Hospital

by Julie Salamon

  He continued, “I tell them, ‘Guys, I would rather spend the night at the base of a nuclear reactor than spend one night in a hospital that I didn’t have to.’ Frankly, the people at the nuclear reactor get more sleep. But you’d be surprised at the number of patients who want to stay here. My only question there, if you open up the heart of compassion, is to think how scary must their world be at home that this seems like a safe place. Hospitals are scary places to almost everybody. They must feel so alone and abandoned if a hospital feels safe, feels comfortable, feels home.”

  September 27, 2005

  Daily Log—J.S.

  The hospital at night. Maybe Marty Payson was right: It is like a movie set. The neighboring streets are dark, mostly residential, but the hospital is fully lit. Bright lamps beam down from the overpass connecting Eisenstadt and Gellman, turning street into glimmering stage, floodlights casting otherworldly glow on hospital workers standing outside grabbing a smoke, big Orthodox families trooping in to visit relatives.

  Pam Brier has been holding town-hall meetings all day in Schreiber Auditorium for the staff. Tonight, more town hall. The politician in the policy wonk likes to mingle. At Bellevue she walked the halls late at night, like an old-fashioned chain-store president dropping in on one of his outlets to make sure the shelves were stocked and the help was friendly. She told me she took [Peter] Aschkenasy prowling Bellevue on one of their first dates. When she came to Maimonides, that’s what they’d do on a Saturday night—take in a movie and then hang out in the ER or stop by nursing stations on patient floors. If the nurses offered, she tasted their food and ended up taking home goat curry for next night’s dinner.

  Now she limps. Walking around had not been easy for Brier even then, before the accident; she had scoliosis and related back problems for years. Since the accident, prowling has been out of the question for Aschkenasy and difficult for Brier, still hobbled two years after. The quarterly town-hall meetings gave her the chance to feel like she was communicating. Two in the morning, two in the afternoon, this one—8:00 P.M.—and one at midnight. She’s letting Mark McDougle handle that one. Number two can stay up late.

  The morning sessions had been packed, Brier’s secretary told me, but only a couple of dozen people were there tonight.

  Brier sat on the edge of the stage at the front of the auditorium, talking without a microphone . . . nice intimate touch for a small crowd. Good theater. She talked about how there were only forty-two days until Joint Commission on Accreditation of Healthcare Organizations, aka JCAHO—called Jayco—the nonprofit organization that evaluates nearly 15,000 health-care organizations and programs in the United States. [Maimonides had received a score of 96 out of 100 in the previous inspection.] The hospital was gearing up; “a readiness team” of fifty employees was on stealth alert, looking for soft spots in procedure for diagnosis, communication, teamwork, safety, lab results, HEICS, the Hospital Emergency Incident Command System—looking for dirt, junk piled in hallways and patient rooms.

  Brier said that Maimonides had not been picked as a Magnet hospital, an award for nursing excellence given by the American Nursing Association. Only 150 hospitals in the country had won Magnet status, but Sondra Olendorf and her nursing staff had been working for four years documenting their case. “We missed by this much,” Brier said, holding her forefinger and thumb close together.

  A group of “environmental workers”—people who cleaned the hospital—gave a report on a yearlong study they were doing to improve procedures. Brier said, “When this group tells us what we need, we’ll implement it—all we can pay for. We know, as Hillary Clinton is apt to say, it takes a village to keep Maimonides clean.”

  Someone asked about Katrina. Did Maimonides have an evacuation plan?

  Brier gingerly scooted off the stage, as though preparing to escape. Maybe the Katrina question was too serious to answer sitting down. “We have an evacuation plan, but it wouldn’t be sufficient for a complete evacuation,” she said. “The Greater New York City Hospital Association is looking at it. Of course it’s patients we have to provide for, plus health-care providers. We will take a look at the issue and follow the lead set by city agencies. We have drilled and practiced for other kinds of disasters.”

  The man nodded, as though he were satisfied, as though the answer had been more reassuring. Maybe people just want answers.

