Fraidkin had been shaking things up at Maimonides from the moment she got there. She found conditions at the Brooklyn hospital to be about a decade behind the Manhattan hospitals; she had previously worked at Beth Israel. To convince the board that the staff had no idea how to deal with an emergency cardiac arrest, she started doing mock codes, filming the physicians’ and nurses’ responses. She had put a dummy equipped to simulate human response in a room, called a Code-3, and videotaped the reaction of the medical staff.
She took the evidence to the department chairs and said, “Your physicians are killing our patients.” Within a few months of arriving at Maimonides, Fraidkin had forced mandatory CPR courses on doctors and nurses, reorganized the operating-room schedule so half of them were no longer sitting idle during lunch break, and made sure the surgeons, nurses, and anesthesiologists got to the OR on time. They couldn’t lie to her. She was at the hospital by 6:30 A.M., her presence marked by her silver Infiniti sports car, always parked in the same space. By 6:35 it wasn’t unusual to find a physician in her office, wheedling and cajoling. Cunningham dryly referred to her as their “mommy.”
Fraidkin, born Lilia Maria Escobar, was of Puerto Rican descent, having become Jewish and a Fraidkin via a marriage that ended after twenty-five years. (She said she stopped using Lilia because “gringos” always mispronounced it.) She wore three-inch heels and short skirts that emphasized her famous (at Maimonides) legs. She was loyal to her physicians and, as she put it, had no trouble boxing their ears when she thought it was necessary.
Brezenoff recognized Fraidkin’s talents; when he and Brier took charge, Fraidkin became chief of staff. She was also given the task of outreach, beginning in Bay Ridge, an Italian and Irish enclave that viewed Maimonides as “the Jewish hospital.” Fraidkin joined organizations, went to community meetings, ate unidentifiable food at banquets, and froze to death watching endless parades with local politicians.
When she discovered that nearby Lutheran Hospital, a major competitor, won Italian patients not just by attending the Ragamuffin Parade—an annual costume parade for kids in Bay Ridge—but by entering a float, she went to Brezenoff. “I want a Maimonides float. I want it to be the Wizard of Oz.”
“I’ll pay for it if you’ll be the witch,” he replied. Thus began a tradition: Fraidkin as bad guy. The Wicked Witch of the West one year, Cruella de Vil the next. It was a role she relished. More than once, Brier told Fraidkin she was scared of her. Everyone knew that it was not wise to cross Lili.
Payson also relied on Joe Cunningham, Dr. Cowboy Boots, the Hemingway man. In recent years new nonsurgical procedures had taken the shine off cardiac surgery, and this, along with personal problems, had in turn taken their toll on Cunningham. But he remained a powerful force, not least because he had won Payson’s loyalty.
Cunningham and Fraidkin were old friends; they had arrived at the hospital around the same time, in the early eighties. They had both thrived under Brezenoff’s leadership. Brier and Cunningham, on the other hand, were not natural allies. He found her quirkiness irritating and thought she was a snob. Now, Stanley Brezenoff, he would say, Stanley had a “presidential air,” whereas he described Brier as a “micromanager.” Brezenoff was someone he could relate to—and Brezenoff admired him as well. They recognized in each other a particular catalytic force; they were alpha males. As for Brier, her feelings were complicated: appreciating Cunningham’s history with the hospital, cognizant of the loyalty Payson felt was owed him, but wary of the old-boy network he represented. Now she would have to add gratitude to an already thick gumbo of feeling.
In Albany, however, she was a patient, not a hospital administrator, and Cunningham was by her side. Whether he was there as a friend or to take charge of the hospital that had become part of his identity would later be a matter of speculation. But what Brier subsequently remembered from the painkiller fog that sheltered her the first days in the intensive care unit was a critical conversation with Cunningham. She asked him whether her husband was going to live (the answer was yes) and whether he was going to walk again (the answer was maybe, probably). From then on, no matter what her frustrations with Cunningham, she would remember that he had provided comfort for her, in the way she needed, at a crucial time.
