Hospital

by Julie Salamon

She was talking about changing the colostomy bag, but she was also emoting for both of them. Richard could have been sitting at a card game.

  “He says he’s weak, but I think he’s depressed,” Linda continued.

  “I have a nurse coming tomorrow, and she will show you how to play with this toy,” Nella said. “People are afraid if someone bumps, it will spill, the smell.”

  Richard acknowledged, “I’m having trouble sleeping at night. I sleep all day. I’ll get my energy back when I can sleep. I hate nighttime now. I look at that clock all night long, and they won’t give me stronger medication.”

  Nella gently injected some analysis, which Richard batted aside.

  “I think you’re afraid of sleep, you’re afraid of the disease,” she offered.

  “No,” he said tersely. “I’m not afraid of sleep. I can’t sleep.”

  From the back, his friend spoke. “I see Richard sleeping all day. I know he’s depressed. He can’t stand the bag. But he’s a lucky man. He had lung cancer and survived, and now he had colon cancer and they got it out.”

  Richard’s voice didn’t change. “I know I’m lucky.”

  A large-boned woman with an angular, lined face looked at him. She, too, was a no-nonsense type who had earlier described her reaction to a breast-cancer diagnosis. “This happens to other people.” She had advice. “My brother had a colostomy,” she said. “Carry a match. It gets rid of the smell.”

  Another woman, sixtyish, small, chimed in, looking disapprovingly at Richard’s friend sitting next to the wall. “When this man tells him to be grateful, I feel like when someone tells me, ‘Look at the person with two amputated legs.’ It doesn’t make you feel better.”

  She had said she was treated for melanoma seven years earlier and was scheduled for a breast biopsy the next day. “I was a nurse, and I dealt with colostomy bags,” she said. “It isn’t the nicest thing. But please God give you the strength you need to change your own bag.”

  Nella took the cue. “We need to give you some help,” she said to Richard, and then glanced at the woman who had just spoken. “But in the end you are saying it’s his problem and he’s the one who needs to deal with it. We need to deal with concrete situations. We will send a nurse and social worker to help you.”

  The small woman spoke again, offering one of those unexpected moments of grace with a tender ferocity. “I had keloid scars from when I was a kid and my mother was so judgmental,” she said. “I was ashamed. Then, when I was married, my husband said that scar is a sign of life. Maybe one day instead of seeing that colostomy bag as an ugly, foul, and smelly thing, you’ll see it as life.”

  Khenkin sensed that Jay Cooper found her methods too homespun. When she asked to take one of her groups to the family room, designed for private conversations, she was told no, because they were not allowed to eat there. “We are not animals,” she said. “I tell myself I should not be upset by little things, but it hurts.”

  Another cultural divide loomed before her. Could she cross it, and did she want to?

  Khenkin, who had been in charge of office celebrations, had planned an elaborate presentation for the staff holiday party, built around the idea of the birth of the cancer center. She bought a large stuffed cow, representing the milk supply for the new baby, and a Spider-Man doll to present to Jay Cooper, as protector of the baby, and other gifts for the “uncles”—Astrow and Huang. She bought a chess set for Kopel, the mastermind. When she presented her ideas for the center’s staff holiday party to the planning committee, the group told Nella they worried that Cooper would think the gifts were too corny. Khenkin understood. She left the gifts under her desk and canceled the entertainment she had planned, a man who dressed as a big Gypsy doll and made people dance.

  Several months later she still felt unsure about the direction the center was taking. They were preparing for National Cancer Survivors Day in June. The year before, Khenkin had planned the party, with an Elvis impersonator and music. Cooper had met with the center’s directors and told them the program should be educational, that Elvis didn’t set the right tone. Khenkin worried: Had they become so intent on luring more affluent patients, or those with better insurance, that they would forget their mission to serve the community? Their patients had enjoyed the Elvis party.

