Hospital

by Julie Salamon

  “So the guy was constipated. What else is new?” she said. “I go on this seeming tangent because it is part and parcel of pain management. If you went down the hallway at Rusk [the Rusk Institute of Rehabilitation Medicine at New York University] and asked every single patient what their biggest problem was, they would tell you it’s their bowels. But people just pretend like it isn’t happening, and doctors don’t talk about it with their patients. It makes me crazy!”

  Pain, both its management and its side effects, had been part of her life for years. Every so often her narrow face looked frozen and her eyes glazed, as if she were holding in something fearsome. The pain had begun not, as I thought, with the accident but long before that, with flaring back pain in college. It wasn’t until she was fifty that she learned she had an advanced case of scoliosis. Over the years she had tried it all, at the best hospitals: physical therapy, acupuncture, surgeries, and had dealt with a gruesome assortment of side effects, including nerve damage. She had taken revolting drugs that made her mouth feel dirty and painkillers that knocked her out or made her throw up. Percocet turned her into Mr. Hyde, she said, so out of control and obnoxious she decided she would rather be in pain.

  Finally she found relief with an anesthesiologist who was director of pain management at NYU. Every eight to ten months, he injected Botox, the drug often used to relax facial lines, into her lower back. “It’s not very pleasant and not all that scientific,” said Brier. “He pokes around with his finger and tries to find the spasm, and when he does, he buries deep, marks it with a pen, and then sticks in the needle and wiggles it around to get the Botox in there. Very gross, and it does hurt. I must have very relaxed buttocks, I’m sure.”

  For the past eight years, she had regularly taken methadone. “To say I’m addicted to pain medicine is to state the obvious,” she said. “David Cohen told me, ‘You are so crazy to say you’re addicted, because you’re going to need it for the rest of your life.’ No one in their right mind would bother to get addicted to methadone, by the way. It’s not very pleasant.”

  She explained why she wanted this on the record. “Too many doctors are Calvinist and cover-your-ass-ish. I had a very good surgeon who called me and begged me not to take anything for pain. I just said, ‘Don’t you think there’s some correlation between having your pain managed and being able to walk right away and walk so much? I am a hawk about it, and it has influenced what we do. This is a big problem and a big cause of dissatisfaction among patients. It is fundamental. So I have set money aside to begin a pain service.”

  I thought of a complaint about Brier—that she started many projects that couldn’t be followed through because of lack of resources. As if she were reading my mind, she said, “I don’t care if it can’t be everything, but we will start where we can afford to start.”

  Pam Brier was one patient of Beth Popp, the hospital’s specialist in pain management and palliative care. Another was the immigrant Chinese restaurant worker known as Mr. Zen. By early April eight months had passed since he was admitted to the hospital with a cancerous tumor. His unpaid medical bill had crossed the $1 million mark months earlier. His attachment to this earth was growing weaker by the day.

  I began spending time with Popp and her team as they became a crucial part of the final phase of Mr. Zen’s life. His arms had become skeletal; his eyes were large and haunted. The bones of his face stuck out in sharp relief against his black goatee and mustache. The only part of him that was thriving was the enormous tumor pressing on his pelvis. PLEASE WEIGH PATIENT DAILY, said the sign on the wall behind his bed, a reminder to check the growth or shrinkage of the appendage as a ratio of the patient’s body size. A computerized PCA pump (patient-controlled analgesic) dispensing pain medication was attached to an intravenous line. Mr. Zen could push a button to release more of the drug when he was in pain, but he rarely did, even when he was suffering.

  Popp had come by with Nagander Mankan, one of the Indian oncology fellows, a slender, dark-skinned man with a thick mustache, and Anita Kaminer, the nurse-practitioner who specialized in pain management and palliative care. Mankan said he believed that the tumor weighed somewhere between five and ten pounds. After he finished his oncology fellowship that summer, Mankan planned to move to Georgia, he said, where it was quiet.

  Before entering the room, Popp talked to the team. “He has been in the hospital since August and has undergone all kinds of treatment,” she said. “He has no family here, sends money to his mother and sister back in China. He communicates with his mother by cell phone and wants her and his sister to be his health-care proxy. His oncologist speaks Mandarin and he speaks Cantonese, so it’s only a little better than me. Last time we had a speech pathologist who speaks Cantonese who translated. Mr. Zen’s condition is getting worse. We will continue to treat his pain and keep him comfortable.”

