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Westside Observer  
June 2012 at www.WestsideObserver.com

Laguna Honda Hospital Book Review
Errors Haunt “God’s Hotel”

by Patrick Monette-Shaw

One wonders whether God’s Hotel — just published by former Laguna Honda Hospital physician Victoria Sweet, MD, PhD — uses LHH as a backdrop to illustrate her career, or to lament the loss of long-term care skilled nursing beds, a necessary component of the “Slow Medicine” she advocates for.

While in many places the book is insightful, to those who worked there and know the hospital’s history intimately, the book’s omissions and factual errors are disturbing.

Glowing reviews of God’s Hotel have appeared in publications ranging from the Wall Street Journal, to the Boston Globe, to the Huffington Post. But those reviewers hadn’t witnessed events that transpired at Laguna Honda as this reporter has for 13 years, and aren’t aware of key errors in, and omissions from, God’s Hotel.

Aware since May 2010 Sweet’s book was in development, during an invitation-only April 28, 2012 book launch party this reporter was startled when Dr. Sweet indicated — literally while passing — “Patrick, I hope you won’t be too disappointed by what I left out,” (or words to that effect).

I wondered: Why had Sweet anticipated disappointment?

The book is an amalgam — part memoir, part a story involving Sweet’s journey acquiring a PhD in the history of medicine, and part an extended Op-Ed arguing for a return to “slow medicine” — set against a backdrop of a very selective history of nearly two decades of patients and staff at Laguna Honda as it was transformed from a “medical model of care” for poor, safety-net patients to a “social rehabilitation model of care” for San Francisco’s homeless.

A central character in God’s Hotel — a title taken from the French “Hôtel-Dieu,” a Middle Ages “almshouse” taking care of the chronically disabled — is twelfth-century mystic, nun, and medical practitioner Hildegard von Bingen, whose idea was that human bodies are more like a plant to be carefully gardened, rather than a machine of broken parts. Sweet’s premise is that doctors should be more like gardeners than mechanics, and that many non-desperate illnesses might be better treated by Slow Medicine, by nurturing viriditas, the natural greening power of healing.

Throughout the book, Sweet offers many insights that take your breath away. In one patient vignette about having an accurate diagnosis, Sweet notes she saved the healthcare system approximately $400,000 by making the correct diagnosis that an artificial hip had been dislocated from its socket, detected by a relatively inexpensive X-ray. “If doctors were going to held accountable for [healthcare] costs,” Sweet writes, “why shouldn’t we get some kind of credit for savings?”

In another vignette, Sweet acknowledges that “almost every patient I admitted had incorrect or outmoded diagnoses,” often taking medications for diagnoses they didn’t have and placing patients at risk for adverse outcomes. Many of the misdiagnoses Sweet attributes to over-zealous medical student interns at San Francisco General Hospital, who are apparently never held accountable for misdiagnoses that drive up healthcare costs and endanger patient outcomes.

She wonders how outcomes might be improved with correct diagnoses, instead of incorrect ones, and visits to emergency rooms avoided if doctors are provided sufficient time to spend with patients. These insights — and others — make God’s Hotel an important read.

But maddeningly, although Sweet acknowledges Hildegard “took care to mention dates in her writing … to preserve her work for the future,” Sweet avoided including any dates throughout God’s Hotel’s 348 pages (although a few dates do appear in the end notes at the end of the book), making it all but impossible for readers to place events at LHH and during her PhD studies into perspective. How could any historian with a doctorate in medical history write a book with no dates documenting a hospital’s history?

From the vignettes, Sweet concludes LHH’s three principles are “hospitality,” “community,” and “charity.” She relates these principles by examining the etymology of many Latin words, including curare, splitting cure (doctors) and care (nurses), that has long fueled a battle for command and control of hospitals. Which model — care (nurses) or cure (doctors) — would triumph at Laguna Honda?

Sweet notes that during the French Revolution, medicine began to change; doctors wanted control of the Hôtel-Dieu in Paris to correlate medical treatments with patient outcomes. The nuns, of course, objected on moral grounds that using patients as experimental things was a bad idea; they protested, refusing to serve under the doctors and refusing to leave. Eventually, administration rescinded its order giving doctors control, returning control of the Hôtel-Dieu to the nuns providing nursing, until they left after it was secularized in the 1900’s.

