Twerski continued, “He was a brilliant politician. She is not the consummate politician that Stanley was, but Pam has the courage of her convictions. Pam knows how to fire people.
He seemed to like the sound of this. “Pam knows how to fire,” he repeated. “Pam is a better firer than Stan was.”
On the other hand, she saw herself—and she was far from alone in her assessment—as a nurturer and friend of the underdog, a broad category that included anyone who might be despairing. She embraced the unions that represented the vast majority of Maimonides’ 5,700 employees, and she was vehement in her support of the hospital’s nurses. At Maimonides, as at Bellevue, she was known for walking the halls, stopping to chat with nurses, asking an aide why she wasn’t wearing her name tag, picking up gum wrappers off the floor. When I visited her first husband, Steven Brier, at his office at the City University of New York, where he was an associate provost, he reminisced about one of the first stories he heard about his ex-wife, told by one of her aunts.
“When she was five years old and about to begin kindergarten, Pam urged her mother to go early,” he said. “It occurred to her the parents of the kids would be coming to the school and they wouldn’t know each other, and she thought it was important she be there to introduce the parents to one another. As I like to say about that story, the personality was formed early.”
Pamela Sara Engel grew up in Los Angeles and was educated at UC Berkeley during the free-speech movement of the 1960s. Her political consciousness was awakened even as she followed the old-fashioned tradition of bagging a husband before she graduated. When they married, she was twenty-one and Steven Brier was twenty years old. Her father was a peripatetic businessman who left her and her mother when Pam was thirteen; his father was a fur worker and a union man. When they married, Steven Brier recalled his father telling him, “‘ Stevie, you’re about to make the same mistake I did. You’re about to marry a petit bourgeois.’ I told this to Pam, and her response was, ‘Not so petit!’ She was insulted by the ‘petit’!”
Brier had gone east in her twenties because Steven got a job in New York. It was a difficult move, but she survived and eventually rose through the city’s public-health system, the New York City Health and Hospitals Corporation (HHC), to become a powerful bureaucrat, worthy of gossip and speculation. Brezenoff had been her mentor.
Her aspirations were large, but not grandiose. She had no illusions that she had the answer to the problems of health care in the United States. When I asked her for a solution, she gave me a withering look. “Well, if I knew that, I guess I’d be a candidate for the Nobel Prize, wouldn’t I?”
When Brier had her first face-to-face encounter with Maimonides, she was almost fifty years old, divorced from Steve Brier, her husband of twenty-six years, and dating the man who would become her second husband. Her only child was grown.
“I’ll never forget the first time I saw Maimonides,” she told me. “It was a March day. I had just accepted the job. Peter took me for a tour of Borough Park and the hospital. We drove around Tenth Avenue, and my heart sank because it looked so unattractive on this very cold March day. No flowers, no trees, no nothing. And there used to be another overpass, which we finally took down, which was so ugly it just took your breath away.”
One day I imagined what it must have been like for her when she first confronted the hospital’s ungainly physical plant and the unusual surrounding neighborhood. I was approaching the main entrance at Tenth Avenue and Forty-eighth Street and had to circumvent a crowd of chattering elementary-school boys as they gathered on the sidewalk. At first glance they looked like any group of little boys, but then I noticed their side curls blowing in the breeze. The children attended Yeshiva Kehilath Yakov Pupa, the Jewish school housed in an old brick building across the street; the Maimonides boardroom on the top floor of the five-story administration building had a view of the school’s rooftop playground. A tall, skinny Hasid in a black coat and big hat—style, Poland circa 1850—walked alongside the little boys as they formed a line, each placing one hand on the shoulder of the boy in front of him. As they began to march down the street—make way for Yiddishe ducklings—the lone adult appeared to be clutching the side of his head. Closer inspection revealed a cell phone in his grasp. Maybe the coming of the Messiah would be heralded by a text message.