Brier refused to be treated as an invalid. For the first several weeks after the accident, Hatzolah medics took her to work and back home by ambulance because she couldn’t get in and out of a car. For months she needed a wheelchair but insisted on having the Hatzolah driver park around the corner from the entrance so she would not have to be pushed through the front door. She would rather limp in on her own.
The effects of the accident would linger.
Two years later, when I was trying to convince the hospital’s management to let me hang around, I met with Brier several times. The second of those early conversations took place in a hospital room at Maimonides. The patient was Brier, recovering from yet another round of surgery, this one a knee operation to repair damage from accident aftershocks. Her blond hair was carefully combed (she made weekly visits to the Tribeca branch of Privé, the Beverly Hills salon), the nails on her delicate hands were well manicured. She wore an Issey Miyake jacket over a pair of sweatpants. Despite the attempt at gloss, she seemed tiny and frail—a first impression she soon dispelled by issuing a series of quick orders to Lili Fraidkin, who had delivered me to the room.
I had already heard about Brier’s idiosyncrasies. People remarked that Brezenoff’s meetings were electric; Brier’s were often chaotic. She would get up while someone was talking, walk to a cabinet, pull out a bag of popcorn, and pour it into bowls. Her gaze was always wandering, landing on curtains that were crooked, which would compel her to leave her chair to adjust them. “She cannot sit still for a full meeting,” Fraidkin had told me. “At first when she gets up and straightens out the window shades we went, ‘Oh, my God! This lady’s nuts!’ We just couldn’t believe it.”
As Brier talked to me from her hospital bed, it was obvious she recognized and enjoyed her own foibles. “I was in the hospital for back surgery and was doing rounds just for exercise,” she told me. “Peter was with me. It’s boring to go to the same floors, so we went to pediatrics. I was in my night-gown and came across a family there, really obnoxious, and the nurse very politely asking them to leave—I thought very politely, and the family was being very disrespectful. I went up to them and said, ‘Excuse me.’ And this person totally blew me off! And I said, ‘Excuse me, I am the executive vice president of this hospital,’ and Peter was saying, ‘Not now, Pam,’ but I ignored him and said to this family, ‘You’ve been most impolite here, and I would like to see you listen to this nurse, and I would like you to go. Go now!’ And they did.”
She grinned as she remembered the spectacle. “I don’t know what I thought, wearing my bathrobe, that I could draw myself up like a pooh-bah!”
Pooh-Bah. The character from The Mikado also known as Lord-High-Everything-Else. I would come to see this as vintage Brier, relishing the incongruous, invoking the light comic opera of Gilbert and Sullivan in Borough Park, the Orthodox Jewish heartland. Yet it was also no joke. She wanted to be a pooh-bah, defined by Webster’s as “an official or leader who maintains full control.”
Less than six weeks later, I saw her in full pooh-bah mode, at the official opening of the Maimonides Cancer Center, the same cancer center that had drawn Alan Astrow—and then me—to Brooklyn, Borough Park.
The opening was the kind of event that Brier approved of: a tasteful gathering attended by important people paying attention. A white party tent had been set up in the parking lot adjacent to the brand-new building—so new, in fact, that the first floor was still under construction.
For the opening she again wore clothes from her favorite designer, Issey Miyake, this time a yellow-gold jacket, worn over an orange Miyake dress. But she was quite different than she’d been the last time I’d seen her, when she appeared to be helpless, the way patients tend to appear,
even those who are hospital presidents. Now she was wispy but authoritative, apparently comfortable in her role as chief executive of a large, complex institution. She surveyed the crowd of three hundred well-dressed people crammed together on folding chairs. One group had the side curls and beards required by Orthodox Judaism; nearby sat a Pakistani imam accompanied by a small entourage; a few seats away she could see the leader of the local Caribbean community and a Roman Catholic monsignor. Young men and women wearing doctors’ jackets shivered in the unseasonably sharp wind. The sky above the tent was alternately cloudy and sunny.
