Hospital

by Julie Salamon

  When she found it, she realized that the beeping had infiltrated her inner consciousness. It was only a dream. The beeper hadn’t gone off.

  For a moment Ceriale’s entire being seemed to sag with weariness. “I started at the busiest time of year without a mentor and came into a situation that was a big mess,” she said. “I’ve been here for six weeks, and three days out of five I’ve gone home crying. It’s not something you can show either. You don’t want them to see you sweat, like they say on the deodorant commercial. Every other day I’d like to quit, but then on the in-between days I think it was a good move and I’m happy to be here.”

  She straightened herself. “Now the holidays are over, staffing is starting to get a little bit better, my job will start to get a little bit better,” she said. “I have a lot of confidence in myself. I think I can do the job. Not even think— I know it.”

  On that hopeful note, we said good-bye and agreed to meet later in the week.

  Four days later—Friday the thirteenth—when I stopped by the ER, someone told me that Ceriale was gone. No one knew where she was or if she was coming back.

  Nine

  The Code of Mutual Respect

  MAIMONIDES MEDICAL CENTER

  Department of Perioperative Services

  You are invited to the first

  Crucial Conversations training session

  Topic: “Getting Unstuck”

  Learn: How to recognize what Crucial Conversations are, and the

  consequences of not having them!

  DATE: Friday, January 13, 2006

  TIME: 7:00 A.M.-8:00 A.M.

  PLACE: Schreiber Auditorium (Admin Bldg., 2nd floor)

  It had been a long time since Alan Astrow had thought about the former colleague at St. Vincent’s he once referred to sarcastically as “Mr. Doctor” (as in, “He thinks he’s so great he calls himself Mr. Doctor”). Three years earlier Astrow was covering the oncology service when one of Mr. Doctor’s patients was about to go into surgery, to have his spleen removed for a cancer biopsy. The patient was elderly. Before the surgery, pathology reported to Astrow that the lab already had tissue that showed metastasis of cancer, making the biopsy unnecessary. Unable to reach the patient’s doctor, Astrow spoke to the surgeon, and they decided to call the surgery off. When the family asked why the procedure had been canceled, Astrow told them. The cancer had spread.

  The next day, just before his daughter’s fifth-birthday party, Astrow received a call from Mr. Doctor.

  “You asshole,” the conversation began.

  You asshole!

  Mr. Doctor continued, “You shouldn’t have talked to the family.”

  Astrow couldn’t believe it. They might have killed this patient in the OR. Okay, maybe the surgery wouldn’t have killed the patient, but it wouldn’t do any good. Why should an old person with serious hematological malignancy run the risk of major surgery for no good reason?

  And his thanks for preventing what could have been a disaster?

  You asshole!

  So he gave it right back to Mr. Doctor.

  He spoke softly as usual, but his words were riposte, not reply.

  “You almost killed this patient,” he said. Even as he spoke, Astrow knew he had gone too far. Mr. Doctor’s recommendation for surgery hadn’t been unreasonable with the information he had. He was angry with Astrow not because he’d called off the procedure but because he had delivered the upsetting diagnosis to the patient’s family instead of waiting for Mr. Doctor to return.

  Astrow’s empathetic self knew that Mr. Doctor was concerned for the patient’s family and for his own reputation, and that hundreds of cuts and slights and deliveries of painful diagnoses had turned him into the brittle, rigid, wounded individual that he was. Astrow knew he should apologize, because someone had to bend.

  But sometimes he got tired of bending.

  The bitterness ruined his daughter’s birthday party for Astrow. For weeks he agonized about the nasty exchange, alternating between anger at Mr. Doctor and frustration at his own inability to ask forgiveness even if he did think the other man was a self-righteous jerk.

  The patient received appropriate treatment—chemotherapy—but the relationship between the two doctors was terminal. Neither apologized, and the department chief declined to get involved.

