Hospital

by Julie Salamon

  “They specifically talked about doctors,” she said. “They didn’t say they were pigs that throw things on the ground—”

  David Feldman interrupted. “Yes they are.”

  Brier continued, “But they are not-nice non-pigs throwing down things and getting grouchy and maybe a little retaliatory. We need to work on this. This is not the hallmark of a mutually respectful workplace.”

  A few minutes later, Feldman and Kathryn Kaplan, the organizational specialist, introduced their strategy for giving the Code of Mutual Respect some bite—or at least some recognition. For the pilot program, they selected perioperative services, in part because Feldman ran it and also because it was a hospital epicenter for frayed nerves and robust tempers (vying for top place with labor and delivery and the emergency room).

  Feldman and Kaplan had been trained in Crucial Conversations, the trademark of VitalSmarts, a company based in Provo, Utah, that specialized in helping organizations—mainly corporations, a handful of hospitals— instill what might be considered rudimentary social skills in managers and employees. Clearly, the World Wide Web, with its magnificent, instantaneous transferral of information and ideas, had not made it easier for people to communicate. VitalSmarts published two handbooks, Crucial Conversations and Crucial Confrontations, both of which were New York Times best-sellers and had been translated into eighteen languages.

  Feldman and Kaplan laid out the plan.

  In January they would begin a customized version of the training for the perioperative staff. The department chiefs had agreed to relinquish one Friday a month, for a total of eight sessions, one of the weekly morning slots reserved for surgical conferences. The training sessions were the theoretical part. The practical application: Those who misbehaved would be called in for an accounting with Feldman, along with the person who felt offended. Each could bring an ally. The sessions sounded like a cross between an administrative law proceeding, couples counseling, and a nursery-school time-out.

  There would be two preparatory stages. Four days after the leadership meeting, on Friday, September 16, at the quarterly perioperative-services meeting, Feldman, Kaplan, and Pam Mestel would introduce the plan. Most important, they felt, was that Brier would come to the meeting to endorse the Code of Mutual Respect.

  In December, they explained, forty-five volunteer members of the hospital staff—including nurses, clerks, and physicians—would receive training that would allow them to be Code Advocates—the “influencers,” Feldman called them, chosen because they were believed to have the respect of their peers.

  The marketing jargon grated, inviting uncomfortable associations from the wider world, past and present, raising a Stalinist specter of institutionalized snitching. But then Feldman said something that made me think again. Did bullies always have to win? “People know something is happening, but there haven’t been any major changes,” he said. “The people who yell and scream are still yelling and screaming.”

  “Code Violators,” someone wisecracked.

  Feldman smiled. “I like that. Yes. Code Violators. I want to put up a plaque with this quote—it isn’t mine: ‘Respect is like air. When you lose it, nothing else matters.’”

  Brier muttered, “No plaques.”

  That Friday Feldman addressed a packed house in Schreiber. He reminded the audience that the Code of Mutual Respect had been endorsed by the hospital’s medical council in 2004; all members of the medical staff were given a copy and asked to promise to abide by it.

  Facing a wall of blank faces, he asked, “How many of you have heard of the Code of Mutual Respect?”

  Six people raised their hands.

  No one responded when he asked, “How do you feel about doctors’ respect for one another? If you’re a clerk, how do you feel about how doctors respect nurses and other doctors? How do they respect you?”

  No one responded when he projected the Code of Mutual Respect on the big screen at the front of the auditorium.

  “Other institutions call it a code of behavior,” he said. “I think that’s too punitive. It is not a bylaw or a policy but a way of life.”

  The crowd did come awake when he asked, “How many of you have been treated disrespectfully in the last week?”

  Encouraged by the noticeable ripple in the sea of scrubs and suits, Feldmancontinued. “Sounds like an epidemic,” he said. “How many times have you been in a situation where someone starts yelling or insulting?”

  A wave of appreciative giggles.

  He told them how, earlier in the year, a court had ordered a doctor to pay three hundred thousand dollars for bullying.

  Another wave.

  He played a video showing two nurses talking.

