Hospital

by Julie Salamon

  Maybe it was the way she ended her sentences with question marks, but she seemed oblivious to her own slightly crooked beauty. When she told me that her last name was Pfeifer, I said, “Like Michelle?” (The movie star.)

  “Yes,” she said, “only with two f ’s, not three.”

  “You must get that a lot.”

  “Yes,” she said. “Isn’t it ridiculous? She’s probably the most unique-looking person on the planet. I don’t look anything like her.”

  Her modesty wasn’t false, but she was not an accurate judge of her own appearance. The comparison to the beautiful blond actress wasn’t as ludicrous as Pfeifer insisted.

  I told her about my visit to the ER that morning. “I was following Dave, and first he checked out this skinny little Jewish man wrapped in his phylacteries, and next to him was an eighty-year-old man from Trinidad. Has he talked much to you about what it’s like for him?”

  She swallowed a bite of bagel sandwich.

  Jenn’s diagnosis:

  “It’s pretty difficult,” she said. “Did you get his e-mail about learning to count to ten when he was doing ob-gyn rounds? He learned to count to ten in Mandarin, some words in Russian, probably can’t remember any of them now, but at the time he could do that. It’s a frustrating experience to feel you’re competent at doing something but then all of a sudden the language barrier is in the way and you can’t do what you know you can do. Sort of disempowering.”

  As she talked I could see she was preoccupied by the logistics of their relationship. He had two and a half years to go in his residency, and he was always tired. She was considering trying to transfer to Columbia or NYU, so they could live in the same city—something they hadn’t really done.

  “He calls me every day and makes all this effort, but he’s missing the energy that he had a year ago,” she said sadly. “The exhaustion is breeding some sort of apathy. You’re so tired you don’t want to make yourself feel better about anything. Then he gives these temporary glimpses into something being really good, really elating. He tells me about cases he has that sound so exciting, pretty awesome, miraculous. But then it immediately gets squelched by the day-to-day reality of, ‘Oh, I have to go back in there again, and I’m really tired, and I’m losing weight.’”

  He was disappointed by his first performance review. Marshall had told him, “You’re doing fine, but people are worried you’re a little too laid back.”

  Pfeifer’s eyes looked weary as she defended her man.

  “That’s an additional dimension of culture I hadn’t thought about, that there’s this New York way of doing things,” she said. “He’s not that way. He’s not intense and quick. Not that he’s not quick. He’s laid back and nice and compassionate and relaxed, and I think he’s getting the feeling that’s not acceptable. Maybe when they’re evaluating you as a resident, they take being laid back as meaning you’re hesitant, you don’t know what you’re doing. It never means that to him.”

  She sighed. “I thought he might feel better if he could get some food he likes.” Trying to help, she scanned the Internet and found several online services that delivered organic food. The prospect of whole grains seemed like manna from heaven, until Pfeifer found that every local zip code she tried was rejected. None of the health-food people delivered to Borough Park.

  “It’s definitely harder than I thought it was going to be,” she said, the “it” clearly encompassing more than the availability of tofu.

  The next day an e-mail from Gregorius:

  Julie,

  I’m sorry I couldn’t talk more yesterday. There really never is time to stop in this ER. I didn’t even eat my lunch Jenn made me, and I never went to the bathroom all day! And yep, i’ll be on Medicine for the next month and then Medical ICU after that. I am not sure how much down time there is but I’m sure it’s more than when you are in the ER. I am told that the Medicine month really sucks, but the MICU month is cool, and not so bad. We’ll meet up again sometime for sure.

  DAve

  I didn’t see him for a while but then received another e-mail that made me think that Davey was starting to feel at home.

