Hospital

by Julie Salamon

  Suppiah didn’t immediately appreciate the declaration of faith. “Who the hell are you? What is this about?” he said. “I know what you’re doing, this guilt crap.”

  But long after the friend walked away and the party was over, Suppiah couldn’t stop thinking about what he’d said. Did he, Kathir Suppiah, have some special quality? Could he be one of the gifted ones who could help a patient heal, even when there was no cure? He returned to his residency and applied to specialize in the hematologic-oncology program. One day (to his surprise) he found he was feeling much better about his profession, about life in general.

  “Yes, it’s depressing, but it’s the best job in the world,” he said. “Yes, it’s heartbreaking almost every single day, but it also gives you newfound meaning. Have you ever heard the saying ‘One man’s misery is another man’s happiness’? Horrible as it sounds, seeing how unfortunate other people are actually allows me to live.”

  Idealism was one casualty of his medical training; his marriage was another. One more lack of communication. They met in college, and she, too, became a physician, specializing in ob-gyn. He admired her. “I try to be her,” he told me. “She is very, very good. If you want a physician, that’s what you should have. Very, very smart, incredibly dedicated.” But after eight years of marriage they split up, he said, because her dedication surpassed his.

  “She clocked in one week at a hundred and twenty hours,” he said. “I clocked her. I don’t know when she defecated and urinated. She was more than obsessed. She just couldn’t let go. She didn’t stop talking about it when she came home. She couldn’t stop. She had to be the best. Number one in high school, number one in college, number one in medical school. She strived so hard to be the best she couldn’t stop. I’m the opposite. When these doors close behind me, you’ll never hear me discuss a case outside of work. I deal with the difficulties my private way.”

  I think in your book you have to have a whole chapter on diversity,” Lilia Colon told me. “We focus so much here on diversity, but in this country people do not have the smallest idea of what diversity is. They think it is black and white. But you have culture, you have race, you have age, you have position, you have education, you have so much to it.”

  Colon was Puerto Rican, willowy, gorgeous, stubborn, smart, and impatient, with flashing black eyes sparked by an electric intensity that could attract or repel. She was a nurse by training and had spent years as a clinician before becoming a consultant on labor-management issues, one of Pam Brier’s abiding passions and a significant component of care in New York’s unionized hospitals.

  Colon’s office was tucked off a ramp leading away from the second-floor administrative offices into an odd little alcove, part of the hospital’s haphazard design, which often seemed more archaeological than architectural.

  “I am not from this country, and so I come already with a whole understanding of diversity and tolerance, and sometimes I don’t have it,” she said. “Sometimes I’m human, and in the heat of the moment I’m not that . . . tender. But I see awareness here, more than other places—even if people don’t have the skills.”

  Awareness didn’t require great skill; it was impossible to avoid. “The community here changes every three blocks. The Hasidic, the Hispanic, the Asian—even between Latinos you have different types of cultures and they are right here, and they are segregated,” she said. “Walking here from patient accounts upstairs, I passed a Mexican group, a Dominican group, a Cuban group, a Puerto Rican group.”

  But she must have seen diversity at the other hospitals she worked at in Manhattan, hadn’t she?

  Colon leaned forward, exposing a bit of décolletage, unusual at Maimonides, where everyone tended to cover up—except patients, forced into immodesty by the open flaps of hospital gowns.

  “Don’t forget we have a visual reminder of diversity, and that’s the Hasidic population,” she said. “We are in a very melted pot, though we’re not melted, we’re segregated, but we’re so close together we look melted. I’ve worked in the city all my adult life. You see black, white, yellow, Latino all over. But here you have something unique. You’re in the heart of a Hasidic community. Eighty percent of our patients are Hasidic.”

  I thought I had misinterpreted. Her English was impeccable, but perhaps her Spanish cadence had altered a syllable.

  “Eighty percent?” I said. “You must mean eighteen.” The actual percentage was more like 20 to 25 percent.

  Colon looked genuinely surprised.

  I said, “Think of what it would be like if it were eighty.”