  “Remember Dr. So-and-So’s parting shot?” said one of them. “He said baboons could take better care of his patients. I see one of the good doctor’s patients has an elevated temperature. Ninety-nine point five. Maybe I’ll call him.”

  The other nurse widened her eyes with the exaggeration of a sitcom character. “It’s two A.M.!” she shrieked. “You wouldn’t!”

  The other nurse picked up the phone, and the screen went dark.

  By then the mood in the room had shifted from dutiful to interested, from listless to attentive.

  With new confidence, Feldman became fervent. “We need a culture change,” he said. “Our patients are savvy. They see what’s going on. You can’t tell me they won’t get better quicker if the staff is more respectful. This is Day Zero. It is no longer okay to act disrespectfully in the operating room.”

  He paused and looked out over the room. “I know what you’re saying,” he acknowledged. “This is the way it’s always been here, and it isn’t going to change. Well, this is like psychic surgery.”

  He explained about Crucial Conversations, and Kathryn Kaplan explained that sometimes the conflicts would be among peers. “We’re going to have interventions when there’s an unfriendly exchange between a physician and an anesthesiologist,” she said.

  Someone in the audience muttered, “An anesthesiologist is a physician.”

  Feldman accepted the challenge. “How many of you think this is not going to work?” he called out.

  Almost every hand in the room went up—the converse of the showing for who knew about the Code of Mutual Respect.

  Feldman decided it was time to introduce Brier. She peered into the auditorium and noticed Enrico Ascher, the $3 Million Man, who had walked in late wearing a sleek suit, sitting in the back of the room. “Dr. Ascher,” Brier called out to him. “Don’t be afraid to come to the front.”

  She then turned her gaze to the room at large. “What is a good workplace?” she asked. “It’s a place where people know they’re going to be treated respectfully. Without it you’re sunk. We’re piloting this program here in the OR because it is the hardest. It’s a tough one. But let me be really straight with you. No one in this hospital is so good, so special, so talented, that this doesn’t apply to you.”

  Big round of applause.

  “Hopefully, it won’t come to that, where people don’t get it and don’t get it,” she said. “You can hold us accountable.”

  Everyone was asked to fill out a survey. Then the session was over.

  Survey results: Almost 85 percent of the respondents felt that the Code of Mutual Respect would positively enhance the workplace, though only 76 percent said they had a clear understanding of what it was. Thirty-seven percent believed that leaders handled disrespectful behavior effectively, and 62 percent felt that physicians were held to the same standards of professional behavior as were staff. Almost 90 percent of the respondents felt they treated others with respect, but only 61 percent felt they were treated with respect by fellow workers.

  Sixty-seven percent of the people in the room answered the survey; of these, 53 percent were physicians, 27 percent were nurses or technicians, 3 percent were ancillary/clerical staff, and 17 percent were “other.”

  Doctors were the worst offenders in
every category. It was believed by 46 percent of the respondents that doctors treated other doctors with respect; only 39 percent felt that doctors treated nurses and technicians with respect.

  My acquaintance with the Code of Mutual Respect deepened three months later, in early December. On a drippy, gray morning, I trudged through the slushy residue of the previous night’s snowfall to the hospital’s “learning center.” It was located ten blocks from the main campus, on a weary residential street of small houses stuck behind elevated train tracks. Antiseptic fluorescent-lit classrooms shared the building with the Maimonides ambulance corps employed by the hospital, not to be confused with Hatzolah, the Orthodox volunteers.

  Waiting for the train that morning, I’d heard a woman tell her companion why she loved her doctor: “I saw this old lady on the street, and her skirt and underpants fell to the ground. Dr. K. was walking by, and he just reached down and pulled up her underpants and buttoned her skirt,” she said in a Caribbean accent. “He’s an old-lady magnet. They all love him. He’s gay, but all the old ladies come to him. You have bad news to hear, you want him to be the one to tell you. He is kindness itself.”

