“Fishing kills me exactly as it keeps me alive.” The Old Man and the Sea
David (aka Davey) Gregorius, first-year resident in emergency medicine, had bumbled into an agreement to spend three years of his life at Maimonides Medical Center because of his infatuation with a beautiful, long-legged blonde, who also happened to be brilliant, kind, and humble. He met Jennifer Pfeifer when he was a medical student at the Midwestern University-Arizona College of Osteopathic Medicine, near Phoenix, on his way to a rotation at a hospital in Sacramento. Pfeifer was at UCLA working on a Ph.D. in developmental psychology; one of her classmates, a boyhood friend of Gregorius’s, introduced them. They fell in love. Gregorius was back at school in Arizona when Pfeifer told him she had been thinking about doing postdoctoral work at Columbia or New York University. So after Gregorius had already sent out twenty-five applications to hospital residency programs, she said to him, “Why don’t you send a couple to New York?”
Later he remembered picking Mount Sinai because one of his teachers in medical school had gone there. As he recalled, “The other one was obviously Maimonides, but I really don’t remember picking it,” he said. “I thought I put Methodist. I thought I put some kind of M. But the whole application process is clicking on computers, you know? Click, click. When I got the e-mail back inviting me for an interview to Maimonides Medical Center in Brooklyn, whatever, I went WHAT? But I still went. I thought, I’ve never been to New York, I’ll check it out.”
He traveled on the overnight flight from Phoenix, landing bleary-eyed in New York on a cold Sunday morning in December. He spent the day in Manhattan, staying with a friend on the Upper West Side. She showed him Times Square, Central Park, the usual tourist stuff. On Monday morning he took the subway to Borough Park, crossing the East River, away from the Manhattan skyline toward Brooklyn, once described by another transplanted midwesterner, Ian Frazier, as having “the undefined, hard-to-remember shape of a stain”—in other words, a place you wanted to be from, not head toward. In recent years, however, the real-estate craze in Manhattan had given the borough new definition, no longer stain but hot spot for the disenfranchised young people who couldn’t afford the East Village or Lower East Side and for cramped, growing families looking for bigger spaces, more sky, yards.
Gregorius, born in Missouri but raised in Nebraska—fifth generation at least—had a vague TV- and movie-inspired notion of Brooklyn “as a knife and guns place.” When he disembarked from the D train, he was relieved to find himself in a safe-looking (only slightly shabby) neighborhood, with rows of two- and three-story houses and little stores—newsstands, flower shops, delis, bakeries, and shoe-repair places—some of them displaying signs with Hebrew lettering.
On the short walk from the elevated subway tracks to the hospital, he passed worried-looking bearded men dressed in long black coats and large black hats and young women wearing matronly clothes and herding large groups of children. There were black people whose words floated by with a Caribbean lilt and Pakistanis with bright scarves sticking out from under winter coats. He didn’t pay much attention; he was mentally preparing for his interview with John Marshall, the residency program director.
They hit it off. Marshall was balding but youthful, a calm man with dark, penetrating eyes, who seemed intellectual yet also knew how to have fun. He was thirty-seven, from Detroit, had been in the air force, and was a passionate downhill skier. What a coincidence! Gregorius had fantasized about becoming a fighter pilot but quit the Naval Academy at Annapolis when he was told his less-than-perfect eyesight nixed that ambition. He transferred to the University of Colorado at Boulder and reverted to his back-burner dream, being a doctor (like his dad). And yes, he would figure out how to combine work with pleasure. Maybe a job in an emergency room in the Colorado mountains, maybe two or three shifts a week. Make that an emergency room in Vail, add ski patrol a couple of days, leaving time for fishing twice a week.
The hospital in Borough Park did not fit Davey’s blithe vision of work hard, play hard. His memories of his first foray into the Maimonides emergency room were vague: It was crowded. Really crowded. Stretchers with patients were lined up two and three deep, with the lucky ones semisecluded behind curtains that barely closed. He noticed but didn’t fully comprehend that the melting-pot mayhem—Hasids, Chinese, Pakistanis, Haitians, Russians, Bulgarians—did not seem to include anybody like him, a tall, skinny, curly-haired, dark-eyed, non-Jewish, non-Muslim, non-Asian, non-African, non-Italian white surfer-ski boy from the Midwest. The visual overload was matched by the audio: Tower of Babel at top volume, accompanied by the constant beeping of monitors, pagers, telephones. The usual ER smells of antiseptic and bodily stink, but also strange spicy odors he couldn’t place.
