 Toward the end of college, I discovered the writings of Carl Jung, in particular, his memoir, Memories, Dreams, and Reflections. And I loved it. I loved the meaning that he brought to his life and the expectation of meaning. And I particularly loved how he'd set up his life living on the lake of Zurich, living in that sort of stone tower he'd built for himself. And seeing well-paying, articulate patients in the morning and illuminating manuscripts and studying alchemy in the afternoon. I decided that was what I wanted to do when I grew up. And so that meant I would be a Jungian analyst. And at the time, it meant I had to go to medical school. So that's how I got to medical school. It turned out I liked medical school a lot more than I thought I would. Especially the last two clinical years where you finally get to meet patients and you get to do what's known as the workup, which means taking the history, which means asking the patient what's wrong with them and then listening. What I liked about that is it was a real art to it. You had to listen to what the patient said and what the patient didn't say. There was a lot of psychology to it. And then it turned out I loved the physical exam because there's thousands of signs on the body that you can either rule out a diagnosis or many times actually make the diagnosis just from examining the patient. And then I loved sort of putting it all together and figuring out what are the possible diagnoses and what labs do I need to get and what x-rays do I have to get. So putting it all together in the differential diagnosis and the plan, that's called the workup. And I thought it was a brilliant method. Nevertheless, I carried on with my own plan, which was to be a Jungian analyst. And I started a psychiatric residency. But I was a little naive. And I ended up doing the psychiatric residency in the counties only, not this county, down in Southern California. The counties only locked ward. So the patients I saw were not Jung's articulate, neurotic, well-paying patients. They were severely psychotic. And they responded much better to the psychiatric medications we used than they did to the talk therapy I tried. So I was a little disappointing. And I had my license by then. So I decided I was just going to go out and practice medicine. And they ended up practicing medicine for quite a few years in community clinics and county clinics. And they were fascinating places to practice medicine. Because every time there was a war or a rumor of war, we'd get a wave of patients from that part of the world. And they would bring their language and their culture and their diseases and their way of looking at the body with them. So I ended up seeing amazing things. I saw every parasite known to man. I saw three cases of leprosy, for instance. Not very far from here. I saw all kinds of interesting unusual diseases, infectious diseases, interesting cancers. But I also got a sense of different ways of looking at disease. It was very instructive. And eventually I went back and did a residency in internal medicine. And then I went back again to practicing in a community clinic. And the longer I practiced medicine, the more impressed I was by modern medicine's method. It's way of arriving at a diagnosis. It's logical, step by step. But also the more impressed I was by what it left out, of what it saw and anything that didn't fit its logical, rational method. So after several years, I started looking into alternative medicines. Homeopathy, naturopathy, Chinese medicine and Ayurvedic medicine particularly. They were brilliant systems, I thought, particularly the Chinese and Ayurvedic. But I realized that unless I knew their language, I would never really be able to understand this alternative way of looking at the body, this different way of looking at disease. And I even thought about going to China and learning Chinese or learning Sanskrit. But in the end, I decided that probably, even if I learned their language, their culture was just too different for me to really understand this alternative way of looking at the body. It was at this discouraging moment that I ran into a book that really intrigued me. This was Hildegarde of Bingen's Medicine. Hildegarde of Bingen's Medicine. It had just been translated from the original Latin into German and German into English. And as I read the book, I was more and more fascinated. Hildegarde was a 12th century nun. There she is. And she was also a mystic and visionary and a composer of music. And as it turned out, she'd been a medical practitioner. And as I read her book, this was her medical book, I was really quite surprised because it was not what I'd expected from a medieval medical text. It wasn't eye of Newton, toe of frog and praying and scattering holy water on people. It was a real medicine for real patients with real diseases. But it was based on a completely different model of the body from my own mechanical model of the body. And I decided, I couldn't really know, I couldn't really get what was so different about it. It was a lot like Chinese medicine or Ayurvedic medicine. And I thought for a while maybe it was the missing piece of Western medicine, the not rational piece. And I decided I was gonna go back to school and get a PhD in medieval medicine with Hildegarde of Bingen as my focus. To do that, I didn't wanna give up medicine. I wanted to find a part-time job so that I could practice