by Lewis Thomas
I objected, but very mildly, for fear they might be convinced by any arguments I might make. I pointed out that I was by that time a long way away from clinical medicine, which was obvious, and that my previous experience had been as much in pediatrics and neurology as in medicine. I said the obligatory things about how the committee ought to look further afield to find someone better qualified, but then I said, loudly enough, that if they really wanted me to do it I’d move in a minute.
Not that I was discontent in pathology. I wasn’t; I loved the job and the department and was having the time of my life, and I could happily have stayed a pathology professor all my life. But the chance to run the clinical services in Bellevue Hospital was simply beyond resisting.
Bellevue was rather like the Boston City Hospital, an ancient set of buildings beginning to fall apart, long open wards filled with the sickest and poorest of New York’s citizens, inadequately supported by the city but obliged, unlike any other hospital in Manhattan, to take in all patients who came to its doors. In 1958, the medical services were divided among NYU, Columbia, and Cornell; NYU had responsibility for the third and fourth divisions, occupying four floors of wards in the old C & D Building on the south side of the Bellevue campus facing the East River. Columbia had the first division and Cornell the second, each with two wards. There was a lively, sometimes bitter rivalry among the three schools for space and prestige, but the other two directors, Dickinson Richards of Columbia and Thomas Almy of Cornell, were universally respected figures in academic medicine and also good friends of mine. The only hard problem was the other NYU medical service, the fourth division, which had always been managed by the postgraduate medical school, a separate part of New York University with a clinical staff based some blocks away in the old Postgraduate Hospital. It had been used for many years to teach refresher courses to practicing physicians who came to the wards for periods of several weeks throughout the academic year, but it had never had medical students roaming its wards, nor did it possess much in the way of space or facilities for research. My job was to organize a single NYU medical service, to combine the fourth division with the third, and to use all four floors—about 120 beds—to teach medical students and house staff. It seemed a risky business at the outset, feelings waiting to be hurt at every turn. There were two separate missions involved: undergraduate medical education and postgraduate teaching, seemingly incompatible with each other; also, the two professional staffs were potentially at odds with each other, one devoted to fundamental aspects of scientific medicine with ambitious plans for building more extensive research laboratories, the other committed almost entirely to the practice of medicine. Moreover, there were problems ahead of the very worst kind, having to do with the economics of medicine: plans were already being drawn for a brand-new hospital for private patients to be built just to the north of Bellevue, into which the old Postgraduate Hospital would be moved with its name changed to University Hospital. Would this be for the private patients of the physicians on the fourth division, or the third, or both, and how would the beds in the new hospital, on which doctors’ incomes would surely depend, be apportioned?
There was another problem. One of NYU’s most difficult tasks, not shared by Cornell or Columbia, was the management of another set of wards within the Bellevue Psychiatric Center, called the psychomedical division. These were the beds occupied by patients who were simultaneously psychotic and medically ill—schizophrenics, manic depressives, alcoholics, and senile patients who were brought to Bellevue with pneumonia, meningitis, heart disease, diabetes, or any other condition requiring the skills of internists as well as psychiatrists. These wards had to be integrated somehow with the other parts of the NYU medical service and used for teaching and research.
It seemed an enormous job, and neither I nor any of my friends in the NYU faculty was sure it could be done. It was assumed that there would be academic squabbles all over the place and resistance on all sides to any sort of change. As it turned out, it was remarkably easy, and I held the position for eight years, a record for me at that time. I only left it, and then with reluctance, to become dean of the medical school.
What made it work was the quality of the people involved. Although engaged in quite different commitments and obligations, the senior members of the two staffs were, with a few exceptions, extraordinarily skilled in their lines. Moreover—and this made all the difference—most of them had been trained and brought up in Bellevue, and had chosen to stay for their careers in that hospital. My closest friends—and the best clinician-scientists I have ever encountered—were Saul Farber, a noted kidney specialist, and Sherwood Lawrence, the discoverer of the “transfer factor,” an important component in immune reactions. These men, and their colleagues, were in love with Bellevue—the whole hospital. The two departments became a single working unit, almost overnight.
It may also have been an advantage for me to have come into the chairmanship from such a mixed background in academic medicine. I was not conceivably a threat to anyone. It was conceded that I knew something about infectious disease and immunology, but unimaginable that I could turn myself overnight into a Geheimrat ready to dominate all branches and specialties within NYU medicine. Also, it was clear enough that I was not likely to convert myself magically into a master practitioner and take over the beds in the new hospital.
Gradually, over the next few years, the department expanded with some coherence into a fairly large organization with clinical and research disciplines of solid strength. There were several floors of unoccupied rooms, some of them bedrooms used long ago for patients with tuberculosis, and these were converted into serviceable research laboratories. Other laboratories were made available in the medical school building itself and, when finally constructed, within University Hospital. It became a big department for the time, with a house staff of more than sixty interns and residents and a somewhat larger number of postdoctoral fellows and research assistants. By 1966, the department’s group of young clinical investigators and teachers were turning up as selected speakers on the podium of the Young Turks (the American Society for Clinical Investigation) at the annual May meetings in Atlantic City, in numbers to match their competitors in the other research-oriented universities elsewhere in the country. To have a paper on the program in Atlantic City was the most important event in an academic career in medicine in those years, a firm step up life’s ladder. It still is, although when that city became the center for gambling casinos, the meetings were scheduled in other cities; it is still officially announced, each year, that the “Atlantic City meetings” will be held in San Francisco, or Washington, or wherever.
