Mr. Conley looked around. Everyone was staring at him. No one spoke. And then everyone spoke at once.
If Laguna Honda was not a hospital, we asked, then who were those sick, demented, frail, one- or no-legged, coughing, yellow people we took care of every day? In their wheelchairs, gurneys, and beds? With their IVs, feeding tubes, catheters, casts, oxygen, and tracheotomies? What were they doing here? Where would they be in the new, no-hospital Laguna Honda? Would they be elsewhere?
Mr. Conley didn’t hang his head exactly, but he did stop and stare into space for a moment. A vision went past his tired blue eyes. Those patients. The ones whose beds he sat on, whose hands he, even he, Mr. Conley, BS, MPH, executive administrator, held.
“Hospital” stayed in our name.
It was the day before Thanksgiving.
Phoebe, our new secretary, told me when I came in that Dr. Dan was going to notify the losers of the layoff lottery that day. He would page them into his office, one by one. She knew who they were, of course, and after I’d looked into her eyes—and considered the case of Janice Gilroy—I felt pretty safe. I was paged all day long but never by Dr. Dan, and in the late afternoon I went back to Phoebe’s office to find out who the laid-off doctors were.
Dr. Dan’s choices were puzzling. He’d laid off Dr. Lydia, our oldest and longest-serving physician who’d been so helpful with Radka, and Dr. Rajif, our youngest and last-hired physician. I could see Dr. Lydia, who no longer needed the job financially, and Dr. Rajif, the last hired. But he’d also laid off Dr. Stacks, tall and thin and African-American. Had personnel told him to play it safe and choose one of each—tall and short, white and black, young and old? His fourth choice, though, was Dr. Talley, and I was nonplussed. Dr. Talley fulfilled every one of Dr. Dan’s stated criteria: She was board-certified, procedure-doing, and full-time. Plus, she was intelligent and cheerful, competent and beautiful. If Dr. Dan could fire Dr. Talley, he could fire anyone.
Everyone wanted to know: What had been his criteria?
Dr. Dan wouldn’t say. He didn’t have to. The doctors served at the pleasure of the medical director; he was assistant medical director, and Dr. Sonnen, upstairs, had agreed with his selection.
Over lunch, in our offices, and in the hallways, we looked at one another with a certain look. A rebellion began, like one of those fires that start with a frayed wire, a spark, and then a flame spreading under the floor and into the walls. One by one and unknown to one another, the doctors went to talk to Mr. Conley and then to Dr. Stein. It wasn’t organized. But it was fierce and resolute.
On the first working day of the new year I walked into Phoebe’s office to sign in. Dr. Dan was standing in the doorway, white as a ghost. Dr. Jeffers, looking solemn, was walking out. Something had happened.
I looked at Dr. Jeffers and we exchanged the glances of people who’ve known each other for years. Something had happened—yes. He couldn’t talk about it; it was not quite as serious as his solemnity implied; I should talk to Larissa. So I found Larissa and, sure enough, although no more than forty-five minutes had elapsed since whatever had happened, had happened, she knew all about it.
“Dr. Dan and Dr. Sonnen have been fired,” she told me, with a gleam in her disenchanted eyes. “First thing this morning. Mr. Conley called Dr. Sonnen into his office and told him he had to retire and Dr. Dan’s job had been eliminated. And by the way, the layoffs of the four doctors were rescinded, since the elimination of his and Dr. Sonnen’s positions satisfied Dr. Stein’s budgetary requirements.”
Now, Larissa liked Dr. Dan, but she also liked Dr. Talley. And administrative reversals of fortune warmed her Russian soul. So she was saddened, amused, and relieved all at once. Also alert. In her experience, such reversals meant other changes—abrupt promotions and demotions, capitulations, even executions—and she was usually on the wrong side. So she didn’t want to talk too long. In these situations, you never knew who might be listening.
The news went around the hospital as quickly as only word of mouth can. Many nurses asked me why Dr. Dan was fired.