  Astrow had suppressed the memory of Mr. Doctor. At first he didn’t connect the incident to the e-mail about Crucial Conversations that showed up in his mailbox just after the New Year. In fact, he had forgotten about the meeting, which he didn’t plan to attend. But that Friday morning he’d gotten up early. He was happily engrossed in something he was reading when he remembered the e-mail, which he had been sent as a courtesy, as a department chief. The meeting was mainly intended for the surgery department.

  “If you want the surgeons to use the cancer center, you have to show up,” his overdeveloped superego lectured him. “It’s a matter of showing respect for other people.” He groaned as conscience and sobriety pried him from his comfortable chair.

  Maybe he could have ignored the internal prodding if the cancer center’s numbers were better. But they weren’t. Face time with his colleagues, many of whom still didn’t know him, would be politic as well as polite.

  So he took a quick shave, rushed to get his car from the garage a couple of blocks away, and drove to Brooklyn. When he walked into Schreiber, he was twenty minutes late, but not the last straggler in the crowd of about 250 tired-looking souls, many wearing green scrubs, some in white doctor’s coats, others dressed in street clothes. These doctors, nurses, medical students, and technicians came from the various surgical groups—cardiac, orthopedics, vascular, neurosurgery and so on—as well as ancillary services like anesthesiology and radiology.

  Astrow arrived in the middle of a bizarre piece of theater. On the stage in the front of the auditorium, Stephen Lahey, chief of cardiothoracic surgery, was screaming at a tough-looking nurse with short, iron-colored hair.

  Lahey, a full-bodied Irishman with a curly mop of gray hair and that unmistakable Boston accent was yelling, “This is not a hernia! This guy is going to die! When I have to send this guy home in a box, I’m going to tell the family it was your fault! So when you’re finished here, you can go straight to the goddamn medical-malpractice lawyer!”

  The nurse glared at him and folded her arms.

  He yelled some more.

  Finally she yelled back, “How dare you!”

  The improvisational skit had the bite, if not the brutal poetry, of a David Mamet play. Big applause. The venom spewed by the amateur players clearly resonated as something familiar and true.

  A broad-shouldered, balding man of looming height, with piercing eagle eyes, about fifty, with a mustache and goatee, took over. Standing at a podium and then striding up the aisles like a television talk-show host or motivational speaker, he began to speak in the soothing yet provocative tone common to both.

  David Feldman, former chief of plastic surgery, had for the past eighteen months been in charge of perioperative services. He was responsible for how patients were treated from pretesting—the labs or X-rays and case histories required to evaluate their ability to safely withstand surgery—through discharge, either to home or to a hospital bed. That antiseptic description didn’t reflect the messy reality of the job, which was handling the complaints and hysteria of distraught patients and their families, impatient doctors and nurses, and beleaguered technicians. Operations were delayed for understandable reasons, like emergencies, but just as often for paperwork foul-ups and administrative errors.

  “We know what the problems are at Maimonides,” he said. “How do we know? Because you are all calling Pam and me every four days to tell us.” Pamela Mestel, his nursing counterpart, stood nearby, nodding.

  Feldman had acquired another, more ephemeral job. He had become the hospital’s dean of deportment after writing the Code of Mutual Respect that every doctor had been required to sign.

  The
y signed it and then forgot about it. Pam Brier didn’t forget, however. She decided to make good behavior an official hospital goal, part of the strategic plan, part of her overall desire to civilize her willful troops. Eighteen months earlier she had hired Kathryn Kaplan, an organizational-development specialist, who had helped design programs to prepare physicians to become leaders—instead of simply promoting them—at Mount Sinai and NYU. Brier had already picked Feldman as a physician leader, so Kaplan became his partner. The Code of Mutual Respect was part of the arranged marriage; the project became her baby, too. It was the perfect assignment for Kaplan, a smart, apprehensive woman with a singsong voice, not young but girlish, a gentle person who wrote poetry and wanted to believe in the sweeter, softer side of human nature. She held on to this belief even after spending a year in operating rooms as a consultant and witnessing a great deal of bad behavior among doctors. “The people who bring in the most money can be the most abusive,” she once told me, sounding sad and disappointed at this unsurprising observation.