During my time in Bellevue, the ward rounds in which I took the greatest interest were on the psychomedical service. These wards had previously been regarded by the teachers, house staff, and students as a Siberia, but they became, on close scrutiny, a gold mine for teaching problems, easily the most intellectually stimulating area in all the vast reaches of Bellevue Hospital. Patients who were brought in with what seemed to be commonplace, everyday illnesses, neglected because of mental incapacitation in their homes or on the New York streets, turned out to have one exotic disease after another superimposed on mental illness or even, on occasion, problems like thyroid disorders hidden away as the cause of the mental illness. I have never seen, before or since, so many different manifestations of chronic alcoholism, most of them brain syndromes due to alcohol itself—delirium tremens, Korsakoff’s syndrome, Wernicke’s disease, polyneuritis, acute alcoholic hallucinations, aphasia. I had been taught, long ago, that most of these were irreversible and that nothing could be done to change the course of events once alcohol had started dissolving away the brain. It was a constant surprise to see some of these patients gradually emerge from their version of hell, get well, and, clean and neatly dressed, leave the hospital, most of them on their way back to the Bowery despite the strident warnings and finger-pointing exhortations of the house staff a
nd nurses. I knew one middle-aged man who was in and out of the psychomedical ward ten times over a three-year period, each time with profound aphasia and total loss of memory; each time, with nothing but bed rest, nourishment, and good nursing care, he was transformed back into an intelligent, thoughtful but rueful, good-humored man, on his way once more to the skid rows of town.
Bellevue served as the city’s hospital for sick prisoners sent in from Rikers Island or the House of Detention in Manhattan. Some of these people were known to be dangerous, and beds were provided for them on locked and guarded floors in the psychiatric building, known as the psychoprison wards; others, convicted of minor crimes, were admitted to the open wards of the NYU services, always accompanied by police officers, who were stationed at the bedside in rotation throughout the day and night. The police seemed to like this leisurely duty, but the interns were always indignant at what seemed an infringement of their authority and a waste of city money. I remember one such patient on a ward I rounded, an elderly, obese man caught pickpocketing in Times Square who had gone into congestive heart failure while serving time on Rikers Island. I examined him, propped up inside his oxygen tent and breathing what looked plainly like his last, while an armed cop stood sharply on duty looking over my shoulder. It seemed to me that both of us were performing a futile ritual at a death bed. My contribution surely could not help, his certainly wasn’t needed to keep the poor man in bed. Luckily, digitalis and diuretics were unexpectedly effective, and after several weeks the man was out of his tent, able to sit in the chair alongside his bed, chatting amiably with his police guards. Finally he was discharged and taken back to jail to finish his short sentence, and that was the last we saw of him until six months later, when he arrived back on the ward, once again in an oxygen tent, arrested again in Times Square for pickpocketing. We lost track of him after that admission. For all I know, he may still be at it.
For an intern, Bellevue was a unique place for learning how to provide the best of all possible medical care for the sickest of patients under the worst of conditions. If you could make it at Bellevue, you could thereafter cope with almost anything. One of my interns, a quiet, reserved, very bright graduate with top marks, vanished from the hospital a week after beginning service; the police found him unconscious in a midtown hotel room where he had gone to kill himself with Nembutal. He was revived, and we took him back, after he explained apologetically that he had been afraid of not being good enough, afraid of making mistakes. Reassured vehemently, he went back to work and later turned out to be one of the best doctors in the hospital.
Every kind of medical equipment, every item from penicillin to toilet paper, was in short supply and often lacking altogether. Interns on one ward learned to swipe from other wards in emergencies, also to hoard supplies. Everything needed repairing: beds, wheelchairs, litters, radiators, windows, elevators. Especially elevators, malfunctioning or out of commission almost half the time. When Dickinson Richards retired from the Columbia division, we gave him a dinner at the Century Club, and after the speeches we presented him with a bronze paperweight, cast to duplicate the elevator buttons in the A & B Building and their accompanying notice: one button stamped UP, the other DOWN, and a small sign reading PUSH UP FOR DOWN.
The trouble with Bellevue was not so much money as the way the money was doled out. There was a central administrative office in Bellevue, but New York City’s Department of Hospitals acted as actual day-to-day administrator, as it did for each of the municipal hospitals, from offices several miles away at 125 Worth Steet. Every request even for minor expenditures, surgical gowns for instance, had to be threaded through anonymous bureaucrats in the department offices, and most of these required initialed approvals by other officials in the city’s Department of Purchase and the Bureau of the Budget in different city office buildings. Actually, the total budget assigned to Bellevue at the beginning of each fiscal year was ample for the hospital’s needs, but it could only be spent line by line from downtown. The real budget was always much less than the amount allocated, in some years 25 percent less. Bellevue served as a sort of piggy bank for the city: $35 million would be appropriated on paper, but with the expectation of spending $25 million in that year, leaving the city $10 million to draw on for snow removal or subway maintenance or potholes.