  “Maybe we will need to wear a tie now,” Khenkin told me. “I felt in the past my role was to get to every patient, but especially to those who are more in need, who are indigent, who do not have anything and I need to help them. Now I also learned that now we need to concentrate on people who have good insurances, to serve them better, and by serving them we will get money we can redistribute for other people. I’m learning new attitudes, but some things I can’t understand. We need to find the happy middle. Sometimes I would agree we need to wear a tie, and sometimes I would be willing to take off the tie, to be closer to the patients.”

  Khenkin understood the need for change. She agreed with the decision to restrict the pharmaceutical-company representatives from freely wandering around the center peddling their goods, the way they used to (even though she risked losing a backchannel source for medicine some patients couldn’t get any other way). She saw the value of adding a more professional veneer, just as she appreciated the design and comfort of the décor approved by the feng shui consultant.

  But she worried about what might be lost. “I just don’t want us to be too uptight,” she told me. “We’ve come to another extreme. Now when I start talking to someone, they say, ‘Write me a memo.’ I don’t need to write a memo for each little thing. I don’t understand it. Maybe it’s a new way of how people communicate. However, when you work with people, you can’t do it all by e-mail. I believe we should find the middle. We should be with a smile, and we should be buttoned up and zipped up, but in an appropriate way. I’m afraid we might lose our soul.”

  The changes Khenkin was pondering at Maimonides had been happening everywhere. In the United States, it is the custom to mow down the old to make way for the new, but the pace had accelerated. Deference to the past had historically been left to the rotting empires of Europe and Asia, but now the bulldozers were ubiquitous, from Shanghai to Coney Island. Rents in Brooklyn were climbing, even in once-blighted areas like Bedford-Stuyvesant and Red Hook. Medicine, however, could be gentrified only so much. Yes, the technology was amazing. But the profession remained a peculiarly hands-on trade that required manual dexterity as well as a good mind, apprenticeship as well as academics, affability as well as ability. The skill to acknowledge and detect individual deviations from randomized trials required intuition as well as intelligence, a willingness to receive and pass along wisdom. Despite the push to standardize care, hospitals are very much creatures of their environments, tied to the customs and desires of their locales, the peculiarities and ambitions of the people who keep them running.

  I once asked David Kho—the Spanish- and Chinese-speaking resident who was born in Singapore, raised in San Francisco, graduated from Columbia University College of Physicians and Surgeons—what he thought distinguished Maimonides.

  “Giving people a second chance,” he said, a twenty-seven-year-old doctor-in-training swiveling kidlike on a chair at a nurses’ station during a break. “Making gold out of water, or wine out of water.”

  Could he explain that?

  “It’s one thing to take a lot of resources and transform it into a great hospital, which is how the Manhattan hospitals run, with a huge endowment, doing this for a couple of hundred years, getting the smartest doctors and best equipment,” he said. “This place is the opposite of that. With barely any endowment, they cover really most of specialized care that any community could want; that’s amazing to me. And to be profitable! Unfortunately, because of that razor-thin balance, the institution has a lot of insecurity. It is not the Manhattan hospitals. This place day to day has a lot of insecurity about where it’s going.”

  Then he brought up a subject that had been nagging at Alan Astrow for month
s, as the hematologic-oncology chief tried to recruit full-time doctors for his staff. Who should the next generation be?

  “A lot of the doctors here are osteopaths or trained overseas, in the Caribbean or Europe,” Kho pointed out. “Most of the other hospitals in Manhattan, the doctors are trained in traditional big medical schools in the States. It is significantly more difficult to get a residency spot if you’re from overseas. Here they take people who have a hard time applying for a job in Manhattan—not because they’re no good, but there is built in discrimination against foreign schools. My point is, they take people that weren’t regarded as being the top and turn them around and build this amazing place with people who wouldn’t have been given a chance at many other places. They aren’t this flashy, fancy, get-all-these-doctors-from-Harvard place, but they get the job done, and that’s amazing to me.”

  But many of the new chiefs at Maimonides were flashy and fancy, and they wanted to mold the place in their image. Steve Lahey told me, “I trained at Brigham [and Women’s Hospital, in Boston]. They take five residents a year, so they’ll take one from Stanford, one from Duke, maybe one from MIT, and one other one, maybe the Midwest. My job is to make this place as good as that in attracting residents.”