I could only guess. Dr. Talley was a friend of Dr. Stein’s, but I didn’t think that was the reason. It had more to do with Dr. Dan’s pushing back against the changes coming down. He’d come to understand the uncoordinated but relentless pressure squeezing the hospital’s Old Medicine into the New Health Care, and he had resisted, with flushed face and with eloquence. True, he inclined more toward the Way of Nursing than the Way of Medicine, but it was to Miss Lester’s Way of Nursing, which was, in one respect at least, the same as the Way of Medicine: Both were personal, and health care was not. Dr. Dan was in the Way, and he was in the way.
Dr. Dan didn’t leave immediately. He finished all the tasks he’d taken on, found a new position, and packed up his office. He sent around a thank-you note to all the staff. He signed off his patients to other doctors. Then he walked to every ward and took his leave of every nurse, and left Laguna Honda for the second time.
Then Mr. Conley himself called a meeting of the medical staff. His red beard was almost white, and there was a new bulge around his middle and bulges under his eyes, which were slightly out of focus. He no longer looked like the young Henry VIII at the time of his wedding to Anne Boleyn; he looked like Henry VIII after Anne’s head was cut off.
What he wanted to tell us was that the decision to dismiss Dr. Dan and Dr. Sonnen was entirely his. Dr. Stein had no part in it. As he said this, he looked at us in a vague way and we did not believe him. He could not have dismissed the medical director and the assistant medical director without the involvement of Dr. Stein. Besides, it wasn’t in him.
Also, he’d hired a search firm to find a medical director for the new Laguna Honda, someone experienced and efficient, and board-certified in medical directing. In the meantime, Dr. Jeffers would be acting medical director. Everyone looked over at Dr. Jeffers, who shrugged and smiled. That was fine with us. We liked Dr. Jeffers. He would do whatever was necessary and nothing more.
Six weeks later Mr. Conley did not show up for his morning carpool.
This had never happened before and so his carpool called the paramedics, who went over to his apartment. When he did not answer their knocks, they broke down the door. They found Mr. Conley sitting on the sofa in his work clothes, tie off, collar loosened, and dead. That afternoon the coroner did an autopsy and determined that Mr. Conley had died at seven-thirty the night before, of a heart attack due to the sudden blockage of a large coronary artery by a blood clot on top of an existing cholesterol plaque.
But we knew that Mr. Conley had died of Laguna Honda. It had just been too much. The budget cuts; the patients and the name change; the firings of Dr. Dan and Dr. Sonnen.
His memorial service took place in the recreation hall, and it was filled with staff and patients. A photo of him from his first days at the hospital, when his beard was still red and his eyes still bright, hung on an easel in the front. There was a color guard and bagpipes, and Dr. Stein bicycled over to give the encomium. Dr. Stein even cried. He felt responsible for Mr. Conley’s death, he told us. Mr. Conley had been a friend of his and took on the job of transforming the old almshouse into a modern health-care facility to help him out, and he felt responsible for the death.
The next day, Dr. Stein announced Mr. Conley’s replacement. It was Mirene Larose, RN, MS, CNS, also a friend of Dr. Stein’s and our current co-director of nursing.
Mirene was small and wore tiny but expensive skirt-suits, with stockings and pumps; and she was warm and enthusiastic, confident and decisive. She had a wide smile and an open face, and was easy to like, especially at first. The day after her appointment, she moved into Mr. Conley’s office, and the day after that she fired her only competition, the other co-director of nursing. The next week she sent around a revised organization chart that showed the previously medical departments of laboratory, radiology, and social work transferred from medicine to herself.
And that was just the beginning.
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br /> Mirene’s main ally in her new job was Adrian Serf, director of marketing. He was a petite, dapper man, with well-cut brown hair, curious brown eyes, and a birdlike tilt to his head. When he arrived at Laguna Honda, he put his new marketing department in the priest’s flat in the turret, redecorating its old-fashioned bathroom and kitchen in creams and taupes. The turret had its own entrance, and so he could come and go without the distraction of entering the hospital. Adrian was just about the only man left standing and he stepped up to the plate. He began attending the meetings that Dr. Dan once went to, and whenever there was a problem in the hospital—even a medical problem—there he was. He filled the niche left by Dr. Dan, although, as a lawyer, he was more concerned that nothing went wrong than that something went right.
