Excerpt: Care and Caring, Time and Efficiency

In her debut, God's Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine, long-time physician Victoria Sweet pulls the curtain back on her 20 years at San Francisco’s Lagunda Honda Hospital, the country’s last “almshouse” for the poor and chronically disabled. A student of social medicine and history (with the Ph.D.s to prove it), Sweet links the past and present of medicine in the dramatic story of a now-unique health care center that’s faced challenges financial and criminal—including a just-finished, 15-year investigation by the U.S. Department of Justice. In this excerpt, Sweet explores a fundamental principle in Langunda’s concept of healing.

I learned a lot from Dr. Curtis, but it was with the case of the missing shoes that he taught me the most about care and caring, time and inefficiency.

On this particular day, I met him by accident in the wide, windowed corridor that ran the length of the hospital and connected all the wards. He was in a hurry.

Where was he going? I asked.

Back to the rehabilitation ward, he said, where he was covering for a few weeks.

The rehabilitation ward, like the admitting ward, was its own minihospital within Laguna Honda. It admitted the patients with the milder strokes and the less traumatic head injuries, most of whom would recover and be discharged back to their homes, if they had them, although its patients, too, were often without friends, money, or health insurance. Like the admitting ward, it had its own physicians to admit, examine, and discharge its patients, and this month, Dr. Curtis was one of them.

He’d just come back from outside the hospital, he told me, and was headed back to a patient who, having been rehabilitated after a stroke, had been ready for discharge for months. But every day when Dr. Curtis made his rounds, checking on the thirty-six patients on the ward, this patient was still there, still zipping around in his wheelchair, still going to therapy.

“Finally,” Dr. Curtis said, “I asked him why, since he was able to walk, he was still here? Why was he still in a wheelchair? Why hadn’t he been discharged?”

“No shoes, Doc. They ordered me special shoes, but they’re waiting for Medicaid to approve them.”

“How long have they been waiting?” Dr. Curtis asked.

“Three months.”

Dr. Curtis thought a bit. “What size shoe do you wear?”

“Size nine.”

Dr. Curtis reflected for a while. He thought about his duties, his other patients, the charts he had to dictate, the quality-assurance forms he had to fill out. And then he left the hospital, got in his car, and drove to Wal-Mart, where he bought a pair of size nine running shoes for $16.99. He’d just come back with the shoes and was going over to the ward to put them on the patient and write the discharge orders.

Was he planning to submit his receipt for reimbursement? I asked.

He laughed.

As I watched him hurry back to the rehabilitation ward, I wondered: Why had Dr. Curtis done this? And why hadn’t anyone else?

It was a simple thing to do, but it never would have occurred to me to do it. I would have been frustrated with the shoe delay, of course, and I would have filled out a second or even a third Medicaid request. I might even have written Medicaid or braved its phone tree to complain about the time that pair of shoes was taking. But it would never have occurred to me to go to Wal-Mart and buy the patient’s shoes. I had too much to do, too many forms to fill out, too many other patients to see. It would have meant crossing a kind of inefficiency boundary. And yet Dr. Curtis got in his car without much questioning; and he was hurrying back to the ward with the shoes to put them on the patient—himself.

He reminded me of an aphorism I loved but had never understood: “The secret in the care of the patient is caring for the patient.” I’d always assumed that it meant caring about the patient—loving or at least liking the patient—but when I saw Dr. Curtis rushing off to put shoes on a patient he barely knew, I thought there must be more to it than that. So I tracked down the quote and found it in a talk by Dr. Francis Peabody to the graduating medical class of Harvard in 1927. It turned out that Dr. Peabody didn’t mean caring about a patient but caring for a patient, which, he explained, meant doing the little things, the little personal things that nurses usually do—adjusting a patient’s bedclothes or giving him sips of water. That took time, Dr. Peabody admitted, and wasn’t, perhaps, the most efficient way for doctors to spend their time. But it was worth it, he told his students, because that kind of time-costly caring was what created the personal relationship between patient and doctor. And that relationship was the secret of healing.