  Many nurses commented or complained, depending on their inclination, that the Orthodox received so many visitors from family members and rabbis and charitable groups that it was often a struggle just to make it to the patient’s bedside. For the cleaning staff, known as environmental workers, the visitors’ goodwill translated into another obstacle to hospital hygiene. Hard to sweep in a crowd.

  Similar thoughts must have occurred to Colon, because she nodded vigorously. “You’re right.”

  She knit her eyebrows together, trying to analyze the Freudian slip.

  “I guess it’s because of the observances,” she said. “The elevator is blocked on the weekend. You need to provide them a place for their prayers. The cafeteria accommodates them.”

  We both understood that she had touched on something significant with the 20 percent who felt like 80 percent.

  “Play this out a little,” I asked her.

  She was game. “I’m speaking for myself, okay? For me, the visual of the attire is a big part of it,” she said. “The same happens when I see the Middle Eastern women with their veils. The visual is a reminder that I have to stop and understand that I am not going to speak from a different language perhaps but from a different perception, and I have to be sensitive to that. I don’t know how they perceive us. I don’t know if they see us as different the way I see them as different. Going back to the eighteen and not the eighty. Change the equation. They are making the eighty percent stop and think. It is the visual and tangible awareness that I have to be more tolerant of, because his faith and culture have to be respected just like mine.”

  Her office was filled with graphs and flow charts, so it was natural that this numbers game appealed to her. “I don’t know, when I said eighty, if this was a slip or my real perception,” she said. “It feels like an eighty, because the eighty percent is the STOP sign to stop and be sensitive. At this moment in history, we are hating each other, especially the Muslim and the Jewish groups, but I think the history is more at a political level than individual. Just like black and white in the United States. Blacks sometimes pull the race card on me and say, ‘You just say that because I’m black,’ and I say, ‘That’s not even funny.’ But at a different level, you can go to labor and delivery here and have the Muslim woman sit next to Hasidic and be worried about the baby of the Hasidic and vice versa.”

  (Actually, the hospital didn’t ask people what religion they were, but patient-satisfaction surveys did inquire whether they kept a kosher home. Between 2003 and 2006, the percentage of patients who said they kept a kosher home varied between 20 and 25 percent, except in obstetrics, where 70 percent of the babies delivered had mothers who kept kosher homes.)

  Maimonides had hired Colon to work on staff development, which meant she spent most of her day wrangling with managers and employees over rights and duties while trying to make them appreciate one another— and while trying to create systems that made the hospital run more efficiently and deliver higher-quality care to patients. All on a tight budget. No wonder she usually felt frustrated.

  “I am a vehicle to create a culture of mutual respect, collaboration between two groups that historically have seen themselves as adversaries,” she said. “In utopia, in the ideal world, you will have a whole curriculum where employees are required to attend classes on how to work with each other, and there will be a staff to run it. They would learn how to use conflict ra
ther than avoid it. How do we use information that gets dumped on the table? How do we hold multiple realities so we can accomplish our goal while we are listening to each other and understanding how we are different from each other?”

  Colon felt that Brier’s message was not filtering down through the system. “We have limited resources,” she said. “We don’t have money to hire people to make sure each department gets these classes on how to build a team and how to solve conflicts. We always say ‘the developers,’ but I am the developer. So this is very far from utopia.”

  Her impatience extended to the man who had been instrumental in developing the labor-management collaborations at Maimonides. Peter Lazes, an old friend of Brier’s, had been working as a consultant to the hospital for almost eight years. Lazes, a faculty member at Cornell University’s School of Industrial and Labor Relations, was an idealist who believed in the concept of a civil society that centered on meaningful work. “If people have more responsibility—no matter what level the job or pay—the more they become involved in civic participation,” he told me. He believed that union participation would create systems that would increase patient safety and improve patient care.

