Vision for a Free Hospital Based on Fun and Friendship

by Patch Adams
Read French translation [1]

I entered medical school in 1967 to use medicine as a vehicle for social change. I used my free time to study the history of health care delivery around the world and to look at contemporary models with the idea of creating a medical model that would address all the problems of the way care is delivered. I didn't intend to create a model that would be the answer to the problems; but to model creative problem solving, and to spark each medical facility to design their own ideal rather than succumb to the garbage of managed care, or a resignation to the impossibility of humanistic care. Beginning in the climate of the political "war on poverty," I felt confident that a free hospital to serve the poorest state, West Virginia, would find easy funding and that we would be built in four years. I smile writing this as we enter our 33rd year without having broken ground on the hospital. However, we have asked our architect to go to finished drawings so that we can begin building as soon as we have funding in hand. None of the journey has gone as I imagined and the vision is so much deeper, more comprehensive and far-reaching as a consequence of such deliberate progress.

The original vision had all the principles we have maintained all these years. There would be no charge for the care. Barter was also not an option. In fact, we wanted to eliminate the idea of debt in the medical interaction as a way to begin recreating human community. We didn't want people to think they owed something; we wanted them to think they belonged to something. We could not conceive of a community that did not care for its people. This also meant a refusal to accept third party reimbursement, both to refuse payment and to sever the stranglehold that insurance companies had on how medicine was practiced. We would have nothing to do with malpractice insurance, which forces fear and mistrust into every medical interaction. We espouse the politics of vulnerability and are clearly aware that we can only offer caring and never promise curing. In such a flagrantly imperfect science, we need the right to make mistakes.

The loudest cry of patients was for compassion and attention, which was a call for time. So initial interviews with patients were three to four hours long, so that we could fall in love with each other. Intimacy was the greatest gift we could give them, especially at a death bed, with intractable pain or chronic, unsolved medical problems. It was natural to insist on a house call to sweeten this intimacy. When I made a house call, I opened every drawer and snooped in every closet. I wanted to know the patients in all of their complexities. An apparent secret in the practice of medicine (so easily erased when business is the context) is how care is bidirectional. This intimacy is as important for the care giver as it is the patient. The bidirectionality of healing is at the core of preventing burnout. The business of medicine has connected the word care with the concept "burden," to describe all who need care, who are not wealthy. But we found the unencumbered practice of medicine is an ecstatic experience.

In spending this amount of time with patients, we found that the vast majority of our adult population does not have a day to day vitality for life (which we would define as good health). The idea that a person was healthy because of normal lab values and clear x-rays had no relationship to who the person was. Good health was much more deeply related to close friendships, meaningful work, a lived spirituality of any kind, an opportunity for loving service and an engaging relationship to nature, the arts, wonder, curiosity, passion and hope. All of these are time-consuming, impractical needs. When we don't meet these needs, the business of high-tech medicine diagnoses mental illness and treats with pills.

What the majority need is an engagement with life. This is why we fully integrated medicine with performing arts, arts and crafts, agriculture, nature, education, recreation and social service, as essential parts of health care delivery. We knew that the best medical thing we could do for the patients was to help them have grand friendship skills and find meaning in their lives. This is a major reason that the staff's home was the hospital. We insisted on friendships with our patients (made easy by not charging, and giving them our lives). A patient ideally would bring their whole family while they were healthy, and stay a few days as friends, becoming familiar with the hospital (home, sanctuary), so that just being there was relaxing, even healing.

We wanted patients to bring all their interests and skills to essentially become temporary staff as well as patients during their stay. For example, if a car mechanic came as a patient, we could notify the poor in our greater community who might need their car fixed, and have it happen while the mechanic was getting care. The mechanic may also give classes on basic mechanics. All these features help build community, creating a sense of interdependence. Those receiving care can not feel indebted because they become both the help and the helped.