medicine and also study Hildegarde and get a PhD. And at the time, it took me months. I went all over the barrier looking for a part-time job. And the only place I could find a place that would let me practice medicine part-time was at Laguna Honda Hospital. That's how I got there. When I went over for the first time, I had never seen it. And I had admitted patients before to Laguna Honda. How many of you have seen Laguna Honda? Yeah, right, this is California, San Francisco, right? And how many of you actually went inside the old one? To most people, well. So I had admitted patients as a doc, but I had never seen it. So when I drove over there for the first time for my interview and I suddenly saw it high on the hill overlooking the ocean, I was just completely taken aback because it looked like a 12th century monastery, right? That is. We can talk about that later. There's a reason for that. Then I went, so I went for my interview. And after my interview, the medical director took me out for the tour. And I was just flabbergasted. The place is enormous. As you know, it's on 60 acres of land in the middle of the city. At the time, it had almost 1,200 patients. So the medical director took me around and she showed me those long, open, they're called Florence Nightingale wards, where the nurses would have this eye of the patient and there'd be 30 beds in the ward. And then we went upstairs and she showed me the surgical suite, which is an old-fashioned operating room that had been used in the 50s. And it looked like a place from the movies of the 30s, right? Where Humphrey Bogart gets his face redone in Dark Passage, it looked just like that. And then we'd go down the stairs and we're walking past the beauty salon, which all the ladies are in the beauty salon in the 1950s steel helmet air dryers. And then we get to the church, really. I mean, it's a chapel, but it was really more like a church. It had polished wooden pews and stained glass windows and very politically incorrect stations of the cross along the walls. And then we went outside and the medical director showed me the greenhouse, the aviary and a little farm yard so that patients could pot plants, watch chickens hatch from eggs and even see animals, even if they were bedbound. Later, I would see the activity therapist trumbling in a rabbit or a black pig and have the patients be able to put the rabbit on the patient's bed. I didn't know that at this time. So we get finally back to the medical director's office and she offers me the job. And I have to tell you, I really wasn't sure about this place. So I told her I would come for two months and I ended up staying for more than 20 years. And I did that because it turned out that Laguna Hondo was a really, hospital is a really fascinating place to practice, in part because it was originally the San Francisco almshouse. So this was a picture of one of the original almshouses in San Francisco on the same place where Laguna Hondo was. This was built in the 1860s. And the almshouse model was how we used to take care of patients of the sick poor before there was health insurance. Because we did take care of the sick poor. San Francisco still has this system and it's a pretty good system. Used to be that every county, just about in the country had the system we have, which is that there's a free county hospital that you can go to, more or less, no questions asked if you're acutely ill. And then if you need more care, you need chronic care, you need rehabilitation, you need subacute care, nobody knows what to do with you, you're unemployed, you're homeless. And in the old days, if you were an orphan, or if you were mentally ill, or if you were pregnant and not married, they send you to the almshouse. It was a pretty effective way of creating a real safety net. And what happened in every other county, as far as I can tell in the whole United States, except here in San Francisco, was that those almshouses were closed one by one, mostly during the 50s. It was a kind of interesting collusion, if you look back in history, between the left who wanted to close the almshouses because they thought they were unjust, and the right who wanted to close the almshouses because they thought they were expensive. And so they got together and started closing them all around the country. And as far as I can tell, San Francisco's the only place that effectively has its almshouse, Laguna Honda Hospital, i.e., some place where if you don't know what else to do with the patient, you can send them there for things to sort themselves out. And the thing about an almshouse, and the thing about Laguna Honda is it typically would get patients who were at the bottom one-tenth of 1% of whatever, right? The patients who fell through the holes in the safety net successively down to this level. And they were very, very interesting patients. They were interesting, interested as people. I used to think that they were actually two standard deviations from the mean. Any mean. That's true, really. They were the tallest and the shortest patients I ever had. And they were the fattest and the thinnest. And they were the smartest and the not smartest. And the most interesting patients in many ways of any patients I ever had. And they had almost every disease too. Because if you are a catchment area for 600,000 people or 800,000 people and something happens in medicine one in 100,000 times, we'd see several