  “It’s very practical,” he said. “Most people want to be consulted in decision making about their work. There’s research about that. I don’t think it has anything to do with whether you’re well educated and well paid or less educated and less paid. And in health care it’s much different than working in a factory. People go into this because they have some compassion for people. A hospital setting in general has a better ability to engage people—as opposed to, say, a Xerox plant. They want to feel they are contributing to someone else’s well-being.”

  Before taking on Maimonides as a client, Lazes had tested his central theory—that union participation could improve workplace results—at the Xerox Corporation, Bell Laboratories Works, Levi Strauss, and the World Bank. In 1995, when the Warnaco Group said it would close the Hathaway shirt plant in Maine unless costs were brought down, Lazes helped the union workers and management cut costs by working in teams and changing job roles. The factory stayed open—for another six years. But the worker triumph ended when a new owner moved the manufacture of the shirts overseas, where labor was cheaper.

  In the eight years Lazes had been advising the hospital, Maimonides had established forty-two joint hiring committees; employees helped hire managers and directors of departments. The hospital had several departmental labor management committees (DLMCs), described by Lazes in a report as “a forum for labor and management to share critical information about their department’s performance and labor-management issues.”

  Maria Ferlita, the vice president of finance who was in charge of medical records, recalled the initial response to the DLMCs in her department. “I’ll never forget. I met with the medical records staff and told them this is what we’re doing, not just 1199 [the hospital workers’ union] employees but management as well, and they looked at me: ‘Okay, what have you been smoking? ’” Twice a month the group met to discuss the problems. “Work-related issues like, ‘We can’t do our work because we don’t have enough chairs,’” said Ferlita, “. . . problematic employees calling in sick time, not accepting responsibility for their work, blaming their shift for their lack of productivity.”

  The medical records department was a mess, with something like six hundred feet of unfiled documents containing information on patient care and reimbursements. The employees worked out a system to increase productivity;the department’s delinquency rate dropped to 4 percent, far superior to the Joint Commission’s requirement of below 15 percent.

  In cardiology, strategies developed by labor and management were credited with reducing response time to cardiac-patient alarms and monitors to less than one minute, from an average response time of between three and eight minutes.

  But too often, Lazes complained to Brier, the DLMCs never got past communication to action. The Environmental Service DLMC was set up in 2002 to help the hospital meet the Joint Commission’s standards of daily cleanliness. Three years later, after dozens of meetings, visits to other hospitals, endless discussions, Maimonides was substandard in that respect. The lobby in particular had a shabby air; the door leading into the volunteers’ room run by the Bikur Cholim, right by the main elevator bank, was especially scruffy.

  “I don’t understand it,” Lazes told me. “We’re trying to systematically get rooms up to speed, get everyone trained, get equipment. They look for brooms and mops, so people steal each other’s mops. You go to a floor and want to do a good job and don’t have a mop. You learn through the grapevine, go to this other unit and steal it.”

  In August 2005 a new manager was hired, after being interviewed by a joint management-labor committee. Almost a year later, Michael Yohannes, born and raised in Ethiopia, was still mystified by Maimonides.

  “The employees feel free to go all the way to the top,” he said. “It’s good and bad. It’s good because the employee has another venue to vent, but it’s bad because it doesn’t send the right message. I feel employees are taking advantage of that. Not all of them, just a few. But it makes it difficult for management to run. It isn’t an easy path.”

  Colon echoed his sentiments. “So much waste of time, money, resources, energy, and yet Maimonides is still the most advanced hospital in this area,” she said. “Though in the entire industry they are furthest ahead, after eight, nine years very little has been accomplished. That’s no way to engage in a mission.”

  In Mendel Warshawsky’s view, the social experiments taking place at the hospital—both the purposeful and the unintended—had created fertile conditions for a kind of anthropological graft-versus-host disease.

  From the Web site of the National Marrow Donor Program:

  Graft-versus-host disease (GVHD) is a common side effect of an allogeneic bone marrow or cord blood transplant (also called a BMT). An allogeneic transplant uses blood-forming cells donated by a family member, unrelated donor or cord blood unit. In GVHD, the immune cells from the donated marrow or cord blood (the graft) attack the body of the transplant patient (the host). GVHD can affect many different parts of the body. The skin, eyes, stomach and intestines are affected most often. GVHD can range from mild to life-threatening.