  Hi Julie-

  Dave Gregorius here. We had an ER “happy hour” today and one of the Pediatric ER attendings, Dr. Garcia, and one of the nurses and myself and another resident were discussing one more interesting aspect of our hospital and community (which we think we could write up for a paper actually) but mentioned to Dr. Garcia that this is part of the observational stuff you might like for your book-

  anyhow-

  Dr. Garcia and our most veteran Peds nurse have observed (and this is so true), you can pretty much predict which babies will come into the Pediatric ER at which hours. for example at 11pm-12 midnight you see a bunch of Chinese babies all come in at the same time (this apparently because that is when the Chinese restaurants close, and sure enough, they usually smell like they have been in a restaurant all day), then between 3-5am, suddenly you get a bunch of pakastani babies (when the cab drivers get off work)

  and the Chasidic Jewish babies seem to come in at 10pm usually, but we are not sure of why.

  i know this seems like we are being ethnocentric or stereotyping- but it is true. At least that is when we get a sudden rush of babies each night.

  interesting. i thought you’d find it amusing. once again . . . . only at Maimonides.

  Dave

  Eight

  No Margin, No Mission

  From: Lillian Fraidkin, Senior Vice President & Chief of Staff

  Date: December 29, 2005

  Subject: Budgetary Restrictions

  Please be advised that due to major budgetary constraints, there will be no approval of the following until after the first quarter of 2006:• Monetary support for employees to attend conferences outside of the hospital

  • Temporary or agency usage

  • Catering, unless approved by the SVP

  In addition, there must be a dramatic decrease in overtime usage.

  These requests are our last attempts at avoiding layoffs. If we are unable to fulfill them, I will be forced to request a layoff list from each of you.

  Thank you.

  January 5, 2006, dawned with a crisp burst of light that was soon overtaken by a damp, gray chill. When Pam Brier met with her department chairs and administrative staff at 8:00 A.M., the weather had already shifted from promising to grim, matching her mood.

  As usual, the hospital president had chosen her outfit carefully—a pink sweater and an old pair of pink shoes, reserved, she told me, “for occasions that require extra fortification.”

  “Happy New Year to all of you,” she greeted the group gathered in 2C, an austere conference room lit by unforgiving fluorescent lamps. “Sorry about this.” She nodded toward the hospital’s preliminary budget, being passed around the table where two dozen of the top physicians and managers waited, glum and hungry. The apology extended to the small table in the corner, usually laden with breakfast pastries, fruit, and coffee, now barren as per Fraidkin’s directive.

  No one spoke of the medical matter dominating world news that morning. Israeli prime minister Ariel Sharon had suffered a massive stroke at age seventy-seven, threatening fresh chaos in the Middle East, another potential front in the U.S. war in Iraq. Brier had more immediate concerns, her own parochial crisis, the $8 million gap between the hospital’s projections and the actual budget.

  “You’ve heard, I’m sure, of hospitals around the city laying people off, but it can’t be solved by layoffs,” she said. “Union layoffs take forty-five days, so don’t even think of it.”

  Bob Naldi, the terse financial chief, explained the problem succinctly: Expenses had gone up 5 percent, and reimbursements had gone up 2 percent; the $8 million lay in that 3 percent differential. Anticipated increases in surgery hadn’t materialized, while the cancer center had produced far greater start-up costs than expected. Naldi looked exhausted; his group had spent the last month narrowing a $30 million
budget gap, but even with a hiring freeze, the hospital was $8 million short.

  “We need eight point five million dollars over the next two weeks,” he said. “You look at every single item to see if you guys can find more cash.”

  When Brier spoke, her voice was steely, but underneath the table one slender leg was bobbing with nervous energy. A few minutes into the meeting, she left the room to call one of her assistants, who soon appeared with a cappuccino in hand.

  Brier’s message was unequivocal. “It is the fifth of January, and we don’t have a balanced budget,” she said. “And that is my one fundamental professional fear in life—that we won’t have a balanced budget. It is what allows us to do what we do. We are going to have a balanced budget.”

  Though he wasn’t seated at the table, Stanley Brezenoff hovered in the room, a spectral presence, a reminder of the glory days, when things might have been worse—much worse—but were improving at a swift and measurable pace.

