Hospital

by Julie Salamon

  “There is such a thing as a white lie,” he told me one day. “Telling someone they are going to live when they are going to die is too serious a white lie.” Yet when Marie told him in winter to cure her by June, he did not tell her that it was almost impossible to cure stage-four gastric cancer. He told himself he had some doubts. There were false-positive CAT scans and false-positive PET scans sometimes. He, like almost every doctor, had had patients who’d been written off and then, after treatment, lived for years.

  So he offered Marie a partial truth. He said, “I’ll try.”

  The chemotherapy didn’t work, and neither did the pain medication, as the mass in her stomach created unbearable nausea every time she tried to eat. When he visited her room, he always pulled a chair next to her bed so they could talk face-to-face. He would begin, “Let me tell you how I see things, and you tell me how you see things.”

  She told him that she was in terrible pain, but the pain medication made her so nauseated that even water made her vomit. She said she hadn’t eaten for a week, but she didn’t care about food. “I just want a glass of cold water,” she said. He told her he would try to find a different kind of nourishment, through a tiny tube inserted directly into her stomach, that wouldn’t cause vomiting.

  By June 1, Marie had become skeletal. The leopard blanket was rolled up on a chair, and she was wearing a standard-issue hospital gown. She was being fed and medicated through intravenous tubes. Her stomach was swollen with fluid.

  When Beth Popp and Anita Kaminer dropped by that day, Tina said she wanted to stop all the IVs in her sister and that she would ask Astrow about draining the fluid. Out in the hallway, Tina told me she didn’t want people to think her sister was pregnant when she died. She told me Astrow called every night.

  Back in the room, we could see that Marie was already somewhere else. Her large eyes looked enormous now, only half open. She didn’t respond when Tina leaned over and yelled, “Marie! Mommy’s here.” Their mother, a small Italian woman with carefully teased hair, wept in the corner of the room.

  Tina told us that the previous weekend some cousins had brought her sister a pair of Manolo Blahnik shoes. By then Marie was rarely conscious, but she rallied when her sister showed her the shoes. “She insisted on trying them on in bed even though her feet are so small now,” Tina said. “She didn’t like the color, but she wore them.”

  Tina walked to the closet and pulled out a box that had a $628 price tag on the outside. “They are handmade,” she acknowledged, as she removed one of the shoes and examined it. “We like a higher heel and more strappy.”

  Their mother spoke. “She go crazy to buy those shoes.”

  Kaminer, the nurse-practitioner, offered, “My niece bought a pair like that for her wedding.”

  All of us stared at the Manolo Blahniks, with their totemic power. Tina said, “She said to me, ‘I like them a little strappy,’ and I said, ‘I’m sorry, I didn’t pick them out.’”

  Tina had many hours at her sister’s bedside to think about what Marie would like to wear at her funeral. There was a beautiful new $200 skirt to consider, and a lovely wig. There was the leopard headband.

  I remembered standing with Tina and Astrow by the elevator bank, after a conversation about whether Marie should go into a hospice program.

  “So long as she doesn’t know,” Tina said. “She doesn’t want to hear it. She associates hospice with terminal.”

  Astrow told Tina, “If there’s anything she wants to let her children know, now is the time.”

  She shook her head. “The children were here, but she couldn’t communicate, she was so drugged.” She said a priest had come to visit.

  Haggard from lack of sleep, wearing jeans and a long-sleeved T-shirt, she glanced down at her feet. She apologized for wearing flip-flops and then looked up at Astrow, in his white doctor’s coat.

  “Marie likes your beard,” Tina told him.

  Astrow’s mother had died that spring, and he decided to follow the dictates of shloshim, a thirty-day mourning period during which men don’t shave or get haircuts.

  He smiled through his stubble. “Dr. Kopel told me to shave.”

  Then Tina asked him to respect her sister’s wishes, to avoid telling her that she was dying. “Out of respect for her, you can’t tell her.”

  Astrow said, “She knows what’s going on.” Then he said, “You’ve been doing beyond what any person can do. It’s been inspiring to see what you’re doing.”

