Hospital

by Julie Salamon

  My encounter with Astrow led me to reread Cancer Ward, the great novel by Aleksandr Solzhenitsyn, and to a passage that I couldn’t stop thinking about. “Sometimes I feel quite distinctly that what is inside me is not all of me,” says one patient to another. “There’s something else, sublime, quite indestructible, some tiny fragment of the universal spirit. Don’t you feel that?”

  A couple of months later, I received an e-mail from a friend who had been diagnosed with ovarian cancer two years earlier. The prognosis was neither dire nor completely reassuring, but a year after massive surgery and chemotherapy she was reporting a healthy exam. She said she was feeling optimistic and energetic, but also sad, because the doctor she loved was leaving St. Vincent’s for a new cancer center that was being opened in Brooklyn, at a place called Maimonides. Her doctor was Alan Astrow. In her e-mail she wrote:

  Astrow is a smart and caring doctor—how many others take their patients’ phone number home with them so they can call at 10 Friday night to check up on them?!?!?

  I decided these three events were related—bashert, Yiddish for “karmic connection,” or, as the Chinese say, min zhong zhu ding, “life is predestined.” The next day I sent an e-mail to Jo Ann Baldwin, a year after we met, as though no time had passed.

  Made one of those weird small world connections this morning I thought you would appreciate:

  Link one: My friend Lila, who has just been through a terrible bout with cancer, wrote a wonderful progress report, making special note of her amazing doctor, Alan Astrow.

  Link two: A few months ago, said Alan Astrow (unbeknownst to Lila) had invited me to a series of lectures he’d arranged on spirituality and medicine.I went to one in December and was bowled over by what a brilliant, caring person he is. He invited me because he’d read Rambam’s Ladder [my book about Maimonides, the philosopher, also known as Rambam].

  Link three: Lila’s note informed me that Dr. Astrow is moving to Maimonides Hospital in Brooklyn!

  Link four: There you are!!!

  Soon afterward I boarded the D train and headed across the river for Brooklyn.

  Walking into the waiting room at Maimonides for the first time rekindled my first impression of New York when I was a newcomer, just out of college, feeling that same paradoxical rush of being overwhelmed and utterly engaged by the motley chaos, the interplay of harshness and sentimentality, the magnitude and intimacy of human convergence. In the small rural village in southern Ohio where I spent my first eighteen years, my family had been the diversity; being the Other was part of our job as the only Jews in a fundamentalist Christian farming community.

  The Hasids who seemed to treat Maimonides as their home were alien to me, but also familiar, part of my background as a descendant of Eastern European Jews. Just as recognizable were the many people—patients and caregivers—speaking broken English in many accents. My parents, too, were immigrants—Hungarian speakers from Czechoslovakia—and my family had intimate connections with medical issues. My father had been a patient as well as a physician; he died of lung cancer when I was still a teenager. There was another connection. Borough Park was said to have the largest remnant of Holocaust survivors outside Israel; though my parents settled in Appalachia, they, too, had survived the death camps.

  My father had been able relocate in an unlikely spot because he offered a necessary ingredient: He could tend to the sick. In return, this small, rural village provided him a haven and a source of meaning after he had lost so much. Was that formulation lost to history? Judging from the foreign names of the doctors who have replaced him, I didn’t think so. But it was a different world.

  Between 1970 and 1998, the foreign-born population in the United States increased from 9.6 million to 24.4 million (according to official tallies, a low estimate). In 2004 the foreign-born population numbered 34.2 million, or 12 percent of the total U.S. population, approaching the 14 percent who moved here during the last big immigrant wave a century earlier. The attacks on the World Trade Center in 2001 exploded any residual sentimentality for the American melting pot. Now the mass movement of newcomers fueled larger apprehensions. The war on terror morphed into the war in Iraq, and large divisions loomed everywhere: Muslim versus Christian and Jew, Muslim versus Muslim versus Hindu, modernity versus fundamentalism, consumerism versus environmentalism, us versus them, us versus us.