cases at Laguna Honda. So it was a fascinating place to practice medicine. And I ended up staying there, not just because it was convenient for my study but because it turned out to be a marvelous place. And in fact, it gave me the name for the book which is God's Hotel because in the old days and still today in France, a hotel gieau which means God's Hotel is what we used to call hospitals for the sick poor. Think about that, isn't that interesting? And in Paris, they still had their hotel gieau and I bet many, many people have been to Paris. If you're anything like me, you've never seen a hotel gieau. You really should see it next time and I'll tell you why. It's right next to Notre Dame. And it's always been next to Notre Dame since when it was founded in 661. There was Notre Dame with the cannons and the monks, cannons being a kind of monk, right? Who took care, who lived a part of Notre Dame and they had this hotel gieau, this hospital for the sick poor because it was part of the whole religious vocation of the monks. And it's still there, it's still right next to Notre Dame. And in fact, it looks a lot like the old Laguna Honda. It was really interesting when I finally walked in there. Like the old Laguna Honda, you can just walk into it. There's nobody there. They got the long wards, they got those staircases, they've got that sort of outside, the area that's sort of almost like a cloister where patients can go outside. And it turns out there's a reason for that because the guy who was the architect for our Laguna Honda was a man named James Reed in the 20s. He'd actually studied in Paris and he studied at the Beaux-Arts and I'm sure he knew the hotel gieau. So he ended up staying at Laguna Honda for actually 21 years because it was such a fascinating place with so many interesting patients and I learned so much. I learned about hospitality, real hospitality and community and charity. But if I had to put what I learned into one sentence, it would be that medicine is personal. And when it's personal, it works. What do I mean by personal? It's kind of a funny word to use but what I mean by personal is first of all, medicine is not virtual. Medicine is not healthcare. It's not a commodity that we take off the rack and give you a sell you a box of healthcare. Medicine is personal because it works when it's person to person and face to face. They also mean that it's gotta be taken personally, especially by the docs. Personal responsibility, they have to take their patients personally. And what I mean by works is that the patient is happy, the doctor is happy. We have the right diagnosis and the right treatment and all for the least amount of money. That's how I define works. This idea that medicine is personal and when it's personal, it works, gelled for me the day I ran into my friend Dr. Curtis and he was just coming back from outside the hospital. He was in a rush but I wanted to know where he was going and where he'd come from. He told me he was going back to the rehabilitation ward to see a patient who'd been ready for discharge for months. But every time Dr. Curtis saw this patient, he was still zipping around in his wheelchair, still going to therapy. Finally Dr. Curtis told me I asked him why since he was ready for discharge, he was still there. Patient said, no shoes doc. I need special shoes and they've submitted the forms to Medicaid and now they're waiting for Medicaid to approve them. So Dr. Curtis said, well, how long have they been waiting? Three months. So Dr. Curtis thought about that and then he asked the patient, well, what size shoe do you wear? Patient said size nine. So Dr. Curtis thought about all the charts he had to write and the forms he had to do and then he went over to his car, got in his car, drove over to Walmart and bought a pair of size nine running shoes for $16 and 99 cents. And now he was going back to the ward to put them on the patient himself and write the discharge orders. Was he going to submit his receipt for reimbursement I asked? And he laughed. As I watched him walking off, I realized that he reminded me of an aphorism I'd always loved but had never understood. The secret in the care of the patient isn't caring for the patient. Now I'd always thought that that meant caring about a patient, loving the patient, or at least liking the patient. But as I watched Dr. Curtis rush off to put shoes on a patient he barely knew, I thought there must be more to it than that. So I looked it up and I found it in a speech given to the Harvard graduating class of medical school in 1927 by a man named Dr. Francis Peabody. And it turned out that what Dr. Peabody actually said meant was not caring about a patient but caring for a patient which he defined as doing the little things, the little personal things that nurses usually do. Giving a patient sips of water or tucking in their bedclothes. That wasn't Dr. Peabody admitted the most efficient way for a doctor to spend their time. But it is what created the personal relationship between doctor and patient and that relationship is the secret of healing. So what Dr. Peabody really was saying was that the secret of healing was inefficiency. And it was particularly ironic because just at this time Laguna Honda had hired a group of healthcare efficiency experts to come to the hospital and they were all over the place and they were finding all kinds of inefficiencies. And if they'd heard about Dr. Curtis and those shoes I'm sure they would have thought it very inefficient, very wasteful of a time, the time of a highly trained physician. But you know when you think about it Dr. Curtis had been providing the most efficient healthcare of all. He'd gotten the right diagnosis, no shoes. He'd gotten the right treatment, shoes. And all for the least amount of money. 