  I was ready for Phase Two, training the forty-five Code Advocates, the “influencers,” the missionaries enlisted by Kaplan and Feldman to spread the Gospel of Mutual Respect. I joined one group of these influencers—doctors, nurses, techs—for the first day of what would be a sixteen-hour cram course in the art of Crucial Conversations. Each of us found a Crucial Conversations Participant Tool Kit on our tables. There were chapters on “How to Spot the Conversations That Are Keeping You from What You Want,” “How to Speak Persuasively, Not Abrasively,” “How to Listen When Others Blow Up or Clam Up.”

  My tablemate was Irving Pineiro, a doe-eyed young man whose job was to keep track of nurses and aides and help orderlies set up for surgery. He told me he had come to work at Maimonides as a janitor, nineteen years old, newly arrived from Puerto Rico, no English. Now he was an administrator, wearing a shirt and tie to work, dating the secretary who worked for Steve Lahey, chief of cardiothoracic surgery. The hospital had been good to him. He told me he believed he’d been chosen to become a Code Advocate because he had complained about nurses being rude to families of patients undergoing surgery.

  Pam Mestel began. “We work in a high-stress environment,” she said. “We know it’s not one person’s fault a screw isn’t in a tray, the blood work isn’t there. The system isn’t what it should be, and we tend to take it out on the person who is there. The question is, how can we change the culture? And the doctor is the most notorious offender. We’re taking you out of work two days in a row, and David’s spending numerous hours with chairmen, talking them into giving up their precious M&M’s [morbidity and mortality meetings] once a month.”

  “I know you’re sitting here thinking, ‘Oh, yeah, we did this five years ago.’ But this is serious. Will it happen in a week? No. But we’re calling people on the carpet. Our vision is that in the future you’ll be able to take care of these situations. It’s like Dr. Feldman said: ‘It’s just respect. Who doesn’t want respect?’”

  Kathryn Kaplan asked, “Do you know how long a culture change takes?”

  Someone called out, “One hundred years?”

  Kaplan laughed. “Wow, this isn’t going to sound so bad,” she said. “Five or six years.”

  The group learned that they would have to distinguish between rudeness, incivility, and bullying, which were Code of Mutual Respect matters, and sexual harassment and racial discrimination, which were union issues.

  Paul McMurray, the consultant leading the sessions—chubby physique, preacherly style—told people to introduce themselves. Meanwhile, sitting at a table near the front, a taut man dressed in blue shirt, slacks, and necktie opened his laptop computer and began receiving and sending e-mails. Steven Konstadt, the new chair of anesthesiology, looked tightly wound as he typed furtively, his almost-hairless head glistening under the lights.

  McMurray the consultant asked Elvia Johnson, a feisty nurse with long braids, “How do you stay in dialogue when a doctor has yelled at you?”

  She laughed. “This happens to us all the time,” she said. “They yell at us, we tell the doctors to call Dr. Feldman. He calls us, we tell him what happened, he calls them, and then they are pussycats.”

  Marion Contino, a nurse with short hair and “don’t mess with me” body language, chimed in, “They respect the doctor’s word more than the nurse’s, so we say, ‘Call Dr. Feldman.’ The doctor sees the doctor on the same level.”

  Pineiro said, “I don’t personally have a problem with this, because I respect them, but I see what happens. If someone has a little higher rank than you, they’ll scream or yell. The doctors yell at the nurses. The nurses yell at aides. That’s how I see it.”

  Konstadt kept typing.

  Another nurse asked, “What do you say to a doctor who says, ‘I wish the patient would die so I could sue you’?”

  Soon McMurray was barraged with lively examples of conversations gone wrong. The gripe session bubbled along, complaints flowing like champagne,gathering festive momentum until Elvia Johnson brought the proceedings up short with a nod toward Konstadt, still typing.

  “I hear what you’re saying and appreciate that this institution is committed to this,” she said to McMurray, Mestel, and the other group leaders. “Then I see Dr. Konstadt sitting using his laptop through the whole thing, and I think that’s very disrespectful. I don’t want to sit here for two days if this is just lip service. There is still a hierarchy here. If this is to work, everyone should be committed, not just us front-liners.”

  Konstadt froze, no longer typing, staring straight ahead. The incriminating laptop remained open.

