Hospital (7 page)

Brier acknowledged the $5 million that New York City had contributed to the center and then announced how the hospital was going to show its gratitude. “We are partners in a special effort to eliminate colon cancer in our borough,” she said. “We are going to have free colon-cancer screening regardless of someone’s ability to pay. And if someone has cancer, we can’t say we won’t treat you if you don’t have money. So we promise to treat any citizen of Brooklyn who has colon cancer regardless of their ability to pay.”

She was rewarded for this nod to community responsibility with applause. She did not discuss the distasteful aspects of this gesture of noblesse oblige. How would the hospital convince people to take advantage of the freebie, especially once they understood this wasn’t simple, like getting a flu shot, but a time-consuming procedure that required a nasty prep.

“Thorough cleansing of the bowel is necessary before a colonoscopy,” explained the National Digestive Diseases Information Clearinghouse (part of the National Institutes of Health) on its Web site, “You will likely be asked to take a laxative the night before the procedure. In some cases you may be asked to give yourself an enema.” The helpful guide failed to mention that the “laxative” meant drinking a gallon of a foul-tasting liquid designed to induce massive diarrhea, but it continued, “The doctor will then insert a long, flexible, lighted tube into your rectum and slowly guide it into your colon.”

Even for free it wasn’t going to be an easy sell.

A good percentage of Brier’s own senior staff hadn’t had colonoscopies, which annoyed her. Okay, maybe you could excuse Robert Naldi, the chief financial officer, fifty-four years old, not a medical man. But the scofflaws also included Samuel Kopel, the hospital’s medical director and an oncologist. He was almost sixty years old—a decade past the recommended age for a first-time colonoscopy—and still eluding the scope.

Pragmatism as well as altruism had led to the conclusion that Maimonides should open a cancer center. Cancer was a growth industry; the National Cancer Institute reported in 2005 that cancer treatment in the United States accounted for an estimated $72.1 billion in 2004, just under 5 percent of total U.S. spending for medical treatment, and an increase of 75 percent from 1995. The institute predicted that cancer costs would grow at a faster rate than overall medical expenditures.

In the health-care business, however, large investments were often made on predictions that turned out to be wrong. A few years earlier, Maimonides had spent more than $1 million each on two robots that could do complex surgery. The robots generated far more press than patients, and their costs weren’t expected to be amortized anytime soon, probably never.

The cancer center required a much larger investment, about $12 million to build plus an additional $40 million commitment on a twenty-year lease. While Brier talked earnestly about the 2.5 million people in the borough of Brooklyn who didn’t have a comprehensive cancer center, she knew that the numbers that really mattered were the people who lived in the zip codes surrounding the hospital. These weren’t the hipsters of Williamsburg, the artists and musicians who could no longer afford the East Village, nor were they the aspiring burghers of Brooklyn Heights and Park Slope. Maimonides tended to treat new immigrants and the working middle class—except when they had cancer. The finance people had conducted a study and found that only 26 percent of the people in the surrounding area came to Maimonides doctors when they had cancer. Where did they go? Most of them went across the bridge to Manhattan.

The statistics were worse, from a financial viewpoint, when you broke them down. “As many as fifty percent of people who get cancer diagnosis in Brooklyn receive some part of treatment in Manhattan—and those tend to be the people with private insurance,” said Kopel, the medical director. “If you’re a woman in Park Slope or Brooklyn Heights and find a lump on your breast, chances are you’re going to Manhattan for treatment. If you live somewhere else in Brooklyn and are from Bangladesh, you’re more likely to come to us.”

Like the Brooklyn clerk played by John Travolta in
Saturday Night Fever,
the hospital administrators understood that they were perceived as something less because they sat on the wrong side of the East River. Proving that the care at Maimonides was as good as that of the Manhattan hospitals was an institutional obsession. It wasn’t unusual for people to cross the bridge for radiation treatments and chemotherapy but then end up in the Maimonides emergency room when it was time to die. The cancer center was created to convince enough people—especially those with good insurance—to stay in Brooklyn for treatment as well as death, and to trust that for most types of cancer Maimonides could offer results comparable to Memorial Sloan-Kettering or Columbia Presbyterian, leading lights in the field. None of the administrators at Maimonides believed they could keep everyone close to home, but they figured they could do better than 26 percent. They didn’t need 75 percent for the finances to make sense, only 45 percent.