  It took just a few visits to see that Maimonides was an epicenter of these social forces, a petri dish of the post-9/11 world. What is alien and what is common? The question of community identity and responsibility was under constant discussion and examination. Ten years earlier the hospital had been in trouble because of a fractious board and an administration that wasn’t responding to the community—make that communities—but specifically not to the local Orthodox, the original constituents. The board enlisted a politically connected outsider—Stanley Brezenoff, former deputy mayor under Ed Koch—to run the place, and he hired Pamela Brier, then the executive director at Bellevue Hospital Center in Manhattan, the oldest public hospital in the United States, most famous for its psychiatric ward. Within five years Maimonides was on the front page of the Wall Street Journal, featured in a laudatory article about a turnaround involving a bureaucratic overhaul and a new way of dealing with a population that demanded both kosher and Chinese food. Five years after that, the hospital was running in the black and in the middle of a major expansion—including building a bigger emergency room—that would improve the physical plant but not increase the number of inpatient beds. A comprehensive cancer center was about to open. These were ambitious plans when so many hospitals, including sophisticated teaching hospitals, had been struggling financially.

  The hospital prided itself on the well-regarded doctors who had chosen Maimonides as the place to perform sophisticated technical procedures that required special skill and expensive equipment—and earned one Maimonides surgeon more than $3 million a year. But like any institution that is part of a particular place, Maimonides was also peculiar. It was a community hospital that employed many relatives—even generations of families— resulting in relationships that intertwined in ways that were healthy and ways that were not. It was a place in flux.

  For every comforting parable about cross-cultural coexistence, there was an angry diatribe about rudeness and misunderstanding. In 1995, consultants hired by the hospital issued a report that declared “the level of rude behavior at MMC is astonishing.” The report portrayed a “dirty environment” filled with angry patients, hostile nurses, and uncaring physicians. The prevailing mood, the consultants concluded, was “a culture of nastiness.” How the hospital had been changing—and continued struggling to change—had become embedded in its lore. Many of the new administrators and medical practitioners felt that part of their mission was to civilize Brooklyn—a mandate that didn’t sit well with the Brooklynites, another cultural clash.

  At Maimonides nothing was simple. Half the staff couldn’t even pronounce the hospital’s name:

  My-Mom-i-dees.

  My Noni-dees.

  Ma-Mo-nie-dees.

  Maimonides (“my-MON-i-dese”) Medical Center, I would soon learn, was the exact opposite of buttoned up. “There’s an openness here, a willingness to allow people to express themselves, and it is not limited to the titled positions here in the hospital,” said Carol Kidney, the nursing director for women’s services, including obstetrics, an Irish immigrant who had worked there for twenty years. “Everybody believes they can and should speak up. That’s a positive thing. You’re going to pull out the best ideas, you’re going to have innovation, you’re going to have creativity, you’re going to have good problem-solving skills.”

  Then, with characteristic Maimonides bluntness, she added, “If you open the venue for conversation and encourage the exchange of ideas, there’s an opportunity for miscommunication. When you throw multiple cultures into the pot, there’s plenty of opportunity for misunderstanding.”

  It was that lack of inhibition
that led Pamela Brier, the hospital’s president, and Martin Payson, the chairman of the board, to eventually agree to my impudent request: I wanted to spend a year at the hospital, without a minder, using the opening of the cancer center as a focus.

  Later, Brier confided that she had always wanted to write a book about life in a hospital but never got beyond sixty or seventy pages of a journal she’d once kept. Payson never divulged exactly why he opened the door. Brooklyn born and bred, son of a father who bought and sold string and a public-service-minded mother who was an air warden during World War II, Payson rose to the vice chairmanship of Time Warner and then was squeezed out of the company after a bitter corporate battle. Upon leaving the corporate world, still in his fifties, he directed his energy to hiking the Himalayas, cross-country biking, and good works. Still, he had spent more than twenty-two years in the entertainment world, and his take on the hospital world reflected his time there. He told me, “When I first got here ten years ago, I realized hospitals have a lot in common with the movie business. You’ve got your talent, entrepreneurs, ambition, ego stroking, the business versus the creative part. The big difference is that in the hospital you don’t get second takes. Movies are make-believe. This is real life.”

