What inspired you to write The House of Hope and Fear?
When I came to work at Harborview, the hospital was doing about $40 million a year in charity care. Five years later, it was cranking out $120 million in charity care and still operating in the black on very little government funding. The question was how this public hospital was managing to get by, and the answer was by acting like a business. The administration was finding ways to attract patients to the high-end services that they do so well. That was pretty interesting to me.
What happens when a public hospital is run like a business? One result is that the rich, the poor, and the middle class have to share some pretty tight quarters. It’s a situation you don’t come across very often in our society. We live in neighborhoods and go to schools with people who are mostly like us. Even where you shop for groceries is probably determined by your socioeconomic class. But at Harborview there’s a great social mixing. That interested me a lot.
Did you need permission to write the book?
Obviously, you want to think hard before writing a non-fiction book about your employers. I talked with dozens of people to learn how the hospital works — patients, physicians, nurses, social workers, the community relations folks, and hospital administrators. Harborview is managed by the University of Washington, and staff physicians are faculty at the School of Medicine, so it was recognized that my freedom to write was important to uphold. While I don’t know that everyone at Harborview will agree with everything that’s in the book, they supported me in writing it.
Harborview is a real place. Are the people in the book real, too?
Hospital staff and officials appear under their real names, except where I’ve noted it, and they know they’re in there. For privacy reasons, the identities of all patients were altered, and in some cases the characters are blends of two or more people whom I cared for. Some of my colleagues will be surprised to find that there aren’t any terribly wild and crazy cases in the book. Harborview has its share of those, but that wasn’t the point. One of my goals was to describe people who live beneath our social radar, to find out whether my average patient was really different than anybody else.
Is this book just like Grey’s Anatomy?
My medical school housemates and I were devotees of the TV show ER, which just wrapped up its final season, after 15 years. I think that show paved the way for the dozens of medical memoirs that have been published in the last decade and a half, my first book included. Personally I hit my quota for medical tele-dramas pretty early on, so I’ve never seen Grey’s Anatomy, which is set at a fictional public hospital in Seattle. I’m willing to speculate that the doctors on Grey’s Anatomy have more interesting social lives than the people in House of Hope and Fear. But the characters in my book are incredibly passionate about what they do. It’s a story that offers lots of drama!
One of the main stories in your book is that the hospital is often on the verge of grinding to a standstill, because of much larger systemic forces at play.
Many mornings at the hospital that was the first news we heard, and it was something could affect the rest of the work day. In the 1980s, there were six Seattle hospitals preferentially caring for uninsured or underserved patients. Today there’s only Harborview. It’s the only hospital left with a charter specifically mandating that it care for the down and out, and in 2007 they performed ten times the charity care of any other hospital in town. But can the hospital survive in the face of these exploding numbers of patients who can’t pay for care? For many people, that may seem like a pretty remote question. But it affects all of us. Costs are shifted around the health care system in incredibly complex ways. This “cost-shifting” happens in every hospital in America, not just Harborview. In 2005, $900 of every family’s health insurance premium went to cover the costs of caring for the uninsured.
So these are important questions — what happens to health care in this town if Harborview doesn’t survive? What happens to health care in America if we don’t figure out how to provide better health care for the uninsured?
What gives an upper middle class physician the right to speak for a homeless person?
The question here is whether a person like me can really understand what a raw deal life is for some people. I tried to learn and understand what my patients’ lives are like, and the book describes things that I saw in the hospital, on the streets, and in shelters. I didn’t pretend to be someone I’m not. The story is my own.
So what do we need to do to fix health care?
Smart people have been working on that question for eighty years so it’s really not possible to give an answer in a paragraph. My ideas are sketched broadly in the book.
You no longer work at Harborview. Why not?
Doctors spend their lives taking care of other people but aren’t always very good at taking care of themselves. To generalize, that seems to be particularly true of many female doctors. I loved working at Harborview, but my husband and I tried to start a family for years, and it was time for that to be the priority.
Check out Q&A on my first book, What Patients Taught Me.