  In “The First Five Years of the 21st Century,” Brier’s progress report to Marty Payson and the board, written in November, she emphasized behavior. “The code’s implementation has now been transformed into a hospital-wide priority with structured skills development for doctors, nurses and support staff. Our expectation is that Maimonides will become recognized within the next few years not only for its outstanding and humane patient care but also for the way staff treat each other, as well as our patients and their families.”

  There were plenty of people who snickered. There were mutterings of, “Madam President, heal thyself,” referring to what Sondra Olendorf politely called Brier’s “behaviors.” What next? Spankings for cursing? Time-outs for littering? Was this political correctness run amok?

  Feldman’s cynical humor and tough-minded reorganization of the operating rooms helped him subdue the cranky and the skeptical. He had been willing to take on this quixotic assignment because he had reached the stage of disillusionment that can be liberating. He was able to say frankly that he wanted to recapture the satisfaction he’d once felt at just being able to help, before he spent his time worrying about whether he was being nickel-and-dimed by insurance companies. That he missed the collegiality, when doctors came in twice a day to make rounds and then stopped in the lounge to grab a cup of coffee or a smoke—you could smoke in the hospital then. Who had time to do any of that anymore?

  “In the hospital we get so caught up in what we’re doing—mostly in the service of patients, I will say—we get nasty to each other,” he told me. “But the way people get treated is every bit as important as what they are being treated with. I believe this.”

  There was a tendency to sentimentalize bygone days of warm relations between doctors and patients. But rudeness was nothing new to the medical profession. The men who drafted the charter of the American Medical Association, approved in 1847, felt it necessary after all to warn physicians to “avoid all contumelious and sarcastic remarks.”

  The AMA’s early concern about etiquette was a matter not just of manners but of salesmanship. In The Social Transformation of American Medicine, Paul Starr observed that in an era when their financial status was precarious, “physicians were much concerned to maintain a front of propriety and respectability.” Not a lot of time had passed since the days when medical practice required supplemental income. Starr offers examples of one eighteenth-century doctor who also sold tea, sugar, olives, grapes, anchovies, raisins, and prunes; of another described as a surgeon in his obituary but as a wigmaker in his will; and of a midwife who cured ringworm and piles but also made dresses and bonnets.

  By the twentieth century, these stories had become quaint history. Sophisticated procedures and new drugs elevated the status and mystery of doctors, as well as their incomes. Medicine became a lucrative profession, and doctors became a staple of popular mythology, centerpieces in endless television episodes depicting dramatic collisions of life, death, and sex. One generation was reared on shows like Ben Casey and Dr. Kildare; the next tuned in to M*A*S*H, and then St. Elsewhere, E.R., Scrubs, House, and Grey’s Anatomy. Reality television brought the operating room home. You could watch liposuctions being performed and babies being delivered without leaving your couch.

  Medicine-as-entertainment was thriving as the twenty-first century began, but real-life relationships between doctors and patients were suspicious and confused. Like everything else in the world—from the balance of global politics to the way people communicated—medicine was in flux. The familiar bulwarks no longer held fast, not even the nuclear family. The 2000 U.S. Census reported that the percentage of married-couple households with children under age eighteen had declined to 23.5 percent of all households, compared with 45 percent in 1960. The family doctor, treated like a second-class citizen by insurance companies, became another endangered species. Low value was placed on the generalist who saw not just a patient but recognized a person with a history, a place in the community, a functional part of a larger system.

  Specialization had led to superior technical results but also to a fragmentation of care that injected an element of distrust into even the friendliest relationships between doctors and patients. Physicians felt embattled by the rising cost of malpractice insurance, cumbersome insurance reimbursement, and regulation. Patients felt incidental, like inconveniences to be dealt with between computer entries.

