EP. 14: MEDICINE, FAST AND SLOW

Jun 8

WITH VICTORIA SWEET, MD

A physician writer and historian shares the value of “slow medicine” and what pre-modern medicine can teach us about healing.

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Episode Summary

Dr. Victoria Sweet is a prize-winning author, medical historian, and professor of medicine at the University of California, San Francisco. She is the author of two bestselling books: God's Hotel, which details her time as a doctor in the last almshouse in the United States, and Slow Medicine, a memoir that outlines her approach to medicine as both a craft and art. In this episode, Dr. Sweet discusses why she reframes the doctor-patient relationship from one of a mechanic repairing a machine, to one of a gardener tending to her plants. Through vivid stories of her remarkable experiences, she illustrates how combining insights of premodern medicine with advances of modern health care can lead to better healing.

Dr. Sweet is an Associate Clinical Professor of Medicine at the University of California, San Francisco, and a prize-winning historian with a Ph.D. in history. She practiced medicine for over twenty years at Laguna Honda Hospital in San Francisco, where she began writing. As a historian, she has studied the works of Hildegard of Bingen, a 12th century German abbess and medical therapist.
Dr. Sweet is best known as an advocate of slow medicine, the philosophy that medicine works best—that is, arrives at the right diagnosis and the right treatment for the least amount of money—when it is personal and face-to-face, and when the doctor pays attention not only to the patient but to what’s around the patient. She believes that, put into wider practice, slow medicine would be not only more satisfying and beneficial for patient and doctor, but also less expensive for everyone.
In 2014, Dr. Sweet was awarded a Guggenheim Fellowship.
In this episode, you will hear about:
• How the writings of Carl Jung drew Dr. Sweet to medicine - 2:18
• The story of how a resourceful nurse and a stubborn patient taught Dr. Sweet what it meant to be “a real doctor” - 9:36
• The origin of the Slow Medicine movement and how it shapes Dr. Sweet’s approach to patient care - 16:19
• The Philosophy of the Minimum and why examining side effects and placebo groups is critical to delivering the best patient care - 22:03
• Dr. Sweet’s time at Laguna Honda Hospital, the “last almshouse in the United States”, and what she learned about healing from the slower pace of that hospital - 27:07
• How studying medieval figures like Hildegard of Bingen influenced Dr. Sweet’s appreciation for premodern medicine and how she pairs it with modern medicine - 33:58
• Dr. Sweet’s advice for clinicians facing the mounting challenges of the modern corporate medical landscape - 40:02
Transcript

Henry Bair: [00:00:01] Hi. I'm Henry Bair.

Tyler Johnson: [00:00:03] And I'm Tyler Johnson.

Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?

Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are, by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

Henry Bair: [00:01:02] Modern medicine has given us unprecedented advances in technology with ever quicker and more precise diagnostics and therapeutics, enabling us to fix diseases in ways that just a generation ago would have been unthinkable. But is this always the best kind of medicine? Is there something missing here? Our guest today, Dr. Victoria Sweet, argues that good medicine takes more than amazing technology. It takes time, time to respond to bodies as well as data, time to arrive at the treatment that is uniquely right for each patient. Dr. Sweet is a leading advocate of what she calls slow medicine, which is relational, personal and even spiritual. Dr. Sweet is a professor of medicine at the University of California, San Francisco, and a prize-winning author and historian with a PhD in medical history. She is the author of two bestselling books. The first, God's Hotel, details her time as a doctor in the last almshouse in the United States caring for the poorest residents of San Francisco. The second book, Slow Medicine, is a memoir that outlines her approach to the art and craft of medicine and her surprising revelations about what healing means. In 2014, she was awarded a Guggenheim fellowship. Dr. Sweet, thank you very much for being here with us today.

Victoria Sweet: [00:02:16] Well, thank you for having me.

Henry Bair: [00:02:18] Before we get into slow and fast medicine, I'd like to hear about your origin story in your book, Slow Medicine, you take us through your medical journey from the early days of medical school to your multiple residency programs and to your doctoral studies on what medicine was like in the Middle Ages. Can you take us all the way back to the start and tell us what first drew you to medicine?

Victoria Sweet: [00:02:41] Well, I always loved school and after college I didn't have any plans of what I was going to do. And so I kind of knocked around Europe for a while and did some various and sundry things. And there were sort of two things that happened. One was that I discovered the writings of Carl Jung, the psychiatrist. I particularly his memoir, Memories, Dreams and Reflections in a bookstore. And I loved it because he'd been an M.D. and he'd become a psychiatrist. And the depth that he brought to his medicine and the depth he brought to his patients and the way he structured his life, as I read in his book, just fascinated me. And I thought that would be really fantastic. I want to be a brilliant analyst. And at the time, you had to actually have an M.D. just to go get training as an analyst. So that's what made me decide to go to medical school. But a really large additional piece was that I figured, you know what, I get to go back to school for four years at least, maybe seven or eight years. I won't have to decide what I'm going to do for another eight years. It was the longest amount of school I can imagine going to. So we're sort of two interlocking reasons. But the essence of the matter is I was going to be a brilliant analyst because I just and I still do. I love the way he looks at things.