  McMurray jumped in with the enthusiasm of an acting coach whose student has just opened a vein. “Before I let him talk, let me respond,” he said. “What you see is a doctor with his laptop open. You see laptop open: disrespect . My path, I see something different! I see a doctor who says, ‘I can’t be here today. I have pressing matters beyond my control. I can’t be here.’ But he is here. If he brings his laptop, he can participate at some level. I’d rather have him semiengaged than not here. I tell myself I’d rather have a doctor with a laptop than no doctor at all.”

  Johnson was not impressed. “You see, he gets away with it and I don’t!” she said with a theatrical shrug.

  McMurray changed tactics. “What is going on here?” he asked rhetorically. “Why is the doctor more important than me?”

  Contino said, “We did confront. We went to Dr. Feldman during the break.”

  McMurray continued, “You can see from body language and tone: ‘I am here, I don’t count, I’ve got emotional issues and work issues, but I am frustrated as hell. I am pissed and want to bring a computer tomorrow.’ Or maybe he doesn’t want to be here either, but he can do what he wants because he’s a doctor.”

  Konstadt clutched his knees and then absently pecked at the computer while McMurray went off on a long story about his fears of riding the subway. Pineiro leaned over and whispered to me, “Do you see what’s so bad about him being on the computer?”

  Lunch.

  After the break, before doing damage control with Konstadt, Feldman discussed the mechanics of how the mass training was going to be conducted, once a month in Shreiber.

  A nurse asked, “There will be attendance taken?”

  Feldman looked pained. “There are hundreds of people,” he said. “I’m not sure. The idea right now is, we passively support bad actions. If they see everyone else talking differently, we hope they’ll change. I have Pam Brier’s support. I run the OR. We don’t want to get to the point where I say, ‘I won’t book rooms for you.’ We don’t want to do that, but we want that threat to be there.”

  Konstadt was back on the computer.

  McMurray nodded at him. “Now we’re going to hear from the other side.”

  Konstadt stood and spoke. “I want
to apologize to anyone who took my computer as a sign of disrespect,” he said mechanically. “I’m going to be here four days this week, and I have things to do before the weekend. My beeper is disruptive, so I arranged with my secretary to e-mail me things. Seven years ago I finished an executive M.B.A. program, and I was looking up my notes about negotiations. For this. On a personal note, I have a psychology that could be called multitasking or ADD; it’s part of my learning style. I don’t want to be disrespectful, and I apologize if this ancillary tool is causing any disruption.”

  Feldman explained that Konstadt had already been involved in a trial crucial conversation involving an anesthesiologist and a gastroenterologist. Each of the doctors brought the chairs of their department to meet with Feldman. “That’s the first problem,” said Feldman. “To put five doctors in a room takes three weeks of scheduling.”

  The case involved a patient who spoke only Italian, who entered the hospital with a minor problem and ended up with a cardiac stent, very sick. The anesthesiologist began to discuss the case with the gastroenterologist immediately after the surgery, but he said, “I can’t talk about this now,” and left without explanation. The anesthesiologist was upset and complained to Feldman. He forced a meeting. At this conference, the doctor explained that the patient’s family was sitting outside and wanted to talk to the gastroenterologist. “It didn’t help that one is Syrian with a thick accent and the other is Chinese with a thick accent,” said Feldman.

  They discussed the Maimonides Method: “One of them screams at me, and I scream back louder, and he says, ‘Why are you screaming?’ and I say, ‘When you stop, I’ll stop.’ ”

  Class dismissed.

  Maimonides had a history of freewheeling behavior. Old-timers spoke nostalgically of the giddily righteous tumultuousness of the 1970s, when a group of social workers from psychiatry, angry at cutbacks, stormed the executive office and took the hospital president hostage for several hours. The young union mental-health worker who led the charge, a striking African-American man named Clarence Davis, wasn’t punished but was recognized as a leader. Now, thirty years later, Davis was an executive, director of hospital safety and security, still trim and muscular, still on the move. Every time I saw him, he was racewalking from building to building. I would run to catch him and ask if I could schedule an appointment to talk about emergency preparedness.