  Kaminer, the nurse-practitioner, about to become a grandmother, wore flouncy skirts and shoes that looked like ballet slippers. She was an attractive woman who carefully tended her makeup and smooth, dark hair. She was a quiet, sympathetic presence at Popp’s side. Kaminer told me the nurses were worried because Mr. Zen didn’t use the PCA pump. He wore a pain patch that contained fentanyl, a narcotic to control severe pain; the patch had to be changed every three days.

  “He’s been amazingly stoic,” said Popp. “He has a huge pelvic mass that’s invading the nerve supply to his left leg. He doesn’t have enough strength to walk. He won’t be able to have surgery. He’s had a variety of chemotherapy and been schlepped back and forth for radiation. Gregory Todd, his physician, said the patient is in terrible pain.”

  When we gathered around Mr. Zen’s bed, he blinked his eyes in greeting.

  Popp had asked the speech pathologist to interpret, but she hadn’t arrived yet. In English, the physician asked Mr. Zen, “What is your pain?” A sign with cartoon faces calibrated a pain scale of one to ten. Smiling faces at the low end, sad ones in the eight, nine, ten area.

  “Between eight and nine,” said Mr. Zen in a weak voice, in English.

  What was it before?

  He barely opened his mouth. “Over ten,” he whispered.

  The sun poured in through the window.

  He pointed to his hip. “It hurts here, a little,” he said.

  Popp nodded and asked if he pushed the button when he had pain.

  “No pain,” he said.

  “When you lie in bed and aren’t moved, do you have pain?”

  Yes.

  “Do you push the button when you have pain?”

  No.

  “If you have pain and push the button, you get medicine.”

  No.

  “It doesn’t help?”

  No.

  “So you don’t push the button.”

  Yes.

  The nurse-practitioner went to the computer in the hallway to make an entry, and the speech therapist arrived, a young Asian woman who had a long discussion with the patient in Cantonese.

  “His leg really hurts him,” she told Popp.

  “Did the medicine we give him help?”

  The interpreter nodded and turned back to Mr. Zen. After more discussion, she said, “He would like more medicine.”

  Popp said, “From yesterday to today, he pushed his button very few times. Why?”

  The question was conveyed. “He says he did press it,” the interpreter said. “I asked him if he knows what it is for. He said yes. He knows to press it when he is in pain.”

  The discussion continued for half an hour, and then the pain group stopped at the nurses’ station, where Popp made an entry in the chart in neat left-handed script. She was wearing a new wig. Mr. Zen’s chart was in a binder several inches thick. Eileen Keilitz, the floor nurse who had taken care of Mr. Zen since he arrived in the hospital the previous summer, came to talk to the doctors.

  “Until very recently he wanted to do everything himself,” she said. “For us, because we’ve been with him all the time, we’ve se
en him through a long process. I can’t imagine he would want to be in tremendous pain. Usually Chinese people are very stoic, but maybe it’s the human being who doesn’t want to leave planet Earth. Most times you say to him, ‘How is your pain?’ and he says, ‘Okay, okay okay.’ With someone like that complaining, he must be in excruciating pain.”

  Keilitz said sometimes she went into Mr. Zen’s room and pushed the PCA pump button for him. “I know this defeats the purpose.” She sighed. “He’s supposed to push it. My concern is for him to be comfortable. We’re his family now, in essence. You don’t want to see them suffer.”

  The pain team left for another patient on another floor, a Pakistani woman in her early forties with metastatic breast cancer. She would be followed by a ninety-two-year-old Alzheimer’s patient, tended by his son, who wore a yarmulke. Next on the list was a Jehovah’s Witness from Jamaica, followed by an elderly Italian woman who didn’t explain why she burst into tears when lunch arrived, mashed potatoes and meat.