The cancer-center strategy was as much a dream as a plan, but that was enough. No one understood better than Brier that plans were mutable and that change could be slow and maddening or quick and catastrophic. She was almost sixty years old and had been maneuvering through the hospital world for twenty-five of those years. Compromise was part of the terrain. She also knew from personal experience that one misstep—in an operating room or in life—could destroy confidence and threaten everything she cared about in an instant.

More than almost anything, Brier believed in the rules of propriety. She tried to charm the Orthodox Hatzolah wives with her designer clothes, which she made sure were cut modestly, and with her willingness to come to their numerous luncheons honoring somebody or other. She accepted home-baked cheesecakes with lavish thanks (and then deposited the cakes on the snack table outside the ladies’ room on the executive floor). She believed that hostility and rudeness among the doctors and staff would translate into diminished care for patients. More than once I would hear her say, “I don’t care what they think so long as they behave properly. That’s the
least
they can do.”

Brier’s preoccupation with process was another thing that drove Fraidkin crazy. “Stanley was a doer,” Fraidkin said longingly of Brezenoff. “I’ve gone to all the retreats, sitting there for two days and dying because we’re not moving, we’re just sitting and coming up with the big vision. I can do that also. Do I like it? No. Get it out, spit it out, it doesn’t take you two days to see where we have to go. But you do it, you put up with it.”

In the middle of a meeting, Brier would pull her cell phone out of her pocketbook and make a call; a few minutes later, her assistant would appear with a freshly made cappuccino. During a telephone call with a fellow hospital president, she might make a truly odd pronouncement, like, “I want you to know I’m considered one of the great constipation experts in the borough of Brooklyn.” When Brier got the point of a presentation—and her mind worked fast—she might cut the speaker off abruptly. On occasion she would realize a few minutes later what she had done and would apologize, in front of the group. Her manner could be taken as refreshing or annoying, amusing or distracting—and sometimes as cruel. Yet most people seemed to believe that her skills outweighed her oddities.

“Stanley was a brilliant administrator,” Aaron Twerski told me. He was dean of the Hofstra law school, a prominent torts scholar, and a Maimonides board member. His poetic features—haunted dark eyes, long gray beard— seemed like a living rendition of Rembrandt’s
Portrait of an Old Jew.

Twerski continued, “He was a brilliant politician. She is not the consummate politician that Stanley was, but Pam has the courage of her convictions. Pam knows how to fire people.

He seemed to like the sound of this. “Pam knows how to fire,” he repeated. “Pam is a better firer than Stan was.”

On the other hand, she saw herself—and she was far from alone in her assessment—as a nurturer and friend of the underdog, a broad category that included anyone who might be despairing. She embraced the unions that represented the vast majority of Maimonides’ 5,700 employees, and she was vehement in her support of the hospital’s nurses. At Maimonides, as at Bellevue, she was known for walking the halls, stopping to chat with nurses, asking an aide why she wasn’t wearing her name tag, picking up gum wrappers off the floor. When I visited her first husband, Steven Brier, at his office at the City University of New York, where he was an associate provost, he reminisced about one of the first stories he heard about his ex-wife, told by one of her aunts.

“When she was five years old and about to begin kindergarten, Pam urged her mother to go early,” he said. “It occurred to her the parents of the kids would be coming to the school and they wouldn’t know each other, and she thought it was important she be there to introduce the parents to one another. As I like to say about that story, the personality was formed early.”

Pamela Sara Engel grew up in Los Angeles and was educated at UC Berkeley during the free-speech movement of the 1960s. Her political consciousness was awakened even as she followed the old-fashioned tradition of bagging a husband before she graduated. When they married, she was twenty-one and Steven Brier was twenty years old. Her father was a peripatetic businessman who left her and her mother when Pam was thirteen; his father was a fur worker and a union man. When they married, Steven Brier recalled his father telling him, “‘ Stevie, you’re about to make the same mistake I did. You’re about to marry a petit bourgeois.’ I told this to Pam, and her response was, ‘Not so petit!’ She was insulted by the ‘petit’!”