16 dollars and 99 cents. And so I started thinking about this as the efficiency of inefficiency. And we all know this on our own lies. Everywhere you work there's the one person, whoever they are who just is the person you go to and they just figure things out, just having that little wiggle room. So in the meantime I had actually gone back to school and I was getting my PhD in Hildegarde of Bingen in pre-modern medicine. And my idea was to try and understand her medicine from the inside, as if I were her student. So I wanted to understand her, can you guys hear this? I wanted to understand her medicine from the inside, I wanted her to understand her language, her culture and her history as she understood them. So I went and I learned medieval Latin and German and paleography and codicology because I wanted to read her texts in the original, not in a printed book, because they were all handwritten. I learned some medical anthropology and folklore because I wanted to kind of contextualize what she'd written about. And then I also experimented with some of her remedies. So I planted some of her herbs in my garden. I made her potions. I brewed up some of her medicinal beers and I even made some of her antidepressant cookies. And gradually I began to get a sense of how her medicine differs from our mechanical model. So we have more or less an idea of the body as a body as a machine, right? And then this really beautiful poster by Fritz Kahn from the 20s. You know, the brains of computers, really a collection of machines, right? The brains of computer, the hearts of pump, the lungs or bellows, the kidneys of filter. And when something, and disease is a question of a mechanical breakdown. And the doc's role is to be more like a mechanic to find out what's wrong and then to fix it. Hildegard's model of the body, I gradually, too many years, realized was not a mechanical bottle, it was much more a model of the body as a plant. And the doctor as a gardener. What's the difference between it? What's the difference between a machine and a body as a plant? Difference is that someone else has to fix a broken machine. But a plant can heal itself. And Hildegard called the power of a plant to heal itself, it's veriditas. From the Latin virides, which means green like the French ver and the Spanish verde, right? Veritas is greenness or greening power. And Hildegard felt that not only plants but human beings had their own veritas, their own natural healing power. And that the job of the doctor was to nourish that and remove obstructions to it. Took me years to figure this out and even though I sort of got that point I really didn't understand it as a doctor until my patient who I called Terry Becker in the book. Terry was homeless and she lived on the streets with her boyfriend, Mike. And she smoke and they drank and they took drugs. Then one day Terry woke up and she was paralyzed from the neck down. So Mike and she went over there, San Francisco General Hospital and they admitted her and they diagnosed her. She had transverse myelitis which is a rare viral disease which has no treatment but which usually gets better on its own. So they sent her over to Laguna Honda and I was her doctor and she did start to get better with just rest and R&R for the first couple of weeks. Then the first of the month rolled around which is when citizens in San Francisco can, at least they used to be able to go over to city hall and get cash. So Mike shows up, her boyfriend and takes Terry out. Now he assures me it'll just be for the afternoon. I remember watching them walk out. He was pushing a wheelchair and I didn't see Terry again for a year. Later I found out that during that year she had gone to the emergency room 28 times. That Mike had taken a two by four to her once and fractured her skull, broke her leg, robbed her and abandoned her on the streets of San Francisco and that she developed a bed soar. She'd been admitted to the general three times to try and graft the bed soar, to cover it with skin. Every time after the surgery and on the very expensive surgeries, first month would roll around, Mike would show up and out Terry would go and the graft would deteriorate. So finally the bed soar was so huge that the surgeons at the general just threw up their hands. They said, we can't do it. We don't know what to do. So they said, we're going to Laguna Honda and I was her doctor again. And I have to tell you when I saw Terry and when I saw her bed soar, I was just absolutely shocked. It was this huge hole in her backside. It was just a hole. It went from the middle of her back all the way down to her sits bones and it spanned her whole back, her whole backside. And it was so deep, I could see bone at the bottom. I could see Terry's spine. And it was filled with all the decayed and decaying tissue from all the failed skin grafts. It was just horrifying. I mean, it was too big, it was clearly too big for anybody to graft it, which meant it would have to heal by secondary intention, it's called. It would just have to heal on its