Mirene and Adrian began making the key decisions at the hospital, in consultation with Dr. Stein and the mayor, of course. And although their decisions were not bruited about, there was a lot going on, a kind of strange, out-of-balance tension; you could feel it. Every day there were new forms, committees, directives. Nurses were promoted, demoted, or transferred; doctors disappeared; wards were closed. And week after week there were retirement parties and the consequent reshuffling of staff.
The final straw was the Ja Report.
Davis Ja, PhD, had been hired by Mirene and Adrian simply to document the psychiatric care in the old hospital, but he used his report in addition to lay out a kind of blueprint for the new facility. It was going to be a radically different place, his report made clear; and for the first time we, the doctors, finally understood the plans. After the move, Laguna Honda Hospital would no longer be an independent hospital but part of the County Hospital, and the director of public health would henceforth be in charge of the medical staff and patient admissions. Almost half of the new facility would be reserved for the psychiatric homeless, and the focus for the rest of the patients would be on rehabilitation and a speedy discharge. Even the model of care would be different we learned. In the new Laguna Honda, the old-fashioned “medical model” of physicians would be replaced by a “social model”—whatever that was—and “health-care workers,” nurses, social workers, and psychologists not physicians, would take care of “clients.”
It was a pretty stunning blueprint, although we’d had plenty of hints about where the hospital was headed. Still, we’d all been in denial. I, for one, had always thought that whatever happened, the spirit of what I privately, in my own my mind, called “God’s Hotel” would somehow triumph. But after the Ja Report, I wasn’t so sure and I began to wonder whether my twenty-year escape from health care was coming to an end.
Many of the doctors felt the same way and Drs. Kay and Romero, according to their temperament, wrote a brilliant rebuttal proving the Ja Report ill-conceived, poorly thought out, and illegal. They also contacted the neigborhood association to let it know that the new Laguna Honda was slated to become a psychiatric facility for the homeless. Last, they demanded an audit of the two-million-dollar Patient Gift Fund.
Now, there was no policy connection between the Ja Report and the Patient Gift Fund. But there was a strategic connection because Drs. Kay and Romero had discovered that hundreds of thousands of dollars were missing from the fund, and they knew that Mirene, as head of the hospital, would be drawn into any scandal resulting from that. She would bring Adrian, as her chief advisor, along with her; also Dr. Stein, as her supervisor, and even, perhaps, the mayor. An investigation of the Patient Gift Fund might put an end to one or all of them, and, therefore, to the radical transformation of the hospital. So when Dr. Kay and Dr. Romero finished their rebuttal to the Ja Report, they requested the records of the Patient Gift Fund, going all the way back to Mr. Conley’s arrival.
Also they submitted an ethics complaint about the financial dealings of Dr. Stein and Mr. Davis Ja.
Mirene, Adrian, Dr. Stein, and the mayor were not happy about these requests and complaints, and Drs. Kay and Romero were stonewalled for months. They received nothing, and the Ja Report was accepted as written.
But immediately after, the medical staff received momentous news. Mirene had finally hired a new medical director. It was Dr. Talley, one of our own doctors, who’d been laid off by Dr. Dan exactly one year before, and whose layoff had precipitated a rebellion. It was a typical Laguna Honda turnaround, in the premodern era known as a Turn of the Wheel of Fortune. Each of us is attached to that wheel, which is Time, and sooner or later we will go down, and sooner or later we will come up.
The medical staff was delighted with Mirene’s choice. Dr. Talley was a good doctor; she knew the hospital well; she liked it the way it was and would, we felt sure, try to keep it that way. So she was a hopeful pick, a gauge, we thought, that everything would turn out all right.
Then Dr. Talley called her first meeting of the medical staff. She had several announcements, and all of them were disheartening.
First, Dr. Jeffers was retiring after twenty-eight years. We would miss him, Dr. Talley said, knowing, however, that no one was more deserving of rest and relaxation than Dr. Jeffers. Second, she had decided to move the medical director’s office from its old place at the back of the hospital into the administration wing. It was time for medicine to say yes instead of no to change, she told us; to ally itself with administration and nursing—to be part of the solution, not part of the problem.