Much of Laguna Honda’s history during the past 20 years parallels the same battle for control, a feud between doctors, nurses, and administration played out in most hospitals to this day. For her part, Sweet acknowledges the dynamic between the Nursing, Hospital Administration, and Medicine departments needs to be kept in close check to advance optimal patient outcomes.

In a long vignette about a patient with transverse myelitis, an inflammation of the spinal cord, Sweet’s point of view changed from focusing on her patients “vaguely surrounded by his environment.” Instead, she stepped back and learned to focus on the environment surrounding her patients, asking herself when anything interfered with her patient’s natural healing powers and their environments, what she could do to remove it.

Throughout the book, it becomes clear that Sweet didn’t venture into the political environment at Laguna Honda, and didn’t become involved in efforts to stop the transformation of its medical model of care, or efforts to permanently alter LHH’s environment.

Sweet acknowledges that the same disability rights activist lawyers who disastrously shut down state mental hospitals around the country are now the same people hell bent on shutting down skilled nursing facilities caring for the frail elderly. Their test case was shutting down Laguna Honda Hospital.

Sweet erroneously reports that just after John Kanaley was appointed as Laguna Honda’s Executive Administrator in 2004, Sister Miriam Walsh requested a meeting with him. In fact, within the first month of his tenure, Kanaley summoned three vocal LHH staff members to his office in a bald attempt to exert his authority. None of the three had requested meeting with him.

First, he summoned Sister Miriam Walsh to his office for a discussion about her advocacy against the “flow project” involving the transfer of psycho-social patients from San Francisco General Hospital to LHH. When asked what Kanaley wanted, Sister Miriam reported “He wanted me to agree to a deal to keep Laguna Honda’s name out of the media and asked me to pipe down. I told him, ’No deal,’ and that was the end of the meeting.“

In short order, Kanaley summoned Dr. Maria Rivero and this reporter, separately, to his office for the same talk, and we both essentially told him the same thing: “No deal.” Kanaley’s attempt to bully vocal staffers by intimidation set the tone for the duration of his bull-in-a-China-shop administration.

In another act of bullying, in June 2008 — following Sister Miriam’s May 2008 Westside Observer article “Farewell to Laguna Honda’s Clarendon Hall” — Kanaley wrongly accused this author of abusing Sister Miriam as a frail, elderly woman to advance my political and personal “gain,” because he falsely assumed I had written her article, which was a complete lie.

Many Minor Errors …

• In the chapter “Wedding at Cana,” Sweet describes the wedding of two patients — the “Teal’s” — in LHH’s chapel, comparing it to Jesus’ first miracle, the transformation of water into wine at a wedding in Cana. From this, Sweet concludes — quite ironically — that Laguna Honda’s second principle is “community.”
  
  Sweet asserts “almost all of Laguna Honda” poured into LHH’s Chapel for the Teal’s wedding, but observers report that attendance was actually quite low. Some observers wonder whether the stretched attendance was carried over into other areas of God’s Hotel for literary effect. The exaggeration, in itself, wasn’t terrible, but why do it, they wonder?
  
  But the irony is that the low turnout may have been because most staff at LHH were painfully aware that Bride Teal was, in fact, already married to another man; many staff may have stayed away from the wedding, not wanting to witness polygamy being blessed. Why a minister was brought in — ostensibly with LHH administration’s approval — to conduct marriage vows for a woman already married amounted to sanctioning polygamy. Bride Teal didn’t want her family to know about her latest wedding. Rather than providing her with a reality check that she could have a party with her new love, but couldn’t throw a full-fledged wedding because she was already married to someone else, a handful of staff chose to “enable” Bride Teal, fueling her fantasies. Could Sweet’s new definition of “community” involve polygamy? Why did Sweet choose this story to illustrate “community,” when there were so many other examples of real community at LHH that she could have drawn from?
  