  The Internet had revealed the secrets of the medical profession, opening once-shrouded information reserved for a highly educated elite to anyone who could plug in a computer. Patients felt free to question the wisdom of their doctors and to shop around when they didn’t like the answers. Yet the increased availability of information didn’t lead to a greater sense of power. Even as cures were found for more diseases and new drugs proliferated, a sense of frustration prevailed. Almost every day brought pronouncements of a medical advance, many of which were soon modified or retracted, creating a fearful atmosphere of unrealistic expectations followed by disappointment. There was more data about cure but also more reports of failure, like the aforementioned 1999 Institute of Medicine report with its estimate that as many as 98,000 deaths a year could have been avoided were it not for the mistakes of medical professionals.

  Each medical advance made death seem less like an inevitable, natural part of existence and more like an insult, a cop-out, a failure. But medical science had not yet made humans invincible. Sometimes people simply died. They died too young, they died mysteriously, they died despite receiving the best medical care possible. Too often they died feeling abandoned and alone, shielded from fear by neither science nor God nor the reassurance of a doctor who seemed to care about them. In turn the doctors struggled with their feelings of guilt, anger, or shame at failing and, worse, with the emptiness they felt when they recognized their own indifference.

  Eric Scalettar, vice president for planning at Maimonides, said it well:

  “Can I quantify whether the doctors are better or worse than my father’s generation?” he asked me. “They’re clearly more educated today than in my father’s generation. Do they care as much or invest as much of their time or energy? That I doubt. Do they bring the same dedication and devotion to their practice? I don’t know. I don’t think so.”

  He continued, “Why would they? We don’t treat them as well. We don’t hold them in as high esteem. We chastise them in the newspapers and watch their every move to see if they’re conducting themselves right or wrong. It’s real different today.”

  This combative atmosphere forced physicians to consider their presentation as well as their medical practice. In 2001 the AMA made idealistic additions to its principles of ethics, encouraging physicians to consider patients’ rights as well as their dignity, and to participate in activities that contribute “to the betterment of public health.” The threat of sexual-harassment suits and the rising numbers of female doctors had made outright crude behavior less acceptable among medical colleagues
. But flirting and sexual innuendo were inevitable in a profession suffused with physical and emotional rawness. A macho ethos prevailed in many places, particularly among surgeons—“the big-dicks-swinging school of management,” in the words of Holly Hartstone, a hospital consultant who worked for Maimonides.

  All over the country, hospitals were writing codes of behavior, as the medical profession tried to win back the confidence that had been eroding for decades. At Maimonides the task fell to David Feldman. He became an expert in behavior modification in the same way he had become an expert in pressure sores—for reasons that perplexed him. “Am I that interested in it?” he said. “I don’t know.”

  He had an impulse to organize and rationalize. When he was a resident in plastic surgery at Duke University Medical Center, he was assigned to give a talk on decubitus ulcers, or pressure ulcers, dangerous wounds that can result in uncontrollable infections and death. Commonly known as bedsores, they result from immobility, when people lie in one position for a long time or suffer from diabetes or other circulatory problems. “We saw them when the patient had already developed them, and they’re horrific,” he said. “The care is very complicated for the patient and family. The purpose was to prevent them from ever happening, which is not usually the realm of a plastic surgeon.” He did research on the subject and suddenly found he had developed a specialty.

  His interest in ethics and communication evolved the same way. Feldman was an organization man. His father was a dentist and his mother a professional volunteer. When he was growing up in the suburbs of Long Island (not far from Alan Astrow), Feldman’s parents decided to get their M.B.A.’s together at night. Their son helped them with their calculus homework. So even as a young surgeon, Feldman wasn’t satisfied with writing book chapters on pressure sores; he organized a Committee on Pressure Sores. He started a program at Duke on the business of medicine. Plastic surgery paid the bills, but what fascinated him was the organism of the hospital.

  He understood that hospitals confront the same issues that come up in any organization—rivalries, jealousies, envy, people feeling that their bosses are dumping work on them or giving them crummy assignments. There are always unpleasant jobs that have to be done and people trying to shift those jobs onto somebody else. But there’s a crucial difference: The doctor’s job is dealing with disability and frailty, with life and death. The emotional stakes are huge; the consequences of a misstep can be irreversible.