Had he landed in the Third World, or a developing nation, whatever the correct terminology of the moment was? Before he could panic, he came across evidence that he was indeed firmly situated in the First World, twenty-first century: Maimonides had HealthmaticsED, a very cool, very tomorrow computer system that, among other things, allowed doctors and nurses to track a patient in real time. The computer monitors were stationed like beacons of sanity throughout the room. For Gregorius they made the chaos seem almost comprehensible.
On the screen the mass of humanity was personalized—somewhat—by identifiable characteristics, but also depersonalized, transformed into useful bits of information. That large gray-blond uncomprehending woman staring into the noisy glare with frightened eyes became Yevnosky, Irina, 41; F; vaginal bleeding; 11 minutes with nurse, 4 hours waiting for bed. The husky kid wearing a Yankees T-shirt, off in the corner talking to a young woman, was Diaz, 18; M; difficulty breathing; 14 minutes with doctor. The old man in a cubicle was Wang, L., 83; M; pain in abdomen; 15 hours, 9 minutes waiting for bed.
None of the emergency rooms he’d worked in—Sacramento, Phoenix, and certainly not Nogales, Arizona, a border-town hospital with ten ER beds—had such a sophisticated setup. Maimonides had been named one of the nation’s one hundred “Most Wired” hospitals and one of the nation’s twenty-five “Most Wireless,” by Hospitals & Health Networks, a journal of the American Hospital Association (AHA).
Overcrowding had become commonplace in American emergency rooms, which had, for people without medical insurance, become the doctor’s office. In June 2006, almost a year after Gregorius began his residency, the Institute of Medicine of the National Academies would publish a report that warned, “A national crisis in emergency care has been brewing and is now beginning to come into full view.” The emergency department at Maimonides, which would process more than 84,000 patients in Gregorius’s first year, was not the busiest ER in the country or in New York City. But it was arguably the most intense. Using a formula that measured not only numbers of patients but the square footage available in which to squeeze them, Steven Davidson, the department chairman, a crusty type who admitted he got along better with numbers than with people, once measured the concentration of humanity in terms of patients per square foot per year. Then he compared the density to other hospitals of comparable size. By this measure, Maimonides was packing in six patients per square foot per year; the average at other hospitals seeing comparable numbers of patients was two or three. The next-worst he could find logged a mere four and a half.
Surely this was the perfect fix for the adrenaline junkies who chose emergency medicine as their specialty. But even thrill seekers need a rest, and at Maimonides the flow of need was relentless. “Years ago you came home from one day when you are crowded like this and nobody died and you felt great because you’d reached up and found the capacity to deal with it,” Davidson told a visitor one afternoon around a quarter to five, grinning a little crazily through his short, graying beard as he took in the scene. Actually, he was yelling, and pressing against the back of a resident to avoid being swiped by a gurney holding a young woman who had come in unconscious, just out of detox.
He continued trying to tell his story through the din. “But it happe
ned once that month,” he shouted. “The rest of the time you sat in the lounge and chatted with the nurses. One day in thirty, it happened, and you felt like a hero. But when it’s one day a week, two days a week, or more, it grinds people down.”
Gregorius was one of 450 applicants for the nine first-year positions in the three-year emergency-department residency at Maimonides; as Gregorius knew all too well, the computer click made it easy to apply. Marshall, the program director, interviewed 120 of the applicants, the ones who had decent medical-school records and good letters of recommendation, preferably from someone he knew. How did he decide which of those had the stamina to endure the Maimonides ER? On the medical side, he was looking for people who could handle the particular pressures of emergency-room medicine. As he explained it, in the quiet of his office, “In internal medicine you play the game to win, to get the right diagnosis, to figure it out. In emergency medicine you play the game of medicine not to lose. You want to make sure somebody doesn’t have the things that are going to kill them. So if I exclude the fifteen things that are going to kill this patient, . . . I don’t care if I don’t know exactly why they have it so long as it doesn’t kill them. I’m looking for applicants who are able to think that way, who have proven they are comfortable with a degree of uncertainty in not finding exactly the right answer.”
