Jacobowitz left the hospital for a few years and then came back. Bygones were never bygone, however; every slight was recorded and remembered. The lines were drawn through the ranks: doctors, nurses, technicians, and administrators. Some were loyal to Jacobowitz, others to Cunningham. By the time I arrived at Maimonides, the heart doctors were in the midst of their own palpitations. Cardiac surgery, once the fastest-growing procedure, had dropped by 30 to 40 percent, giving way to less invasive remedies like angioplasty. The feud didn’t help.
Jacob Shani, the cardiologist, became the heart star (he would be adopted by Brier as a personal friend), designer of the “Shani Right,” a specially angled catheter used in angioplasties, the process of clearing clogged arteries. The Shani Right was designed to make a tricky journey, from the groin— where the catheter, a tiny tube, was inserted into an opening of a couple of millimeters or so—through the entrance to the right coronary artery, about a yard away.
Shani, an Israeli who didn’t mind feeding gossip about the feuding doctors, cheerfully described the relationship between his group and his surgeon colleagues: “We were eating their lunch.”
Cunningham had been replaced by Stephen Lahey as chief of cardiothoracic surgery, but the older doctor remained a power center of the hospital, with a full contingent of friends and enemies eager to adorn or desecrate the legends that grew around him. Remaining head of surgery and the hospital’s senior vice president for strategic initiatives, Cunningham commanded respect and fear as he prowled the hospital in his cowboy boots, exuding king-of-the-jungle bravado, even as his allies and antagonists wondered when he would be ready to lay down his scalpel. “One of the most tragic things is to watch a great surgeon at the end of his career become a cranky old man,” said Lahey. The new cardiothoracic chief of surgery continued to have a difficult time asserting his authority in Cunningham’s old territory, a year after he’d been imported to Brooklyn from Massachusetts for a hefty price tag (Crain’s Health Pulse reported him in the $1 million-plus category as well).
“Joe is a great figure—a phenomenal figure,” Lahey told me. “I’m not saying he’s a great man. I don’t know about that. He is a tremendous character.”
I replied, “But those things are quite different.”
Lahey nodded. “They are quite different.”
He added carefully, “I told him I respect him tremendously. But now it’s my turn to put my imprint on this. He understood that.”
That understanding didn’t stop the feuding, which remained corrosive, Lahey said. “I still hear doctors in the community say they won’t send patients here because there’s feuding, and ‘If I send patients to one guy, the other one is going to call me up and say, “Why are you sending patients to him?”’ ”
The feuding surgeons were almost perfect archetypes. Cunningham was Alabama molasses; his jabs were coated in sugar. (“It’s a shame about Izzy, too, because he’s a hardworking guy who’s very talented, he just has this problem. . . .”). Jacobowitz was Brooklyn pastrami, salty, spicy, and apt to cause heartburn.
“If he were polished and slick and political, this wouldn’t have happened,” said Mark McDougle of Jacobowitz, whom the executive admired because he was a good and a fearless surgeon but who also was exasperated with his temper tantrums. “Izzy makes himself an easy target,” said McDougle. “He gets angry, loses control, he’s emotional.”
Like Sam Kopel (and Jacob Shani), Jacobowitz was a product of the Holocaust, born in a refugee camp. He was wired, wounded, defensive. “I don’t think I’d be off base saying Marty Payson and Pam Brier feel they owe some debt to Joe Cunningham,” he said accurately. “I don’t understand it. They weren’t here since 1982. I have been. Maybe it’s my ego, but I think Jacob Shani and Israel Jacobowitz have had as much to do with the growth of cardiac as Joe Cunningham. I think Joe is a good administrator. He can be charming. I guess along the way he developed the allegiance and support of a number of people from within the institution and the board.”