  
• Sweet reports that voters passed Prop. “A” in 1999 to rebuild LHH for $500 million, and that half would come from a general obligation bond and half from the tobacco settlement revenue account. This is untrue: First, voters were told the hospital’s replacement budget was $401 million, not $500 million (although the cost overruns 12 years later pushed the cost to well over $593 million). Second, the bond was for $299 million, and just $100 million was to come from the TSR account, not half and half.
  
  
• Sweet accurately reports there were two committees involved in the 2006 Prop. “D” ballot measure: “San Franciscans for Laguna Honda,” and the “Committee to Save Laguna Honda.” But she misreports that doctors Kerr and Rivero were members of both committees. This is patently untrue. The latter committee was formed by this author, Sister Miriam, Virginia Leishman, LHH resident Robert Neil who was then president of the Resident’s Council, and family members of the Traumatic Brain Injury Support Group. At the time, Kerr and Rivero made the correct ethical decision that they could not violate their doctor-patient relationships by joining an advocacy group that included patients of the facility.
  
  
• Sweet asserts the hospital’s 1,200-bed replacement plans had included three identical six-story buildings. In fact, the third residential tower eventually eliminated was a 420-bed, seven-story building containing crucial infrastructure elements like the data center that then had to be shoehorned into one of the two remaining 320-bed six-story buildings.
  
  
• Sweet reports that following a meeting between Sister Miriam and Mayor Gavin Newsom, Newsom ordered then Director of Public Health Mitch Katz to halt the many incarnations of the so-called “Flow Project” shuttling SFGH patients to LHH. Since this reporter attended that meeting, I can vouch that meeting wasn’t with the Mayor, it was with his Chief of Staff Steve Kawa, who has long been considered San Francisco’s real mayor ever since Willie Brown’s tenure. Earlier, this reporter had also attended a meeting between Sister Miriam and Mayor Newsom, which also included former City Attorney Louise Renne — the chairperson of the Laguna Honda Foundation — but Sweet makes no mention anywhere in God’s Hotel about Renne’s meddling in Laguna Honda’s affairs.

There are a host of other minor errors.

… Along With Many Major Errors

• When Sweet turned her attention to the U.S. Department of Justice’s first letter to then mayor Willie Brown in May 1998, she speculates the DOJ had been “tipped off” to investigate LHH. Sweet dissembles, first speculating it may have been doctors Kerr or Rivero who contacted the DOJ, before Sweet then speculates it may have been LHH’s forty-four-year Director of Nursing Virginia Leishman who provided the DOJ a tip, an allegation Leishman adamantly denies. (Leishman has, reportedly, received numerous calls since God’s Hotel was published, some encouraging her to consider slander.)
  
  Observers at the time note that it may have been a former LHH Executive Administrator who may have “tipped off” the DOJ if anyone had, since he may have been miffed when plans to hand him a job converting the Department of Public Health into an “enterprise” department that would receive no City General Fund support fizzled, along with his promised job. Regardless, there is no proof that the DOJ had received any tips, and may have launched its investigation simply by reviewing sentinel event, or annual inspection, reports.
  
  
• Referring to the same first letter from the DOJ, Sweet asserts the DOJ was initially concerned only about LHH’s Nursing department, saying the DOJ blamed Nursing for almost everything, except LHH’s old-fashioned wards and aging infrastructure. This is also patently untrue. The DOJ, in effect, also blamed the Department of Medicine — which had then rightfully contained the sub-specialty of physical medical rehabilitation, including speech therapy, occupational therapy, and physical therapy, all components of physical medicine — for failing to provide specialized rehabilitation therapy. The DOJ asserted in 1998 that only 50 residents were receiving physical, occupational, or speech therapy — which services require referrals from physicians — to prevent functional decline, failing health, and premature death.
  
  Speech Therapy, the DOJ claimed, had only assessed one-third of residents at LHH who were at risk for aspiration, and had assessed only 70 of 700 residents requiring eating assistance.
  
