Hospital

by Julie Salamon

  There had been full disclosure; in an early interview, the chair of medicine had told Astrow about the Bashevkin-Kopel feud, and how it might affect the cancer center. Hiring Astrow made sense for Maimonides but, Sulmasy wondered, did the move make sense for his friend? Astrow had a thriving practice at St. Vincent’s in Manhattan and a warm feeling for the Catholic hospital where he had spent most of his career. When the morning recitation of the Lord’s Prayer came crackling over the loudspeaker, Astrow actually listened, taking the Christian prayer (“Forgive us our sins as we forgive those who sin against us”) as a daily reminder to be humble. Life was comfortable. He had the freedom to organize his conferences on spirituality and healing and to teach. He had enjoyable and satisfying relationships with his group of nurses and physicians’ assistants. On nice days he rode his bicycle from his apartment on the Upper West Side, down the bike bath along the Hudson River, and over to St. Vincent’s, which was surrounded by streets full of interesting restaurants conducive to long discussions and debate.

  I saw what he was giving up when I visited Sulmasy in the old wing of St. Vincent’s; the old-fashioned main hall had the hushed feeling of a monastery. Astrow had told me he wasn’t that worried about losing the amenities. It was the loss of a whole history of relations. “Suppose I’d forgotten to call a doctor I’d done a consult for,” he said. “At St. Vincent’s, I had a whole history of giving good service, a wellspring of goodwill I’d built up over twenty years. If you’ve done things for people you know and like they’ll cut you some slack. If you lose your temper or don’t say the right thing, they’ll know it wasn’t quite you. At a new place, everyone is sizing you up.”

  Sulmasy told me his concerns for Astrow had to do with the job itself. Sulmasy was a clean-cut, handsome man who appreciated fine food and appeared to choose his wardrobe carefully. But he was consumed by higher callings. He was a Franciscan friar and chair of the bioethics committee at St. Vincent’s, and he couldn’t understand why a thoughtful, sensitive person like Astrow would want to become an administrator in any hospital. “One of the problems of being a leader of a section or a department in medicine these days, so much of it is running a business,” he told me. “It’s about cash flow, marketing to communities, coming up with gimmicks to get patients in. It almost sickens me in terms of what medicine should be about, part of that medical-industrial complex. I have no interest. I was worried in some ways about Alan pursuing that.”

  Sulmasy was a seeker. He had trained as a physician at Weill Medical College of Cornell University, done a fellowship in internal medicine at Johns Hopkins Hospital, and then completed a Ph.D. in philosophy at Georgetown. He thought of Astrow as a companion intellectual and a genuine healer. On the day Sulmasy arrived at St. Vincent’s, seven years earlier, in 1998, Astrow was conducting a symposium called “Spirituality, Religious Wisdom, and the Care of the Patient,” where scholars from different religions spoke to physicians, nurses, and social workers about the role of religion in medical treatment, particularly with very sick people. Astrow had invited Sulmasy, and though he wasn’t able to attend, Sulmasy was impressed by Astrow’s intention.

  “He was thinking about getting scholars talking to doctors and nurses about the role of religion in the care of patients beyond simply complaining this person’s religious beliefs won’t let me transfuse them, or this person’s religious beliefs lead them to denial, or complaining that religious beliefs won’t let us get the DNR [do not resuscitate] order we want,” said Sulmasy. “He wanted doctors to take religion more seriously, to acknowledge that the fear of dying is not new, and these traditions have dealt with them for centuries and still might have something to say.”

  Sulmasy and Astrow decided to continue the discussions and obtained funding for them from the John Templeton Foundation, which had been founded by John Marks Templeton, a Wall Street financier from Tennessee, who became a naturalized British citizen and was knighted by Queen Elizabeth II for his philanthropy. The foundation, based in West Conshohocken, Pennsylvania, was giving away about $40 million a year to projects concerned with exploring the benefits of cooperation between science and religion. In the late 1990s, Templeton had been giving medical schools grants to begin courses on the subject of spirituality and medicine. With the grant, Astrow and Sulmasy put together an all-day colloquium that drew five hundred participants. A few months later, with another foundation grant, they began a year’s worth of monthly discussions, including the session I attended at New York-Presbyterian Hospital, which they videotaped and hoped to distribute to medical schools.