  As we left Mr. Zen’s floor, Popp said to me, “I think the nurse was more or less saying, ‘Nice for you to pop by for a half hour and have your opinions, but we’ve really been with this patient for almost eight months, and we know him. ’”

  The following Friday, Gregory Todd, the Kentucky convert to Buddhism who was Mr. Zen’s attending physician, told Keilitz to go say good-bye to Mr. Zen. “I went in and put my hands on his head, and I said a little prayer over him,” she said. “I didn’t think it mattered what his religious or spiritual beliefs were.”

  Todd read to his patient from the Heart Sutra, a brief but fundamental text of East Asian Buddhism containing a mantra that addresses the quest for Perfection of Wisdom. Mr. Zen was not a religious man, but he had discussed Buddhism with the doctor. Todd told me he didn’t know if Zen heard him as he read, “‘ Go, go, go beyond, go thoroughly beyond, and establish yourself in enlightenment.’”

  “I’m not sure exactly what he knew at that point,” he said. “We often believe people hear things when they are dying. That was the least I could do for him.”

  Eleven

  The Big Brass Ring

  If you want a happy ending, that depends, of course, on where you stop your story.

  — ORSON WELLES

  In the parallel universe of the hospital, many motives competed and collided. The desire to heal scuffled with ambition and exhaustion; the reality of sickness and death fed vague desires for eternal life through legacy. Buildings and pavilions were named for dead and living relatives, while the people who worked in them carved out little empires, not quite believing that nothing lasts forever. Almost every evening, somewhere in Borough Park, it seemed that someone was being honored for something, a plaque was being inscribed. Abraham Gellman, the young doctor killed in the previous century’s World War II, smiled his Mona Lisa smile in perpetuity in the lobby of the wing that carried his name. The bronze bust of Lena Cymbrowitz, death by colorectal cancer, greeted patients at the Maimonides Cancer Center.

  Yet the very mechanism of the hospital militated against the wish for permanence. Almost everything was transitory: length of stay, standards of care, payment systems, drug protocols, technology, patients, doctors, nurses, bosses, underlings—even the buildings themselves, as architecture and design tried to keep up with the fast-moving changes in medical theory and practice. In New York, as in other densely populated cities, the process of physical redesign was complicated by the scarcity of affordable real estate. Expansion often required grafting one building onto another, by going up, under, or around existing structures.

  Spring came, and the anatomy of the latest addition to the main hospital was taking shape. One way I marked my year at Maimonides was by how high the girders had risen on the sleek, nine-story building that would contain an expanded emergency room, new surgical facilities, and a neonatal unit, plus attractive patient rooms. It was scheduled to open in early 2007 (a date that would be postponed). The construction had to swallow and reconfigure the Hortense and Jacob Aron Pavilion, a living example of visionary miscalculation. Completed in 1964 by a distinguished Manhattan architecture firm, Charles B. Meyers Associates, Aron was round, on the theory that a circular structure would allow nurses sitting at the center a 360-degree view of patient rooms. The design didn’t anticipate the storage closets and elevators that obscured the 360-degree sight lines. This lack of foresight gave the building the dubious distinction of almost instant obsolescence. Month by month, bit by bit, the Aron Pavilion disappeared, an evaporating mirage.

  Dr. Joseph Cunningham remembered what it was like to be the next new thing. Twenty-three years had passed since he was the prodigy from Manhattan, part of an earlier Maimonides effort to play in the big leagues, to rein-vent itself as an academic center, not just a good local hospital. Bypass surgery and stents had revolutionized cardiac care; the hospital’s ambitions were focused on heart doctors, the industry’s superstars. At the time, 1982, Cunningham was forty-two years old, part of the heart team at New York University’s medical center. These self-described “young Turks” trained under Frank Spencer, a legendary heart surgeon whose minions went on to become chiefs in many prominent hospitals.

  Cunningham had been wary of me from the beginning. The first time we talked, he explained why he thought I should make the book a work of fiction. “Who wants their dirty laundry hanging out there?” he asked. He told me that after he’d been at Maimonides a few years, Esquire magazine had assigned a reporter to do a story about him. They met two or three times, in Cunningham’s recollection, and then the conversation got personal. “I’d been married before, and I gave him crap about that stuff,” Cunningham said. When the writer refused to agree to let Cunningham preview the article, the surgeon pulled out. “It became important to me that there were certain things about myself I didn’t want exposed to the world,” he said with a look I took as a warning.

  I understood that this was a man who wanted to control his own mythology.

