Hospital (2 page)

Over cappuccino in Greenwich Village, she told me about Maimonides Medical Center (originally Israel-Zion Hospital) in Borough Park, Brooklyn, which had been opened a century earlier to serve local residents. For decades the mandate had remained the same: to take care of the community, which meant the Orthodox (and, increasingly, Hasidic) Jews who dominated the neighborhood.

As in urban areas all over America, Brooklyn’s neighborhoods were constantly changing, as immigrants prospered and their children—the second generation—left, making room for new groups arriving from other countries. The area around Maimonides was no exception. While Jews still made up a substantial minority of the hospital’s local patient demographic, the rising majority derived from every kind of ethnicity and hailed from all over the world. New Chinese immigrants represented the fastest-growing population in the vicinity. Meanwhile, the hospital’s kosher kitchen was run by Patrick Lamont, born in Jamaica, and sixty-seven different languages, more or less, were spoken in the hospital.

Baldwin talked about the hospital’s determination to understand its patients’ languages and beliefs—an attitude, if not a practice, that had become more commonplace in many medical institutions. She ticked off a list of homey examples: For one thing, it had taken the hospital staff a while to figure out that the white blankets in the emergency rooms were keeping Chinese patients away. White, they eventually learned, is the mark of death in Chinese culture. Soon enough, new beige blankets were ordered for the entire hospital. They had learned the hard way (from the patients who had fled, never to return) that among many groups there was still a taboo against uttering the word “cancer,” never mind acknowledging the disease. They’d also had to learn how to deal with patients like the pregnant woman, shrouded head to toe by a chador, who, when she unwrapped herself for examination, shocked the doctor by showing him that she was covered with chicken pox.

Baldwin painted a vivid picture of a big, bustling institution that was representative in many ways of any major medical center. Thanks to advances in science and technology, many illnesses that once required hospitalization no longer did, meaning that the inpatient population tended to be sicker and older, more difficult to treat. The emergency room was crowded with uninsured patients who couldn’t afford anything else.

With 705 patient beds, Maimonides was a big hospital, among the largest 5 percent of the country’s 4, 936 hospitals. Its patients were primarily middle class but spanned the spectrum, with a sizable contingent of poor and elderly people who qualified for Medicare and Medicaid.

In 2003 the hospital admitted 38,667 patients, 127,319 people were treated in its outpatient clinics, and 81,190 passed through the ER. These patients generated $626 million in revenues; the hospital paid $618 million in expenses, including $17.7 million in malpractice insurance.

Four hundred and sixty new doctors trained there each year. Each week the kosher/Chinese/Italian/Caribbean kitchen used 2,000 pounds of chicken, 5,400 pints of milk, and 30 gallons of Jell-O. In 2003, 6,230 babies were born at Maimonides, more than in any other hospital in the state of New York. There were 1,075 deaths; 35 of those were stillborn babies.

What did it take to run a factory like this—and did it feel like a factory?

By the beginning of the twenty-first century, the practice of medicine had become industrialized and often seemed impersonal. What was the role of the hospital in a technocratic world where information and options were abundant while common sense and tenderness were scarce? What were the financial, ethical, scientific, sociological, personal, and cultural matters that determined what kind of care people received? What did it mean to care anyway?

As Baldwin talked about the social forces converging on the hospital in Brooklyn, I found myself mesmerized, though she never got around to telling me what, exactly, she wanted. When our meeting concluded, interesting as it was, I figured that was that. Still, every so often I would find myself mentally replaying that conversation, which felt unfinished.

A few months later, I received an intriguing invitation from a hematology oncologist at St. Vincent’s Hospital in Manhattan, Dr. Alan Astrow. He, too, had read the Maimonides book, and he was inviting me to a series of lectures he’d organized, looking at how doctors do and do not deal with the spiritual concerns of very sick patients. I gathered that he wasn’t advocating so-called alternative medicine or spiritual healing but was trying to understand how physicians, nurses, and other caregivers might help patients connect hope and reconciliation, deal with fear and despair—in other words, how to treat that part of the human entity not taught in anatomy class. I declined Astrow’s invitation because I had something else to do that evening. He persisted, and I succumbed, unable to resist his gentle, insistent sincerity.

The speakers—a Jew and a Catholic—had nothing startling to say, but I was impressed by the heartfelt reaction they stirred in the 150 or so doctors, nurses, and social workers in the audience, who had stayed after hours on a freezing winter night to participate.

Mainly I liked Dr. Astrow. He handled the proceedings smoothly and intelligently, but at fifty still seemed like a gawky adolescent who hadn’t quite adjusted to his growth. His shy smile and mournful blue eyes conveyed warmth and worry. A few days later, I received a thank-you letter, in which he wrote about his attempts to find a balance between his desire to be there for his patients, his need to set limits on emotional entanglement with them, and his professional ambition. I could see he was searching for something.

My encounter with Astrow led me to reread
Cancer Ward,
the great novel by Aleksandr Solzhenitsyn, and to a passage that I couldn’t stop thinking about. “Sometimes I feel quite distinctly that what is inside me is not all of me,” says one patient to another. “There’s something else, sublime, quite indestructible, some tiny fragment of the universal spirit. Don’t you feel that?”

A couple of months later, I received an e-mail from a friend who had been diagnosed with ovarian cancer two years earlier. The prognosis was neither dire nor completely reassuring, but a year after massive surgery and chemotherapy she was reporting a healthy exam. She said she was feeling optimistic and energetic, but also sad, because the doctor she loved was leaving St. Vincent’s for a new cancer center that was being opened in Brooklyn, at a place called Maimonides. Her doctor was Alan Astrow. In her e-mail she wrote:

I decided these three events were related—
bashert,
Yiddish for “karmic connection,” or, as the Chinese say,
min zhong zhu ding,
“life is predestined.” The next day I sent an e-mail to Jo Ann Baldwin, a year after we met, as though no time had passed.

