Thursday, March 14, 2013

Decline and fall of the last American hospital

kw: book reviews, nonfiction, medicine, hospitals

From the word hospital, derived from host, we get the word hospitality. Sadly, as shown in a recent Time article by Steve Brill on the Chargemaster system and hospital administration practices, there is precious little hospitality to be found at any American hospital. Put that together with a flood of anti-doctor and anti-medical-establishment books in the past ten years, and I find my attitude towards "health care" in America is pretty bleak. Thus, I was cheered to read about Laguna Honda Hospital in San Francisco, the last Almshouse operating in the U.S.…at least, I was cheered for the first third of the book God's Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine by Dr. Victoria Sweet.

Nearly every hospital throughout Europe and America began as an Almshouse, a charitable organization usually connected to a monastery or convent. (Side note: The Roman Catholic church canonized Mother Teresa a few years ago. During the late Twentieth Century she was nearly unique, but prior to about 1930, there were thousands of Mother Teresas in Almshouses around the world and across America.) And until recently, the 2/3 of hospitals that are private, non-profit entities were low-cost facilities where doctors could provide more specialized care for major conditions. They took advantage of economies of scale, sharing the cost of operating theaters and later intensive care wards.

Then two trends collided. Technology produced "imagers"—CT (formerly CAT) scanners, MRI (formerly NMR) scanners, PET scanners, EBT scanners (e.g. HeartCam) and other multi-million-dollar imaging machines—and then "Gamma knife", daVinci robotic surgery and an increasing number of high-tech "procedure" devices. And the number of tests that can be performed on a blood or urine sample continues to multiply. All are very costly. I also count the huge pharmaceutical industry as a segment of technology. No longer an enterprise devoted to finding natural chemicals that kill bacteria or amend hormone imbalances, the drug trade is now all about designer substances intended to increase the cost of treating a growing array of symptoms (many are now just "marketing illnesses" that were once considered normal variations), primarily for the benefit of their stockholders.

Perhaps starting a little before the technology trend that began in the 1920s, the "efficiency" trend promoted by Frederick Taylor and Frank Gilbreth gained sufficient steam by the 1970s to totally transform medical "care". Today, the "health care" establishment—both hospitals and insurance companies—primarily cares for continually increasing stockholder value. Doctors' time is squeezed, so that many feel pressured to see between four and six patients (increasingly called "clients") per hour. Nurses' time is squeezed, so that paradoxically, nurses are being laid off (and new nurses can't find jobs) at a time when the Baby Boomers' need for health care is rising rapidly.

As God's Hotel shows from its middle chapters on, a third trend, of "rights" for everybody except those who are supposed to know what they are doing (doctors and nurses), has collided with the other two, demanding ever increasing "services" while ignoring their costs.

Dr. Sweet began her career with a double ambition. Of course, she was a newly-minted M.D. with her residency completed, and wanted to practice medicine, brim-full of allopathic training. She had also experienced things that seemed to go beyond Twentieth Century medicine, and at a propitious time, encountered Hildegard of Bingen's Medicine, written in the Twelfth Century. This epitome of "premodern medicine" had an entirely different view of the human person, well or ill, than "modern medicine". It also described quite a variety of treatments known to be effective, many of which are still used. Think Aspirin for minor pain: you can make it yourself by extracting willow bark with vinegar, as people did for centuries. Think "eyeblink" diagnosis (also called Augenblick, from German): when you've seen a syndrome, you will recognize it again in an instant. See many and sundry sick people, and you'll "get an eye" for this. My uncle was a master at this, as was his father. Dr. Sweet was able to pursue a PhD in premodern medicine while carrying on medical duties at LHH. Her experiences there, and a 4-year pilgrimage she undertook with a friend, form the framework of the book.

Sometimes the "eyeblink" can take a little time. Thus the value of sitting with a patient. Late in the book, Dr. Sweet (called "Dr. S" by nearly everyone at the hospital) writes of being stumped by a very sick patient who took a turn for the worse, could not endure a touch without screaming, threw off the bedclothes and her gown, and lay writhing on the bed. So the doctor sat by her bedside and watched. Soon she realized the woman looked like she was trying to drive a poison out of her system, and pondered what the poison could be. Thinking through the long list of medications, she realized that many of them increased retention of Serotonin. She diagnosed Serotonin Syndrome and cut way back on those medications. The woman recovered, fortunately, because the syndrome is frequently fatal and is hard to detect with a blood test. The diagnosis relied on application of modern knowledge together with an ancient technique of simple observation. It took less than an hour, and used no blood tests, indeed no physical contact with the sick woman at all.

What is an hour of a physician's time worth? My family doctor charges $150 for a half hour's visit (he eschews the HMO limits of 10-15 minutes, thus cutting into his income, but providing better care, genuine care). He has rent and utilities to pay, staff to pay, and probably pays himself less than half that, but suppose he is "earning" $150 per hour. That works out to $300,000 per year for an 8-hour day, but I reckon he works longer hours. When I go for blood tests, a simple "metabolic panel" has a retail cost of $300, though the insurance company discounts that to $160. Just a blood count (hematocrit) is $100 or more. The venipuncture by the needle girl is $50. I don't know what kind of blood test can detect Serotonin Syndrome, but I bet it costs more than $150, and I am sure Dr. S was paid less than $150/hr in the year 2002 or so.

The book is full of examples that show how "efficiency" is far from efficient. The paperwork to buy shoes for one patient who had none was taking weeks and weeks, until one doctor bought a pair for $60 and gave them to the patient. He could then be discharged. How many days, at a few hundred dollars a day, would he have been kept in the hospital waiting for the "efficient" service to occur?

Laguna Honda treats (or treated) the poor, the really poor, many sent over from the County Hospital after they had run the course of "acute care" available there. They ranged from very ill to nearly dead. Many were drug addicts. Some had nearly no liver left from heavy drinking. Most were too sick to return home, ever. The Almshouse provided a synergistic mix of allopathic and pre-modern medical care. But, during Dr S's twenty years there, things changed. The Twentieth Century intervened, with its "efficiency", its technological gimmicks and gadgets, and its nannyish "rights" enthusiasts. It was somehow against the "privacy rights" of the patients to have open wards with 30 beds, even though 90% of them preferred the community spirit that resulted, and LHH had a few private rooms for those who really, really didn't like sleeping in an open ward (once they recovered enough to notice). But the nanny-state decreed otherwise.

A 10-year Justice Department review resulted in a scathing report that required either shutting LHH down and paying (by California and S.F. county, of course, not by the Feds) for some level of "care" in their "homes", usually skid row hotels. Even though a number of the patients had been kicked out of such hotels for infractions such as starting fires or having fights (imagine two people too sick to stand, having a fight)…or being replaced by a new, "modern" facility up to DoJ standards. Amazingly, the voters of San Francisco voted in favor of a bond issue to the tune of a third of a billion dollars, and the architectural review began, followed by construction, and finally, moving all the patients to the new place.

The book ends in a way that led me to infer Dr. S left LHH at that point, or soon after. There is no way the former standard of caring could be carried out in the new facility; it is devoted to "modern care", which we must remember, only cares for the bottom line. There is no "hospitality" left in American hospitals. All are mis-named. The book made me laugh a time or two. More often I breathed, "Oh, wow!". Sometimes I wept. During a few months living in Switzerland, Dr. S saw medicine practiced in a way more similar to LHH than to anything else in America. To get caring care, now Americans must travel abroad. Sic transit Miraculum.

No comments: