Hospital

by Julie Salamon

  Twerski also seemed skeptical about the whole idea of a debate between religions, and he questioned the validity of the distinction between ethics and spirituality and religion. Astrow explained he wanted to demonstrate that you could disagree with another person and yet listen respectfully to him or her.

  Listening to the silence on the other end, Astrow realized he hadn’t convinced Twerski and probably wasn’t going to. So he took Mark McDougle’s advice. He explained that the conference wasn’t about ethics or religion but about spirituality, which was different. He said it wasn’t really for the communitybut a continuing-education program for the doctors and nurses, for which they would receive credits. In other words, the conference could be explained to the touchy rabbis as hospital business, not a competition for the souls of Borough Park.

  During the conversation Twerski remembered that Astrow had taken care of one of his relatives. He told the doctor he and his family were grateful and suggested that in the future Astrow should consider checking with the religious-affairs committee of the board before inviting lecturers to speak on such sensitive subjects.

  Later Astrow would say that the whole episode was a blip, maybe because happiness evaporates while disappointment lingers—the way months or weeks or even days of illness inhabit memory more powerfully than do years of health.

  But Jill Nathanson was a witness to her husband’s happiness that night. She looked at him and saw the self-assurance with which he wore his nice dark suit. The bandage had been removed from his forehead, which showed no trace of the stitches. Someday he might shrug it off, but that night there was no mistaking the expression on his face. He couldn’t deny it. He was happy.

  There was a fruit platter and wine and cheese. The chairs had been delivered—seventy-five of them—and they were filled. The light fixtures were in place, and the walls were painted.

  Jay Cooper even cracked a joke. “This room didn’t exist just a few days ago,” he said by way of opening the first conference at the cancer center.

  Astrow stood up to introduce the speakers. First, though, he explained why they were there.

  “As physicians, nurses, and other health-care professionals, we may recognize that caring for patients involves several dimensions,” he said. “The most obvious is the technical, the scientific, the biomedical—to diagnose and treat illness with thoroughness, attention, and skill. A second dimension might be termed the emotional, or the psychosocial, in which we try to engage with our patients as whole human beings. Who are our patients? What do they care about? What worries them? How do we show our concern for them as unique individuals? Here in the heme-onc division at Maimonides, we attempt to address these interlocking realms with our fellows in our weekly biopsychosocial rounds, organized by Dr. Allan Novetsky with the assistance of Dr. Sheldon Berman.”

  He may not have been smooth, but he could be eloquent. “There is a third dimension, which for want of a better term I’m going to call the spiritual, which may underlie the other two. By spirituality I refer to the unseen, often unspoken, values that motivate us. In the contemporary world, when we speak of an invisible hand that drives us, it is often assumed that we are referring to the marketplace and the invisible hand of economic self-interest. But most physicians and nurses, I think, want to see themselves as more than simply one party in a financial transaction. Why do we do what we do? What keeps us going? Not just that we ought to care, but why? Faced with a suffering or demanding patient whom we might prefer to avoid, where do we find the strength to enter the patient’s room? What is the conception of the human person and the role of the physician and nurse that medical practice relies on?”

  That night Alan Astrow was in his element.

  Seven

  We Speak Your Language

  On the home page of the Maimonides Medical Center Web site:

  SPANISH, RUSSIAN, CHINESE, ARABIC, YIDDISH, AND MORE . . .

  At Maimonides Medical Center, providing culturally sensitive care for patients who aren’t fluent in English is important. One of our priorities is facilitating better health care access for non-English speaking patients and their families. To achieve this goal and to serve our culturally diversified community, the Medical Center has been recruiting multilingual physicians, nurses and staff, especially for patient care areas. A prime example of this effort can be seen in the emergency department. As a result of an increasing Chinese, Russian, Spanish, and Arabic patient population in the emergency department, we now have coverage twenty-four hours, seven days a week by multilingual patient representatives who are available to assist patients and their families who speak languages such as: Arabic, Chinese, Czech, German, Greek, Hebrew, Hindi, Italian, Polish, Russian, Spanish, Ukrainian, and Yiddish. Informational brochures and relevant hospital forms have also been created in many of these same languages to assist patients.

  More than a quarter century had passed since Arthur Kleinman, the Harvard medical anthropologist, began promulgating the importance of cross-cultural awareness in the 1970s. Kleinman understood that the potential for misinterpretation went beyond words. The language of healing had to encompass gestures, fears, desires, superstitions, beliefs. But it was only in the last decade that aiming to achieve “cultural competence” had become a national, institutionalized goal. In 1998 the Association of American Medical Colleges recommended that medical schools teach “knowledge of the important non-biological determinants of poor health and of the economic, psychological, social, and cultural factors that contribute to the development and/or continuation of maladies.” That same year the National Council on Interpreting in Health Care was established to help health-care providers learn how to speak to patients from different cultures.

  As research and symposia on the subject proliferated, and the study of cultural competence itself became an industry, one conclusion was indisputable: Language was easy; comprehending was hard.

  Sometimes Kathir Suppiah thought it was all just crap. Suppiah was one of the ten fellows in hematologic oncology, doctors who had completed their residency and were M.D.’s but had decided to specialize, requiring an additional three years of training. Son of a diplomat from Malaysia, he carried himself with the confidence of privilege. I thought of him as “the Prince.”

  “I hate to say it, this is horrible to say right now, but I’m going to say it,” he told me one day. “I have lived around the world and thought I was the least prejudiced person you’d ever meet. Since coming to Brooklyn, I’ve become, believe it or not—I shouldn’t even say this—I’ve become a lot more prejudiced. I actually feel bad sometimes. I say, ‘How did I come to this?’”

  Whom did he dislike the most? I asked him.

  He was hard-pressed to choose.

  The Orthodox Jews?

  He nodded. “Maybe,” he said. “They become so demanding and are actually so derogatory when they speak to you that you think, ‘Remind me again why should I help you?’”

  Maybe the Chinese?

  “They’re very rude people,” he said, nodding. “Go to Eighth Avenue. They don’t listen to anything you tell them. They don’t talk to you unless you’re Chinese. They don’t even look at you.”

  Russians?

  “Oh, God, take it back. The Chinese aren’t so bad. Not compared to the Russians.”

  What about Sam Kopel or Alan Astrow, two of his mentors?

  “No! No! They’re very very different,” said Suppiah. “I don’t consider them Jewish. I don’t think of them that way. They’re the more modernized Jew, very decent people, I don’t care whether they’re Jewish, Chinese, whatever.”

  Dr. Huang?

  “He’s very different,” said Suppiah. “He’s one of the people who makes you feel bad about saying bad things about Chinese. You say, ‘Damn. He breaks the mold.’”

  This unvarnished analysis had been triggered by a case presented at a biopsychosocial meeting, involving a patient who didn’t speak English. These weekly meetings were part of the fellows’ training, where
they discussed the nonclinical aspects of cases—ethics, behavior, feelings.

  One of Alan Astrow’s responsibilities as chief was to moderate this weekly meeting, whose purpose wasn’t to arrive at a diagnosis or treatment plan. He had inherited biopsychosocial from Allan Novetsky, who had begun the oncology fellowship program in 2001, in anticipation of the new cancer center. Novetsky saw these sessions as the place the fellows would learn “to be doctors,” the humanistic counterweight to the bulk of their training, which was devoted to the impossible task of keeping up with the latest research; according to the Institute of Health, the number of clinical drug trials conducted had grown to nearly ten thousand a year at the turn of the twenty-first century, roughly three hundred a day.

  Novetsky said he loved these theoretical, humanistic discussions, but his own rules of practice were inflexible. God forbid one of his patients should show up late for an appointment. He told them at the outset he expected them to arrive on time or he would cancel.