He elaborated. “They need to be able to multitask. In most medicine you proceed diagnostically and then therapeutically. In emergency medicine you have to proceed diagnostically and therapeutically at the same time. You have patients coming to you with acute pain; they’re sick, and we start treatment not knowing what we’re treating. We’ll give you an aspirin because we think this may be your heart before I figure out whether it really is your heart. You have to be able to do that with multiple patients at the same time. You need to be able to maintain situational awareness.”
Those were standard emergency-doc requirements. But “situational awareness” at Maimonides took an extra-special something. Maimonides— representing Brooklyn, early twenty-first century—was an epicenter of the cultural forces that had been rocking and roiling the American experiment for a generation. The ideal of assimilation, finding your inner WASP, had given way to the glorious mosaic. Assimilation was out; the hyphenated American was in. Culture became multicultural. Then, September 11, 2001, the World Trade Center felled by Islamic terrorists, and suddenly the mosaic—or pieces of it—became suspect. The hospital, by necessity and tradition, remained a demilitarized zone, where patients dragged in not just their wounds, fevers, and malfunctions but their accents and customs, their immigration and insurance problems, their feelings about being outsiders. Hope and heartache in sixty-seven languages. Sick and scared, they yearned for kindness and prayed for competence from the doctors, nurses, floor cleaners, lab technicians, paper pushers, and social workers, who had their own troubles and were often newcomers themselves. This jarring symphony of strangers, an ongoing work in progress, was created out of exigency, in moments of greatest stress with an overwhelming crush of expectations, needs, and bureaucracy. At Maimonides, cross-cultural forces made for one big surf tide.
Was Gregorius right for the task? He didn’t think so. After the interview, realizing he had six hours to kill before his flight left, he said to himself, “I’m never going to be in New York again, let’s go!” He pulled a pair of tennis shoes out of his suitcase and then, still wearing his interview suit, went on a frantic tour—to the Guggenheim, to Ground Zero—pulling along his suitcase. “I’ll never be back,” he remembered thinking.
“David’s nickname during the interview process was Deer in the Headlights,” Marshall recalled. “He’s so open, so impressionable, so wow!”
That openness—and the enthusiastic letters of recommendation Gregorius brought with him—made Marshall think the Deer in the Headlights would do just fine. He was wrong only once every couple of years. One of his residents had washed out because, as Marshall put it, “the multitasking thing didn’t sink in.” Another left the program because his wife had severe postpartum depression, so first he took a leave of absence, and then he left altogether.
Marshall was from Detroit and might have gone into the auto industry like his grandfather, father, and brother. But he was drawn to the mix of a different life. His wife was Iranian, an artist, and he had majored in anthropology and writing as an undergraduate at the University of Michigan. The air force paid for his medical-school education, which he repaid by spending four years of his life in San Antonio, Texas, at the Wilford Hall Medical Center, the air force’s main teaching hospital—interrupted by a six-month stint in the Middle East, with stops in Afghanistan, Uzbekistan, Turkey. Not by choice: Three weeks after the September 11 attacks in New York, the base doctors got a phone call asking for a couple of volunteers. A few of them flipped coins to see who the lucky ones would be. Marshall lost the toss, which landed him in an army field hospital in Afghanistan, where his job was to stabilize the wounded brought in by helicopter so they could be put on a plane to Turkey or Germany.
For a fairly young man, he had seen a lot. Before he came to Maimonides, between medical school in Hawaii and residency in Denver and moonlighting, he had treated patients in fourteen ERs. At Wilford Hall in San Antonio, the military hospital took care of 250,000 retirees in the area who had access to the system, also lots of geriatric patients and children. The trauma center brought in Spanish-speaking patients from San Antonio, more Mexicans than Texans. In Denver he figured that Spanish was the first language of 20 percent of his patients. In Hawaii he treated Chinese, Vietnamese, Portuguese, and Samoan people. But nothing in his experience matched the cultural cocktail he found in Brooklyn. Maimonides served up diversity on steroids.