  Tina said, “My brother won’t like you right now, because you can’t tell him what he wants to hear. I had to tell my parents, my sister upstate. She lost her husband to cancer a couple of years ago.”

  Astrow reassured her, “We gave her aggressive treatment.”

  Tina’s face was pierced with grief. “She looked good until the last time you saw her in the office, before the hospital,” she said. Her assertion sounded like a question.

  Astrow paused, as though making sure he got the answer right. “Your sister looked beautiful,” he agreed.

  Tina nodded and turned back toward her sister’s room.

  It was then that Astrow asked me, “Did you know what you were getting into when you decided to write this book?”

  Short internal answer: Of course not, how could I? Who ever knows?

  I must have known that it was likely I would encounter death. I must have known that the likelihood increased exponentially the minute I decided that Alan Astrow, an oncologist, would be a significant figure. As he said to me, “There are plenty of happy cases, but in the hospital you see the worst cases. At the cancer center, you see a range. Most patients are fine, they go to work—they are fine. But for solid tumors—usually lung, stomach, even colon—despite all the hype and hoopla about the progress we’ve made, the number of people who benefit is a minority.”

  Did I know what I was getting into?

  I responded with the journalist’s trick: Answer a question with a question. “Did you know what you were getting into when you decided to be a doctor?”

  He conceded the point with good humor. “I guess not,” he said.

  Months later his son Raphael Astrow, then thirteen, told me he had gone to work with his father three times. The last visit, he said, made an enduring impression.

  “It wasn’t my favorite,” he said. “My dad had to tell someone she was about to die. It was really sad, terrible.”

  He also said, “I didn’t expect anything like that on his job, really. I didn’t expect that.”

  Did it change the way he looked at his father?

  Raphael was dark-haired and slender, a smart and earnest boy with pale skin and braces, a boy who appreciated good books and the New York Jets. He took his time to answer.

  “No, not really,” he said. “It changed the way I look at his job.”

  How?

  “It was tough,” he said. “Tougher than I thought. I knew it was very difficult, but I didn’t know emotionally it was so tough.”

  Did he tell you that?

  Raphael shook his head. “Not really,” he said. “Not so clearly. You can’t really know what’s going on until you see it.”

  On National Cancer Survivors Day, Jay Cooper and Nella Khenkin found common ground in a conference room decorated with a large rainbow. Khenkin chose the entertainment, which included a Russian woman playing the keyboard, Chinese fan dancers, and a junior-high student with a thick Brooklyn accent who belted out a Mariah Carey song. The fan dancers were late, so the program was rearranged; next came the long lecture on nutrition and the role of herbs in a healthy diet, to please Cooper. Still waiting for the fan dancers, the patients and former patients joined in a spontaneous sing-along, gaining momentum with “You Are My Sunshine.”

  Cooper acknowledged the rainbow. “For those of you who like symbols, this year’s symbol is a rainbow of hope,” he said. “To some degree you can pick how you want to interpret that rainbow. One interpretation is that the rainbow has many colors. There are
many kinds of tumors, many kinds of treatment, many ways we make progress day by day. . . .”

  Alan Astrow thanked the patients and their families and friends for coming to the celebration and singled out Khenkin for making it happen. Then he introduced Bill Camilleri, who a few days earlier had been told by McDougle that the hospital wanted someone else to take the cancer center to the next stage. “He built this place from the ground up,” said Astrow. “It is a beautiful facility, and a lot of that is really thanks to you.”

  Camilleri was gracious. “I’m happy to see everybody here,” he said before reading a canned message from President Bush and introducing Steven Cymbrowitz.

  Out in the hallway, a slight elderly man who said he was Marty Payson’s cousin complained. “My wife, she has colon cancer, now the lungs, and I’ll tell you, she knows more than the oncologist knows,” he said. Nodding toward the sounds coming from the celebration, he grumbled, “My approach would be different. No speeches! No songs! You’ve got to make them laugh, laugh is the thing.”