  Cunningham told me he got a call from Edward Lichstein, Maimonides’ chief of cardiology, who would become the chief of medicine, asking the heart surgeon if he would come to Brooklyn. Lichstein was the same man who, twenty-three years later, would deliver roughly the same message to Alan Astrow, just substituting cancer for heart disease: Too many patients were crossing the bridge toward Manhattan; Maimonides wanted to reverse the traffic flow.

  Sitting in his big, masculine office with its sportsman’s trappings, including the portrait of Hemingway and the boat, the Swamp Fox, Cunningham told me he had been intrigued by Lichstein’s invitation for two reasons, one personal and one entrepreneurial. “I had been at NYU almost ten years, and I was forty-two,” he said. “I had aspirations to be my own boss, to run my own show, to build something I could call my own. In your early forties, that’s your first opportunity. Then, in your mid-fifties, you realize you’re either going to stay or make yet another move. Where I am now, I can’t go sixteen different places. At forty-two you are fearless because you have many avenues.”

  Assessing the situation at NYU, he recognized that his boss, Frank Spencer, was at an age where he wasn’t going anywhere for a decade or more. Besides, Cunningham wasn’t the only hotshot in the pipeline; he knew he wasn’t going to jump in front of Wayne Isom, two years ahead of him. (Isom also left NYU. In 1985 he was recruited to become chair of cardiothoracic surgery by the New York-Cornell Medical Center, which would become New York-Presbyterian Hospital after the merger of the New York Hospital and Presbyterian Hospital.)

  Cunningham told Lichstein he wanted to be not just chief of cardiothoracic surgery but chief of surgery as well. Lichstein agreed to his terms.

  There was ego gratification on the one hand, profit potential on the other: Cunningham saw the chance to earn a good deal of money. “It was the glory days of reimbursement,” he recalled. “We were all making nice bucks.”

  As he saw it, the situation was no-lose. “Maimonides had a failing cardiac program doing a hun
dred twenty-five cases a year with twenty-percent mortality rate,” he said. “What made it easy was that I was already doing a lot of patients from Brooklyn, so I didn’t have to come here and develop a new practice. The pie was so big you could slice it fifteen ways and everybody could still have plenty.” By 2006, Crain’s Health Pulse, a newsletter reporting on the health-care business, reported his annual compensation at just over $1 million. The mortality rate for coronary bypass surgery was well below 2 percent, not among the very best in the country but significantly better than the national mortality rate.

  The doctor who introduced Lichstein to Cunningham was Israel Jacobowitz, who had trained as a resident at NYU under Cunningham and joined his surgery practice. In Brooklyn they thrived—until, like Sam Kopel and his former partners, they quarreled and disbanded. By the late nineties, Maimonides cardiac surgeons were doing as many as twelve hundred major cases a year, with Jacobowitz as the biggest producer. In the early eighties, Maimonides had also hired Jacob Shani, a former resident who had gone on to train at Beth Israel in Boston, to build cardiology. The hospital’s heart program prospered, and eventually Maimonides was designated one of the country’s “Top Ten Heart Hospitals” by Solucient, another company whose business was measuring cost, quality, and market performance of hospitals.

  Like the Kopel-Bashevkin contretemps, the Cunningham-Jacobowitz split may or may not have been about money but it was certainly about the things that they believed money measures. “It wasn’t money, it was principle,” Cunningham told me dryly. “Izzy’s the Rodney Dangerfield of cardiac surgery. In his mind he don’t get no respect. No one can ever stroke him enough.”

  Yet, as usual, the trigger point had been division of the spoils. Cunningham and Jacobowitz had a third partner. No one disputed that Jacobowitz was the hardest worker; it wasn’t unusual to stand outside the hospital at nine-thirty or ten at night and see him walk out and drive away in a pale blue Mercedes convertible. Nor did Jacobowitz resent Cunningham’s smaller caseload, understanding that official hospital duties cut into his surgical volume. It was the proportion paid to the other partner, a friend of Cunningham’s, that irked Jacobowitz. “It was an ultimatum: ‘Either get rid of him or I’m out,’” said Cunningham. “Blood is thicker than water, so I said, ‘Well, Izzy, see ya.’”