Henry Bair: [00:03:55] In your book, you describe the transition from psychiatry to internal medicine. In fact, I believe you left your psychiatry residency after having only completed that first year, the intern year. So can you tell us more about what made you switch from psychiatry to internal medicine?

Victoria Sweet: [00:04:14] Well, you know Jung had a very particular philosophy. And what happened really in terms of my own interest in psychiatry, you could say, was the psychoactive medications, particularly for schizophrenia. Because what I was doing, I actually did an internship. I didn't finish my residency. I did an internship in psychiatry. And I was struck by how well the medications worked and how not well, any kind of insight therapy, Freudian, Langian, or Jungian worked with the patients. So when I finished my psych internship because you get your license after that, I had my medical license and I thought, you know, I don't think it's possible to be a Jungian analyst really in the psychiatry profession. And I liked medicine and what I liked about medicine. It was a little bit ironic, but what I thought to myself was I thought psychiatry asked the right questions. You know, why are we here? What's it all about? What does it mean You see things that are there? But had no answers. And medicine, I thought, didn't have really great questions, but it had answers to its questions like, what's wrong with this patient? What can I do to fix it? So I found it actually intriguing because there was still so much psychiatry, as you know. Henry, to the doctor patient relationship, maybe not psychiatry, but let's call it psychology. Just walking into the room and immediately getting a sense of things and figuring out. And sometimes, you know, in an internal medicine practice or most medicine, you have 5 minutes, 8 minutes to figure that patient out in the sense of what kind of questions can I ask this person? How would he respond to? What is the silence, this whole, where do you sit? All this kind of stuff that have to do we call it the doctor patient relationship, but it's really bigger than that because it's a person to person relationship.

Victoria Sweet: [00:06:08] And yet you as a doctor, speaking of being a leader, you as a doc have to have enough variety, I would say, of styles that are true to you to be able to match, to some extent, your patient and you can't fake it. I'll give you an example of what I mean. I loved practicing in community clinics and county clinics because I loved the variety and I really like the patients because they're in general pretty down to earth people. But you'd open that door to a community clinic, and it could be anybody from any part of the world. Man or woman or child, any language, any religion that you had no idea and any style. So you'd open it up. You just had that initial. And then you had to realize that not only were you picking up the patient's style, but they were looking at you. So you weren't just the leader, right? Or the actor in the play. You was an actor, you were an actor, and we were both in each other's audiences.

Victoria Sweet: [00:07:07] So that's kind of what I mean. And I'll give you one example that I teach my students with just because I thought it was so interesting. So they had done a study, I think, at Stanford years ago about comfortable distance between doctor and patient. So it turns out that there are this was maybe 30 years ago and it may have changed, but there were definite ethnic, national comfortable distances so that northern Europeans or people of northern European extraction like two arms length distance, whereas southern Europeans, Italians, Spanish, etc. like one arms length. People from Mexico generally like you to sit next to them, and if you get too close, people will feel uncomfortable. And if you stay too far away, people will feel coldness. And obviously somebody can look like a northern European and have being brought up in India and vice versa. So it gets very interesting, just your sense of where you walk. Where am I going to sit? Am I going to sit or am I going to stand? And they get to sit on the patient's examining table. So that's kind of what I mean about psychology. And the entire 15 minutes you spend maximum 15 minutes, you know how you approach the physical exam and when you're going to explain to patients what you're going to do if you don't to some extent use their language, not just their actual language, but the way they do things. They can't hear you.

Henry Bair: [00:08:36] You know. Dr. Suite, one of our recent episodes featured Dr. Abraham Verghese, who was very well known for his advocacy of the transformational power of the human touch and of the importance of presence and the physical examination. You know, he describes it as a crossing of the threshold. I think the word he uses is a ritual. It is a ritual through which a transformative process happens between the doctor and the patient. So I love how you just added your own complementary perspective to that. So you mentioned that you enjoyed working in community clinics because of the breadth of things you got to do and the breadth of patients you got to see. So in one of your chapters in your book, Slow Medicine, you describe how shortly after, I believe, completing your psychiatry internship?

Victoria Sweet: [00:09:33] Internship, internship, internship. Yes, exactly.