  All winter Astrow had agonized over what kind of credentials should weigh most heavily as he picked members of the future team. Should he choose Mohammad Razaq, the Pakistani fellow who would demonstrate to the growing Pakistani and Muslim communities that Maimonides welcomed them? Or was the preferable choice Sam Kopel’s man, Mendel Warshawsky, the yeshiva-trained South African cancer survivor? Maybe Warshawsky would lure the Orthodox community—the Bashevkin group’s constituency—that had yet to show up at the cancer center in significant numbers? Astrow had also interviewed Yiqing Xu, a gentle, unassuming Chinese doctor he liked very much—a friend of Yiwu Huang’s—who had trained at Ohio State and was living in Columbus. Jay Cooper made it clear that his favorite candidate was Petra Rietschel, a product of Harvard’s Massachusetts General Hospital, currently at Sloan-Kettering. Rietschel was pedigreed— and intense and attractive and interesting. She was a German who had spent eighteen months after medical school working at Chris Hani Baragwanath Hospital in Soweto, South Africa, the largest hospital in the world, where more than half the patients were HIV-positive. She was in the middle of a messy divorce and custody fight and with visa issues that made living and working in Brooklyn appealing—but only on her terms. She was a tough negotiator.

  Astrow finally decided on the two women, Rietschel and Xu. Then Kopel made an end run on behalf of Warshawsky, getting McDougle to agree to pay his salary separately from the hematologic-oncology budget, so the department got an extra oncologist.

  Razaq accepted defeat graciously. “I didn’t blame Dr. Astrow,” he told me. “I know it wasn’t his decision alone. I think he likes me, but there are other factors, people who think it’s better to take people from the outside. I got a little upset, but I don’t blame him.”

  Warshawsky, too, said he had no hard feelings. “I think Astrow’s a nice guy. A very nice guy. He’s just weak. I think he’s worried that people don’t take him seriously. He’s always saying, ‘I’m the boss here,’ and trying to put his foot down to show he has the authority, and I think that comes because he really doesn’t have it yet. I like him, I think he’s a good guy, a good doctor, but I don’t know if he’s ready to take on this place. This is a very tough place. This is a really tough place. This is not a simple walk in the park here. This takes a Kopel.”

  But when I asked him if he saw a difference in Astrow from when they first met, almost a year earlier, Warshawsky nodded and blithely contradicted himself. “Oh, yeah!” he said. “He’s much more authoritative, less meek. If you come through this place, you’ve got survival skills.”

  The cancer center continued to be a financial drain. Bill Camilleri, the administrator hired by Brezenoff and ignored by Brier, felt a noose tightening around his neck, squeezing forth the anger and helplessness of the unjustly condemned. “I defy anyone else to build this place the way I built it,” he told me. “When I arrived here three years ago, we did not have drawings, a plan. We did not even have the property. We had a verbal agreement between upper management of HIP and upper management of Maimonides on a price of what the building would be. The people who worked in the building for HIP were not aware they were going to move, so the lease itself was a six-month process. HIP had nowhere to go, so they vacated only forty percent of the building at first; the rest didn’t leave until March of last year, two months before the opening! We were still able to finish the construction in an occupied building. In less than two full years, we went from nothing to an operational building.”

  He was breathing hard. He had a reputation as a fighter but he looked like a weary munchkin, a short, stocky man with a thick beard and a tired heart. He was fifty-two years old, yet appeared to be a decade older. Just a few months earlier, he’d had what he called “a major cardiac event” but returned to work two weeks later. The heart defect that had dogged him since birth— tetralogy of Fallot, the “blue baby” disease—never let him rest. He’d changed his pacemaker sixteen times since the first one was installed when he was fifteen years old. He knew he needed a heart transplant; it was a struggle to walk back from lunch on Sixty-third Street, a block away. But he didn’t have time.