  “I’m glad you raised that,” Brier said, looking worried. “Sobering thought.”

  Her cell phone started ringing inside her bag.

  She ignored the sound, which persisted.

  “It’ll stop ringing,” she told the group. “I don’t know how to turn it off.”

  Was there nighttime in cyberspace?

  What time was it?

  Administrators work nine to five unless they stay till midnight.

  Surgeons come in at six.

  Residents never sleep and always wear pajamas.

  The emergency room gets crowded at 2:00 P.M., like clockwork.

  Nurses come and go in twelve-hour shifts, three days a week.

  Day for Night. François Truffaut.

  Man, woman, birth, death, infinity. Ben Casey.

  Which beep in the patient’s room is the ticking clock?

  Babies arrive, old folks hang on, people suffer, they heal.

  Time stands still.

  Premature death.

  Endless waiting.

  Jewish time, hospital time, resident time, secular time. Ramadan.

  Time is of the essence. The tick-tock is people.

  Ecclesiastes 3, a time to be born a time to die

  For every purpose under heaven

  What’s that David Bowie song?

  Time is senseless, the musician said.

  A whore, a “sniper in the brain.”

  Checked his watch at 9:25 and thought

  “Oh God I’m still alive.”

  It wasn’t clear if Mr. Zen—illegal alien, undocumented worker, very sick man—was counted among the 47 million uninsured people in the United States, since he officially did not exist. But he was definitely part of the daily census at Maimonides, a crucial figure in the numbers game that obsessed the managers on the second floor of Eisenstadt, where the Maimonides executives were clustered. The “executive suite” was a humble row of little offices, many of them windowless, on either side of the hallways that intersected in the reception area, where the undistinguished portraits of former hospital presidents were hung at uneven angles. No feng shui there. Brier and McDougle had larger offices than the rest, but nothing fancy. Budget-conscious was the operating motif.

  Maimonides managed to stay in the black—barely—without major benefactors because it almost always had an occupancy rate of 99 percent and because in the previous decade it had reduced the average length of stay from 8.24 days to 6.24 days. That was the magic equation: full house and not too many people allowed to overstay their welcome—not past the billing guidelines of the twenty-one insurers the hospital dealt with (compared with five or six in the days before the idea of managed care through competition took hold in the 1990s). The equation worked only if most of the patients kept moving through.

  As Joseph Cunningham, chief of surgery, said, “You take any two hospitals, if I can do a coronary bypass and get a patient out into a secondary location—home, rehab, family—a day shorter than Lutheran, I’ve put another ten thousand dollars in my pocket. Every discharge across the board is at least ten thousand dollars to a hospital.

  “It’s all about turnover,” he told me. “The more you can get in and out, the more times that cash register clicks. It sounds like business, and it is business, but the caveat is, you can’t get them out if they’re not ready. We’re not kicking them out. But if you get them out two days later, for every discharge you lose, you’re losing ten thousand bucks.”

  Everyone felt the pressure to build volume. “All these people crunch numbersevery day,” said Amit Schwartz, the young neurosurgeon who often showed up at t
he cancer center’s interdisciplinary meetings. “You know when you’re being looked at by Mark McDougle or Lillian, or Naldi [the chief financial officer], there’s a number on your head of how many cases you did in the last month. They look at that number all the time. I can walk in the hallway and the president of the hospital will say, ‘Okay, you did ten operations last week.’ They know everybody—who they did, how much they did.”

  Pam Brier acknowledged that this was true. “I look at the volume every damn day,” she said. “I wake up every morning, I come to work, I read admissions and discharges. I read about patient discharges by service and by doctor on every single service. You sort of live and die by it.”

  Surgery numbers had been down over the summer, especially in cardiac; newer technology—stents, angioplasties—had steadily taken over. Waiting outside Pam Brier’s office one day, I heard her yelling on the phone to Fraidkin, “These fucking surgery numbers are keeping me awake at night!”