Henry Bair: [00:09:36] You started working in a community clinic in the Californian Central Valley where you write that it was here you learned what it meant to be a real doctor through a particular experience caring for patients. Could you talk a little bit more about what you did learn and your experiences at this clinic?

Victoria Sweet: [00:09:57] Yeah, it was fabulous. So it was in the Central Valley and I had just finished my psych internship. So I had four years of medical school and, you know, four months of medicine and eight months of psychiatry under my belt. But I had a friend who was practicing in the clinic, and I liked the idea of just practicing medicine and seeing if I liked it, because I didn't really like psychiatry that much and I did like medicine. So this was a clinic run actually by three docs. They had three different clinics, and this particular one was in a little town called Shafter. An Shafter was like 7000 people, but it wasn't too far from Bakersfield. So, you know, you had access if you absolutely needed it, to surgery and imaging and all that. But it was about a half an hour drive, so patients really didn't want to go for every little thing. We had an x ray machine and when I started there, I had to get my X-ray credentials so that I could actually use and take pictures myself. We had a laboratory. I would look at, you know, when microscopes and I did fungal things because it was all this hands on, which was much more what we did back then than now even then. That was a lot to be expected to do to be able to experiment with. But best of all, there was my nurse Kathy or the nurse Kathy and I have found nurses have just, you know, immensely taught me how to be a doctor.

Victoria Sweet: [00:11:23] And in this particular case, Kathy was an amazing nurse. She just was a remarkable in that chapter. I actually it's really I kind of called the chapter Kathy and the particular patient where I was really struck by it was a patient. Mr. Schneider He was. 70 year old guy and he was sent over by the town chiropractor because he was having chest pain and the chiropractor knew when he didn't know something. So they sent him over to our office. And when I saw him, what I was struck by was that he said he hadn't seen a doctor for six years. So that immediately told me that whatever was up there was something important because this guy was 70 years old. The guy doesn't go to the doctor now he's there some chest pain, just not a great diagnosis. But one of the things I learned in medical school, which highly affected me, was the physical exam and how effective it is. Not just for what Dr. Verghese talks about establishing the doctor-patient relationship, deepening that too, but for actually finding out what was wrong with the patient and what wasn't. So I really to this day, I love the physical exam and I tend to do a complete physical exam, especially with I don't know what's going on.

Victoria Sweet: [00:12:39] So I did a complete physical exam and I did an EKG because we did them back then and I didn't know what was going on. So I sent him to the emergency room and I figured they'll figure it out. But the next day he was back in the office again and his chest pain was worse. They'd seen him in the ER and they told him he had bronchitis and they'd given him antibiotics and I didn't think it was bronchitis, so I reexamined him and I did another complete exam. And this time I found a large, pulsating mass in his abdomen that hadn't been there the day before. And I knew that hadn't been through the day before because I'd done a complete physical exam. So I walked out of the room and I say to Kathy, I say, Oh, you know, you didn't have a yesterday. And Kathy goes, Oh, dissecting abdominal aneurysm. That's bad. I said, Yeah. So we go back in the room and I explained to him, he's got to go to the hospital stat he doesn't want to go. And we went yesterday and finally convinced him. He goes and the next day is back again. Day three, they didn't find it, they didn't. They ignored it. So this time I was like, no, you actually you have to go back. This, this is going to explode.

Victoria Sweet: [00:13:51] You will die if this blows. Explain that. You know, an aneurysm is like having a tire explode when the tire piece gets weak. And he really didn't want to explained it. And I drew pictures and he said, No, doc, you know, I've been there twice. Yeah, I'm not going it. So he left and he went home and I at that time I was like, well, I explained to him he could die. He made the decision. Patient autonomy. Kathy said, that's not happening. She said, I'm leaving. She gets in her car. She said, I called a good friend of mine who is a vascular surgeon, and he's going to stay late to examine Mr. So-and-so. And she drove over to the guy's house and stood there, knocked on his door and insisted and get in her car. She would not leave him. He got in the car. She drives all the way to Bakersfield, to her friend, the vascular surgeon who was in the midst of examining this aneurysm when it bursts. And because they're in the hospital, the guy has emergency surgery, ten units of blood. And like I said, and I even heard about all this, what happened afterwards from Kathy. But ten days later, I go into the room and there he is sitting there with a little brown paper bag. And the first thing he says, This is for you.