  Maybe it was his showbiz inclination to want publicity or the adventurer’s spirit in him, but eventually Marty Payson—and Brier—convinced the other hospital administrators to sort out issues of patient privacy and to let me see Maimonides “warts and all” (Payson’s words).

  What Payson meant when he spoke of “real life” at Maimonides, I would learn, was action no less vivid than that in movies and TV shows, but more diffuse and often less obvious. There were, as would be expected, poignant, terrible, disturbing, and uplifting medical stories, and there were also bitter internal feuds, warm personal connections, comedy, egotism, greed, love, and loss. There were rabbinic edicts to contend with, as well as imams and herbalists and local politicians. Profound ethical issues gave juice to the proceedings, though most of the drama was humdrum but urgent, revolving around mundane work matters, like systems foul-ups that kept blood-test results from being delivered on time, anal-compulsive bosses, careless record keepers, shortages of everything except forms to fill out, an ever-changing regulatory requirement, recalcitrant and greedy insurance-reimbursement systems, and the surprising difficulty of figuring out how to keep rooms clean and get doctors to wash their hands.

  Politicians have long made unkept promises about reforming a health-care system that has devolved into an unfathomably complex maze of overlapping bureaucratic fiefdoms. I began to see the hospital as a place of repairing and damaging, birthing and dying—and red tape and budgets and stress—but also a community struggling with the thorny social forces changing the world around it. As I filled reams of paper with my hand-scrawled daily logs, and boxfuls of taped interviews, I discovered the very human quality that remains the keystone of what can seem like a giant, impersonal enterprise.

  Over the course of a year, I would become privy to many conversations and miscommunications, as well as the thoughts, interactions, successes, and failings of a remarkable confluence of compassionate and contentious people. They were ambitious, shortsighted, altruistic, selfish, foolhardy, and wise. They tried to respect themselves and their patients, a task that often appeared far more difficult than diagnosing illness or performing complex medical procedures or speaking one another’s languages. They tried to remember— against the odds posed by a greedy and corrupted health-care system and by institutional and human frailty—that healing was the heart of the matter.

  One

  Occam Lied

  Occam’s razor (sometimes spelled Ockham’s razor) is a principle attributed to the 14th-century English logician and Franciscan friar William of Ockham. The principle states that the explanation of any phenomenon should make as few assumptions as possible, eliminating those that make no difference in the observable predictions of the explanatory hypothesis or theory. The principle is often expressed in Latin as the lex parsimoniae (“law of parsimony” or “law of succinctness”): Entia non sunt multiplicanda praeter necessitatem, which translates to “Entities should not be multiplied beyond necessity.”

  This is often paraphrased as “All things being equal, the simplest solution tends to be the best.”

  —FROM WIKIPEDIA, THE FREE ENCYCLOPEDIA

  NEW SUCK REPORT, VOLUME 1, ISSUES: LOTS JULY, 2005

  Dudes

  Greetings from the Big Apple, or as I shall henceforth refer to it as . . . . New Suck! . . . I actually am winning the War on Cockroach Terror, but it is a non-stop battle, so keep me in your prayers. So things here in The Brooklyn are not what I thought they would be. I only thought it would blow slightly, but alas, it blows severely. Anyone who said that New Suck is the greatest city on the planet obviously never lived in San Diego. or Boulder. or Denver. or the North Pole. Or even Grand Island, Nebraska. Yes, i would rather live in G.I. Nebraska than here. Sure there is lots to do. if you like doing them in a giant hot smelly city at the same time as a gillion other people, and paying up the wazoo to do them. . . .

  I’ll give you the goods now: I live in a place in The Brooklyn called Boro Park, which is the highest concentration of Orthodox Jewish people in the world, bordered by Sunset Park and the most diverse zip code in the United States. Our hospital has translators for 67 different languages, if that tells you anything about the population here. And the people here are also very sick. Not like “Dude that run was sick!”, but more like “dude that old man is sick as hell, I’m pretty sure he’s gonna die in 5 minutes!”