  When I walked in, Brier was sitting at her desk, very ladylike, straightening one of the already-very-neat piles of paper on her desk. “I love the synergism of my job,” she said with a stagy smile as I pulled out my tape recorder. “Is the recorder on?”

  Chris Kam wasn’t joking when he said that his real assignment had been, as he put it, “to kick Zen out.” Before Kam was assigned to the case, not long after Mr. Zen came to the hospital, Janice Yang, director of outreach to the Asian community, got a call from a social worker at the Brooklyn Chinese-American Association. Yang, a slender, pretty thirty-seven-year-old woman with straight black hair and an almost constant look of worry, had moved to New York from Canton (Guangzhou) when she was fifteen years old. She still had a heavy Chinese accent. When Yang learned that a friend of Zen’s had complained that the hospital was trying to kick him out, she contacted the friend. Yang explained that the hospital wasn’t meant for long-term care and that it was usual procedure to send patients home or to rehab or hospice or a nursing home. Yang tried to talk to Mr. Zen without success and then sent a series of interpreters, who got nowhere trying to convince Mr. Zen to move.

  “He hesitated to talk to Asian faces,” Yang told me. “Everyone is afraid they’ll get a bill or we might ask them for money, so they try to protect themselves, they don’t want to release information. It happens to a lot of the cancer patients, especially the Chinese patients. Either they are illegal here or have no insurance. Even people with insurance, not a lot of them do preventive care, so they end up in the emergency rooms. They’ve never been checked up, so once things happen, they go to the emergency room and find out it’s too late.”

  She sympathized. She didn’t speak English when she arrived in the United States. She and her brother and sister worked after school until eleven at night, because the family had no money. Her father had been a doctor in China but in the United States worked in an antique store staining and painting furniture. She remembered what it was like eating on the floor of an empty apartment because they couldn’t afford furniture.

  “I know it’s not easy to be a new immigrant to this country,” she told me. “We can’t speak, we can’t hear, we can’t read. I want to help the community, because I went through the pain.”

  Patients like Zen clogged the system, curtailed patient flow. But Chris Kam seemed unconcerned about consequences for failing in his assignment to “kick Zen out,” and Gregory Todd, the physician, said he never felt any specific pressure to discharge a patient before he believed it was time. Nevertheless, he said, “We all have the general pressure of shorter length of stay, which every hospital wrestles with every day. We always comment when we do it well—we don’t know how we did it and how to reproduce it.”

  The tender care of Mr. Zen, spread over a period of months, was an anachronism. Old medicine. Social workers like Kam and Keen were replaced by nurse case managers, who had no leisure to spend time at bedside, because they were occupied with moving patients through the system. New medicine demanded cultural competency, clinical excellence, and psychological awareness, but not at the expense of efficiency, coordination, and speed (none of which conformed to the vagaries of illness, insurance compensation, and the availability of aftercare for the elderly and the infirm).

  Every day, it seemed, a new study or book was published discussing the failures of the system, the pressures placed on health delivery by the domination of pharmaceutical and insurance behemoths—“How health care in America became big business—and bad medicine,” to quote the subtitle of one of them (Critical Condition by Bartlett and Steele). But at Maimonides most people were too busy to ponder the larger forces that were making their lives difficult. Thinking about the big picture could crush you: Health-care expenses in the United States rose from $1,106 per person in 1980 ($255 billion overall) to $6,280 per person in 2004 ($1.9 trillion overall). Yet in 2005, 44.8 million in the United States, an appalling 15.3 percent of the population, had no health insurance.

  “I don’t spend a lot of time thinking about global issues,” Robert Naldi, the chief financial officer, told me. He had curly graying hair and a rat-a-tat way of talking that seemed just right for a numbers guy. “When I hear Medicare is being cut six billion dollars over the next ten years, Medicaid cut four billion dollars the next, that ten billion dollars doesn’t change what I do on a Thursday morning. I just don’t get into that trap. I worry about our little hospital in Borough Park. . . . I have a luxury. . . . We have a very strong core business. People in the community like us a lot. It has its ups and downs, ebbs and flows. Me, I don’t even read about it, to be honest. I don’t spend any energy forecasting the next three or four years, because I don’t think anyone can do that. We’re lucky if we forecast the next six months, things change so rapidly. I just don’t waste time on it.”