Marshall had specific ideas about what kind of person would be, as he put it, “comfortable in a polyethnic urban setting.” It didn’t matter to him whether the candidate had ever experienced a mishmash like that before. He was looking for a certain receptivity. “You get a sense from the thoughtfulness with which they answer a question, the openness they have to the questions, whether they are open to the experience, to listen to what people are saying instead of hearing what they expect to hear based on their closed-society cultural experience.” He saw those qualities in Gregorius.
Marshall asked his residents if they had learned Occam’s razor: Given the choice between multiple explanations for any given phenomenon, the simplest explanation is almost always right.
Forget that, he told them. At Maimonides, he said, the simplicity principle doesn’t apply. To underscore the point, he intended to give his residents T-shirts that declared OCCAM LIED.
“Our patients never have one problem,” he explained. “They almost always have a heart attack compounded by a urinary infection compounded by muscle breakdown. . . . There’s never one clear explanation for the pathological phenomenon we see in a lot of our patients.”
The reason? Maimonides patients tended to be exceptionally old, or exceptionally foreign. So fewer ankle sprains, broken arms, colds and flus. More belly pain, chest pain, strokes, heart attacks, sepsis. More weird symptoms and inexplicable infections. More off-the-boat things. “The pathology is great!” Marshall said.
Also, Friar William of Occam clearly had never had to contend with Hatzolah (from the Hebrew for word for “rescue” or “saving,” in the sense of saving someone’s soul). Hatzolah was the volunteer emergency medical service run by Orthodox Jews, and another undeniably complicating fact of life in the Maimonides ER. In the mid-1990s, the hospital was avoided by the local Orthodox community because local leaders felt that their needs were not being met. New management came, which actively courted the religious community—especially the leaders of Hatzolah, who decided which hospitals got their business. The plan worked. So by the time Gregorius arrived for his interview, Hatzolah was a major supplier of emergency patients, and Hatzolah patients tended to be religious Jews. (Orthodox Jews—people identifying themselves on patient surveys as keepi
ng kosher—made up 20 to 25 percent of the inpatient population.) Hatzolah brought in as many patients as New York City’s official EMS, 400 to 500 patients a month. Significantly, the Hatzolah patients were older and sicker; about 55 percent of them ended up getting admitted versus 30 percent of the regular EMS patients. Admissions were how the hospital made money, and Maimonides prided itself on staying on the plus side of the ledger, a rarity in the not-for-profit hospital world.
The Hatzolah men (there were no women) were tough—and tender, too, but the doctors and nurses had to contend with the toughness. The Orthodox ambulance-squad members were not content to drop their patients off. They hovered, ready to nudge, cajole, argue, and demand if they felt their charges were not being attended to quickly enough or with enough diligence. “It’s really like having unionized patients,” said Marshall. “Those patients, because they’re part of the union, can demand certain things of the administration, though there’s not a specific contract. The union can strong-arm the hospital. Hatzolah can say we’re not bringing patients to the hospital, and then the hospital starts losing money—it’s happened before. So they can demand things for their constituency.”
The Hatzolah men could be a nuisance, but they cared about the sick people they brought into the ER, and they had clout, so you had to learn to deal with them. The hospital was multicultural but kosher, and its mission statement made clear that the Orthodox had special status: “We welcome patients of all faiths, and at the same time remain uniquely committed to serving the special healthcare needs of the Orthodox Jewish community, whose religious and cultural traditions help guide the provision of Maimonides’ services.”
Dr. Carl Ramsay, the emergency department’s medical director, a weathered beanpole who wore his graying hair pulled back in a ponytail, just sighed when he was asked about Hatzolah. “It’s the good and it’s the bad,” he said. “This is an academic community hospital with a very interested community that wants to make their place better. That’s what I keep telling myself, because if you don’t say that you might as well walk out. That’s how I always look at it. Plus, there’s the whole Buddhist thing. They’re my teachers.”
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