  Over at the hospital, a banner had gone up:

  Maimonides Congratulates Its Graduates and Welcomes New Interns and Residents

  I sat on a bench outside Gellman on a warm, windy afternoon with David Gregorius, about to celebrate his one-year anniversary. I hadn’t recognized him when he first walked up; he’d grown a mustache and beard.

  “Are you going Hasidic?” I asked.

  He laughed and shook his head. “No, I’m not! I’m not!”

  “No payot?” I teased, twisting my finger next to my ear, referring to the side curls common among the Hasids in Borough Park.

  “Is that what they’re called?” Gregorius replied. “My attendings are doing that, too. ‘Hey, dude, what’s up with the beard?’”

  He explained he was preparing for his tenth high-school reunion in Nebraska. “Some of my friends are having a mustache-growing contest.”

  “How are you?” I asked.

  “I’m enjoying the warm weather,” he said. “Oh. You mean, how do I feel about New York? Maimonides?”

  “Yeah.”

  “New York is growing on me a little bit, but still not somewhere I want to be forever,” he said.

  That’s when he told me about Loma Linda.

  “Actually, I attempted to transfer to a program in Los Angeles, where my girlfriend is, but I didn’t get in. The whole process made me appreciate here, because I had to tell all my program directors and everybody, and they were so upset. They understood completely. They had met Jenn. They said, ‘We don’t want to lose you, and we hope it all works out for you, but we also hope it doesn’t.’ I had to ask five or six attendings for letters, and they were reluctantly happy to help. I never felt so appreciated.”

  I said, “Like going to your own funeral.”

  “Exactly!” said Gregorius. “Like the living funeral. So that California thing didn’t work out. Which is fine. I took a shot. If it was meant to be, it was meant to be.”

  As we sat there, some young African-American women in scrubs stood on the curb smoking cigarettes and talking. A group of black hats, Orthodox men in long black coats with beards and payot, walked by. Gregorius grinned and tugged at his beard.

  Across the street a group of about thirty significantly pregnant Chinese women waddled through the doors of Eisenstadt, following a woman holding a clipboard talking to them in Chinese. Every month the hospital had a special Chinese-language orientation for pregnant women. They met for a couple of hours in the boardroom and then were taken across the street to visit the Stella & Joseph Payson Birthing Center, named for Marty Payson’s parents.

  Gregorius looked at them. “I did a month in labor and delivery,” he said. “It was funny, ’cause a young girl, normal—I shouldn’t say ‘normal’—a young girl would come in and say, ‘I’m having a baby, I’m having a baby.’ You say, ‘Yeah, yeah, sit down. I’ll take a look.’ Then you examine them. They’re having a baby? They’re not having a baby. They’ll have a baby in about twelve hours. But when an Orthodox Jewish woman comes in and says, ‘I’m having a baby,’ the red flag goes up. You say, ‘What number is this?’ They say, ‘Eleven.’ You say, ‘Let’s go!’ I’m not kidding. We have so many on more than number ten. Most women are freaking out because they think they’re having a baby, but they have plenty of time. When the Orthodox women say they’re having a baby, the baby is right there ready to drop out.”

  John Marshall, Gregorius’s program director, had told me that the young doctor from Nebraska had been chosen as Intern of the Year. “He’s a good clinician, very much a team player, hard worker, people really like him, people hated the thought of him going.” He told me that Gregorius was a leader—“despite his humor and sort of lackadaisical personality”—pretty much a shoo-in for the position of chief resident the following year.

  I asked Gregorius, “If you look back on this year—this is a huge question, but how do you think you’ve changed, if you have?”

  Gregorius gave me what I deserved. “Have I changed?” he said slyly. “I have more facial hair.”

  I persisted. “What do you think the imprint of this experience will be?”