  Mr. Zen was part of “the bed-management problem,” the bureaucratic way of referring to the fact it could take twenty-four hours and sometimes more for patients admitted through the ER to make it into a bed. Almost every day the scene that shocked Chuck and Carolyn Gregorius, Davey’s parents, was reenacted in the emergency room that was Zen’s entry into Maimonides. In the hallway leading to the ER, it was routine to find patients backed up like airplanes on a runway in lousy weather. Just in case any of the administrators up on the second floor of Eisenstadt forgot about the situation, Carl Ramsay, medical director of the ER, periodically held his cell phone aloft and snapped a picture, which he then transmitted to them by computer.

  “The right leaders have to see it in real time,” he said. “We have twenty-eight people waiting for beds, average wait time is twelve and a half hours.”

  When this digitized vision of chaos popped up on Lili Fraidkin’s computer, she shrugged. “The emergency room is a pot of gold,” she said in her unflappable way. That was Brezenoff’s theory: Contrary to prevailing popular wisdom, that ERs were money losers, he recognized early on that the emergency room didn’t just fulfill the hospital’s civic responsibility, it offered a way to build volume. Sometimes the ER brought in those who couldn’t pay at all, like Zen, but more often they drew in people with some kind of insurance—or for whom some kind of insurance could be gotten.

  The variables may have been different, but the essential economic assumptions were the same in Lincoln, Nebraska. Chuck Gregorius, David’s father, said the system reminded him of a popular bar and grill in Lincoln called P.O. Pears, with a menu that was decidedly not Borough Park, offering items such as the Jiffy Burger, a hamburger covered with peanut butter, bacon, and jack cheese. “You go up to a window to order, and the window looks like a big old pair of lips,” he said. “On those lips it says, ‘We lose a little on each sale but make it up in volume.’ Sometimes in health care, because of the constraints on money, we have to spend on health care, sometimes it feels like they are using the P.O. Pears approach. Sometimes in health care, that’s the way it comes out.”

  Fraidkin may have been unperturbed by the snapshots Ramsay e-mailed her way, but she didn’t like the l
ast part of his message: “We have three hours of diversion,” meaning three hours in which patients were sent to other hospitals. For the ER to be a pot of gold, it needed constant refilling. But more patients meant more stress on the system.

  David Cohen, senior vice president, clinical integration, whose office was just down the hall from Lili Fraidkin’s, had come to Maimonides six years earlier, after a career in public hospitals, including ten years as the medical director at Bellevue. He and Brier were friends, and she urged him to come there to help streamline the hospital’s unwieldy systems. Brier’s husband, Peter Aschkenasy, called Cohen the living embodiment of “think Yiddish, dress British,” by which he meant someone who was practical, smart, a man of the people, but who also aspired to a certain gentility. Cohen lived on Manhattan’s Upper East Side and was a theater fanatic; he and his wife on occasion would fly to London for the weekend to catch the latest shows. In a hospital where everyone said what they thought as the thought occurred, Cohen revealed little.

  Cohen saw the hospital, all of it—David Gregorius, Mr. Zen, the crazy ER, the pregnancies and deaths, the rabbis and the politicians—as Brownian motion. It was typical of his erudite sensibility to connect the glatt kosher institution in Borough Park with the nineteenth-century Scottish botanist Robert Brown, who found his place in history when, studying pollen grains under a microscope, he noticed they were gyrating in a strange, jittery way. Brown’s name became linked to small, random movements that weren’t apparent from the surface, a concept that became valuable to Albert Einstein in thinking about the atomic nature of matter and to David Cohen about the management of big-city hospitals.