It was an awful system, and Richards, Almy, and I spent many hours down at Worth Street arguing bitterly with the commissioner of hospitals, whose regular response was that he was on our side but could not change anything. On several occasions we ended up in the mayor’s office, explaining carefully that our patients’ lives were jeopardized by the way Bellevue was managed. One day I met a high-perched city official at a committee function. I thought I had finally reached the center of the administrative demonology and launched our appeal for help, but he displayed equanimity: Bellevue had all the money it needed, he said, and added that the city should not be spending any more on a place “filled with bums.” I spluttered and said something in a raised voice about bums being a small minority of Bellevue’s patients, the hospital was filled to overflowing with men, women, and children who were there because they were poor, and then I made the case for changing the system to give the hospital enough authority to make its own decisions about spending, even on a smaller scale than the official budget. I got nowhere. The budget bureau, I was coolly informed, had been at this for many years, and how long had I been a professor?
I became, overnight, an outraged, offended reformer. I wrote indignant letters, made speeches, caught the ear of any elected official I could find, even went for a secret meeting with the Democratic Party boss of the day, Carmine De Sapio, to complain about the System (someone had told me this would be a good idea; it wasn’t).
One day I learned the name of the functionary in the budget bureau whose initials always appeared on Bellevue’s canceled budget lines, and I went down to the Municipal Building to see who he was and what he was like. His desk was one of two dozen in a huge room filled with clattering typewriters and steadily ringing telephones. Stacks of paper covered the desk. He was a hugely fat man with the kindest of faces and a courtly, avuncular manner, leaning back in a sturdy swivel chair with a red pencil (red!) in his hand. What could he do for me, he asked. I explained that I was a Bellevue director of medicine, concerned that the hospital was broke, worse than broke. Ah, he said, that was something he understood, and he was working hard to fix it. We had a brief, unsatisfactory conversation. He explained that he had been at that desk for twenty-five years, having come into the position from a career as a civil engineer, and he knew all about hospitals. Good luck to you, Doctor, he said, as I walked away from his desk.
We decided to organize. A friend of Almy’s, a professional public-relations man, volunteered his services and put together a new, tax-exempt society named “The Better Bellevue Association,” dedicated to two principal objectives: to persuade the city to get on with a long-deferred plan to rebuild the entire hospital and, at the same time, to wrench Bellevue out of the hands of the downtown bureaucracy and provide the institution with some sort of autonomy. The first was the easy part. Architectural plans had already been drawn up, and all that was needed was to turn up as a delegation before the Board of Estimate and declaim in favor of haste. At that time, in the early 1960s, such a huge public-works project had many political attractions regardless of cost, and anyway, no one possessed an accurate notion of what the cost might be. The official estimate was $50 million; when the elegant new hospital was finally finished, twelve years later (nine years behind schedule), the cost was probably three times the original guess.
But the second mission was a lot more difficult, even, as it finally turned out, impossible. At the end, the City Charter itself got in the way. There was simply no legal mechanism for freeing Bellevue from the fingers and red pencils of the overseeing agencies in lower Manhattan; everybody would be in jail if we tried. At last, we developed a new plan and carried it north to Al
bany. It was a design for a piece of legislation to create a quasi-public corporation, patterned after the Port Authority of New York and New Jersey, which would own and operate the municipal hospitals but also mandate that each institution would be, administratively, a tub on its own bottom. The central feature of the bill was the lifting of the whole system clean out of City Hall, with all the funds to come from Medicare and Medicaid. At the time, in the late 1960s, it seemed entirely feasible. The bill sailed through the state legislature, but at the very last minute, just before it was ready for passing, someone inserted the provision that the mayor would appoint the president and board members of the new corporation, thus effectively retaining the same control over the hospitals as before. What then happened was the creation of a new, highly centralized bureaucracy, duplicating the former Department of Hospitals, running the hospitals from the same distance. It was a discouraging enterprise. I still think it might have worked as a public authority. Even with the cutbacks in health-care funding since the 1970s, it would work better today than the present system.
When I became dean of the NYU medical school in 1966, I moved out of the hospital and up the street, but not completely out of Bellevue’s business. There was still a severe housing problem, affecting both Bellevue and the school. All the adjoining blocks were slum properties, with many abandoned, decaying buildings but no places for married interns, nurses, or technicians to find living quarters. The Phipps Foundation took up the problem, and back we all went to City Hall with a proposal to clear the seven-block area between Twenty-third and Thirtieth streets for the construction of new apartment buildings. By the late 1960s the plans had been accepted, and within a few years Bellevue South emerged, meeting the needs of the local residents as well as the Bellevue community.