  Sulmasy explained what attracted him. “Part of this groundswell of interest in spirituality comes from a sense of alienation that is not just experienced by the patient anymore. The past few decades, patients have been saying, ‘I feel I’m just a machine, a widget on the assembly line.’ But lots of doctors are now beginning to experience that, because of the medical-industrial complex that treats doctors as another widget. It’s all interchangeable parts, and the chief virtue becomes efficiency rather than caring, compassion. Lots of physicians are feeling a sense of emptiness, alienation: ‘Is this why I went into this? Is this what it’s all about? If we’re addicted to technology, is this the way out? Is there more to this than just thinking about how many colons I can put a scope up per day and how many polyps I can remove and how fast I can be and how few complications I can get?’”

  He continued. “People have speculated that the Baby Boomers just don’t want to accept the fact that people are going to die, and technology can’t give us the solution. It’s everybody’s obsession. Of course, physicians can’t be exonerated from this. We’ve been telling people we’re going to win the war on cancer for decades, since [Lyndon] Johnson, and now they’re playing the tape back: ‘Why are we losing this war after spending so many billions on it?’ It’s hard, when they are playing back what we told them, to say we aren’t to blame for patients’ misconceptions.”

  Astrow thrived on this kind of debate, and he was aware of the pitfalls of becoming an administrator. But he had been determined to try it, and if the job at Maimonides hadn’t come through, he would have gone somewhere else.

  The stakes for him were high. He was fifty years old, with two young children, one in middle school and one in elementary school. He was tossing aside a secure job for an uncertain future at a hospital in Brooklyn in a brand-new enterprise that could fail. As a cancer doctor in New York, he was always acutely aware of status. Memorial Sloan-Kettering was the behemoth that always had to be dealt with. His own mother had lung cancer and chose to be treated by an oncologist at Sloan, even though Astrow had recommended NYU, where everyone knew him.

  Nice he may have been, but not naïve. He knew that taking over the department of hematologic oncology at Maimonides would be much more than a simple matter of exchanging crosses on the walls for mezuzahs on the doorposts. He would be stepping into a charged situation—the feud. But, even without that, Astrow was aware that bringing in outsiders automatically set up a kind of class struggle within the discipline. He understood firsthand what it is like to be the old guard in a situation like this. A decade earlier St. Vincent’s had contracted with Salick Health Care—which had been franchising for-profit, state-of-the-art cancer centers around the country. Salick invested millions in equipment and architectural niceties, and it was clear management felt that marquee-name doctors were needed to complete the picture of superior medical care.

  Astrow realized he would never run a division at St. Vincent’s, no matter how capable he was, no matter how much he was loved by his patients, no matter how much he was respected by his peers and superiors. He’d been there almost nineteen years, ever since he completed his training. “If you’re in a place your entire career, you’re seen a certain way,” he said. “I’m a different person than I was eighteen-plus years ago. I was immature. People who have known me all along tend to see me that way. To do something different, you have to leave, so people can see you in a dif
ferent way.”

  He realized it might not seem logical, his wanting to leave. Not only was he comfortable at St. Vincent’s, he hated change. “I drive my wife crazy,” he warned me when we first talked about letting me shadow him. “I like doing the same things all the time.”

  Yet his résumé revealed ambition: Yale University for his undergraduate and medical degrees, residency and fellowships at Boston City Hospital and NYU Medical Center, organizer of symposia, pursuer of grants, and contributor to academic journals. “I’ve felt very capable of organizing things, running things, motivating people to do good work, recruiting people, building a good program, and the only way you can do that is if you are the leader of the division. And it wasn’t going to happen for me at St. Vincent’s.”

