that Sweet, despairing about Terry's prognosis, asked, "What would Hildegard do?" To put that comment in context, Sweet later emphasized how her intimate knowledge of Hildegard led her to feel "even more grateful for modern medicine...especially for its scientific method, which tests the past, rejects what is ineffective, improves on what works, and passes to the future its powerful results."

Sweet doesn't ask you to share her belief that a life force enters the body with a baby's first breath and leaves with the final expiration. Nor does she suggest that viriditas emerges from biochemical processes (analogous to the notion that consciousness emerges from brainwave activity) and disappears at death. Through stories and discussion, she encourages you to swim against the tide of mechanistic commoditized care and embrace the mysteries of life and healing. She presents her case for clinicians to continue capitalizing on the truths revealed through modern science, while integrating aspects of premodern medicine that can serve patients—and clinicians—well today.

Premodern medicine has no place in patient care. What it can do for today's clinicians is what Hildegard's writings did for Sweet at Laguna Honda: offer inspiration and timeless lessons about the value of observational skills, patience, diet, exercise, meaning, connection, community, and tending to the little things.

This complex book devotes a few pages to Sweet's 1,200-mile pilgrimage on foot to Santiago de Compostela. She began that journey with hope of better understanding "otherness" and tasting 12th-century living. Through the hardships of that pilgrimage, she learned to expect the unexpected, find peace in the waiting, and feel satisfaction with "things as they turn out to be"—invaluable lessons for clinicians.

Throughout the book, Sweet weaves the saga of the demise of the original Laguna Honda and the transition to a modern facility. Here, I found her storytelling tedious. Still, those sections helped me think about the relationship between nurses and physicians, and about the roles of architectural and administrative structures in the healing equation.

God's Hotel offers a fresh way to think about the challenges of modern patient care. You'll reaffirm or modify your understanding of what, exactly, you do to facilitate patients' healing. And you may find practical ways to improve your care.