Abstract

As part of the postgraduate ethics sensitisation programme at St. John’s Medical College, the faculty and students read excerpts from the book “God’s Hotel” by Dr. Victoria Sweet. The reading was followed by personal reflection by the speaker and the session concluded with a discussion among the audience. Summarised below are the passages from the book and the reflections from each speaker, with feedback from the audience. The stories explore various dimensions of the doctor-patient relationship, respecting the wishes of patients, care of the terminally ill, coping with colleagues, and dilemmas in patient management.

Keywords: medical ethics, sensitisation, slow medicine, book reading, postgraduate teaching

The Department of Medical Ethics at St. John’s Medical College and Hospital conducts a Postgraduate Ethics sensitisation programme for 2nd year postgraduate students. As part of this, we felt that students need to read other books beyond their text books and freely discuss their responses to them. The book selected was God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine, by Dr Victoria Sweet (1).

Dr Sweet is a physician by training, who has worked in the Laguna Honda Hospital, San Francisco, for over two decades. Her encounters with patients, staff, and management in Laguna Honda, an extended care hospital, are reflected in the book. She celebrates the practice of “slow medicine” in this widely acclaimed book. Traveling into the by-lanes of the art and science of medicine, she delves into the “spiritus” of humanity and the gravitas of the medical profession.

A book reading session was jointly organised by the Department of Ethics and Department of Medicine. The readers comprised both faculty and students, with comments from an expert ethicist and the audience. The programme was conducted as part of the “Friday Clinical Meet”, a weekly academic event at St John’s Medical College and Hospital. This allowed not only the PG students, but faculty from across all disciplines to attend the event. Each speaker chose a passage that appealed to them based on their own varied experience in medicine. After each speaker read the selected passage, they spoke about what it meant to them. A summary of each passage with the personal reflection from each reader follows:

1. The autopsy – Pages 1-3 (JI)

The first post mortem examination attended by Dr Sweet was that of a certain Mr Baker who died of severe emphysema. He was one of her first real patients, a cheerful and lively “pink puffer”, a patient with emphysema. As she watched the autopsy, she noticed the honeycombed lungs, the hypertrophied heart, the blood vessels, and the brain being cut open and examined. She was searching for that something which made Mr Baker the person he was. There was no such un-openable “black box” which the pathologist’s saw could not destroy.

Dr Sweet goes on to describe two such entities which distinguish a living body from a cadaver. There was “spiritus” which was the rhythmic respiration or breathing which was absent from the lifeless body. Likewise, “anima” the invisible energy that animated the body with conscious and unconscious movements. Thus, the very basic indications of “life” in a body are elucidated to the reader.

As medical students, when we learn about the human body and its anatomy, sometimes we fail to see that it was the breath of air in that very same body which made it a “human being”. That unseen energy is the force that animates a body. This piece made me reflect on the person that the body was and that I should respect that individual for that. It made me introspect on my undergraduate years and contemplate on my anatomy classes. The first lesson I was taught was to treat that human body which I dissected with the dignity the person who inhabited it deserves. I will continue to honour this throughout my practice of medicine.

2. The man with the big tongue – Pages 24-31 (AP)

Mr. Lev Grenz, had the misfortune of landing in intensive care with alcoholic pancreatitis, where he battled for several weeks near death, being poked, prodded, and tubed. Miraculously, he recovered and was sent to Laguna Honda Hospital for further care. Dr. Sweet, his attending physician noticed a strange oddity in his tongue. It was abnormally large, thick, dry, beefy-red, couldn’t fit into his mouth, and had left him with incoherent speech. As she further examined him, she observed the slightly dusky hue on his face and his muffled heart sounds. She went over her list of differential diagnoses while she ordered a few tests. The x-ray picked up a massive pericardial effusion! To confirm its acuteness, she rushed back to her patient (and to the lost art of physical examination in medicine) to measure the paradoxical pulse. There she found to her dismay a paradoxical pulse of thirty points and quickly shifted the patient back to the County Hospital where he underwent a life-saving procedure to drain the massive amount of blood in his pericardial sac and avert a deadly cardiac tamponade wherein the pericardium gets filled up with blood and stops the heart from beating. Truly, a clinical finding as simple as the paradoxical pulse can save a life.

Mr Grenz is the typical patient we see in our clinic. No, everyone doesn’t walk in with cardiac tamponade. But everyone walks in with a story waiting to be heard and understood just like Mr Grenz with his incoherent speech. Dr. Victoria Sweet shows us that something so seemingly simple as the history and clinical examination can provide us with far more vital information than the tests we order afterwards. The basic duty of a physician is to understand the patient and his difficulties. Many times, seeing the patient as a whole is something doctors do not do. And, that may be the key to healing a patient and fulfilling the duty of beneficence.

3. The man with no shoes – Pages 77-82 (PH)

In this anecdote, the author narrates the story of the man who, due to a lack of shoes, was kept in the ward beyond his proposed discharge date. The doctor in charge, runs out and gets a pair of shoes from Walmart, and facilitates the discharge. This illustrates the saying in the book where she quotes the famous Indian adage “A good doctor is the one who prescribes the medicine and makes sure he takes it, a better doctor is one who prescribes the medicine and takes the patient till the pharmacy, while the best doctor is one who takes the patient and waits till the patient swallows the medicine”. Finally, the author calls the doctor involved, the best doctor. The doctor here walks that extra mile to ensure that the patient no longer stays back just for want of shoes.