That got me a little worried.
It was true that medicine and nursing and administration had always been at odds, and with Mirene Larose, RN, MS, CNS, as executive administrator, administration and nursing had effectively been merged. So perhaps medicine should join up, too. But then I remembered what Florence Nightingale had written about the struggle between medicine and nursing and administration. That struggle was irresolvable and should not be resolved, she said, because it was in the patients’ best interest. If medicine ever won control of the hospital, too much would be practiced on the patient; if administration, too little; if nursing, medical progress would be curtailed in the interest of the spiritual and emotional care of the patient.
So I worried about Dr. Talley’s decision to move medicine in with administration and nursing. What did it mean about the future of medicine at the new Laguna Honda?
Her third announcement was that, due to budget cuts and with deep regret, she was laying off Dr. Kay. Her selection was in no way punitive; it simply reflected the need for the medical department to meet its budgetary challenges and reorganize clinically. It was entirely her decision. Mirene and Dr. Stein had nothing to do with it.
A sigh went through the room. The last person who uttered the phrase “entirely my decision” had died of it. No one wanted Dr. Talley to die or get sick or gray or get bulges under her eyes. We wanted to support her. And Dr. Kay was an interesting choice to lay off. He was principled, and one of his principles was that he would only take care of his own patients. He almost never took call, or helped out, or covered other wards. So no rebellion broke out, and no one spoke up.
Except for Sister Margaret. When Sister Margaret heard about Dr. Kay’s layoff, she stormed into Mirene Larose’s office, blue-and-white veil streaming behind her. Or so I heard.
“Are you a Catholic!” she shouted. “Tell me, are you a Catholic? How can you fire Dr. Kay? He’s the best doctor for the hospice! … How can you lie? It’s a sin to lie! And what did you do with the money sent by my diocese for the patients? Where is it, eh? A liar! You are a liar, and it’s a sin to lie!”
Mirene knew when not to say anything. Besides, she knew that she was right to fire Dr. Kay. Because he would fight the coming changes on the beaches, in the fields, and on the streets; he was, after all, English. And though she admired the English, Dr. Kay had to go.
So Dr. Kay was laid off. The day after his layoff, he filed a whistle-blower suit alleging that his investigation of the drained Patient Gift Fund was the reason he was laid off.
The day after that, Dr. Romero resigned in protest.
Things were changing i
rreversibly. The admitting ward was closed: Medicine had moved into administration; almost all the doctors I’d ever worked with were gone; and we were on some kind of Journey I didn’t want to be taking, from Institution to Community. Or vice versa.
Then just a few days later, as I was driving in to the hospital in the early morning, I saw that the wraps had finally come off the new hospital—those great white wraps that had covered the rising buildings for years.
There it was.
The new Laguna Honda.
It seemed to melt in a strange way into the old Laguna Honda. It, too, had towers, although they were modern and spare, without roof tiles, decorative cornices, or copper pipes. Stuccoed in peach, taupe, and umber, the new towers were painted in the colors of the old; set into them were flat, modern windows outlined in teal.
It was time to see what the new place was like.
It was time to take the tour.
I called up Dave Jonas.
Dave was the project manager for the new facility, and he would be a congenial guide, I knew. He’d been stationed in the old hospital for such a long time that he had come to appreciate its wide-open spaces, its serendipitous meetings, and its patients. We could meet that very day, he told me, for the tour; I could come over to his office, and he would take me around.
Late that afternoon I did meet him in his office, and we left the old building, walking out of it and directly into the gardens of gray river rock, flowering lavender, and olive trees that landscaped the new buildings. You would never have known, unless you’d been there, that there had once been a wooded valley in that place, with a spring and whiskey bottles.
Dave told me we would start by looking at a neighborhood in the South Tower. “Neighborhood” was the new word for “ward.” I would only have to see one neighborhood to get an idea of the patient spaces, because all the neighborhoods were pretty much identical.
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 34