Hospital (51 page)

The next morning Brier called me to let me know a painter had begun to clean the Bikur Cholim door. She said he told her he had painted the door three weeks earlier. “It had gotten dirty again so fast,” she mused. Then, as she was about to hang up, she said, “I must apologize to Derek.”

Five days earlier I had spent the morning on Gellman East with Margie Morales, a member of the environmental “study-action” team, a subgroup of a DLMC (departmental labor management committee), the labor-management experiment of consultant Peter Lazes. The team was charged with finding better ways to keep the place clean.

Morales, a substantial woman with a shy, eager manner who wore her hair pulled back, had offered to let me follow her around as she cleaned rooms. She was using the Seven-Step Cleaning Procedure the team had developed after interviewing fellow workers and visiting other hospitals.

She told me the hospital’s unchecked stream of visitors was the biggest impediment to cleanliness. The other major problem was staff resistance. “Before, the men mopped and the women picked up the garbage,” she said. “Now we’re all doing the same jobs, forming a concept of teamwork so it’s not a man’s job and not a women’s job. A lot of people don’t want to make the change.”

We entered an empty room, and she began to go down the Seven Steps checklist. “First thing you do is ask, ‘What’s here that doesn’t belong here?’” she explained. “Remove it if there’s a newspaper on the floor or old flowers on the sill, remove it before you do the shine. That’s our first
S
. Sorting the unwanted from the wanted.”

Morales, who told me she had three children between the ages of seventeen and eleven, had worked as a secretary and a bookkeeper before she took the cleaning job at Maimonides two years earlier.

Her reasons were personal. “My husband passed away six years ago, and he was here three months,” she said. “He had cancer. So it means a lot to me to have the rooms clean. I like doing this type of work, making sure the patients have rooms that are clean. What if it’s my family member? I treat every patient like it’s my family. I want to make sure the IV poles are where they are supposed to be and the garbage pails aren’t in the middle of the room where people can slip on them.”

Every day at Maimonides, I was reminded that the “health-care system” wasn’t anonymous or abstract; it was the sum of individual human successes and failures, each of which could build or destroy. Most people didn’t set out to screw things up; they just didn’t take time to remember (or to learn) the legacy of the man whose name the hospital carried. Maimonides the philosopher /physician valued daily self-scrutiny. In his commentaries he wrote that “the perfect man needs to inspect his moral habits continually, weigh his actions, and reflect upon the state of his soul every single day.”

The hospital, however, was populated by humans, imperfect men and women, existing in an imperfect world. Politicians started out believing in the social contract and then forgot their duty to fight for the people they represented. Drug and insurance executives said that their desire was to improve and protect health care, but their jobs and fortunes depended on profitability, not making medicine available to everyone. Technocrats worshipped faster and more efficient machines that helped prolong health and life, but they neglected empathy, understanding, and the probing that requires genuine conversation and time. Doctors planned to devote their lives to healing and then spent too much time analyzing their bank accounts or nursing bruised egos instead of making sure the system provided for their patients. Patients agreed with all of the above but failed to accept responsibility for the abuses they inflicted on themselves by working too hard, exercising too little, and smoking, drinking, and eating too much.

Depending on the day or night, life in the hospital could seem full of exquisite promise or pointless despair. The system was tainted by callous disregard for decent and equitable care, by money lust, by corporate influence, and by lack of political will. But a great many people who were part of the system wanted something better. Yes, individual doctors and nurses behaved badly, sometimes inexcusably so. Clerks were rude to patients and to each other. People made mistakes. Yet I was constantly struck by the sense of urgency that accompanied desires for fairness, for compassionate medicine, for efficiency, for meaning—and yes, for cleaner rooms. Both Pam Brier and Margie Morales struggled to sort the unwanted from the wanted, to make the hospital what it should be. They needed their lives to matter.

Toward the end of my year at the hospital, Alan Astrow asked me, “Did you know what you were getting into?”

His question had been prompted by a visit with one of his patients, Marie, a forty-five-year-old woman with metastatic gastric cancer. The first time I met her, she was sitting up in bed hunched over a plastic bin, retching, while her sister, Tina, watched, her face contorted in sympathetic pain. Tina had more or less moved into her sister’s hospital room. She had done all she could to maintain the illusion that they remained the same people in the picture frame on the room’s windowsill—the young girls, now middle-aged, mothers but still sexy, buff, glowing size-two blond women with large dark eyes. Marie and Tina were only thirteen months apart, so similar (when Marie was healthy) that people mistook them for twins.

Tina often had circles under her eyes, but her own weariness didn’t prevent her from making sure her sister’s hair was combed and her makeup was right. The patient’s bed was covered by a faux-leopardskin blanket from home; she had a matching headband. She wore pretty shorty pajamas. She intended to defy this sickness and go home.

This remained Marie’s professed intention, even during the weeks she lay dying in a comfortable room on Kronish 5, the refurbished wing, which had broad hallways, shiny wood floors, sage green walls.

I told Astrow that I admired how sensitively he talked to Marie and her family, the way he laid hands on his patients during physical exams. For a sometimes-awkward man, he had a remarkably natural touch.

He dismissed the compliment. “I’ve been doing this a long time,” he said.

Yet there was nothing rote or complacent about his manner or his concern. He had been preoccupied with this patient since the first time they met, and she looked at him and said, “You’re going to cure me.”

She was divorced, the mother of two young children, daughter of Italian immigrants, sister of a policeman, a friend of Douglas Jablon’s. Astrow was a doctor who believed in telling the truth, yet he was leery of those who believed there was a moral imperative to give people information they didn’t want to hear. He turned to Jewish theology for help on the question of truth versus
chesed,
Hebrew for “kindness.” He concluded that neither is privileged, that there was a tension between truth and kindness that could not be resolved.

“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.”