This is an ethical dilemma that many doctors face especially in resource-poor settings, and also when the kith and kin abandon the patient. This chapter throws light on the agony of the patient who is kept beyond the due date for discharge and the ensuing “Catch-22” situation the medical team has to face.

4. The malady of polypharmacy- Pages 115-125 (JM)

Mrs Muller is a 78-year-old lady, who has had a fall and sustained a hip fracture eight months earlier. She had undergone surgery, after which she became delirious. The doctors mistakenly attributed the delirium to psychosis from undiagnosed Alzheimer’s disease and started her on antipsychotic medication. During her hospital stay, she complained of hip pain for which she was put on increasing doses of pain medication. Mrs Muller, a previously healthy active old lady, had become withdrawn and unable to care for herself and was therefore admitted to Dr Sweet’s wards.

Dr Sweet found Mrs Muller alert despite the medication. She examined her and noted a decreased range of movement for the operated hip. An X-ray revealed that the hip had been dislocated from the socket many months earlier and had gone unnoticed. Mrs. Muller underwent remedial surgery and her pain was reduced . Dr Sweet tapered off and stopped her pain medication. In her rounds, Dr Sweet was impressed with the accuracy and richness of Mrs Muller’s stories of her past. She suspected that Mrs Muller did not need her antipsychotic medication. She phased it out keeping in mind that it could lead to a worsening in Mrs. Muller’s condition. Dr. Sweet described Mrs. Muller blossoming after all her medication was stopped as “a photograph developing, her self becoming more colorful and more definite with each day”. At discharge, Mrs. Muller left the hospital cheerful and independent after her tryst with “slow medicine”.

Mrs Muller is a prime example of what can go wrong with our modern medicine. At the first hospital, after her surgery, the doctors may have been justified in starting her on the numerous medications. However, a reassessment to stop unnecessary medication is often missing in today’s busy clinical practice. We do not want to “rock the boat” for a stable patient by stopping the medication and observing the effects. To stop antipsychotics for a patient with psychoses runs the risk of the patient becoming delusional, irritable, and violent, a risk that few doctors would take. If antipsychotics are given for delirium, they should be used for a short time till the delirium clears. It is good practice that in patients on multiple medication, the indication for medication be periodically reviewed. Slow medicine is about giving the patient time to heal on their own. It is about making small changes to medication and watchful waiting. It is about rounds that assess not just the medical condition of the patient but allow for time to hear stories from their past.

5. The wedding at Cana- Pages 188-199 (AB)

Mr Teal, a patient, falls in love and marries another patient in the hospital while admitted. The wedding takes place in the hospital premises. This makes Dr Sweet appreciate Laguna Honda Hospital as a tightly knit community.

Usually, when we join medicine, we are trained to be compassionate, sympathetic, empathetic but to remain objective towards our patients. To me, being objective means that there is a boundary which we are not expected to cross while dealing with patients. The wedding that happens at Laguna Honda seems to blur these boundaries and raises two ethical questions:

When a doctor gets involved in a patient’s life, we are at risk of losing objectivity leading to a conflict of interest. Besides, being compassionate towards a patient does not mean being involved in their personal life.

The other dilemma deals with having a place of worship in the hospital premises. One may argue that it provides a feeling of relief to the patients or their families. But I believe that a hospital is a place of science and when a patient comes to us, they are expected to believe in us. They are not just expected to believe in our medical judgement but also believe that whatever we do while managing the patient is in their best interest. Having a place of worship defies objectivity and logic, as the patients believe that a higher power will take care of the situation. This may lead to illogical decision-making.

The solution to the first dilemma seems to be the delineation of clear-cut boundaries in the form of a standard operating procedure for a hospital. I felt the need for this in my career when I was working in the Neonatal Intensive Care Unit and taking care of premature neonates. I realised that there is a certain kind of emotional bond, which develops between a doctor and a patient. Patients who were with me for months would suddenly pass away. It affected me but I was always objective and kept a check on my emotions so as not to undermine my medical judgement.

The rest of the chapter also resonated with me as it spoke about the politics in Laguna Honda Hospital. The Director of Admissions is forced to make decisions, which are out of sync with the ethos of the hospital due to financial and societal pressure. This made me question whether ethics is an abstract concept or subject to everyday pressures. I feel this chapter discusses the grey areas which often exist in medicine. What I liked was that this chapter did not offer stock solutions but allowed us to delve into an experience faced by Dr Victoria. This reading was a revelation that gave me insights into my own ethical and moral conduct.

Comments and feedback

The audience largely enjoyed the session, with a few requesting to borrow the book after the session ended. One point which was raised during the audience discussion was that “The Wedding” has cultural connotations and the doctor’s attendance at the wedding would have been a perfectly appropriate boundary “crossing”, and not a boundary violation. A place of worship in the hospital grounds would also be culturally acceptable. Obtaining spiritual comfort, while undergoing (or delivering) medical treatment, can be useful.

The anonymous feedback which was collected from the postgraduate students (some months later, as part of feedback about the Ethics sensitisation programme), showed that nearly all of them found the session useful, enjoyable and “relatable”, rating it very high in terms of content and delivery (22 out of 63 students gave feedback on this session). However, one student did say he found it a “waste of time”. During the post-session coffee time, many faculty members appreciated the Book Reading as a welcome change from the usual academic meeting format. However, one faculty member remarked that some of the readings were a little long and did not engage her.

In conclusion, the session revealed that book readings could provide pertinent points for reflection and discussion, relevant to the problems faced on an everyday basis by medical professionals. It is a useful and interesting tool to engage students and faculty in a medical ethics discourse.