  There was a budget crisis every year, but this one felt more ominous. Lili Fraidkin referred to it as “the perfect storm,” a calamitous confluence of events. “Normally we might have, for instance, a decrease in surgical admissions,” she told me shortly before the meeting. “This year it’s the combination of so many things it’s horrendous. Reimbursement is down. Cases are down. Expenses are through the roof—and a lot of that is because of new docs coming on board with their needs for staff, their own equipment, salaries. All of this coming together this year.”

  In October the hospital booked its first operating loss since Brier had been there. How could this be? Only six months had passed since Maimonides posted its most successful—financially—month ever. Less than two months had passed since the doctor in charge of the Joint Commission inspection told Brier and the management team, “You’re way ahead of the curve. You’re an outstanding organization and can really hold your head high.” But construction on the new building, containing the new ER, was progressing more slowly than expected. She’d signed on an expensive Manhattan ad agency to promote the hospital, at a hefty cost of $3 million. All these modernization and promotional projects were based on optimistic budget projections that were not coming through.

  Was this to be her legacy, the chief executive who ended an eight-year run of prosperity?

  Like Fraidkin, she could recite all the reasons: recruitment costs for new doctors, greater expenses for nurses’ salaries and training, fuel, malpractice insurance. Length of stay had been creeping up, and yes, she could blame that on the abundance of old, sick patients. The beds were full, but the hospital didn’t get paid according to the number of patients who checked in, rather by how many left.

  “Every hospital administrator has a reason why their patients are sicker, take more resources, are the oldest of the old,” she told me. “I never met a hospital administrator who didn’t say, ‘Oh, mine are sicker! Mine are sicker still!’” Brier could rattle off all the excuses, but she wouldn’t—not to the board. She knew that this flinty crew wasn’t interested in hearing excuses.

  Neither was she—not from the group at the table, not even from one of her pets, Steven Shelov, head of pediatrics, who had capitalized admirably, in her view, on his aura of avuncular wisdom. He was a populist academic, whose credentials included coauthorship of the American Academy of Pediatrics Child Care Book for Parents and appearances on Oprah, Good Morning America, and the Today show. “Some of the vacancies [from the hiring freeze] are physician vacancies,” he said. “Who’s going to see those patients to increase the volume? It becomes Catch-22.”

  Brier shook her head. “Save all your tears and Washington Monument moments for somewhere else,” she said. “At least the number isn’t twenty million dollars now. This is the most up against it we’ve been since I’ve been here. I’ll be damned if we don’t get it right.”

  The most significant drain on the budget was the cancer center. Year-end losses were projected at nearly $8 million, almost exactly the amount left of the $30 million budget gap. Jay Cooper, head of the cancer center, sitting across the long table from Brier, complained about the finance department’s decision to break out the center’s operations as a separate budget line— ironic, since Cooper, who showed up at as few hospital meetings as possible, generally tried to maintain a clear line of demarcation between his bright new outpatient treatment center and the frenetic, messy institution that owned it.

  He revealed a certain attitude during a discussion about Medicare patients and the hospital’s dependence on Hatzolah ambulances, which brought in a disproportionate number of old, sick people to fill Maimonides’ beds.

  “We don’t want more of the elderly, complicated patient,” said Cooper, looking imperturbable in his Father Knows Best cardigan. He then brought up just such a case, a person whose treatment took four times as long as a younger, less complicated patient’s would have. He didn’t have to say, “Time is money.” Everyone at the table knew it, though they preferred the altruistic spin, “No margin, no mission.”

  The cancer center was still the favored child, so Brier overlooked Cooper’s impolitic truth. She defended the losses by invoking Murphy’s law in relation to start-up costs and then proclaimed the importance of the service with a little speech concluding with the party line: “There is no reason to go to Manhattan for cancer care unless it’s some esoteric something or other.”