  As a result of the DOJ’s claim in 1998, Laguna Honda hired within a year a new senior physical therapist, an occupational therapist, and a speech pathologist charged with developing a functional maintenance and restorative care program that subsequently hired four therapy aides to implement the program, which initially proved to be a success. (Unfortunately, that program has fallen into disrepair, given intermittent curtailment of restorative care services on long-term care units.) Before each return DOJ visit across the next decade, LHH physicians increased their rehabilitation physician orders to avoid further DOJ wrath. That meant doctors were finally paying attention to writing rehab referrals.
  
  The DOJ was also critical in 1998 of LHH’s Activity Therapy Department for not providing meaningful activity needs of LHH residents. The DOJ’s concerns weren’t attributable solely to Nursing.
  
  
• Sweet reduces to a single page the 2006 Proposition “D” ballot measure to protect Laguna Honda for the frail elderly with skilled nursing needs, as voters were promised by Prop. “A” in 1999. Sweet wrongly regurgitates — with no critical analysis — the lies Prop. “D” opponents used to defeat the measure: That the proposition would permit the Residential Builders Association to build for-profit residential care facilities on city land, would put a zoning administrator in charge of making hospital admission decisions, and would require LHH to discharge 300 Alzheimer’s and AIDS patients, all of which were lies.
  
  The RBA had no interest in building residential care facilities. The land use attorney who crafted the language for Prop. “D” — being an associate of former City Attorney Louise Renne who now operates the Laguna Honda Foundation — slipped in arcane language thought required for Planning laws, but was actually twisted into possibly allowing for for-profit private development. Nothing in Prop. “D” allowed for-private development, but once City Attorney Dennis Herrera wrote that Prop. “D” would provide a “land grab” by private interests, the lie stuck, despite being a canard uncovered by a respected journalist who looked into the issue and exposed it to be false.
  
  Worse, lacking further critical analysis, Sweet omitted that LHH’s then Rehabilitation Coordinator was the only LHH staff member not affiliated with Prop. “D” who had correctly noted in 2006 that Prop. “D” used the exact same language that was contained in Title 22 and LHH’s own admission policies; he had read Title 22. The dullards running the anti-Prop. “D” campaign — including the Director of Public Health Mitch Katz, Mr. Kanaley, Mivic Hirose, and many MD’s on LHH’s staff — all appeared to have turned a blind eye to Title 22, as if they’d never read it.
  
  
• Sweet doesn’t report that in March 2006 — despite a prohibition in San Francisco’s Administrative Code Section 12G against using city funds to attempt influencing political activity, including ballot measures — then City Controller Ed Harrington, City Services Auditor Leticia Miranda in the Controller’s Office, and Health Management Associates employee Nicola Moulton exchanged a series of e-mails outlining the Prop. “D” ballot initiative and “themes” that might be used to defeat the measure, including whether 300 Alzheimer’s and Parkinson’s patients were part of those who would face discharge if Prop. “D” passed. Harrington and Miranda had to have known — if Sweet didn’t — that Health Management Associates was a contractor receiving city funds who had made recommendations in 2005 to alter Laguna Honda’s service mix. They also had to have known that using a city contractor to help develop arguments to defeat a ballot measure clearly violated Section 12G. Sweet mentions nothing of this.
  
  Nor does Sweet mention that prior to publication of God’s Hotel, she had to have heard news that San Francisco’s Director of Public Health Mitch Katz had been paid $30,000 over a three-year period by Health Management Associates, the same firm he had steered a contract to.
  
  
• Sweet reports that Dr. Katz had given Mr. Kanaley an additional $10 million for more “administrative staff,” but she neglected to mention the $10 million was for transition planning to the new facility, including a host of duplicative doctors and nurses — not administrators — to ensure regulatory compliance. And Sweet omits that much of the $10 million wasn’t encumbered until after the move into the new facility had been completed; was possibly not used as intended by the initial earmark; that as of May 2012, only 74% of the $10 million had been spent; and that the remaining 26% ($2.6 million), had been cost-shifted to funding “facility maintenance contracts,” instead.

There are other major errors too long for this review.

Glaring Omissions

• Sweet mentions nothing about the closure of LHH’s adult day health care program, nor does she discuss the loss of 200 to 300 assisted living facility beds planned for the facility. Nor does she discuss the impact of the loss of LHH’s 420 skilled nursing beds on the rest of the city, and its effect on discharge locations, either. None of this is discussed in relation to “slow medicine.”
  