To help promote diversity and truly to be full service in our planned facility, we insist on integrating all the healing arts. Allopathic medicine, including surgery, ob/gyn, pediatrics, internal medicine, family practice and psychiatry, will work hand in hand with complementary medicine, including acupuncture, homeopathy, naturopathy, chiropractic, ayurvedic, anthroposophic, herbal, body work and faith healing. It will be an exciting opportunity to study how they can all work together under close observation. The entire environment will be an example of preventive medicine exploring how to help a patient and their family grow healthy (or at least healthier!) From the beginning, social, environmental and global health were felt to be essential as part of our medical practice. There, violence and injustice became medical issues. Unemployment, the discrepancies between rich and poor, poverty, pollution, corrupt governments and economic systems all become concerns of a medical practice. There was always an invitation and encouragement to become involved in social change, even if the individual did not feel it affected their life. We want to build a fine community of people whose ethic is caring for all. Now, we have added to our vision a school to teach social change with the whole community as its laboratory. Agriculture will not just be about feeding people, but an exploration into sustainable agriculture. We'll use designing the community as an experiment in appropriate technology.

One of the most radical parts of the vision was that we wanted all of the activity to be infused with fun. I wanted to build the first silly hospital in history. Foolishness was embraced, often to extreme, in even the most profound of situations. We had fun deaths and bizarre, outlandish behaviors with the mentally ill. In our normal, serious world with somber medical environments (even though no research supports being serious and thousands of research papers encourage joy and humor as healing), we saw no contradiction in feeling that a hospital could also be an amusement park, even implying it is important for staff and patient.

The ideal staff people we looked for were, by intention, happy, funny, loving, cooperative and creative. I knew the key to the creation of this beautiful model was in the people deciding and choosing to live there; because it is people that really make a model. Ideas can only be as real as the people living them. Politically, our most potent wedge for change would be living happily together, in constant, joyful service, fully expressing our creative selves at extremely low salaries. The point was not to try to teach a staff this, but to find people for whom this was their way of life.

In our first 12 years (1971-1983) we did all this as a pilot project. Twenty adults and our children moved into a large, six-bedroom house and called ourselves a hospital. We were open twenty-four hours a day, seven days a week, for all manner of medical problems from birth to death. Three of the adults were physicians. We saw 500-1000 people each month, with five to fifty overnight guests a night; totaling 15,000 people over those 12 years. We were never sued. At least three thousand of the patients had mental illness and we did not give psychiatric medicines. We referred out what we could not handle. It was truly ecstatic, fascinating, and stimulating.

These 12 years provided proof of concept, and since 1983 the GI has been working to raise funding for a full scale model of health care based on compassion and service. The movie PA was one such effort; in the meantime we’ve developed educational programs, global outreach and humanitarian clowning to promote compassion in healing.

We stopped seeing patients in 1983 to devote ourselves to fund raising full time for the hospital, by expanding out into the world.

We plan to build a forty-bed rural community hospital. There will be sixty beds for staff and beds for their families in a creative, comfortable communal hospital. There will also be forty beds for guests who would be healing arts students on electives, ophthal-mology teams every three months, plumbers, string quartets, and anyone wanting a service-oriented vacation. There will be 30,000 square feet devoted to the arts in a fully arts-centered hospital. There will be a school for social change and in-depth agricultural programs. It will be funny looking, full of surprises and magic. We'll be exploring how far below the national average our effective operating budget can run—I believe we'll be shockingly inexpensive. Our ideal is that an endowment would cover the annual costs and realize without this we'll find creative ways to pay for its operation. There will be a forty-acre village to house our children's school (also for sick children and children of sick parents) and other important community experiments, like how to integrate all ages in a fun, healthy way. Staff persons who've served for four years and want a little distance from the intensity of the hospital can create their fantasy living space in our village.

At the urging of friends in the US, given the collapse of health care systems in our country, we decided in 2007 to fundraise for phases 4 and 5, the teaching center and clinic, which will provide the indispensible minimum of our hospital vision.