  “You get pissed off,” said Warshawsky, the Orthodox oncology fellow from South Africa. “People want to think there’s this utopia of cultural acceptance. It just doesn’t exist. Doctors are the same as everyone else—same prejudices, perhaps even worse.”

  Fierceness emanated from Warshawsky, who had a boxer’s stance and pugilistic verbal style, his intellectual jab and thrust sharpened at the Lithuanian yeshiva where he studied Talmud in Israel for three years. Behind thick glasses, his eyes were unblinking and had a red, rabbity look, which made him seem wary and combative. Warshawsky, who had once considered devoting his life to Torah study, was competing with Mohammad Razaq for a full-time job after graduation.

  Warshawsky was a man of many interests and many opinions. He’d given me a few chapters of a book he was writing about his experiences in the medical world of South Africa. The manuscript revealed a good eye for detail and—his yeshiva years notwithstanding—a lusty sensibility.

  Warshawsky’s ferocity was genuine, but his aura of physical robustness was misleading. A decade earlier, at age twenty-three, he had stared down death from leukemia. His dry-eyed gaze was a physical condition, the residue of a bone-marrow transplant undergone while he was a medical student in South Africa.

  For him the graft-host analogy wasn’t theoretical. He had endured many variations of the disease. His lungs had been so weakened that it was an effort for him to climb a flight of stairs. Infertility problems had almost kept him and his wife—another cancer survivor—from having a child; it took eight years of fertility treatment to produce their baby. Perhaps worst of all, for someone whose livelihood depended on keeping up with research, he suffered from Sjögren’s (SHOW-grins) syndr
ome, a chronic disease rooted in many causes, including transplants, in which white blood cells attack the moisture-producing glands. The inability to make tears had damaged his corneas, the sensitive membrane covering the iris, the colored part of the eye. His corneas had become scarred; light caused exquisite pain.

  He hadn’t been able to read an entire book for two years, serious deprivation for a Torah scholar and cancer-specialist-in-training. He had heard of patients who suffered so much from the condition they had their eyelids sewn shut. He felt he had almost reached that point when Douglas Jablon— the Mitzvah Man, the fixer—told Warshawsky that Edy, Jablon’s wife, also had been debilitated by dry-eye syndrome; after years of misery she had found relief. Dr. Perry Rosenthal, a cornea specialist who taught at Harvard Medical School, had developed a special lens—called the Boston scleral lens—filled with a fluid that merged with the eye’s own tears and provided a protective coating for damaged corneas.

  Thanks to Jablon’s intervention, Warshawsky had recently returned from Boston. For the first time in years, he could endure light without pain. He no longer needed glasses.

  “I had given up hope, and then I went to see Dr. Rosenthal, this elderly guy, and he put in this lens, and I could see clearly,” he said. His sense of excitement was palpable. “It was a miracle. He’s been on Oprah, on ABC, but the medical establishment has not promoted him the way he should be promoted. The first reason is that doctors, myself included, they can’t believe that such a simple, elegant thing would actually work. The second thing is egos. You’ve got people who have invested their lives in corneal transplants— big high-tech things—they don’t want to give that up so quickly. It makes no sense to modern doctors that something so simple could overtake something so high-tech.”

  I’d cornered Warshawsky in the cafeteria to talk about another low-tech aspect of medicine—the competition between him and Razaq to fill one of the new positions opening up at the cancer center. Each had played his own race/ethnic card with Astrow. Razaq was a soft-spoken Pakistani Muslim who pointed out to the new chief that the Muslim community in the area was growing. Razaq spoke Urdu and Hindi and felt he could draw a different set of patients from an emerging population to the cancer center. Warshawsky, backed by Kopel, knew that his strength was as possible conduit to the Orthodox patients who were not using the cancer center. “I have to see if I can get the Orthodox vote,” said Warshawsky. “I have to compete with Bashevkin.”