own, which would take a long time. And as I was sitting there looking and thinking to myself, what am I gonna do here? Because by the time this heals, Terry's bound to get an infection from all the germs in her body no matter what I did. If I tried giving her antibiotics to stop it, the germs would just get resistant to the antibiotic. So I walked back to my office, which is a little funky little office at the end of the hall and I sat down and I really didn't know what to do. I found myself staring at a plant that a patient had planted for me years before in the greenhouse. And now this time it had grown all over the wall and I found myself staring at it, thinking about Terry and thinking she's gonna die of a bed sore in the 20th century at the time. And I asked myself what I couldn't come up with anything to do. Finally, I thought to myself, I thought about Hildegard and I thought, well, what would Hildegard do? I mean, she didn't have antibiotics, she didn't have surgeons. How would she see Terry's bed sore? I thought, you know, she would be thinking about veritas and this natural power of healing that's coursing through Terry's body anyway. I think what Hildegard would do would be just to remove whatever's in the way of this natural power of healing. What's in the way, I asked myself. Well, all the dead tissue was in the way so that bed sore had to be completely cleaned. Any medications she didn't absolutely need because by then she's on about 20 different medications and about two thirds of them she didn't need. I would take her off all the medicines that she didn't absolutely need. Anything that got in the way of her attention, you know, like wrinkled bed clothes or an uncomfortable mattress I would change. Uncertainty, was she gonna get kicked out of the hospital? Fear, helplessness. Then I thought after doing that, Hildegard would support, would nourish veritas with the basics, good food, fresh air, sunlight, rest. So I wrote my orders and that's what I did. And it was amazing to see how fast Hildegard's prescription started to work. In a few weeks I started to see this wonderful fine glistening down there at the base of this wound. Then the first of the month. And Mike showed up. And he was still pretty cute. The little cute little Levi's and was walking with his little stride. And the nurses had put Terry all the way at the end of the ward. They made Mike go into what used to be our smoking room at the front of the ward. And we all watched Terry wheel herself on that prone gurney all the way down the ward and go into the room and the door closed. And we all stood there and waited. It was a long time. Finally, the door opened and Mike came out and left. Terry had thrown him out. She told him never to come back. Then she stopped smoking. And her appetite began to came back and she started to eat. Gradually that bed soar started to fill in. It was really remarkable. As a matter of fact, it was watching that that made me decide to write this book. Watching that because nobody ever gets to see something like that anymore in our society. It was almost like magic. It reminded me of those fast forward movies that you'd see when we were kids, you know, where the plant grows from a seed in a few minutes and you watch it sort of sprout and kind of like that because I only examined her about once a week. So I sort of saw this kind of magical process where it was glistening at the base of that and then there would be a muscle there and then subcutaneous tissue appeared. And then meanwhile the skins all crawling in from the side. You can't really decide, but it's like every time I'd see her it was a little smaller and a little more shallow. So finally it looked just like a big old scab on her back. And then the scabs started to flake off and there was a new perfect Terry Becker skin underneath. It took a long time. It took two and a half years. But we weren't NNA in any hurry. And neither was she. Social workers were able during that time to find her family lived in the Midwest and wanted her to live with them. They bought her a ticket and they flew her out and there she stayed and did not go back on the streets and lived for many years. Terry really changed the way I practice medicine. After Terry, I not only look at patients with the eye of the modern doctor asking myself what's wrong and how can I fix it. I also step back and I look at my patient in the context of his environment and I ask myself what's in the way of a veriditas and what can I do to nourish it. And what I find is that both ways work well when used on the right person at the right time. So Terry's way works best, Hildegard's way really works best on patients who have slow diseases, slow and coming on, chronic diseases, diseases that are hard to treat, diseases for which we have no treatment. And I began to think of it as almost a slow medicine, kind of like slow food, right? As opposed to the fast medicine like fast food that I also use, which works great, right? If you get hit by a car, you need surgery or you have a heart attack and you need an angioplasty or even if you have cancer and you need chemotherapy. But which doesn't work so well after the surgery, after the angioplasty, after the chemotherapy. Although it's easy to put these two ways in opposition, you know, slow medicine and fast medicine, really what I find is they're just two different perspectives and they work best together. Together, just