Victoria Sweet: [00:15:03] I got the doctors to save my anuerism. And in the little glass jar was his aneurysm. And for me, what that aneurysm having that meant was that Kathy had showed me what a real doctor does. I had almost done it, right? I made the diagnosis. I knew what the treatment was. But the real doctor doesn't stop there. Real doctor, do what Kathy did. You don't let your patients do that. And so in the book in particular, I don't really reference it in the book, but I was thinking about what I think it was Vivekananda. He was a guru from India in the twenties, thirties and forties, and he compared gurus, teachers who said teachers are like three kinds of doctors, said the first kind of teacher is like the first kind of doctor is a good doctor. He listens to you, he figures out what's wrong with you and he gives you a prescription. He's a good doctor. But that's not right. That's not the best doctor. A better doctor examines you, treats you, gives you prescription, walks with you to the pharmacy and watches you get the pills. But the best doctor diagnoses you treat, you walks you to the pharmacy, waits to you get the pills, and then makes you take the pills in front of them. That's the best doctor and that's the best teacher, said Swami Vivekananda. And that's what Kathy said.

Henry Bair: [00:16:19] Yeah. Thank you very much for sharing that powerful story. And it does get us a little bit closer to what you are best known for, which is your ideas about slow medicine. So for our listeners, can you tell us briefly what slow medicine is and how it contrasts with fast medicine and how you came to discover the value of slow medicine.

Victoria Sweet: [00:16:42] So the whole concept of slow medicine, slow medicine is not slow in terms of slowing time. It's neither slower, fast, either assessments. And these are ways of thinking about style. And the concept of slow medicine actually derives from the concept of the slow food movement. And the Slow Food movement, the whole idea of Slow Food was actually came up with in the late 1980s by an Italian who studied at Berkeley, is got his PhD called Opportunity and then he went back to his little village after ten years in Berkeley in Italy, and discovered to his horror that the Italians were losing their home in his little town. Nobody were there fast foods and frozen foods, and he was horrified and he didn't quite know what to do about it until McDonald's announced that he was going to build a golden arches at the top of the Spanish steps in Rome. And Carlo was outraged. And so he decided that he was a bit of a revolutionary, or at least a rebel. So he decided to organize an event to agitate against McDonald's doing it. And so it was going to be on the Spanish steps for your listeners. If you know Rome, then it's very important you visit them in your tourist. And so it was really heretical for McDonald's to put a McDonald's at the top of them. So Carlo decided to organize this events and the idea of selling them what he said against fast food was an event capacity.

Victoria Sweet: [00:18:11] And then he sort of said, you know, against what it is, a slow food. So that's how the whole moniker of Slow Food came in. It was actually as opposed to fast food. It was what fast food is not. And slow medicine came out of the slow food movement in the sense that it's really more a style than the amount of time. So slow food has to do with your ingredients and the way you interact with your ingredients. You know where your food's coming from. You don't have tomatoes in the middle of winter. You go with the seasons. It's how you put something together is sort of the essence of slow food. So Slow medicine came out of that. So slow medicine has about three different facets. So one is fast medicine sees the body very effectively as a machine and the doctor is a mechanic. And the basic principle behind fast medicine is that disease is a breakdown of your machine. And the job of the doctor as a mechanic is to find what's broken and fix it. So it's a very focused, linear, methodical and very effective way to deal with many, many things in the body. I mean, Mr. Schneider definitely didn't want to have a slow medicine approach to his exploding abdominal aneurysm.

Victoria Sweet: [00:19:31] This slow medicine in the back of your mind is this idea of gardening. At least that's how I see it. And it comes out of the way. Medicine was before industrialism in the 19th century, so used to be before the 19th century that we had a model of the body which was much more like a gardener's model of the body. It was a body that responded to the seasons, to weather, to climate, to food. Its principles were the balance of hot and cold, the wet and dry. And it's a model that actually is still alive in Chinese medicine and ayurvedic and a lot of naturopathic medicine. So it's a way, rather than focusing down into what is broken and how can we fix it, that looks at the body from a distance and sort of imagines that the body is trying to get better, but the body wants to get better, and that what we do as a doc is find what's in the way of the body getting better. So it's quite a different style. And the best way to do medicine, in my opinion, is to have both of those styles, both of those ways of looking for any particular patient. Right. And you can pull them out when you need it. So, for instance, even the patient I told you that he got great fast medicine from my exam to Kathy driving to the E.R.

Victoria Sweet: [00:20:52] to the transfusions. But after. Right, they discharge him with this huge scar from stem to stern. He's in his seventies. He's not a sophisticated guy. That's what he would need slow medicine. And that's when the body is wanting to heal. It's going to want to heal what just happened to him and graft in the surgery and the blood and the trauma and all that, once again come. It will heal. And my job as a doc is to make sure there's nothing in its way. What kind of things would be in its way? In this case, I don't actually remember. But these days he would probably have a bag of medications that if he'd been in the hospital for two weeks, he hadn't been on before the surgery, but then he was on. Now three hypertensive is a stat in and maybe he has quote unquote pre-diabetes. Antibiotics, softeners you name it, right, in a whole bag of medicines, all of which you might have needed when he was in the hospital, but probably doesn't need over the next two or three weeks. And so this idea of taking away medicines. Right. He probably was traumatized by the whole thing. So doing something about a psychological kind of telling what happened, reminding him of what happened, this whole thing. Remove what's in the way.