  He turned serious. “It’s definitely made me a stronger and better doctor, but that’s gong to happen anywhere,” he said. “Kind of like you, I’ve learned a lot of stuff about different cultures, that’s for sure. I can say a lot of things in Russian and stuff like that now. I don’t think it’s changed my view of other cultures, but sometimes I am very flabbergasted at the way immigrants who were kids when they moved here now have kids who were born in Brooklyn, and they can be ten or eleven years old and they don’t speak English. Usually the child speaks English and the parent doesn’t, and sometimes it’s even the other way around, where the parent spoke English and the child didn’t. I tell that parent every time, ‘This kid should learn English. This is America, and eventually they’re going to want to leave Brooklyn, I hope. There’s so much beautiful stuff to see. Check out Montana. It’s great!’”

  I asked him if he regretted the mistake he made, pushing the M for Maimonides?

  “I’m more into living by the mountains, by streams,” he began.

  By then, weirdly, the wind had kicked up; on my tape recorder, Gregorius sounded like he could be standing on top of a mountain.

  “But I don’t think of this as a hell nightmare or anything,” he said in his laid-back voice. “I’ve been really lucky my whole life. Things seem to fall into place. I’ve gotten my second choice in about everything. After high school I wanted to go to the Air Force Academy and didn’t get in but got accepted to the Naval Academy, and that was one of the best experiences of my life.”

  He continued. “I saw Top Gun and wanted to be a fighter pilot and then found out I couldn’t because my vision wasn’t twenty-twenty. I wanted to transfer to Notre Dame, and I had like a three point four average, but that wasn’t high enough. So I went to Colorado at Boulder, which was one of the best things that ever happened to me. Then for medical school I wanted to go to Colorado or Nebraska and didn’t get in, so I went to Arizona, and that was one of the best things that ever happened to me.”

  And Maimonides?

  He stretched out his legs and crossed his arms, thinking.

  “New York is a big city that is not my final destination and a really busy hospital that I appreciate working in, though it’s really grueling,” he said. “I’m learning from really brilliant guys, like Dr. Marshall. I think, ‘Man, that guy could go anywhere he wants, and he stays in Brooklyn! In the long run, I think it’s going to be good for me.”

  A few months later, I received this:

  FROM: “DAVID GREGORIUS”

  TO: ; “CARL RAMSAY”

  CC: “JULIE SALAMON”

  SENT: TUESDAY, SEPTEMBER 26, 2:25 AM

  SUBJECT: PLEASE PAY ATTENTION TO THIS ONE . . .

  Comrades—

  I have something important to say. And it’s not-my-usual stupid and
aimless email, so please pay attention . . .

  It is with heavy (but excited) heart that I must tell you all that I will be leaving Maimo and Brooklyn and taking a residency spot in California. It is a long story, starting last spring with my applying for a position at Loma Linda University, it not working out, then I was contacted about a month ago by their Program Director that they still had an opening, and with Dr. Marshall’s blessing I applied for it. And much to my surprise, they chose me for the spot. The timeline for this transition is still up in the air, but I will certainly be moving within a month, probably sooner.

  One day I asked Marty Payson what lessons he thought Maimonides could teach people in the hospital business, or was it just doomed to a state of perpetual crisis? Health-care reform was a major platform of Bill Clinton’s 1992 presidential campaign. Fifteen years later health-care reform would be a major platform of every presidential candidate, including Hillary Clinton, the former first lady.

  The Maimonides chairman had just gone onto the board of the Nassau Health Corporation, responsible for the public health-care system in Nassau County, Long Island. He had been chairman of Tulane University’s health-sciences committee, with oversight of the university medical center, and he was chair of Howard University’s medical-affairs committee.

  Payson’s small office in a law firm on Manhattan’s East Side was decorated with breathtaking photographs of vistas he had climbed to on his mountaineering and long-distance-biking expeditions. He was a roly-poly dare-devil, who insisted that he was careful. He had done plenty of time at black-tie dinners, but he liked to order in lunch from the deli downstairs, using the paper bag as a place mat.

  Payson had just turned seventy years old. He had been on numerous boards and a top executive at a huge entertainment company. “The company I helped build, today it’s just another big company with all its problems,” he said. “The fun has gone out of it. With the hospital, you hope you leave something. You never know, but that’s the goal.”

  What about the big-picture, national health-care policy?