Hospital

by Julie Salamon

  Cunningham recruited him to Maimonides in the early nineties, and the plastic surgeon soon became active in medical-staff politics. Surgery had become routine; skin grafts, wounds, scars, skin cancer made up 75 percent of his practice; breast reductions and augmentations the other 25 percent. Cosmetic surgery had become a $15 billion industry, putting all plastic surgery under special scrutiny by insurance companies. “Plastic surgery is borderline. Is it cosmetic or not?” said Feldman. “We tend to do multiple procedures at one time, and they reimburse for one and not the other. It drives you crazy.”

  He decided to follow his parents’ footsteps and get a business degree. “I could see what was happening in medicine,” he said. “I still love taking care of patients, but a lot of things were bothering me. My back started to bother me. I thought, ‘How long can I take this?’”

  He entered an M.B.A. program at New York University designed for midcareer executives; there were five physicians in his class of one hundred, which included a man who owned a photography studio and a woman from Benjamin Moore paints who had written books about picking out paint. Feldman found it invigorating to see how people outside the cloistered world of medicine thought.

  Pam Brier recognized Feldman’s ambition and wanted to keep him happy. She felt he would leave Maimonides one day, to become the chief executive of a hospital, but she wanted to delay the moment as long as she could. Sondra Olendorf offered to relinquish management of the operating rooms to Feldman. He had the right personality for the job. He was affable but formidable, idealistic but hard-nosed enough, a combination that made people want to please him because they liked him and because they were a little scared of him.

  In 2002, Olendorf told Brier she wanted to attend a conference called the Trust Initiative, about to take place at the Harvard School of Public Health. Organized by David A. Shore, an associate dean there, the conference was designed to confront the poor public perception of medical care. This spoke directly to Brier, who firmly believed that good behavior wasn’t a mere nicety but a crucial part of taking care of patients. She asked Feldman to join Olendorf and Warren Wexelman, a former president of the medical staff, at the conference.

  The conclusions reached at the conference were summarized in the fall 2004 issue of the Harvard Public Health Review in an article by Cathryn Delude, a science and health writer. “Across the United States, trust in institutions that guard the public’s health and provide care has fallen to an all-time low. Patients mistrust insurers and pharmaceutical companies, and lack complete confidence in their doctors; physicians, in turn, are skeptical of clinic and hospital leaders. Citizens doubt government’s ability to protect them from epidemics and bioterrorism, deriding each new ‘orange’ or ‘yellow’ warning as an empty scare.”

  The message resonated with Feldman. “What’s been lost is the ability to separate all this technology from just taking care of people,” he told me. “How does this stuff relate to what I do in the operating room? The OR is a crucible for this sort of stuff. There’s a lot at stake. Things happen quickly; there’s an urgency about things. Surgeons grow up in medicine understanding the need for urgency. It’s a natural place for people to lash out. If people are afraid to say something, patients suffer.”

  The Maimonides group was so impressed that they returned for a follow-up session a few months later. The next conference’s name indicated how completely business was entangled in modern medicine, even when the subject was ethics—Building Clinical and Administrative Trust: Advance Your Mission and Improve Your Margin.

  Feldman used the following example of a case at Maimonides to illustrate the relationship between respect and result. A patient had been prepped for a knee operation. The medical people had followed the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery, required practice in all JCAHO-accredited hospitals since 2004:

  Step 1—Verification (of the patient, procedure and site)—This is conducted independently by each of the following: Surgeon, Anesthesiologist and Nurse, preferably with the patient awake and involved and is the information matched to what is written on the consent and/or OR schedule.

  Step 2—Marking the operative site (in cases where there are issues of sidedness (Left/Right) or levels (e.g. spine))—Presently, the Surgeon marks at or near the site of incision (or insertion) with a “YES”. In March 2007 we will mark with the Surgeon’s initials. This marking must be visible after the patient is prepped and draped.

  Step 3—Time-out—Just prior to the time of incision, the entire operative team does a time-out to reverify the patient, procedure, side, site, positioning and the availability of any needed special equipment.

  Curtain up—until someone asked loudly, “How come the knee being prepped isn’t marked with a ‘yes’?”

  The room went still. Who had dared to speak? It was a medical student— lowest on the hierarchy, except perhaps for the patients themselves, or maybe family members.

  The “yes” was on the other knee.

  What went wrong? At the root-cause analysis, the closed-door meetings where medical people dissect their mistakes, it was discovered that the “time-out,” the final check, had taken place too soon. The equipment had not yet been formally placed on the operating side, and everyone assumed that the leg next to the equipment was the object of the surgery. After that, the time-out was the last thing to happen before the scalpel was ready to fall.

  “You can’t stop these things from happening unless people are respectful to one another,” Feldman explained. “There has to be enough respect so a medical student can raise his hand and say, ‘You’re operating on the wrong knee.’”