Henry Bair: [00:22:03] That's really interesting. Now, you also have a corollary that you've developed called The Philosophy of the Minimum, which is treating patients with the fewest possible medications, the fewest number of times a day, while still preserving good health outcomes. Now, on the surface, this appears to be somewhat in opposition to what is commonly done in medicine these days, which is to do as much as you can for the patient. What more can I operate on? What other medications can I give to address all of the patient's symptoms and complaints? The goal appears to be to give and to do as much as the patient can handle. At least this is how we are inculcated to practice, if only implicitly through the unwritten curriculum. So can you tell us more about how you developed this philosophy of the minimum? Was there a patient you can tell us about Who taught you why This is sometimes the best approach to medicine?

Victoria Sweet: [00:23:09] I might tell the story, but I think the piece that's left out of the style that you just described very well, Henry, of doing as much as we can for the patient, using as many medications we've left out a piece. And that's every medication you give a patient has side effects and adverse reactions. It just does. There is no getting around it. And to leave that (in accounting you're the MBA) that side of the ledger, are we looking at his assets? All we're looking at as a positive of getting somebody an aspirin. Right. But on the other side of the ledger, there's a certain number of people that get GI bleeds. Even from that one baby aspirin, they just statistically do. You cannot name me a medicine that doesn't have side effects and adverse reactions. So our job as a doctor is to use medicines and take those side effects and adverse reactions into account so that we are not actually causing more harm than good. And I was really struck by this long, long, long time ago when I was in my medicine rotation, and there was this really cool old doc. He was our attending on the medicine service for the month I was there. And I was going off service. And so he walked me out to the car I walked him out to his car and I asked him, was there anything that I, as a starting medical student beginning doctor that words of advice he could give me and I've never forgotten it? It's amazing.

Victoria Sweet: [00:24:41] He said, yeah. He said, you know, as doctors, he said patients about a third of the time will get better. A third of the time we'll get worse and a third of the time will stay the same. And all we do is change who does what. And so that was pretty intense, right? So that was a long, long time ago. And I didn't know whether that was true. So ever since then, whenever I read a study, ever, ever, ever, I read a study about a medication I always look at the adverse reactions and the side effects and the placebo group. And I calculate how many lives were saved by this new medications and how many lives were lost by its adverse reactions or the side effects. Because we have the placebo group can compare and I don't accept, you know, I cannot stand this relative risk. It reduces relative risk by, you know, 1,000,000%. I don't really care about that. I want to know if 100 patients take a medicine, Okay? Compared to the hundred patients that are taking the placebo group, what actually happens to those hundred? Okay? And when I look at the good things and the bad things, how do they weigh up? So I'll give you an example.

Victoria Sweet: [00:25:54] Even with baby aspirin to prevent, you know, in quotes to prevent strokes and heart attacks, a baby aspirin, if you look at the studies, you will find that for every stroke you prevent, you cause a GI bleed. Now, that may be worth it. That may be worth it if a patient's at a really high risk of stroke and a very low risk of GI bleed. But that is just how it works. There's almost very few medications that don't have a certain number of adverse reactions and side effects. And if we don't do that, we're not doing our patients any good. So I think that's what's left out of what you're being taught. I'm assuming that is what you're being taught is making sure we realize that. And it has been because over the years, particularly the last, I'd say, ten years, are you to mostly look at the New England Journal of Medicine in JAMA, particularly the only JAMA, the placebo group, has fallen by the wayside. I don't want to use it because I don't like it very much. And so they'll have these different comparisons. You have to root around to just get a simple answer to the question. "If I give 100 patients this medication, what are the outcomes?"

Henry Bair: [00:27:07] Yeah. So one of the most notable parts of your career was your time at the Laguna Honda Hospital in San Francisco, which you describe it as "the last remaining almshouse in the United States." And this was a hospital that treated some of the poorest people in San Francisco. And you had limited resources. And almost by necessity, it sounds like you had to practice this philosophy of the minimum and slow medicine. Can you tell us more about what was so unique about this hospital and how your time there has shaped your subsequent views and approaches to medicine?