The main campus stood about one mile northeast of the cancer center, but in Brooklyn a twenty-minute walk can feel like a trek across a cultural continental divide. A block from the cancer center on Eighth Avenue was a world of Chinese street vendors selling steaming noodles from carts, the noodles doused liberally with fragrant sauces poured from unlabeled bottles— a dollar a serving. Women and men selling piles of bok choy could gather a crowd, and it was common on sunny days to see skinny old ladies shading themselves under open umbrellas. This was no tourist Chinatown, but a crowded neighborhood shopping strip, where almost all traces of the Scandinavian residents of a generation earlier had been replaced by Chinese shops and stands selling fruit and fish, bubble tea and sweet buns, bargain cosmetics and herbal cures.
The cancer center had been carved out of 6300 Eighth Avenue, previously a long, almost-windowless two-story building on the periphery of Chinatown, just across the street from an auto-body shop (Bay Ridge Body Shop/Service and Parts Department). Before the renovation, which required a massive excavation of the parking lot for the underground radiation vault, the building had a hunkered-down look, appropriate to its original incarnation as a Citibank check-processing center. In 1995, Citibank sold this drab relic of brutalist architecture to the Health Insurance Plan of New York (HIP), another faceless enterprise. The transformation wasn’t complete, but at least now there were some inviting windows, and the inside—at least the parts that had been renovated—was airy and serene, in accordance with the recommendations of a feng shui consultant.
The hospital itself, however, where David Gregorius would begin his life as a physician, had an aesthetic that seemed mired in the middle of the twentieth century. While the Maimonides Web site featured a sleek glass structure, this was merely a virtual rendering of the new wing that was being built across from the emergency room on Fort Hamilton Parkway. At the time of the cancer center’s opening, the actual “building” was a mass of girders and heavy equipment, mud and cement. When Pam Brier had been hired a decade earlier, the new wing didn’t exist even in theory. Like many hospitals built in urban areas with limited land, the hospital was a jumble of buildings and architectural styles, add-ons and renovations, with the two main buildings connected by an overpass. Many department chiefs and administrators worked out of the two-story brick row houses—inexplicably referred to as “brownstones”—that lined the streets surrounding the hospital.
When Brier first confronted her dowdy new workplace, she recalled an earlier first, her first day as a hospital administrator, at Jacobi Medical Center, a public hospital in the Bronx. She had had knots in her stomach when she walked through the door and realized she knew nothing about running a hospital. She knew about health-care policy, finance, and government oversight from the decade she’d spent at HHC. But she’d never been a field commander, never directly in the line of fire.
She decided to treat her willingness to admit ignorance as strength. “The first thing I did when I got to Jacobi was walk around and shake hands with every person who was there, and the second thing was take almost every single doctor out to lunch or dinner with a paper and pencil and take notes,” she said. “When I got to Jacobi, I felt like I was playing dress-up, very scary, very sobering. I made them put a sign up that showed the way to the director’soffice. The secretary didn’t want to. She said, ‘They’ll come and bother us.’ I said, ‘That’s all right.’”
Some found her methods disarming; others were dismissive. Steve Davidson, the ER chairman at Maimonides, had been hired shortly before Brier was. In advance of meeting his new boss, he called a physician friend who had worked with her at Jacobi for an assessm
ent. “He said send her pretty flowers every month and send her a nice silk scarf twice a year,” said Davidson. “Neither of which I’ve done since I got here.”
Allan Strongwater, former chief of orthopedics for a decade, left Maimonides for the NYU Hospital for Joint Diseases in Manhattan a few months after the cancer center opened, after many disagreements with Brier over how his department should be run and over fees. “She would like her hospital to be the model for public health,” he said. “Look at her history. That’s where she grew up.” The dispute, he said, was personal. “Most of the people in hospital administration, including Pam, want to deliver good-quality care and be in the black. The difference is, Stanley [Brezenoff ] once told me he didn’t want to be in the front of the crowd or in the back of the crowd—he wanted to be in the middle. He didn’t want to be visible. Whereas Pam, it’s all about Pam.”