  Novetsky had come to Maimonides from Brookdale Hospital, to help lay the groundwork for the new cancer center. The hospital’s interest in Novetsky wasn’t purely academic; he had a large practice, and it was hoped that this would help fill the referral gap left by the departure of the Bashevkin group. That hadn’t happened, which contributed to the decision to hire Astrow, who would take over the fellowship program as the new chief. Novetsky’s final months and Astrow’s first months at the hospital overlapped, adding another undercurrent of tension masked by forced civility—and unwittingly adding another layer to the idea of training fellows “how to be doctors.”

  Whatever Astrow’s other feelings toward Novetsky, he was grateful for biopsychosocial. The physician he respected most was Howard Spiro, who in 1983 had started the Program for Humanities in Medicine at Yale’s medical school, the purpose of which was to help physicians think about the spiritual and ethical components of medicine—the things that obsessed Astrow. Spiro was the only teacher from medical school with whom Astrow remained in touch.

  Suppiah, who usually was quick to jump in with a question or a joke, had sat out the session, doodling furiously in his notebook. I could see that his guard was down and tried a gentle poke to see what it might provoke. “Why so quiet?” I asked him.

  “I had to assimilate to this country,” he told me. “I had to assimilate to Switzerland. I had to assimilate to France. Wherever I went. This disrespect for our country is what I hate. And this is my country now. We cater to this disrespect. Our health-care system completely embraces this kind of stuff. We can’t expect these people to change because we do nothing to change them. When I was in France, they didn’t bend in any way. You either learned French or else. Nothing. They can speak English, but they won’t. Even if you go to a hospital, they expect you to speak French. Here you get translators. That kind of catering is why people have this attitude they can do anything they want.”

  Theme and variation of the biopsychosocial meetings was the failure to communicate. Every week the Maimonides cancer fellows brought up daily frustrations that required interpretive skills far more subtle than knowing the rules of grammar and syntax. Using specific cases, they discussed how to deal with angry families, doctors they disagreed with, nurses who annoyed them, chart notes they couldn’t read, religious and cultural differences, the essential antagonism of the system. They contended with their own behavior— sometimes indulging in relaxing trivia (how patients liked doctors to dress, for example) and sometimes confronting sources of anguish (how to acknowledge the futility of treatment). The fellows were required to attend. They were often joined by social workers, a psychiatrist, the pain-management team, occasionally one of the oncology attending physicians, sometimes a nurse, sometimes a resident.

  They complained about the patients from all over the world who came to the hospital directly from JFK Airport, looking for free care in the emergency room. Maybe soon there would be a special air-traffic-control system just for sick people. While the indigent poor from “over there” were coming here, hospitals in India and Thailand had begun courting U.S. patients with no medical insurance, promoting “medical tourism packages,” combining vacation and surgery for bargain prices.

  The fellows met every Monday morning in a dining area in the back of the Maimonides cafeteria, just behind the tables where the mashgiach hung out with the guys who cleaned the tables, usually young men from Caribbean countries. (The mashgiach were the bearded men in charge of making sure the kitchen observed the Jewish dietary laws; Dov Hikind’s father had been one.) While careful planning went into patient menus, healthy cuisine didn’t seem to be a priority in the feeding of staff. The grill turned out delicious french fries, cut thick and deep-fried. But the laws of kashruth prohibited providing yogurt at lunch when meat was served (except on Tuesdays, dairy day). The separation of milk and meat was taken so seriously that the dairy refrigerator was padlocked during non-milk meals. You could get matzo brei during Passover, and kosher Chinese food and sushi, but it was futile to even think about a cheeseburger.

  For these residents and fellows, discussion of “cultural competency” wasn’t a matter of us and them. They were themselves part of the cross-cultural stew. Besides the Malaysian Prince there was the Russian Princess, Inna Sominsky, the second-year fellow with the streaked blond hair, two small children, parents, her own immigration experiences, and a kind heart. Mendel Warshawsky, an opinionated South African who wore a yarmulke on his shaved head, was competing for a permanent job on the faculty staff with another third-year fellow, Mohammad Razaq, a quiet Pakistani.