Victoria Sweet: [00:27:48] Well, for me, overall, sort of arching over my career is that after I practiced medicine in the little clinic, which I loved for several years, I realized I really did love medicine and that I needed to get good at it because just having a year of internship was nice. So I did go back and do my residency in internal medicine in San Francisco at Kaiser, and as it turned out, the middle of the AIDS epidemic, which was just a remarkable experience, because suddenly we're having to deal with an untreatable new infectious disease that was fatal and contagious. So it was sort of a historical point of view, you know, just wild experience in fast medicine and how it develops and how its logical method kind of takes things apart. And after then I got out with my residency boarded and then I practiced medicine in another clinic, and the longer I practiced medicine, the more impressed I was by fast medicine's logical focus, step by step, way to get at a problem, but also more and more impressed by what fast medicine left out. So things like we've already talked about the doctor patient relationship in its deepest sense, the placebo effect. People that get better when we're supposed to die. What's that about? Right. And so I really interested in homeopathy and naturopathy and Ayurvedic and Chinese medicine, all these kinds of medicines that look at this other way that I end up calling slow medicine and eventually discovered the writings of this 12th century nun called Hildegard of Bingen.

Victoria Sweet: [00:29:26] She'd written a book on the kind of medicine that was practiced in monasteries and nunnery and access throughout Europe until the end of the 19th century. And I got really fascinated in that medicine, which is called premodern medicine, because it was so much like ayurvedic medicine, Chinese Medicine, Naturopathy. I got very intrigued, so I decided I was going to go back and do a PhD in premodern medicine, this whole other old way of thinking. And I didn't want to stop practicing medicine. And at the time I looked all over to find a part time position. And the only place I could find it was at a Laguna Honda hospital in San Francisco, which was at the time I got there, which was about 25 years ago, was a wild place. It looked like a medieval monastery was high on a hill overlooking the ocean. It would been built in the 20s. It had open old fashioned wards at the time. When I got there, it had almost 1200 patients and it was probably the last almshouse in the country. And the almshouse was how we used to take care of the sick poor before there was health insurance, because we actually had a way. It was this old fashioned system of having a free county hospital, and then if the patient needed more care or needed something else, you'd have an almshouse usually on the outskirts of the city, which was a big old kind of farm like place with buildings that anybody could stay.

Victoria Sweet: [00:30:50] And it used to be that across the country, every county had this system. They had a county hospital and the county almshouse. And that's how we took care of the poor and the homeless and the mentally ill and anybody. But in the 1950s, all of those places were discovered and there was a big movement to close the almshouses and all of them were closed except for San Francisco, which was renamed Laguna Honda Hospital, but was in fact originally called the San Francisco Almshouse. And it was a fascinating place to practice medicine. So it would have been fascinating if I hadn't been doing a PhD in premodern medicine. But doing it along there was fascinating because for one thing, there were 1200 patients and for another thing, we had no pressure on us to discharge the patients. We had no quality assurance people. I mean, we had quality assurance, but we didn't have this huge bureaucratic apparatus. Patients lived on these open wards. We did the best we could. The patients were grateful if they had to be hospitalized or needed surgery, whatever medication they needed, they could get. But we as doctors and nurses and the patients had enough time for me to examine patients and reexamine patients, take them off their medications, see if they really needed them, for the nurses to heal bedsores. We had this kind of time. And so what I got to see there was what happens when you're in a situation like that, what happens to patients, what happens to diseases? It was absolutely fascinating.

Victoria Sweet: [00:32:29] So one of the things that was interesting was we had patients that would get admitted to Laguna Honda with fatal diseases. There was one in particular. This woman had Lou Gehrig's disease, ALS. Usually, you know, it's generally going you know, it's progressive, it's a neurological disease. It's devastating. We have no treatment much today and we certainly didn't have any treatment back then. And this patient was admitted to hospice because her neurological disease was progressing. She could walk, she couldn't move, she could barely talk. She was starting to be not able to breathe. And she was admitted because soon she had stopped breathing. And this was a good place for her to be. You know what? She never got worse. As soon as she got there, she stopped deteriorating. She didn't get better, but she never got any worse. So eventually she moved out of hospice and one on one of the open wards, and she was there for like 20 years and it was completely unexplainable. So that was really interesting to see. It was interesting to see what kind of relationships develop among all of them. Because in a place like this, which is really over the hill, the poorhouse was on 62 acres of land. These huge big buildings and gardens and trees and an aviary and a little farm so patients could see animals. And it just was this otherness to it. And really intense things happened there, healing that I never would have thought was possible. Relationships and an immense amount of medical experience.