Soon afterward I boarded the D train and headed across the river for Brooklyn.

Walking into the waiting room at Maimonides for the first time rekindled my first impression of New York when I was a newcomer, just out of college, feeling that same paradoxical rush of being overwhelmed and utterly engaged by the motley chaos, the interplay of harshness and sentimentality, the magnitude and intimacy of human convergence. In the small rural village in southern Ohio where I spent my first eighteen years, my family had been
the
diversity; being the Other was part of our job as the only Jews in a fundamentalist Christian farming community.

The Hasids who seemed to treat Maimonides as their home were alien to me, but also familiar, part of my background as a descendant of Eastern European Jews. Just as recognizable were the many people—patients and caregivers—speaking broken English in many accents. My parents, too, were immigrants—Hungarian speakers from Czechoslovakia—and my family had intimate connections with medical issues. My father had been a patient as well as a physician; he died of lung cancer when I was still a teenager. There was another connection. Borough Park was said to have the largest remnant of Holocaust survivors outside Israel; though my parents settled in Appalachia, they, too, had survived the death camps.

My father had been able relocate in an unlikely spot because he offered a necessary ingredient: He could tend to the sick. In return, this small, rural village provided him a haven and a source of meaning after he had lost so much. Was that formulation lost to history? Judging from the foreign names of the doctors who have replaced him, I didn’t think so. But it was a different world.

Between 1970 and 1998, the foreign-born population in the United States increased from 9.6 million to 24.4 million (according to official tallies, a low estimate). In 2004 the foreign-born population numbered 34.2 million, or 12 percent of the total U.S. population, approaching the 14 percent who moved here during the last big immigrant wave a century earlier. The attacks on the World Trade Center in 2001 exploded any residual sentimentality for the American melting pot. Now the mass movement of newcomers fueled larger apprehensions. The war on terror morphed into the war in Iraq, and large divisions loomed everywhere: Muslim versus Christian and Jew, Muslim versus Muslim versus Hindu, modernity versus fundamentalism, consumerism versus environmentalism, us versus them, us versus us.

It took just a few visits to see that Maimonides was an epicenter of these social forces, a petri dish of the post-9/11 world. What is alien and what is common? The question of community identity and responsibility was under constant discussion and examination. Ten years earlier the hospital had been in trouble because of a fractious board and an administration that wasn’t responding to the community—make that communities—but specifically not to the local Orthodox, the original constituents. The board enlisted a politically connected outsider—Stanley Brezenoff, former deputy mayor under Ed Koch—to run the place, and he hired Pamela Brier, then the executive director at Bellevue Hospital Center in Manhattan, the oldest public hospital in the United States, most famous for its psychiatric ward. Within five years Maimonides was on the front page of the
Wall Street Journal,
featured in a laudatory article about a turnaround involving a bureaucratic overhaul and a new way of dealing with a population that demanded both kosher and Chinese food. Five years after that, the hospital was running in the black and in the middle of a major expansion—including building a bigger emergency room—that would improve the physical plant but not increase the number of inpatient beds. A comprehensive cancer center was about to open. These were ambitious plans when so many hospitals, including sophisticated teaching hospitals, had been struggling financially.

The hospital prided itself on the well-regarded doctors who had chosen Maimonides as the place to perform sophisticated technical procedures that required special skill and expensive equipment—and earned one Maimonides surgeon more than $3 million a year. But like any institution that is part of a particular place, Maimonides was also peculiar. It was a community hospital that employed many relatives—even generations of families— resulting in relationships that intertwined in ways that were healthy and ways that were not. It was a place in flux.

For every comforting parable about cross-cultural coexistence, there was an angry diatribe about rudeness and misunderstanding. In 1995, consultants hired by the hospital issued a report that declared “the level of rude behavior at MMC is astonishing.” The report portrayed a “dirty environment” filled with angry patients, hostile nurses, and uncaring physicians. The prevailing mood, the consultants concluded, was “a culture of nastiness.” How the hospital had been changing—and continued struggling to change—had become embedded in its lore. Many of the new administrators and medical practitioners felt that part of their mission was to civilize Brooklyn—a mandate that didn’t sit well with the Brooklynites, another cultural clash.

At Maimonides nothing was simple. Half the staff couldn’t even pronounce the hospital’s name:

Maimonides (“my-MON-i-dese”) Medical Center, I would soon learn, was the exact opposite of buttoned up. “There’s an openness here, a willingness to allow people to express themselves, and it is not limited to the titled positions here in the hospital,” said Carol Kidney, the nursing director for women’s services, including obstetrics, an Irish immigrant who had worked there for twenty years. “Everybody believes they can and should speak up. That’s a positive thing. You’re going to pull out the best ideas, you’re going to have innovation, you’re going to have creativity, you’re going to have good problem-solving skills.”

Then, with characteristic Maimonides bluntness, she added, “If you open the venue for conversation and encourage the exchange of ideas, there’s an opportunity for miscommunication. When you throw multiple cultures into the pot, there’s plenty of opportunity for misunderstanding.”

It was that lack of inhibition that led Pamela Brier, the hospital’s president, and Martin Payson, the chairman of the board, to eventually agree to my impudent request: I wanted to spend a year at the hospital, without a minder, using the opening of the cancer center as a focus.