  Mendel the Jew versus Mohammad the Muslim.

  The choice would be Astrow’s.

  Besides the Malaysian, the South African, the Russian, and the Pakistani, there were the Indians—Sirisha, Sushma, Ranju, Nagander, and Sramila. And there was Jason Tache, prematurely middle-aged in his thirties, born in the U.S.A., at Maimonides Hospital.

  Many of them would be dispatched on graduation to hospitals and medical practices around the country. (Suppiah was already signed on with a practice affiliated with a big regional hospital in Wilmington, Delaware. Sirisha Perumandla was heading for Iowa.) Better, worse, or indifferent, they would take the lessons they learned at Maimonides with them.

  The Prince rubbed his black-rimmed glasses and grimaced. “If I have to pick the two patients I’m most prejudiced against . . .”

  He paused, looking like a man who had taken a leap off a cliff and realized halfway down that the pool of water he was diving into was a shallow hole.

  “This is so bad, right?” he wailed. “I’ve gone from someone who was open-minded to this. Okay, the Russians are the worst. Even though they can speak English, they refuse to do it. They say, ‘No, I don’t speak.’ I say, ‘I know you can speak English. Can you speak a little bit? I can’t speak Russian, so I’m just going to take a guess at what you have.’ Then you can see the fear start. They go, ‘No, no, no, no,’ and then words start coming out.” He lowered his voice to a whisper, imitating the patients. “They go, ‘Heart, heart, heart.’”

  He shook his head. “This kind of collision is not necessary. It shouldn’t have to be a battle.”

  Then he turned his dark eyes directly at me. “My question to you is, Why would you subject yourself to that when you don’t have to?”

  I asked, “Are you saying we can be happy only if we don’t mingle?”

  No, he said. “But to mingle you need some unifying way of behaving, a language. If you don’t speak the language, bring someone who does. You’re coming into a fricking hospital. You have to give your entire history. How do you think that’s going to happen? I have so many relatives who came to this country and got citizenship status. Do you know how many English classes they went through? They suffered. They went to work; at night they went to their English classes. They don’t expect someone to speak Hindi or Tamil for that matter.”

  Suppiah had grown up in France, Switzerland, Malaysia, the United States, and
had learned a new language with each move. When he was fifteen years old, his family settled in New Jersey. His father enrolled him in a Catholic high school, though the family was Hindu, so Suppiah could learn something about Christianity, his new country’s dominant religion. The idea was to adapt, to accommodate, to become so comfortable that people would overlook the dark skin, the accent, the strange religion. It was useful at Maimonides, the ability to adapt. Suppiah had completed his residency there and was now in his third and final year of the hospital’s fellowship in hematologic oncology.

  His parents had tried to dissuade him from medicine. He preferred playing tennis to studying. They told him to talk to family friends who were doctors. They, too, tried to discourage him. “It sounds glorious, but it’s quite painful at the end of it all,” one of them said.

  Suppiah ignored them all but almost quit after his first year of training. Then providence intervened, or maybe he simply found a story that explained his own secret desire.

  Providence in this case arrived at a party, thrown by his brother. Over drinks, Suppiah talked to a friend from college who asked him what kind of specialist he was going to be. Suppiah told him he wanted to quit. The friend was shocked. Why, he asked? Suppiah said he didn’t think he was going to help anyone, that he didn’t see the point of medicine anymore.

  The friend sat down and told Suppiah a cancer story. When the friend’s mother got sick, he flew back to India to visit. No doctor wanted to take care of her. They said she was terminal and there was nothing to be done. She was forty-two years old, and she died. The friend looked at Suppiah and said, “I didn’t want treatment,” he said. “I wanted someone to take care of her.”

  Suppiah was angry. “Go have a drink,” he said. “Go relax.”

  The friend persisted. “You could have been that doctor,” he said. “You have that quality. Trust me. You can take care of patients. Do it.”