After Jacobi, Brier was put in charge of Bellevue—unwieldy, impossible Bellevue—the city’s own Bedlam, best known for its infamous psychiatric ward. “They’d had ten directors in ten years, and I can assure you they were not glad to see me,” Brier said. “Just the scale of it and the pitch of it make you feel like an ant.” Jacobi felt bucolic next to Bellevue. “There were these huge plants in the back of the lobby, and they were dead, listing to one side. I thought, Oh, my God, what have I done. What are people going to think? You can’t keep the plants alive, what are they going to do to the patients?” She bought new plants, listened to complaints, and ten months into her tenure was featured in an approving article in the New York Times that declared, “She has proved to be a rarity in New York City’s municipal hospital system: an administrator who earns praise from such historical antagonists as the unions, medical schools and the city administration.”
She stayed three years—record-making for a Bellevue administrator— but was ready to leave when Brezenoff asked her to come with him to Maimonides Medical Center as his number two.
“My friends said, ‘You’re going where to do what?’” she recalled. “‘ You’re going to be the number-two person where?’” Tired of city politics and assured that she would be Brezenoff’s likely successor, she went. The doubling of her salary eased the transition. Within a decade at Maimonides, her annual income had reached $850,000, including bonuses, a heady amount for a former public servant, whose conscience was salved by telling herself it wasn’t that much compared to the $2.5 million Memorial Sloan-Kettering paid its chief executive or the $1.5 million that Montefiore in the Bronx paid her counterpart there.
What she found in Brooklyn was not the exhilarating chaos of Bellevue, the rush reminiscent of the sixties, the feeling she was helping society’s outcasts, doing God-or-whoever’s work. Instead she walked into a grim, unfriendly atmosphere where things were done the way they had always been done, where insularity ruled, and where a whole new set of politics had to be mastered, including that of a strong Hasidic community with its own idea of what God’s work meant. The head nurse had an M.B.A. and dressed the part. She didn’t know what to make of Brier, who wore designer clothes but sometimes used a shopping bag as a briefcase and liked to drop into the emergency room for surprise visits at midnight. The hospital board’s members were fighting among themselves, and there was hostility between the core Orthodox Jewish constituency and the nurses, many of whom were Caribbean and African-American. Shortly after Brezenoff and Brier arrived, the nurses went on strike.
“It made Bellevue seem friendly, which, believe me, Bellevue wasn’t,” she said. “In your brighter moments, you could say there are so many things to work on, and in your dark moments . . . oh, dear.” Brier fired the head nurse and another senior nurse because she felt they weren’t doing their jobs. Brezenoff protested, not on the merits but because he believed that loyalty counted for something, and then let Brier have her way.
“I think appearance is very tricky with my mother,” Jenny Brier once said. “Some people look at her and think she’s a twig. But she’s a big trunk in a twig’s body.”
At the cancer center opening, many politicians offered speeches and boiler-plate congratulations. The affair took a distinctly human turn when Steven H. Cymbrowitz, a New York State assemblyman, approached the microphone.
A boxy man with thin hair that was greased and combed back, he was well cast as a local pol. His voice sounded uncertain, but his message was strong as he brought home why it was important to have a multidisciplinary, one-stop-shopping approach to patient management. He spoke of his wife, Lena, a Democratic state assemblywoman, who had been diagnosed with stage-four colon cancer a few years before by a doctor at Maimonides but then was treated at New York University Hospital. He described the arduous experience of Brooklyn cancer patients who are treated in Manhattan and who keep their records in their cars as they move from office to office, doctor to doctor. Cymbrowitz told of the night when there wasn’t room at NYU for a CAT scan and of his agony as he watched his wife being wheeled across Thirty-fourth Street in a gurney, while he stopped traffic. After she died, at the age of forty-three, Cymbrowitz was elected to her seat in the assembly and helped obtain the city’s $5 million contribution to the cancer center. “To make sure there was something to come out of Lena’s passing,” as he put it.