  
• There is no mention of the $190 million in cost overruns of the replacement facility, nor the shoddy workmanship in the new buildings (mold in the new kitchen is but just one problem) that will cost additional millions to repair.
  
  
• While Sweet acknowledges LHH’s current medical director relocated her offices to the front of the building to signal that the Medical Staff was falling into alignment with the Hospital’s Administration to transform LHH, Sweet fails to note that this medical director also jettisoned the medical staff’s autonomy when she permitted Rehabilitation Services — whether or not with concurrence by LHH’s Chief of Rehabilitation Services Lisa Pascual, MD, and LHH’s then Rehabilitation Coordinator, Paul Carlisle — to be placed under the auspices of the hospital’s Facility Operations Department. As far as is known, no other physical medicine rehabilitation department or their parent medical services department in Bay Area hospitals have permitted being placed under the control of facilities operations staff.
  
  
• While Sweet reports doctors Rivero and Kerr had filed a whistleblower complaint about abuse of LHH’s patient gift fund, Sweet never mentions that following a long-delayed City Controller’s audit of the gift fund the hospital was eventually ordered to restore over $350,000 misappropriated from patient benefit.
  
  
• Similarly, while Sweet notes that doctors Kerr and Rivero had authored a “brilliant” rebuttal to the Davis Ja report that recommended “higher-salaried physicians be replaced by registered nursing staff, social workers, and psychologists,” Sweet excluded reporting that over 20 physicians at LHH had signed a letter of support, finding that the Ja report had been illegal, unethical, and harmful to patients, since Ja lacked professional qualifications to assess physician services.
  
  
• Although Sweet rightfully lambasts in God’s Hotel the “social rehabilitation” grant LHH’s Executive Administrator Mivic Hirose secured that became the focus of a heated, politically charged Board of Supervisors hearing in 2005, Sweet failed to note that during the final PowerPoint presentation at the end of the grant, the Nursing Team involved admitted it had not actually implemented any Nursing “intervention” portion of the grant designed to prove to the funding source the efficacy of social rehab interventions, a glaring admission of failure.

Nowhere does Sweet delve into the LHH public relations director’s spin control “deconstruction”; he’s the guy who claimed “LHH’s patient gift fund isn’t for patients.” Marc Slavin was hired in 2007 to squelch “negative publicity about LHH” to help out his benefactress, former City Attorney Louise Renee, now head of the Laguna Honda Foundation non-profit that refuses to release any details of its income and expenses, a fact Sweet must have know about for years, but doesn’t address.

To her credit, Sweet does acknowledge that San Francisco mounted no legal defense against either the Davis lawsuit or the Chambers settlement agreement; the City, with Slavin’s help, simply capitulated to the disability rights activists intent on shutting down Laguna Honda Hospital, contributing to the abuse of this civic institution.

Slavin is reportedly pursuing a PhD degree. While Sweet rightfully wonders about efforts to re-brand a public hospital with a new name that Slavin had proposed eliminating “hospital” from, she doesn’t wade in to whether Slavin’s marketing efforts over the years are designed to re-frame, for advertising purposes, that LHH can be used for just about anything, perhaps part of his pursuit of a PhD. He and Renne are at it again, now trying to “re-brand” LHH’s patient auditorium into a revenue-generating community theater to support Renne’s non-profit Laguna Honda Foundation.

Sweet never addresses LHH Administration’s ascendancy under Slavin, and the negative impact Administration has had on patient outcomes, while casting Nursing and Medicine asunder.

God’s Hotel is certainly no match against Slavin’s considerable skills in on-going deconstruction, and may be too little, too late to stop the transformation in how we provide “slow medicine” to care for the sick poor.

Despite errors haunting God’s Hotel, it may still be worth a read.

Monette-Shaw is an open-government accountability advocate, a patient advocate, and a member of California’s First Amendment Coalition.  He received the Society of Professional Journalists–Northern California Chapter’s James Madison Freedom of Information Award in the Advocacy category in March 2012.  Feedback: monette-shaw@westsideobserver.com.  

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