Regarding Cunningham and Jacobowitz, Mark McDougle, the calm man from Ohio, had the diplomat’s desire for a dispassionate approach, a rare attitude that made his office an oasis of reason. “There’s a lot of bullshit in all the stories,” he said. “In my opinion there’s enough validity in what Izzy says for me to conclude he was unfairly treated. Whether it was unfairly this much”—he placed his index fingers an inch apart—“or unfairly this much”—hands wide apart—“I’m not going to quibble. These little games of personality are, in my opinion, truly pathetic. I know ultimately we’re here to take care of the people who live here. Five years later, maybe ten, pick a number, we’re all going to be gone. The idea is to set the place up to make it better than it is now.”
No matter what actually transpired, that was almost always the idea, the aspiration, the hope: to make the place better. When Cunningham arrived for work in 1982, the Eisenstadt Pavilion was a construction site; Schreiber Auditorium was being built, and so were the cafeteria and the medical library. The office he’d been assigned was a mess. “Everything was pretty much a shell, plaster hanging off the walls,” he told me, leaning back in the chair behind his big wooden desk, drawl caressing every phrase. “I remember the first day I got here, I walked into this office and there was an old desk here, a big cabinet that went ceiling to floor where the prior chief had kept everything from his liquor bottles to his textbooks. He’d been dead five or six years. I open the cabinet, and all this stuff falls out.”
Cunningham unspooled his yarn with the patience and timing of the fisherman he was. “There was no welcome reception,” he said. “I remember I went to the desk and I wrote in the dust, ‘I . . . am . . . here.’”
Jay Cooper, the compulsive, aloof chairman of radiation oncology and director of the Maimonides Cancer Center, was there and not there. The cancer center’s location, almost a mile from the hospital, made life difficult for the hematologic oncologists and surgeons who treated cancer patients in both locations. The radiation therapists, tied to their machines, rarely needed to visit the main hospital. Cooper seemed to like the separation, the clean slate, the ability to build an idealized institution removed from the hospital’s grit and hurly-burly.
The radiation department in the basement reflected his desire for a calm, orderly process. His six medical physicists sat behind computers measuring the shapes and sizes of tumors and customizing the angles and intensity of radiation beams for each patient. It was like a temple down there: quiet and serene, unlike the bustle upstairs in hematologic oncology, crowded with patients coming for consults and chemotherapy.
Cooper, a thin man who always complained that he was getting fat, could seem uptight and out of touch. He was most at home with theory and analysis. But he did care about patients. I realized that one day when he had paused after an extended dissertation about something; I idly asked him whether it really was that big a deal for patients to go to Manhattan from Brooklyn—lots of people, including him, made the commute in reverse every day.
He cut me off. “You don’t understand because you’re well,” he said impatiently. “If you’re well, the trip, whether on the D train or by car, is an annoyance. If you’re sick, if you’re anorexic, if you have no will to live, if you’re dizzy, if you’re nauseous, if you’re in pain—I could go down a longer list— then that trip is impossible.”
At that moment his obsessive meticulousness seemed noble. And I couldn’t discount the fact that he surrounded himself with good people. He had won the loyalty of someone like Bernadine Donahue, the radiation therapist whose talents were uniformly praised. It was hard not to like Donahue, who was as warm and natural as Cooper could be cold and awkward. She was that lucky combination of brains, compassion, and common sense, and she had been willing to follow Cooper from NYU to Brooklyn.
The cancer center was approaching its one-year anniversary. Many pieces were in place, many were not. The Breast Cancer Program covered prevention and treatment, from mammography to surge
ry; the children’s oncology service was expected to move in over the summer. The radiation-therapy group was getting more patients but was not busy enough—despite the excellent medical credentials of Cooper and his team. Referrals remained slow, and the intensity modulated radiation therapy function remained on hold, as testing and analysis continued at Cooper’s insistence. Despite the setbacks he kept repeating, “The good news is we’re a lot further on than we were a month ago, and the bad news is we’re not nearly where we want to be.”
