Hospital, USA

This fascinating portrait of a Brooklyn, N.Y., hospital is about much more than white coats and beeping consoles -- it's 21st-century America in a microcosm.

By Laura Miller

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May 6, 2008 | At Maimonides Medical Center in Brooklyn, N.Y., some 67 different languages are spoken. A private institution, it's among the largest 5 percent of the nation's hospitals, treating (in 2003) 38,667 inpatients as well as 127,319 more people in its outpatient clinics. Each year it trains nearly 500 new doctors from all over the world. Maimonides' E.R. is a scene of orchestrated chaos, especially at 2 p.m., which for some reason is the crush time for emergency rooms. Because the hospital stands in a neighborhood full of new immigrants -- as well as being rooted in an established community of Orthodox Jews -- many of the people who enter the E.R. are undocumented and/or uninsured, and have waited until the last minute to seek treatment. "Our patients never have one problem," says the residency program director. "They almost always have a heart attack compounded by a urinary infection compounded by muscle breakdown ... There's never one clear explanation for the pathological phenomenon we see in a lot of our patients."

In 2005, Julie Salamon -- an author and journalist best known for "The Devil's Candy," her account of the disastrous filming of "Bonfire of the Vanities" in 1990 -- spent a year deep in the teeming organism that is Maimonides Medical Center. She negotiated unfettered access to staff ranging from the cleaning crew to the chairman of the board (although some spoke more freely than others). The resulting book, "Hospital: Man, Woman, Birth, Death, Infinity, Plus Bad Behavior, Money, God and Diversity on Steroids," will surely be catnip to that peculiar breed of person who's fascinated by anything having to do with hospitals and doctors, but as Salamon observes in her prologue, she also viewed Maimonides as an "epicenter" of something larger, a forum for the social forces buffeting the city and nation, "a petri dish of the post-9/11 world."

Despite being related to two nurses, I've never had much interest in hospitals (or been able to sit through an episode of "ER"), but as Salamon expertly sucked me into the saga of Maimonides, I realized that this was about more than white coats, scalpels and beeping consoles. This place was 21st century America in a microcosm.

Of course, "Hospital" does deliver hefty servings of the staple ingredients of medical drama: arrogant doctors, controversial administrators, fed-up nurses, shell-shocked residents and plenty of patients whose stories alternately warm and break your heart. (The one missing element, thank God, is an overwrought love story.) There's the 24-year-old single mother, an uninsured, undocumented immigrant cashier, who has to be told that, due to the cancer that has metastasized throughout her body, she won't live long enough to see her two kids go to school. And there's "Mr. Zen," another uninsured cancer patient -- hospitals are required to treat people who walk into the emergency room until they are able to walk out the door -- a stoic and considerate man in spite of the "excruciating" pain he suffered. He became a staff favorite, and in his final hours, his attending physician sat by his bed reading a Buddhist text called the Heart Sutra. "I'm not sure exactly what he knew at that point," said the doctor, but "it was the least I could do for him."

And -- of course! -- there are the arrogant, preening surgeons: the fading cardiac "star" with his cowboy boots and a photo of Hemingway hung in his office; the medical director so competitive that, when Salamon tells him she accompanied one doctor as he saw a dozen patients the night before, boasts, "You should follow me around. I see about thirty in the day. I'm like a ballerina." The hospital is riven by two major, long-standing physician feuds, each between a pair of former medical partners, and each one, by various accounts "absolutely about money," or, conversely, entirely "personal ... We felt we were treated like chattel." The eccentric president of the hospital, Pam Brier -- a tiny woman given to bizarre pronouncements like, "I want you to know I'm considered one of the great constipation experts in the borough of Brooklyn" -- alternately snubs and mothers her employees, flying an ill staff member's daughter into town (first class), then scheduling the opening ceremonies for a new cancer center so that the director of the center has to rush back from a conference in order to be there.

Along with Brier, Salamon pays particular attention to an idealistic oncologist -- among the first physicians to treat AIDS as it emerged in the mid-1980s, and formerly with St. Vincent's Hospital in Greenwich Village -- as he comes to Maimonides to work at a new cancer center. Alan Astrow is a searcher, known for organizing lecture series on the spiritual aspects of healthcare and a perennial poser of questions in a profession that promises answers: "Why do we do what we do? What keeps us going? Not just that we ought to care, but why? Faced with a suffering or demanding patient whom we might prefer to avoid, where do we find the strength to enter the patient's room? What is the conception of the human person and the role of physician and nurse that medical practice relies on?"

Although at least one of Astrow's oncology fellows speculates that all this philosophizing makes him "too soft" for the rigors of administration, those questions are at the heart not only of the work of this hospital, but of American work life itself. Maimonides' staff wrangles with dilemmas peculiar to healthcare: the stinginess of HMOs, the ever-growing numbers of uninsured patients, diminishing respect for doctors in society in general and the insidious incursions of pharmaceutical companies. In an age when medical advances are trumpeted almost every day (and sometimes retracted a little later, though much further back in the newspaper), expectations run high, people start to feel almost immortal; then disappointments and the inevitability of death become even more devastating.

Nevertheless, the resemblance between the travails of Maimonides and those of the world beyond its walls can be startling. Take, for example, the computerized "bed management" system, designed to help E.R. managers track and locate places to put incoming patients, a chronic problem. The director of emergency medicine complained to Salamon that 40 percent of his hospital's beds are "controlled by all these fiefdoms: anything from patient relations [who reserve them for "VIPs"] to a cardiothoracic surgery nurse," so figuring out which ones are currently empty and available to the "medicine" department is essential. The hospital spent $400,000 on a computerized system to track this information, but the whole thing depended on overworked and underpaid "information specialists" taking time to stop and punch numbers into a telephone on top of all their other duties. These people were paid only $23,000 per year. It's a classic example of too much faith placed in technology and too little account taken of labor.

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