  With a convert’s zeal, the new perioperative chief volunteered to take additional responsibility for an ambitious plan, to not only change the way people behaved in the hospital but to make them considerate of one another. As he pondered the title of the document he was drafting, he decided he didn’t want to call it a code of conduct but rather wanted something that signaled a fundamental shift in attitude as well as behavior. At Maimonides, pragmatism was poetry, an attitude reflected in Feldman’s blunt Code of Mutual Respect:

  On Professionalism. The Staff recognizes that acting professionally entails treating others with courtesy and respect, and refraining from the use of abusive language, threats of violence, retribution, or litigation, and actions that are reasonably felt by others to represent intimidation. The Staff also recognizes that it is unproductive to make inappropriate remarks concerning the quality of care being provided in front of others or to make such entries in the medical record. Finally, the Staff agrees to address concerns about clinical judgments with associates directly and to avoid favoritism or sidestepping rules.

  On Language: All members of the Medical Staff agree not to use language that is profane, vulgar, sexually suggestive or explicit, intimidating, degrading or racially/ethnically/religiously slurring in any professional setting related to the hospital and the care of its patients.

  On Behavior: The Medical Staff agrees to refrain from any behavior that is deemed to be intimidating, including but not limited to using foul language or shouting, physical throwing of objects . . . .

  The admonition against “physical throwing of objects” caught my attention. I brought it up during an interview with Allan Strongwater, former chair of orthopedics. “I’ve worked in lots of hospitals where surgeons have thrown instruments; they get a scissors that don’t cut, they fling it across the room,” he said with a shrug. “I don’t think behavior was worse at Maimonides.” Then he added, “Of course, there were isolated incidents that were very bad. Like the physician who pushed a nurse and another who threw something at a nurse. On the other hand, I was at a hospital where the resident accused the attending surgeon of breaking her wrist.”

  Things had improved at Maimonides in the past decade, he said. He recalled receiving a disturbing telephone call from the head of academic affairs a few weeks before he went to Maimonides in t
he mid-1990s. She wanted to warn him about what he might find. She told him about two chief residents who got into a fistfight and knocked a patient off a stretcher; about a surgeon who carried a gun in the operating room; about residents who were secretly tape-recording conversations with attending physicians, so that when things didn’t go well, they had deniability.

  When I talked to him, Strongwater had recently resigned from the hospitalunder pressure from Brier, after months of unhappiness. When I asked him to explain their differences, he said, “Everyone has the right to health care, but when you buy a Volkswagen, you don’t get a Bentley,” he said. “It’s not that they don’t both work and they aren’t both good cars—they just don’t have the same luxury. The level of expertise of the physician should be the same, but people who pay for health care don’t want to sit in a room with fifty other people. They want to be seen in a timely manner. I think that’s very reasonable.”

  Pam, he said, wanted everyone to sit in the same room.

  (When I asked Brier about this later, she agreed and she didn’t. “We had differences of opinion about how to accommodate patients with managed-care coverage, which is in some cases lesser coverage,” she said. “I wanted to make sure there was some access for people with insurance. That’s what the neighborhood consists of. He felt he could not tell his people to accept managed-care insurance at all. That was one issue.”

  She was hesitant to elaborate. “I was concerned about growth in the department,” she said. “We had differences about management. That’s about all I would say.”)

  Strongwater and I met in his office in lower Manhattan, across the street from the NYU Hospital for Joint Diseases, where he had joined the staff. He told me he had thrived at Maimonides when Brezenoff was there, but he and Brier hadn’t gotten along since she became president. “I had a great relationship with her as chief operating officer,” he said. “But as president she is a politician. She would like her hospital to be the model for public health. That’s okay. But she seems to take things more personally than Stan. If something doesn’t work out, she gets really angry. Business is business, and you have to have a business attitude.”

  For example?

  Strongwater was emotional. He had not wanted to leave Maimonides.

  “For example, the Victory game,” he said, referring to Brier’s decision to put money into the struggling hospital. “We sat around, the leadership— Pam and Mark, Sam Kopel, the chairs, Lillian—talking about Victory. I said, ‘Why don’t we just let it close? It’s in its death throes. It’s substandard. The state wants to let it close.’ She looked at me and said, ‘Don’t you get it?’

  “‘ Don’t I get what?’

  “She said, ‘If we don’t do this, some other hospital is going to go in there and buy it up.’ She’d gotten word Methodist had put money on the table. So what? Is Methodist going to run that hospital on the other side of Brooklyn? No, they’ll suck everything out of it, and then it will close. But she was going to put money on the table and outsnooker them. But the game of snooker is a tough game, and the one who got snookered was her.”

  At first, Strongwater had refused to sign the code. “I thought it was pathetic,” he said. “I thought it was pathetic that you have to tell professionals at that level how to behave.”

  He told a story about an operation he performed several years earlier on a young woman who had been in an accident and suffered from hip dysplasia, a shallow hip socket, a condition that caused severe pain and an inability to walk without limping. Strongwater had been an early user of a relatively new procedure called a Ganz osteotomy, named after the Swiss surgeon who developed it in the 1980s. It is a difficult surgery that rebuilds the hip socket with the patient’s own bone, and it has become a good alternative to hip replacements, which almost always have to be repeated if patients are young.