Henry Bair: [00:33:58] Wow. Yeah. I mean, it sounds like a fascinating place to have been able to practice. The next thing I wanted to talk about was you alluded to the fact that one of the reasons that you started practicing in Laguna Honda is because it allowed you to pursue a doctorate, a PhD in medical history. Which is fascinating to me because in your book you write about having to learn Latin and German from scratch, all the while practicing as an attending physician. You know, I in college, I was an amateur medievalist. I was a medieval studies major. I wrote a thesis. Yeah, I wrote a thesis on the marginal illustrations of gospel books produced in Ireland between the seventh and a ninth centuries. So I was wondering, can you tell us more about what your study of Hildegard, of Bingen brought to you? What did you learn from it and how has it changed your approach to medicine?

Victoria Sweet: [00:34:50] So let me just say that that's very cool. I don't find that too much. But I think just in general. Separate from Hildegard of Bingen, I think what we call the Middle Ages, and you felt this yourself, This is a hugely important part of our culture's -a missing part- of our culture's whole perspective on what's important, on life, on meaning. And I also think if a medieval person appeared today, I ask myself sometimes, what would they find surprising? And what would they not find surprising? And I think they wouldn't find too much that was very surprising, actually. I think I mean, the houses that we live in are medieval houses. Right. They look pretty good. Like go to Europe. They're not right. I mean, that's the threshold and doors that open. The food we eat is pretty medieval with their utensils. We speak medieval, right. Because English is actually medieval. English developed in the Middle Ages and it didn't really develop much past that. And the concepts I think what's going on now politically the medievals would very easy to understand it most of our issues. So I think when you if you're a medievalist you respond to that and it has a sense of yes-ness to it like yeah, they knew what they were talking about. So Hildegard in particular. It was a fascinating person because she was a woman and she lived in the 12th century, which was like the best century. It was so interesting because it was the period there the cathedrals were built and the whole concept of the nation state developed and universities and libraries and cities. These basic concepts of law, of our society that we are deeply, deeply rooted in, developed in the 12th century.

Victoria Sweet: [00:36:47] And then there was these characters, right, such as Hildegard, you know, Thomas of Becket and Eleanor of Aquitaine, you know, Bernard of Clairvaux and just, you know, cool people, very interesting people. And I've left out about a thousand you know. So and Hildegard was really interesting because the woman and she lived into her eighties and she ran a monastery and she practiced medicine and she was a mystic. And she wrote theological texts and everything that I thought I knew about women and progress, She in that old century demolished. Right. Because it wasn't true that we'd been on a progressive path ever since the dark Middle Ages when women were beaten and sold to the count first night. Right. It wasn't like that at all. Women owned all kinds of things and ran things. And Eleanor ran- Queen of England ran England for, you know, 20 years. So that was one thing. But in her medicine was particularly interesting was she wrote this textbook, this book really, which was my main focus of my dissertation. And I spent about 15 years trying to understand what was the model of the body behind it, because it was both familiar and surprising. And what it was, was what I talked about the beginning of our talk, which is the idea that the body was a plant and the doctor was a gardener, and the job of the doctor was not to act like a mechanic and find what's wrong with the body and fix it. It was to remove what was in the way of the body's power of life and healing. And Hildegard had a particular name for that substance.

Victoria Sweet: [00:38:26] It was really a power. It was a substance. She called it Verititas from the Latin veridis. That means green. And her idea was that Verititas was more like almost like what we would call a hormone. It was actually a substance like sap. In fact, verititas actually goes back to the root for "green sap" and that we were like plants in the sense that we had this stuff flowing in our body that fixed things, that repair things or that got in the way, that built up. So it was very Chinese incense of like chi. And so I started using that way of looking at patients along with my fast medicine style after I got clear in my head that notion. So I would try and use and I do to this day use both of those. Both of those I think of left arm. Right arm don't have two arms. We can have two ways of looking at the body and one of them we can go, Wow, what's wrong with this patient? Let's go down, Deep down, let's find what's the actual one and take it out and fix it repaired or replace it. And then also put our patient in context of its its environment and ask what's interfering with verititas? What's getting in the way? What about his diet? What about his social life? What about who he is as a person? That whole things are two ways of looking and one is focusing down, the other one is stepping back; one the idea is taking it out, getting in there, changing it, and the other one is removing what's in a way. And that's all I have to say.

Henry Bair: [00:40:02] Thank you for sharing all of that. Dr. Sweet know that you have laid out your vision for what medicine should look like. What advice do you have for medical trainees and early career health care professionals about what good doctoring means and on how to integrate more slow medicine into their practice? And speaking of this, I think we have to acknowledge that the culture of modern medicine is such that there is an increasing sense that we have become over corporatized, what with ever increasing patient volumes, with incentive structures that reward doing more procedures, prescribing more medications, and with a seemingly never ending barrage of administrative tasks to complete. What advice do you have for clinicians facing these challenges?