like the two perspectives of our eyes, they give us, me, a three-dimensional view of the patient. Well, so by this time, I'd finished my PhD. And as a present to myself for finishing, I decided to walk the medieval pilgrimage across France and Spain to Santiago Compostela here. Well, what's a pilgrimage and why did I want to do that? It's about a 1200-mile walk. Well, I was really intrigued by the whole concept of being able to walk across France and Spain. And I was also intrigued because pilgrimage was such a big part of the Middle Ages. It comes from the word peregrinos, which comes from the Latin pere auger. And it means, pere auger means through a territory that's not yours. So it's got the idea of being a pilgrim is like leaving home and walking through a land that's a strange land with strange customs. That's the essence of being a pilgrim and being dependent on other people's hospitality. In the Middle Ages, being a pilgrim was a big deal. And there were three major pilgrimages. There was the pilgrimage, you could walk to Jerusalem, you could walk to Rome, and you could walk to Santiago here at the tip of Spain. And the pilgrimage to Santiago de Compostela was really the most exotic. And it had started in the ninth century when supposedly the body of St. James the Apostle after he'd been martyred in Jerusalem in 50 AD had been put in a stone boat. And it had floated all the way to the tip of Spain. And it was discovered in the ninth century. And these are his relics and a cathedral was built around it. And people started walking from all over Europe to see the relics of Santiago de Compostela. In the Hilliards period, it was very popular. Hundreds of thousands of people were walking there every year. But then after the Middle Ages, it kind of fell into disuse and it wasn't rediscovered until the 1980s. When I found out you could now still walk that medieval pilgrimage on foot, I decided I had to do it. And I ended up going with a friend of mine from medical school. And what we did is we divided the 1,200 miles into four years. What we would do is we would do two or three or four weeks of walking. We'd come back home. We'd put all our clothes in our shell, in our stick away. And then next year we'd go back, put all our clothes back, and we'd go back to exactly where we left off, pilgriming the year before. And as soon as I would hear the click of my stick on the cobblestones, I'd be right back in that space of pilgrimage. It was like no year had happened. And every year when I went back to Laguna Honda I found that my attitude towards patients, my relationship to patients had somehow changed. So what I'd like to do now is to just read you three or four minutes from the book about what happened with the first, when I came back after the first section of the pilgrimage. You guys can look here. Yeah, it's still, this is probably better. Yeah, okay. There were many stunning moments on that first pilgrimage, but the one I carried back to the hospital was the day it was pouring rain. We were a long way from that evening shelter and would be walking in the rain for a long time. It was very cold. I was soaking wet and my friend Rosalind and I were singing to keep warm. There was mud, fields, rain and I was chilled to the bone. Yet I didn't want to be anywhere else than in that muddy field or doing anything else than walking in the rain or be anything else except chilled. I didn't want to have arrived at our warm and comfortable destination. I didn't want the rain to stop or the fields to stop being muddy. I didn't want to be dry or warm or to be one step further along or one step further back. I wanted to be just where I was because only by being where I was could I experience what I was experiencing, which was pilgriming. As I walked through the field, I thought about how much of my life I had spent trying to make sure I would never be in that place out in the cold, homeless and without shelter. I thought about my patients who lived on stoops, slept in doorways and drank vodka while I was working. Once I'd asked a patient who was so eager to get discharged and back to her stoop, what was the attraction of her life? From what she told me, I thought it was freedom from work, duties, responsibilities. But in the rain that day, I wondered if homeless, cold and sheltered only by her stoop, she meant the feeling I had that day. I was happy and knew I was happy, the happiest I'd ever been. Not blissful, joyous angels coming out of the clouds, but happy as in a feeling of great pleasure or contentment of mind arising from satisfaction with one's circumstances. Happy from hap, as in what happens, things as they turn out to be. When I got back home that year, I put away my things, my stick, my pilgrims passport and shell, my pilgrim clothes. I wouldn't take them out again for a year and yet I didn't stop feeling like a pilgrim. Now and then, as I was walking down the wide corridor between wards, the click of my footsteps would remind me and I would be pilgriming across that muddy field, happy with things just as they were. Perhaps for that reason, my relationship with my patients began to deepen. When you think about it, doctoring has everything to do with not accepting things as they are. And while I did not stop doctoring my patients, there was some new way in which I was appreciating them just for who they were. And this was a good thing because right around this