Lahey had recruited Joseph LoCicero III from the University of South Alabama, where he was chairman of surgery, to be director of surgical oncology. LoCicero came with a weighty résumé, studded with prestigious research and impressive academic credentials, including Harvard Medical School, director of the surgical clerkship program.
Yet almost everyone seemed to agree with Stanley Brezenoff’s assessment: The cancer center needed another type of prominent surgeon, the medical equivalent of a movie star, someone who generated the kind of buzz that sold tickets. LoCicero was an academic heavyweight with a national reputation, but what did that mean to patients in Brooklyn? Another problem, in the ephemeral matter of star quality: LoCicero specialized in the depressing area of lung and esophageal cancer, where cure rates remained abysmal, not the happy-ending treatment medical centers liked to feature in their ads. And while LoCicero was indisputably distinguished, it was felt that Maimonides also needed a charmer, preferably in a discipline like breast cancer, with a relatively high rate of success—a surgeon with a golden tongue as well as golden hands, who could capitalize on the gratitude of his or her patients.
While waiting for this surgical pied piper to appear, Cooper had time to dream. One day he told me his hope for the center. “Suppose someone pulls their car into the parking lot and is going to get chemotherapy the next four, five days,” he said. “I want a system where we say to them, ‘We know you’re not feeling well, you’re slightly nauseated, and you have two kids who don’t understand why mom isn’t home making dinner. Tell us what you want tomorrow for dinner, and we’ll arrange to have some restaurant to deliver it in take-out containers, and we’ll put it in your trunk. Bring in your laundry, and we’ll arrange for it to be dry-cleaned, and it will be back in your car when you go home. Need your car inspected by the Department of Motor Vehicles? Leave it with us, and we’ll have the local service station inspect it and bring the car back for you.’”
As this inspiring fantasy poured forth, I concentrated on keeping my mouth from dropping open in astonishment. Cooper’s relentless pursuit of perfection was admirable, but he sounded like a crackpot. Have the laundry dry-cleaned? Have the car inspected?
A mental split screen popped into my head: Cooper’s utopian vision appeared on one half like a tidy television commercial; on the other half was Nella Khenkin’s real-world existence, a dark, absurdist comedy. I’d spent hours with Khenkin, the cancer center’s sole social worker, watching her try to obtain basic services for patients from the surreal tangle of bureaucracies that dictated medical care as it existed that spring—not in the ivory tower of Jay Cooper’s imagination, but in the U.S. health-care system as it played out on Eighth Avenue at the tail end of Brooklyn’s scrappy Chinatown, in the Maimonides Cancer Center, a converted check-processing plant across the street from an auto-body shop.
Many times I walked into Khenkin’s small office to find her with her pale, fleshy hand pressing against her forehead, ear glued to the phone, able to talk to me for a half hour while she waited for an answer almost guaranteed to be unsatisfactory. Here is one example, among dozens, maybe hundreds, Khenkin could describe in her luxurious Russian alto:
“Patient came, and we are talking about bras and prosthesis she needs,” said Khenkin. “I was calling HIP, and after forty-five minutes they finally picked up and transferred me to five different people and told me all the DME—‘durable medical equipment’—should go through a special partnership organization not with them, with somebody else.”
The story unfolded with the excruciating detail familiar to anyone who has suffered on the waiting end of a “Let me put you on hold, please.”
“After spending so much time, I was supposed to call this other organization! I call this other organization, which is affiliated with HIP, kind of a management program. They told me they can’t tell me anything, they need to get information and get back to me. They called me much later when the patient wasn’t here, and told me the patient doesn’t belong to the organization and I need to go back to HIP, who sent me there.”
Khenkin didn’t give up. “I can’t even begin to start telling you about the frustrations that go with each patient when you need to get something for them,” she said. “So far I didn’t get what I’m looking for—simply, the name of the vendor agencies that are dealing with patients from HIP for this particular supply. Finally I got the name and the phone number late in the evening yesterday. I contacted them and”—she took a deep breath, as if girding herself for the finish—“the phone is disconnected and there is no such agency! So. This is the story.”