  The meeting continued. Brier batted aside suggestions she considered obvious but unhelpful, such as Enrico Ascher’s observation, “We must concentrate on increasing volume.” Ascher, a slender, elegantly dressed vascular surgeon, was known as “the $3 Million Man”; he routinely made the top of Crain’s New York Business annual survey of the city’s highest-paid doctors. Ascher may have looked like a Thoroughbred, but he was a workhorse. Brier called him “the indefatigable among the indefatigable, never met a patient he wanted to give up to another discipline.” He lived and breathed surgery. But even Ascher’s production—still astronomical, still far greater than that of any other doctor in the hospital—had dropped. He’d been credited with discharging 717 patients in 2005, compared with 832 in 2004.

  “Our budget is based on volume increases,” she told Ascher, and then looked around the table. “To the extent you have a tangible, let’s hear about it. Believe me. We don’t want to be shortsighted.”

  Someone asked whether the hospital’s $5 million investment in Victory Memorial Hospital had brought more referrals. Because Fraidkin and Cunningham had been dealing with Victory, Brier looked in Fraidkin’s direction and barked, “All I know about Victory are referrals to another institution, and that has to stop, Lili. That has to stop now.”

  Fraidkin didn’t comment. She knew how to use silence as a reproach. Fraidkin and Cunningham might be handling the day-to-day at Victory, but Brier had been the advocate of the deal. She had the backing of the board, but it was the president’s baby, her bid to be a wheeler-dealer in the game of hospital roulette being played out in New York. If logic ruled health care, divvying up services between overstuffed Maimonides and underfed Victory could well result in better care for the people who lived in southwestern Brooklyn. But money and politics, not logic, determined the allocation of resources. Victory had to stay alive long enough to come up with a new configuration, and the hospital was short of cash. Fraidkin, Cunningham, and Naldi had spent hours each week at Victory, trying to help turn things around. Their task wasn’t made easier by the fact that Victory’s elderly chief executive—who had been at his hospital more than forty-five years—couldn’t stand Brier. (One of his secretaries told Fraidkin he turned beet red every time he heard the Maimonides president’s voice on the phone. Fraidkin told Brier to stop calling.)

  The Maimonides board had agreed to the investment when the hospital felt flush (just a few months earlier). It was understood all along that helping Victory was a gamble, and a long shot at that. Brier was well aware that an act of noblesse oblige (the board’s) could feel like a dumb mistake (hers) now
that money was tight.

  A few minutes after snapping at Fraidkin, Brier seemed to realize she’d been harsh. “The Victory issue is a conundrum,” she said, well after the subject had changed. “That hospital is half full. Figure it out. They are going to make it or not.” She forced a smile and added a compliment that was both sincere and perfunctory. “Despite the herculean efforts of Lili, Joe, and Bob.”

  To wrap it up, Brier tried to lighten the tension with a maternal gesture, but it was awkward, like an idiomatic expression being mangled by someone unfamiliar with the language.

  “You have to eat right,” she said (though not on the hospital’s dime). “Ten steps. No one can get sick here.”

  Yeah, yeah, shuffle, shuffle.

  “I’m serious,” Brier said, flipping from mom to drill sergeant. “No one can get sick. We have to get this done.”

  Sondra Olendorf, head of nursing and hospital operations, who had kept quiet throughout the meeting, now made use of her peppy, schoolmarmish charm.

  “Before you put on your green eyeshades, go discharge some patients,” she said briskly. “We have thirty people waiting for beds right here, right now.”

  Olendorf had sat through the meeting with her hands folded on the table alongside her Curious George lunch box/briefcase. She wasn’t fooled by Brier’s bravado. Brier had confided to Olendorf that Marty Payson, the chairman, was not happy with the numbers, a concern Brier interpreted as a lack of confidence in her.

  Olendorf thought her boss seemed weary. There was doubt there, something new. Olendorf was concerned about Brier. Did she have the stamina to wrestle all the forces pushing and pulling this big, unruly organization? “Stan is a hard act to follow,” Olendorf told me not long afterward. “Pam knows that. I sense vulnerability in her. I don’t want her to appear weak.