He had another personal tie to the hospital, which he didn’t discuss. Two months earlier he had gone to the front door to pick up the newspaper and found he couldn’t reach the knob. When the ambulance brought him to Maimonides, he was paralyzed and couldn’t speak. The hospital’s neurologists dissolved the clot in his brain in time, leaving only a slight weakness in his left hand as a souvenir of the frightening episode.
As he stood before the crowd at the cancer center’s opening, Cymbrowitz was struck simultaneously by three emotions—the sadness he always felt when he spoke of his wife’s death, his loyalty to the doctors who had saved his life, and anger at Pam Brier. She had called him earlier and had the nerve to tell him not to mention Lena. “We’ll have a naming ceremony,” she told him. “This isn’t the place.”
It made Cymbrowitz furious just to think about it. After all the work he had done to put together the government money, Brier was trying to change the rules as he perceived them. He didn’t think he was unreasonable. Taking Lena’s name off the building—that he could understand; the hospital wanted it to be the Maimonides Cancer Center. He agreed to settle on a bust of Lena in the lobby, which would be called the Lena Cymbrowitz Pavilion. Now he was worried that even that might go. He had heard that Brier had been trying to raise private money for the cancer center; the hospital had no endowment like the big academic hospitals. Was the honor just going to go to the highest bidder? “With Stanley this wouldn’t have happened,” he remembered thinking. “Stanley didn’t let anything fall through the cracks.”
Whatever else people may have thought about Pam Brier, she possessed remarkable physical courage that commanded special respect in a hospital. Her most recent surgery—a knee replacement—had taken place a month before the opening. The trunk in the twig’s body seemed to be made of iron.
But the last twenty months had caused her to doubt her abilities. An essential insecurity underlay the bravado, the royal gestures, the wackiness. Could she carry on what she and Brezenoff had started? So much to do, to fix, to build, to prove.
The cancer center’s opening felt like a turning point. For the first time since the accident, she thought maybe she could keep pace with her ambitions. “Following Stanley was one of the worst things I ever did,” she said once. “Truly revolting. He’s the most brilliant public servant I’ve ever watched.”
Then she gave a sharp crazy laugh, as if she realized the absurdity of . . . maybe everything. “That was my biggest worry,” she said, and then laughed again. “Hah! Could I live up to Stanley!”
Three
Insults and Injuries
Douglas Jablon, vice president, patient relations—the Mitzvah Man—said that gossip was the hospital’s most vicious enemy. “That’s why God ga
ve you teeth,” he said, “the cage to hold in the serpent tongue.”
Political intrigue and turf wars were not unique to Maimonides; struggles for space, equipment, staff, and money are part of hospital life. “It’s big business,” said Allan Strongwater, former chair of orthopedics. “Big business with HMOs, big business with insurance companies, big business with the government—big big business. So even though you and I are colleagues as physicians, you are cutting into my market share. Naturally I think I’m doing a better job and should be paid more. If I send a patient to a doctor for a second opinion and he says, ‘It’s not that difficult, anyone could do that,’ you as a patient don’t know. There is this underlying competition for patients and that’s why you get these battles.”
Steven Konstadt, the chair of anesthesiology, who had been recruited from Mount Sinai a year earlier, paraphrased Oscar Wilde: “The joke at Sinai was, you can always tell your friends because they stab you in the front.”
At Maimonides, however, feuds had become part of the personality, the hospital’s yin and yang, nurtured in a familial atmosphere that promoted the idea of unconditional love and tolerance and acceptance, then erupted in fury when conditions, standards, and limits were imposed. Birthdays were celebrated and hurts were sustained with equal tenderness. When a surgeon was diagnosed with leukemia and left abruptly for home without telling anyone, everyone knew anyway by the end of the day. Within twenty-four hours, the physician’s assistants in his department had offered to give him their sick time for the year. But when they called Lili Fraidkin to make the offer, she told them the offer was unnecessary; the senior staff had already donated enough sick-leave time to cover a year’s pay, enough time for the doctor to finish his treatment.
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