  The operation was likely to take six hours and require 3,000 cc’s, or 6 pints, of blood. The family had been adamant that the girl receive blood they donated. She’d had bad reactions to banked blood in the past.

  Blood was taken from the family and stored. The girl was admitted and prepared for surgery. After she was anesthetized, Strongwater made the incision and told the nurse to call for the blood. Normally this step would have come two hours into the procedure, but that day, for reasons he couldn’t remember, he asked for the blood early.

  He heard a rustling on the phone. He waited. The wound was open. He asked the nurse, “What’s the problem?” She said, “They’re looking for the blood.” Strongwater packed the wound and got the head of the blood bank on the phone.

  “What’s going on?” he asked. This was a difficult operation, he had a nervous family on his hands, and he had no blood.

  She told him there had been an emergency over the weekend, and they had used the blood the family had so carefully set aside.

  He told her to explain this to the family.

  He heard her reply, “You’re the doctor, you tell them.”

  He reddened as he recalled the moment. “At this point I’m not calm anymore,” he said. “If I could have reached through the phone and ripped her throat out, I would have. So here’s your Code of Mutual Respect.”

  He composed himself. “I don’t care they used the blood. That’s okay. They saved someone’s life. Good. That was on the weekend, and this was Monday. Why the hell didn’t someone call me and say, ‘Dr. Strongwater, the blood for your patient was used emergently’? Or say on Monday, ‘Don’t do the case, the blood’s not available’?”

  He had to face the mother. He offered her options: They could do the operation and use banked blood or close the wound and do it another time. She said close the wound. Strongwater did the case a month later at the Hospital for Joint Diseases. “So look at the mess,” he said. “Here I am with all this experience, all this education, all this training, and look at this twit in the pipeline, the clerk who never made the call to notify me. You are relying on people with all levels of training, all levels of skill, all levels of commitment.”

  So why didn’t he want to sign the code? In theory, the system of confrontation and conversation was meant to help prevent situations like this from happening. The hope was that the code would force a discussion, illuminate the weak links, improve the system. The case he used as illustration, which took place in 1999, had led the hospital to tighten its procedures for segregating designated blood.

  “I didn’t sign it initially because I thought it made a comment on the medical staff at Maimonides, that it was so bad it needed a written document for behavior,” he said. “I thought it was atrocious the physicians needed it.”

  Then he changed his mind. “I told David [Feldman], ‘This is great.’ People needed to know the organization was serious about working conditions. Not just OR, not just doctors, but across the board. This only works if you implement this across the board,” he said. “That means the guy who does six thousand cases a year has the same responsibility to that charter as the guy who does two. That’s hard to do from a financial standpoint. I have a running bet with Kathryn Kaplan [the development specialist who worked with Feldman on the Code]. The first time one of the high rollers crosses the line, the organization will back down.”

  I heard that same skepticism many times, including from Pam Mestel, the executive director of perioperative services, Feldman’s nursing complement. Mestel’s father was in the garment business, and she had a streetwise sense of how the hospital’s sociological system produced perfect conditions for spikes in foul language and rude behavior.

  “I have nursing attendants who make twenty-eight thousand dollars a year working elbow to elbow with these attending doctors who come into work in Jaguars and take these magnificent vacations,” she said. “When you’re in the room for three hours, you chat, you get to know someone. Some of the nurses have been here twenty years and knew these doctors when they were residents.

  “Think about it,” she continued. “You can’t do surgery without your in
struments. Our instrument techs make thirty thousand dollars a year, and we expect them to be these highly skilled, ambitious people who are going to make sure the tray is going to be built exactly the way the surgeon wants it. But they don’t have the same drive the surgeon has. It’s not the same drive even a nurse may have. I say this to doctors all the time when they tell me these nursing attendants aren’t working hard enough or fast enough. I tell them, ‘They’re not going to work like you work. They’re not going to stay for twelve hours for the good of the cause or the good of the patient or ‘This is why I came into health care.’

  “How do you motivate someone who makes twelve dollars an hour? By saying, ‘Your next raise you’re getting another twelve cents’?” she asked. “I think what beats them down is the hierarchy, the respect they’re given or not given. Everyone beats down on the one below.”

  While Mestel had been eager to help Feldman with the training program, she was both hopeful and doubtful. “There’s a lot of skepticism,” she said. “The nurses say, ‘Sure, they’re going to tell Dr. Cunningham to stop being rude. Sure, that’s going to happen to Dr. Felicia. He does almost three hundred hips a year. Sure, he’s going to say to the nurse, “Fuck you,” and they’re going to do something to him. Sure.’”

  I first heard about the Code of Mutual Respect four months earlier, at the beginning of my sojourn, on September 12, at a “leadership team” meeting in the conference room next to Brier’s office. Much of the discussion was devoted to housekeeping and various plans—ranging from new solvents to new management structure—that could improve cleanliness. Brier reported on a meeting she had with a group of environmental workers, aka janitors.