  The first few months at Maimonides were very hard for him. No one told him exactly what he was supposed to be doing. Despite the fanfare of the cancer center opening, the floor where the heme-onc (hematologic oncology) group would be practicing wasn’t ready. Astrow and his colleagues were stuck in the old building—in the old Kopel-Bashevkin practice space—until the end of September. Camilleri had just fired the billing person, a holdover from the old group practice, which infuriated Kopel. The lab was still under construction so patients had to wait longer for test results. The bright young woman he and Camilleri had hired to manage the department had arrived over the summer and immediately alienated almost the entire support staff by letting the nurses and technicians know she thought they were incompetent. At the same time, he was trying to ingratiate himself with the hospital administration and other doctors by showing his face at meetings at the hospital and at charity functions in the community.

  He was always tired.

  Jay Cooper, the radiation oncologist who was director of the center, kept himself aloof, disconnected from the daily operations and not showing much interest in doing public relations or worrying about his colleagues’ anxieties. Meeting him reminded me of something Howard Minkoff, chief of obstetrics, told me he learned in medical school:

  “We got assigned to a patient who was dying. Part of the course, you had to be in the room when they were told, up to the day they died,” Minkoff said. “They asked, ‘What does death mean to you?’ The humanities people would say, ‘Death is the loss of everything all at once. It’s like losing a family member.’ The science major would say, ‘Death is the cessation of all spontaneous electrical activity.’ So some people come to medicine because they use science to get to people, and some people come to medicine and use people to get to science.”

  Cooper seemed to belong to the latter camp. He told me he chose cancer as a specialty because the minute he saw a tumor under a microscope— experimenting on the thymus of a mouse while at New York University’s medical school—he knew that whatever he did in medicine was going to have something to do with tumors. He was a monologist, the kind of person who would say, “Don’t get me talking about photography,” when what he meant was, “Let me tell you about photography” as long as you’d listen, then do the same for computers and the difference between CAT scans, MRIs, and PET scans, as well as the Tao of tumors.

  “We live in a sea of radiation,” he told me enthusiastically when we first met. “When you walk in the street, you get radiated with cosmic rays. When you fly in an airplane, you get more radiation. You have a granite counter-top?That’s mildly radioactive. We live in it, we’ve adapted to it through evolution. It’s merely a question of dose. If you give any living thing a dose, you can kill it with radiation. The other half of the equation is that if you give enough dose to any normal tissue, you’ll kill that as well. So if you had some magic way of differentiating normal tissue from neoplastic tissue and keeping it out of normal tissue, you could cure every cancer.”

  That, of course, hadn’t yet happened, but technology had refined radiation treatment dramatically. Cooper had convinced Maimonides to purchase two linear accelerators, one equipped to do intensity modulated radiation therapy (IMRT); the other could offer basic radiation therapy. IMRT machines can alter the shape of beams to conform to the shape of certain tumors, making the radiation more effective. IMRT therapy also happened to have a reimbursement rate that was at least three times higher than that of regular radiation therapy. However, the IMRT function had been idle because another hospital had reported an irregularity in a machine made by the same manufacturer; until Cooper had tested and retested the IMRT, he wasn’t going to use it.

  He claimed not to be worried that the patients weren’t lining up at the door for the sophisticated radiation therapy that was available. He believed in the Field of Dreams business model: Build it and they will come. “The way to do it is through education of doctors, and the way you do that is provide a level of care for the patients they’re not used to,” he said. “That’s beyond what they could have gotten in Brooklyn up until now. We’ve seen already the patients we’ve treated have gone back to their communities and said to their physicians, ‘Wow, you can’t believe how well I was treated.’ I think to some degree it’s important we go back to the idea that quality is our most important product.” The implication that the cancer center operated at a different—higher—level than the rest of the hospital wasn’t lost on his colleagues.