Mayor Michael Bloomberg sat on a makeshift stage, wedged between a Brooklyn selectman and Martin Payson, the chairman of Maimonides. Bloomberg looked tired. He was running for reelection and would stay at the Maimonides opening for forty-five minutes. Before the mayor left, he listened politely to a series of speeches, glanced once at his PalmPilot, and gamely exchanged whispered jokes with Marty Markowitz, the exuberant borough president, who frequently and publicly expressed his desire to have Brooklyn secede from the City of New York. It was Markowitz who was responsible for the amusing highway signs about to appear on the Manhattan-bound side of the Williamsburg Bridge: LEAVING BROOKLYN— OY VEY.
Walking to the microphone with a hesitant, awkward gait, Brier presided over the proceedings with her official blend of hominess and hauteur. She spoke warmly of the public and private partnership that had allowed for the creation of the center but couldn’t resist interrupting herself to scold a local politician who showed up late. Her patrician diction could have an imperious overtone, most pronounced when she thought people weren’t behaving as she thought they should. “I know the mayor has to leave before the program is over to celebrate Cinco de Mayo in another part of the city,” she said, peering at the crowd through narrow, black-rimmed glasses. “Not through lack of interest, I’m sure.”
As she talked, she glanced for reassurance at a robust-looking man situated near the back of the tent, sitting in a wheelchair with a woman’s Prada bag on his lap. He smiled and nodded. That was Peter Aschkenasy, her husband. He remained an amiable man—even though he would never regain full physical functioning after the accident—the kind who didn’t mind holding his wife’s pocketbook while she presided over important public business.
Brier acknowledged the $5 million that New York City had contributed to the center and then announced how the hospital was going to show its gratitude. “We are partners in a special effort to eliminate colon cancer in our borough,” she said. “We are going to have free colon-cancer screening regardless of someone’s ability to pay. And if someone has cancer, we can’t say we won’t treat you if you don’t have money. So we promise to treat any citizen of Brooklyn who has colon cancer regardless of their ability to pay.”
She was rewarded for this nod to community responsibility with applause. She did not discuss the distasteful aspects of this gesture of noblesse oblige. How would the hospital convince people to take advantage of the freebie, especially once they understood this wasn’t simple, like getting a flu shot, but a time-consuming procedure that required a nasty prep.
“Thorough cleansing of the bowel is necessary before a colonoscopy,” explained the National Digestive Diseases Information Clearinghouse (part of the National Institutes of Health) on its Web site, “You will likely be asked to take a laxative the night before the procedure. In some cases you may be asked to give yourself an enema.” The helpful guide failed to mention that the “laxative” meant drinking a gallon of a foul-tasting liquid designed to induce massive diarrhea, but it continued, “The doctor will then insert a long, flexible, lighted tube into your rectum and slowly guide it into your colon.”
Even for free it wasn’t going to be an easy sell.
A good percentage of Brier’s own senior staff hadn’t had colonoscopies, which annoyed her. Okay, maybe you could excuse Robert Naldi, the chief financial officer, fifty-four years old, not a medical man. But the scofflaws also included Samuel Kopel, the hospital’s medical director and an oncologist. He was almost sixty years old—a decade past the recommended age for a first-time colonoscopy—and still eluding the scope.
Pragmatism as well as altruism had led to the conclusion that Maimonides should open a cancer center. Cancer was a growth industry; the National Cancer Institute reported in 2005 that cancer treatment in the United States accounted for an estimated $72.1 billion in 2004, just under 5 percent of total U.S. spending for medical treatment, and an increase of 75 percent from 1995. The institute predicted that cancer costs would grow at a faster rate than overall medical expenditures.
In the health-care business, however, large investments were often made on predictions that turned out to be wrong. A few years earlier, Maimonides had spent more than $1 million each on two robots that could do complex surgery. The robots generated far more press than patients, and their costs weren’t expected to be amortized anytime soon, probably never.