  So it will be good to train here I guess. If you can get the translator down to the ER fast enough to figure out what the heck is going on, you can actually save lots of lives here. sweet.

  And my favorite part about New York is . . . i forgot. was there one? I’m delirious now. I am working all night shifts with one day shift this week, so my schedule is all jacked up. . . .

  In summary, New Suck is fairly sucky, hence the name. . . .

  ok i gotta study or sleep or something now.

  Love, davey

  “Fishing kills me exactly as it keeps me alive.” The Old Man and the Sea

  NEW SUCK REPORT, VOLUME 1, ISSUE 2: DAVEY’S DAY OFF

  Alright, so I got a day off and the most logical thing to do here in New Suck would

  be . . . go surfing, duh.

  First problem—I live nowhere near the beach

  Second problem—I do not have a car

  But once I got to the subway stop, all i had to do was1. Take the D Train all the way into Manhattan (8 stops)

  2. Switch to the A- Train, and take it BACK into Brooklyn, through Queens, past JFK, to the stop before the beach (17 stops)

  3. Switch to the S Line (which i had never been on, nor heard of until today), and one stop later you arrive at 90th Street and Rockaway Beach

  4. Barely 2 hours out of Brooklyn and I am in the water and riding my first ever wave in the balmy Atlantic Ocean. And the waves did get bigger, and more fun! Interestingly, I noted that I caught significantly more waves (like a dozen) today than I did 3 weeks ago in Malibu . . . . . funny huh? So a great day off, I must say. . . .

  Love, Davey

  “Fishing kills me exactly as it keeps me alive.” The Old Man and the Sea

  NEW SUCK REPORT VOLUME 1, ISSUE 3: DAVE’S DAY OFF PART DEUX

  Kids,

  After working the night shift (7pm till 7:30am) I went home and slept for about 3 hours then got up to go to the beach again. . . . I know, this seems crazy, but apparently there was a hurricane named Irene not long ago, and her aftermath was sending larger-than-usual swells to parts along the East Coast. So, armed with my new friend Chris from San Diego (and his Jeep . . . . YES! no more surf-board on the subway) we headed off to the same beach where a child was sucked out to sea and drowned the day before . . . . and also near the same beach that one of my kid patients had been swimming at with his infectious diarrhea
from South America the day before . . . wonderful. Ah, New York. Anyhow, I won’t bore you with the details, other than Irene was AWESOME. Much better than the previous week’s adventure. It was not like surfing a hurricane like in the movies, but it was big enough to scare me on occasion, and big enough to have some very excitingly gnarley and fast rides! . . .

  What else. hmm. I have been doing great in the Peds ER, so that is good. I even got the Saved-the-Day Hero award (mythical) two nights IN A ROW, One for eyeballing a kid in the waiting room and deciding she looked a little sick to be waiting for another hour, so checked her out in the wait room and decided she was bleeding in her head, so got the CT scan and the Neurosurgeon involved quickly enough to save the little girl’s brain . . . so that was cool. And the other one was just being in the right place at the right time, noticing a drunk psychiatric patient on a gurney in a hallway who was sawing through his leather restraints with a knife. I learned that I get yelled at if i try to wrestle a knife away from a crazy drunk guy. i guess “that is what security is for” i am told. the same security that let the guy INTO the ER with a knife. outstanding. New York. so that was kind of exciting. a bunch of people that night were like “you saved the day man, i totally respect you now”. what the hell does that mean? did i garner no respect previously? I guess i am skinny with long hair and look like i’m 21, so nobody is quite sure that i am a doctor or something.

  ok. i gotta go to bed.

  Love, davey

  p.s. Danielle, I don’t hate New York completely, for the record. It just sucks completely. for the record. But I think this opinion has a lot to do with the suckiness of my occupation, and my long long hours. davey tired.