Khenkin’s office was a repository of such stories, miserable epics of organizational confusion so rampant it seemed deliberate. The insurance companies had become as insidious and detrimental to the national health as any illness was. The contractual obligation to cover illness and catastrophe had become submerged in a growing mountain of Catch-22’s that seemed freshly minted to justify nonpayment.
“These insurances get worse and worse,” said Khenkin. “Forget about it! Patient is falling apart, they would not send even a nurse, and forget about the aide. If we present patient is very weak and in pain and end stage of disease, they question to you why the patient is not on hospice. If he is so sick, he needs to be on hospice. If patient is not so sick, why do we need to send him a nurse? He should come to the doctor’s office. No matter how hard you try, you can be as a fish on a frying pan. You can’t justify unless there is an injection that should be done or he is diabetic, and even with this they want the patient to come to the doctor to save money, they don’t want to send the nurse. Very frustrating, dealing with these insurances.”
Khenkin found her work dispiriting at times, yet rewarding when she was able to awaken dormant compassion in a bureaucrat, or wheedle drugs from a pharmaceutical company’s representative, or provide help in ways she hadn’t anticipated.
She told me about a young Chinese mother who needed to come to the center for chemotherapy but was too tired to make the necessary arrangements. She asked Khenkin for help. “She has a job off the books in the nail salon, which she can’t keep because she is so frail and weak,” said Khenkin. “She can’t take care of the child, and the child acts out. The child is constantly not in school. The mother couldn’t explain the reasons and now needs to go to court. I believe after I put everything together and talk to the teacher, I will have to involve the lawyer.
“Someone tells me, ‘I don’t have food,’ I arrange food,” she said. “Or someone tells me, ‘Nella, I forget stuff.’ ‘Did you have your MRI?’ I ask. ‘Do you know it’s not cancer? If not cancer, let me send you to geriatric doctor to check for Alzheimer’s or make a referral to adult health center.’ Or sometimes it’s just grab somebody I see crying and bring in here, and we cry together.”
Khenkin was the heart of the place. She met regularly with a variety of support groups at the center: One for prostate-cancer survivors. Another for people undergoing treatment, or who have recovered. One simply called “the feelings group.”
The feelings in all these groups ran the full gamut, pathos and humor, reassurance and resignation, guilt and accusation, fury and acceptance, advice and understanding. Here’s an excerpt from one session I sat in on, names changed:
Richard, large man with mustache, new to group—he’s here with his wife, Linda, ponytail, in her forties, and a friend in the back of the room, not at the table with everyone else, who forced Richard to come to the meeting. The wife is w
eeping, he’s stoic. “I was diagnosed with colon cancer June twenty-fourth. I went for six weeks of radiation and then removed tumor and colon. I had lung cancer two years ago.”
Linda complained about her husband’s experience at the hospital. “The day before Thanksgiving, we were set for the operation, and they canceled it because they were busy,” she said. “Twice they canceled the appointment on him.”
Richard was unemotional. “I considered both cancers my fault. Lung cancer, I smoked all those years. Then with this one, I was supposed to get it checked when I was fifty years old, and I didn’t. I didn’t want anyone to poke around down there, and now I’m sixty-three years old and everyone and their mother are poking around down there.”
Linda was more specific. “He was bleeding for four years. I’d find blood in the laundry, and I’d say, ‘Ricky, what is it?’ and he’d say, ‘Piles.’”
Nella looked around the table in the conference room; eighteen people of various ages and backgrounds, common and uncommon feelings of submission, defiance, hopefulness, and despair.
“So anyone at this table feel like it was your fault?” she asked.
Richard replied in a brisk and businesslike way. “I did it. I had it. They got it. They took it out, and it’s over with. I can’t say, ‘Why me?’”
Nella nodded. “You dealing with colostomy bag,” she said. “How do you do it?”
Linda answered. “He can’t do it. I do it.”
Hospital Page 36