  Camilleri took stock of what had happened in the past year, positive and negative, in the building he’d brought into being. He ticked off a long list of accomplishments and frustrations: systems that had had to be installed, transferred, coordinated, or repaired—the electronic medical records, the lab, reimbursement coding for drugs and chemotherapy infusion, security, marketing, staffing, billing, food. The damn food. A year later, and they still hadn’t found a kosher caterer who would come to Chinatown. So the elaborate plans for a comforting dining area had been downgraded to snacks out of vending machines.

  He’d had to bat a few heads, and he would bat a few more if that’s what it took to get the job done. He got things done. He finished the cancer center on schedule. When Astrow had his spirituality conference in the fall, Camilleri had turned unfinished space into a beautiful meeting room in record time.

  It was all coming together, he told me. “The cancer center isn’t a building but a program, and it’s jelling. Hematologic oncology has recruited a couple of new physicians. Dr. LoCicero is coming on board. Volumewise, things are good; patient-mix-wise, in terms of insurances, not as strong as we’d like it to be. We still have our political issues with the Bashevkin group. We have lots of instances when patients don’t follow instructions. We had a Chinese-speaking patient who spoke English and Chinese. He was told in English and in Chinese by a doctor not to eat when he came in for a PET/CT scan and he walked in eating a candy bar. He did it twice.”

  That kind of mistake would happen less often when they began the patient-navigator program, he believed. One of Douglas Jablon’s patient representatives would soon take the job, to guide patients through the system from the minute they walked in the door.

  A couple of years earlier, Camilleri told Sondra Olendorf, who had been a friend to him, “The writing is on the wall. Pam hates me.” With everything he had done for the hospital, Camilleri had begun to hope the president would relent. Maybe she would recognize his merit, and he would be able to stay at Maimonides until he retired. There was so much he wanted to do! But events and signals over the last few months had led him to believe he should rethink his plans again. Pam Brier had never warmed to him. He had never been invited to her monthly meetings with Cooper, and she never picked him for a single committee he volunteered to be on. Now the cancer center was the albatross dragging down the hospital’s bottom line, and he was the administrator.

  Olendorf worried about Camilleri. “He did get the cancer center built, and that should be celebrated,” she said. “But it’s a slow start-up and an expensive one, and he’s in this position where every budget meeting
we’re talking about the loss from the cancer center, the loss from the cancer center. I feel bad about that.”

  The single-minded doggedness and self-reliance that were virtues during the building phase had sometimes made him seem truculent when he had to deal with daily administration. “He has irritated people,” Olendorf told me. “There have been too many fights. Fight with information services, fight with some of the doctors, fight with some of the construction people. He is so proud he didn’t reach out often and early enough to other people for advice. He is strong-willed. In nursing he wanted to fire everyone in hematologic oncology, and I said, ‘Get them some specialty training, give them a chance.’”

  She wondered if the organization hadn’t set him up for failure. “We didn’t welcome him here with open arms,” she said. “Not anyone. Stan met him and hired him on the spot and just sort of let us know he’d hired an administrator for the cancer center, and then Stan left. Bill, poor guy, innocently enough kept bumping up against people’s ideas of how things should go.”

  Mark McDougle had supported him and protected him, but not long after Camilleri returned from work following the heart incident, McDougle took him out for dinner and told him they were bringing in another administrator. Just to help, McDougle assured him. Camilleri chose to believe McDougle when he said that the new person—Jill Patel—was to be his partner, his helper, not his replacement. After all, Camilleri said to me, would Pam Brier want to take a fifty-two-year-old person who did an excellent job, who had a serious heart condition and needed a heart transplant, and tell him to go out and die? If that is what she wanted, she would have to make it happen, because he had no intention of leaving.

  Brier had only recently turned serious attention to the cancer center. Brezenoff had hired Camilleri just before Brier was scheduled to become chief executive. Then the accident. By the time she was beginning to feel back in control at the hospital, McDougle had been hired. He was interested in the cancer center, so Brier let him be the point man. But her pet project, the free colonoscopies, had gone nowhere for almost nine months after she’d made the big announcement at the cancer center’s opening. So she added that program to David Cohen’s responsibilities, and things started to happen.