  “Sometimes it makes me crazy,” said Sam Kopel, a major Cooper supporter. “It’s hard for Jay, with all his accolades, to get himself to go to some Brooklyn doctor’s office and say, ‘Hi, I’m Jay Cooper. I’d like to help you.’ Alan Astrow wants to. It doesn’t come naturally to him because he’s shy, but he’ll grit his teeth and do it, and I’m proud of him for that. Jay is an intellectual elitist and it’s got to be exactly right, exactly coherent, and he will be glad to explain it to you ad nauseam. I do think he recognizes that’s exactly the wrong approach when you want to go to people to get them to refer to you. You’ve got to be humble; you’ve got to be friendly. Jay can do that but he can’t overlook anything.”

  Kopel had been instrumental in bringing Cooper in as a consultant when the hospital was still hoping to recruit a surgical star—as Brezenoff had wanted—to be director. But when the surgeon that Cunningham had been pursuing decided not to come, Cooper was the obvious choice. His medical and academic credentials—significant publication, membership on national committees—were impeccable, and his punctiliousness was invaluable in a branch of medicine that required the use of toxic drugs and dangerous machines. And he was available. Still, Brier told me she had been uncertain about making Cooper the head of the center and almost let him go before he stepped into the position. Leadership required more than mere brilliance, and she was concerned that Cooper would become “too mired in the details.” Her feelings were a carryover perhaps from their old association, when Cooper ran radiation at NYU and Brier was president of Bellevue. The two hospitals—one private, one public—shared residents and supervisory medical staff, but Bellevue, refuge of the have-nots, was the poor relation, like the sister who didn’t marry money.

  Cooper almost dropped out because of Brier’s reluctance to give him what he wanted. He was insisting that radiation oncology should be a separate department, as it was in most medical centers. Brier wasn’t keen to establish another department, afraid of offending other physicians in the hospital. On the Friday before July Fourth weekend, a year after Brier’s accident, they had a testy meeting. “I very clearly told her that was her decision, but unless it was a department and I was assured it was going to be a department, I wasn’t coming, and she understood I was serious,” said Cooper. He was even more upset when she told him that Brezenoff couldn’t remember making such a promise and that nothing was in writing.

  Kopel bumped into Cooper as he left the president’s office. “He had a very dark look on his face,” Kopel told me. “I asked him what happened. He said that he was on the verge of kissing this entire project good-bye.”

  Kopel stayed on the executive floor that afternoon, waiting to catch Brier before she left for the weekend. “I was quite beside my
self,” he said. “I told her that she might have just extinguished the only legitimate star in our firmament. She didn’t quite see it that way but promised to think it over. Luckilyfor us, by the beginning of the next week, to her credit, she called Jay to apologize.”

  After that, Brier made a point of being respectful to Cooper, and he reciprocated. He did not like being reminded of that heated moment. “That story gets repeated and repeated and repeated,” he told me tensely. “It wasn’t as if Pam and I were yelling at each other or disagreed with each other. It was Pam telling me her understanding of what had happened. My making very clear to her my understanding of what had happened.”

  Back in the nineties, when the cancer center was a notion not a plan, both Brezenoff and Kopel had thought the perfect person to be director of the cancer center would be Estee Altman. Altman, a pharmacist by training, ran Infusion Options, a for-profit subsidiary of the same holding company that owned the hospital. Infusion Options provided intravenous therapies— antibiotics, nutrition, chemotherapy, pain management, fluid, and catheter care—for patients at home, as well as nursing care and equipment. Infusion Options also mixed the chemotherapy drugs at the cancer center.

  Altman, who was a friend of both Bashevkin and Kopel, had both business acumen and diplomatic skills. She also happened to be a beautiful woman—the hospital’s Jewish Grace Kelly, someone called her—not because she was a blond movie star-turned-princess but because she was slender, beautiful, regal, and touched by tragedy. Altman’s parents were Holocaust survivors. On the day I talked to her in her small crowded office near the cancer center, a delivery of flowers came for her, an anonymous gift welcoming her back from a trip. She accepted them with gracious delight but also gave the impression that flowers came her way often.