Brier had gone east in her twenties because Steven got a job in New York. It was a difficult move, but she survived and eventually rose through the city’s public-health system, the New York City Health and Hospitals Corporation (HHC), to become a powerful bureaucrat, worthy of gossip and speculation. Brezenoff had been her mentor.

Her aspirations were large, but not grandiose. She had no illusions that she had the answer to the problems of health care in the United States. When I asked her for a solution, she gave me a withering look. “Well, if I knew that, I guess I’d be a candidate for the Nobel Prize, wouldn’t I?”

When Brier had her first face-to-face encounter with Maimonides, she was almost fifty years old, divorced from Steve Brier, her husband of twenty-six years, and dating the man who would become her second husband. Her only child was grown.

“I’ll never forget the first time I saw Maimonides,” she told me. “It was a March day. I had just accepted the job. Peter took me for a tour of Borough Park and the hospital. We drove around Tenth Avenue, and my heart sank because it looked so unattractive on this very cold March day. No flowers, no trees, no nothing. And there used to be another overpass, which we finally took down, which was so ugly it just took your breath away.”

One day I imagined what it must have been like for her when she first confronted the hospital’s ungainly physical plant and the unusual surrounding neighborhood. I was approaching the main entrance at Tenth Avenue and Forty-eighth Street and had to circumvent a crowd of chattering elementary-school boys as they gathered on the sidewalk. At first glance they looked like any group of little boys, but then I noticed their side curls blowing in the breeze. The children attended Yeshiva Kehilath Yakov Pupa, the Jewish school housed in an old brick building across the street; the Maimonides boardroom on the top floor of the five-story administration building had a view of the school’s rooftop playground. A tall, skinny Hasid in a black coat and big hat—style, Poland circa 1850—walked alongside the little boys as they formed a line, each placing one hand on the shoulder of the boy in front of him. As they began to march down the street—make way for
Yiddishe
ducklings—the lone adult appeared to be clutching the side of his head. Closer inspection revealed a cell phone in his grasp. Maybe the coming of the Messiah would be heralded by a text message.

The main campus stood about one mile northeast of the cancer center, but in Brooklyn a twenty-minute walk can feel like a trek across a cultural continental divide. A block from the cancer center on Eighth Avenue was a world of Chinese street vendors selling steaming noodles from carts, the noodles doused liberally with fragrant sauces poured from unlabeled bottles— a dollar a serving. Women and men selling piles of bok choy could gather a crowd, and it was common on sunny days to see skinny old ladies shading themselves under open umbrellas. This was no tourist Chinatown, but a crowded neighborhood shopping strip, where almost all traces of the Scandinavian residents of a generation earlier had been replaced by Chinese shops and stands selling fruit and fish, bubble tea and sweet buns, bargain cosmetics and herbal cures.

The cancer center had been carved out of 6300 Eighth Avenue, previously a long, almost-windowless two-story building on the periphery of Chinatown, just across the street from an auto-body shop (Bay Ridge Body Shop/Service and Parts Department). Before the renovation, which required a massive excavation of the parking lot for the underground radiation vault, the building had a hunkered-down look, appropriate to its original incarnation as a Citibank check-processing center. In 1995, Citibank sold this drab relic of brutalist architecture to the Health Insurance Plan of New York (HIP), another faceless enterprise. The transformation wasn’t complete, but at least now there were some inviting windows, and the inside—at least the parts that had been renovated—was airy and serene, in accordance with the recommendations of a feng shui consultant.

The hospital itself, however, where David Gregorius would begin his life as a physician, had an aesthetic that seemed mired in the middle of the twentieth century. While the Maimonides Web site featured a sleek glass structure, this was merely a virtual rendering of the new wing that was being built across from the emergency room on Fort Hamilton Parkway. At the time of the cancer center’s opening, the actual “building” was a mass of girders and heavy equipment, mud and cement. When Pam Brier had been hired a decade earlier, the new wing didn’t exist even in theory. Like many hospitals built in urban areas with limited land, the hospital was a jumble of buildings and architectural styles, add-ons and renovations, with the two main buildings connected by an overpass. Many department chiefs and administrators worked out of the two-story brick row houses—inexplicably referred to as “brownstones”—that lined the streets surrounding the hospital.