Victoria Sweet: [00:40:57] That is the question of the hour, isn't it? And my advice keeps changing, too, as it becomes clearer and clearer what's really going on. So ten years ago, I gave different advice than I would give you now. I'm giving you advice I gave ten years ago because there's something true to that. So I think on the one hand, as trainees learning, my advice is learn as much as you can. All the crap that's going on outside you, you know, this is your moment to learn and do what you can to learn the most you can. That's the first thing. And then the second piece is, I would say, depending on what you're planning on being, getting experience that's not corporatized is really fantastic. So, you know, the time that I spent, I did locums where I'd be up in the middle of no place and I was a trek physician in Nepal, places where, you know, I have friends who go to South America and go to a volunteer in Mexico where, wow, you know, there really is just your physical exam and some labs you can get, and it is very wonderful experience. So using your trainee position to get experience like that, again, depending on what you know, if you're going to be a surgeon, what kind of surgeon? Are you going to be a specialist? That would be the first two things.

Victoria Sweet: [00:42:15] I love internal medicine and I think if I were going to do it over again even today, I would probably end up as an internist because I like generalist. But my experience is, is that the generalist internist is completely screwed, way more. It's very weird. It seems to me, from what I've seen, that the more specialized you are, the better chance you have to being able to be a slow cardiologist or a slow pediatric ophthalmologist because it's weird. Internists have like 8 minutes to spend with the patient, but they give a consulting cardiologist 45 minutes. So that's kind of interesting. Just from a practical point of view, you're going like, okay, I really don't want to end up. So I would say, think about that when you choose what you're going to do, because just the practicality of it is it seems like the more specialized you are, the more time you have with the patient, which shouldn't be that way. And I've had many discussions with heads of hospitals and medical directors saying, you know, we should. And I think even at Stanford this there was an article a couple of months ago with I think was Verghese and Chen. I think about let's make internal medicine a subspecialty. Like we can call it complicated medicine, complex medicine or slow medicine so we can get the time with patients that we need.

Henry Bair: [00:43:38] What advice do you have for, say, a resident right now in the wards, a medical student rotating through internal medicine? What steps can they take right now, with they're patients to get started with integrating more slow medicine?

Victoria Sweet: [00:43:52] The biggest thing to do is to sit down. It doesn't take any more time to sit down. And I'll end, therefore, with a study where I got this in a couple of pieces. So yes, it's as simple as that sitting down with the patient, because one of our problems is we don't have enough time. We're running all over and got the beeper and get the iPhones and we've got the texting and the apps and the beeps and the alarms, and it's really a nightmare. There was a fascinating study at least 20 years ago, maybe more, that really affected me. It was a study took place in the hospital where -it was a post-surgical patients- the doc came by after surgery and would stay exactly 5 minutes with the patient. 5 minutes? The patient didn't notice that the doc had some little beeper buzzer or something exactly like this. And the first group would see -of the doc's- would stand at the threshold of the door of the room, you know, kind of hands in pocket. How are you doing? Any pain now to go? Exactly 5 minutes. And the second group would come into the room and stand at the foot of the bed for exactly 5 minutes and say, blah blah blah. But every third group would sit on the bed, either sit in the chair or sit on the bed for 5 minutes and the end of the act as they come in the morning.

Victoria Sweet: [00:45:15] That afternoon they sent all the students to talk to the patient. Oh, how was your day? Blah, blah, blah. How did you see your doctor today? How long did he spend with? The patients whose doc stayed in the threshold? Said, Oh yeah. He was here? Yeah, he's just stayed a couple of minutes. The guy who walked into the room and sort of foot of the bed, he said, Yeah, he was here. I don't know. I'm 6 minutes. I sat on the bed, said, Oh, we had a nice chat. He spent about ten or 15 minutes with me. So ever since I read that, which is a long time ago, I always sit down and they make it hard for you to sit down. Sometimes I actually have to leave the room and go get a chair because there's no chair. Or sometimes I'll ask the patient if I can sit on the bed and I sit on the bed. They make it very difficult, but it's worth the time. You will be surprised as soon as you sit. It takes no more time. But you will calm down. You will relate differently. You are sending an incredible verbal message that says, I'm sitting, I'm yours. Even if it's only 5 minutes.

Henry Bair: [00:46:22] Well, well, on that very encouraging note, I want to thank you, Dr. Sweet, for lending some of your time with us and sharing your philosophy and your stories.

Victoria Sweet: [00:46:31] Thank you very much for having me, Henry. I really appreciate it.

Henry Bair: [00:46:41] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctors Art. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.

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