The cancer center required a much larger investment, about $12 million to build plus an additional $40 million commitment on a twenty-year lease. While Brier talked earnestly about the 2.5 million people in the borough of Brooklyn who didn’t have a comprehensive cancer center, she knew that the numbers that really mattered were the people who lived in the zip codes surrounding the hospital. These weren’t the hipsters of Williamsburg, the artists and musicians who could no longer afford the East Village, nor were they the aspiring burghers of Brooklyn Heights and Park Slope. Maimonides tended to treat new immigrants and the working middle class—except when they had cancer. The finance people had conducted a study and found that only 26 percent of the people in the surrounding area came to Maimonides doctors when they had cancer. Where did they go? Most of them went across the bridge to Manhattan.
The statistics were worse, from a financial viewpoint, when you broke them down. “As many as fifty percent of people who get cancer diagnosis in Brooklyn receive some part of treatment in Manhattan—and those tend to be the people with private insurance,” said Kopel, the medical director. “If you’re a woman in Park Slope or Brooklyn Heights and find a lump on your breast, chances are you’re going to Manhattan for treatment. If you live somewhere else in Brooklyn and are from Bangladesh, you’re more likely to come to us.”
Like the Brooklyn clerk played by John Travolta in Saturday Night Fever, the hospital administrators understood that they were perceived as something less because they sat on the wrong side of the East River. Proving that the care at Maimonides was as good as that of the Manhattan hospitals was an institutional obsession. It wasn’t unusual for people to cross the bridge for radiation treatments and chemotherapy but then end up in the Maimonides emergency room when it was time to die. The cancer center was created to convince enough people—especially those with good insurance—to stay in Brooklyn for treatment as well as death, and to trust that for most types of cancer Maimonides could offer results comparable to Memorial Sloan-Kettering or Columbia Presbyterian, leading lights in the field. None of the administrators at Maimonides believed they could keep everyone close to home, but they figured they could do better than 26 percent. They didn’t need 75 percent for the finances to make sense, only 45 percent.
The cancer-center strategy was as much a dream as a plan, but that was enough. No one understood better than Brier that plans were mutable and that change could be slow and maddening or quick and catastrophic. She was almost sixty years old and had been maneuvering through the hospital world for twenty-five of those years. Compromise was part of the terrain. She also knew from personal experience that one misstep—in an operating room or in life—could destroy confidence and threaten everything she cared about in an instant.
More than almost anything, Brier believed in the rules of propriety. She tried to charm the Orthodox Hatzolah wives with her designer clothes, which she made sure were cut modestly, and with her willingness to come to their numerous luncheons honoring somebody or other. She accepted home-baked cheesecakes with lavis
h thanks (and then deposited the cakes on the snack table outside the ladies’ room on the executive floor). She believed that hostility and rudeness among the doctors and staff would translate into diminished care for patients. More than once I would hear her say, “I don’t care what they think so long as they behave properly. That’s the least they can do.”
Brier’s preoccupation with process was another thing that drove Fraidkin crazy. “Stanley was a doer,” Fraidkin said longingly of Brezenoff. “I’ve gone to all the retreats, sitting there for two days and dying because we’re not moving, we’re just sitting and coming up with the big vision. I can do that also. Do I like it? No. Get it out, spit it out, it doesn’t take you two days to see where we have to go. But you do it, you put up with it.”
In the middle of a meeting, Brier would pull her cell phone out of her pocketbook and make a call; a few minutes later, her assistant would appear with a freshly made cappuccino. During a telephone call with a fellow hospital president, she might make a truly odd pronouncement, like, “I want you to know I’m considered one of the great constipation experts in the borough of Brooklyn.” When Brier got the point of a presentation—and her mind worked fast—she might cut the speaker off abruptly. On occasion she would realize a few minutes later what she had done and would apologize, in front of the group. Her manner could be taken as refreshing or annoying, amusing or distracting—and sometimes as cruel. Yet most people seemed to believe that her skills outweighed her oddities.
“Stanley was a brilliant administrator,” Aaron Twerski told me. He was dean of the Hofstra law school, a prominent torts scholar, and a Maimonides board member. His poetic features—haunted dark eyes, long gray beard— seemed like a living rendition of Rembrandt’s Portrait of an Old Jew.
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