time, the Laguna Honda was discovered not just from, not just by the healthcare efficiency experts, but by the disability lawyers, as many of you know, and the Department of Justice lawyers. And they were all walking around the Laguna Honda and none of them much liked what they saw. I think I'll stay here, yes? It's better, yeah. They had nobody much like what they saw, right? There was the aviary and there was the greenhouse and there was the live-in priest and there was the nun and worst of all were those open wards because it turns out, according to the Department of Justice, we all have a civil right to privacy. And I'd say that I wish I'd known that when I was in a dormitory and as an undergraduate. And not only that, I'd like to say, we don't really have a civil right to privacy. We have a civil right to semi-privacy. I just thought about that today. I'm rather proud of that, actually. So as you know, then what happened is the Department of Justice lawyers, everybody got together and they told Laguna Honda that they had to close down or build a new, beautiful, modern healthcare facility. And there were a lot of fights and there were a lot of battles and nobody thought the bonds would pass and then the bonds passed two to one and then they started to build and it was years and I ignored the whole thing and then one day I was driving in and oh my God, there it was, it was just, they actually had it wrapped. Did you guys ever see the wraps that they had around it? It was like wrapped like a present. So you couldn't exactly see it and then one day the wraps came off and there the new one was and it was that moment I realized that if I didn't write about what I'd experienced there that once the building was torn down, nobody would believe it. So I took a sabbatical to write God's Hotel and to think about what I'd learned there and in the other many years I'd practiced medicine. And my sense of things was that on the whole, the pendulum has swung from the personal to the efficient. And frankly I've been ever more impressed by how inefficient the new efficiency is. Every year we hear that no matter what shenanigans the healthcare economists have come up with, our budget, healthcare budget goes up every year and nobody knows exactly why. So let me end the talk with showing you what I do know which was exactly what happened at Laguna Honda in the 20 years I was there. So in the 20 years I was at Laguna Honda in the interest of saving money, the number of patients we took care of went down from 1,178 to 750. Correspondingly, the number of doctors went down from 32 to nine. And the clinical staff went down from 1,500 to 1,200. And yet the budget rose every year. What accounted for that? Well when I looked into it what I realized is that even though the patients were down and the doctors were down and the clinical staff was down, the administrators were the same number. What did all those administrators do? Well I wasn't sure exactly but one thing there were more of at Laguna Honda when I left than when I got there was forms. When I first got there, there were two single page forms in the chart. The day before I left I randomly pulled a chart out, I opened it up and I counted. There were 43 forms. And most of them were five page, 10 page, 20 page forms. There were so many forms that the charts would just explode when you tried to open them and the medical records had to thin out the doctor's notes to make room for the forms. I'm not kidding. This is the chart I made at the time. Okay so here the patients going down and there's the doctors going down and there's the clinical staff staying about to say the administrative staff saying the same thing and that's the budget and these are the forms. And what I did is I predicted that if present things continue by 2024 we'll have no patients at Laguna Honda. We'll have two doctors. We will have a staff of 1,400 and a budget of $275 million. I decided this should be called doing less with more. And I'll tell you something that's really unnerving is I did that first graph in 2009 and it is right on track. Seriously, isn't that scary? Okay so and the thing is I don't think we can, I don't think it's fair to blame the administrators. They're just reacting to the rain of regulations and rules coming down in them. But I do think we could recognize that this is not what we meant to happen at all. The case of Laguna Honda. We went from in the interest of efficiency we became inefficient. In the interest of putting the patient first we ended up putting the patient, the real patient last in the interest of moving from an institution to a community. We actually ended up with way more of an institution and way less of a community. And sometimes I've asked myself, well what would you do Victoria? What would you do if somebody gave you carte blanche? And I've decided that what I would do if I could do anything would be to put the inefficiency back into healthcare. And I mean something very specific by that. I mean unassigned free time for the doctors and the nurses and the therapists. Because that's what allows you that unassigned free time is what allows you to be personal and to practice slow medicine and fast medicine together. Now the ironic thing is it is the most efficient way to do things. It's the cheapest, the fastest way to get things done. And that I think is what may save our system in the end. So thank you very much. Thank you.