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.
Respect -- or rather, the lack of it -- may be the single most persistent theme in "Hospital." It's hard to say that respect matters more to the people at Maimonides than money, because in this market economy, money is increasingly the only way we measure worth. A former chair of orthopedics says that he fell out with Brier because he wanted to give priority in the waiting rooms to patients who paid out of pocket or who had full insurance: "People who pay for health care don't want to sit in a room with fifty people. They want to be seen in a timely manner. I think that's very reasonable."
Nurses and aides complain that doctors yell at them, and doctors complain that the support staff don't take their jobs seriously enough. But, as one executive director argues, aides "don't have the same drive the surgeon has. It's not the same drive even a nurse may have. I say this to doctors all the time when they tell me the nursing attendants aren't working hard enough or fast enough. I tell them, 'They're not going to work like you work. They're not going to stay for 12 hours for the good of the cause or the good of the patient or because "This is why I came to health care."' How do you motivate someone who makes $12 an hour? By saying, 'Your next raise you're getting another 12 cents'? I think what beats them down is the hierarchy, the respect they are given or not given. Everyone beats down on the one below."
Doctors themselves are subject to similar slights; as Salamon observes, the exaltation of specialists has led to the devaluation of the family doctor, "the generalist who saw not just a patient but recognized a person with a history, a place in the community, a functional part of a larger system." To boost referrals, admissions and the bottom line, administrators feel obliged to lure hot-shot specialists to their hospitals (as Brier was attempting to do when Salamon finished her stint at Maimonides) by offering exorbitant salaries and perks. Competition among physicians for "star" status grows fierce and bitter; the better, more sensitive doctor doesn't always win. When the Maimonides V.P. in charge of perioperative services vowed to enforce a "Code of Mutual Respect," he was greeted with skepticism by many nurses, who scoffed at the idea that a doctor who had to be wined, dined and wooed into joining staff would ever be disciplined for insulting a nurse.
Then there's the community. Maimonides was founded in 1919 by a successful Jewish businessman who thought a hospital in Borough Park, Brooklyn, was needed to serve the Jewish immigrant community there. The hospital's own mission statement describes itself as "uniquely committed" to the healthcare needs of the Orthodox Jews who currently make up 20 percent of its patients. Those needs include a kosher kitchen and an elevator that stops on every floor on Saturdays, so that Orthodox proscriptions against "working" on the sabbath won't be violated at the push of a button.
Still, Salamon writes, "the hospital could never do enough to please" this particular constituency. Cleaning staff complained that the family members of Orthodox patients routinely crowded into rooms, making cleaning difficult and often bearing gifts of messy food, then turned around and griped about the dirtiness of the facilities. One of the oncology fellows told Salamon, "They become so demanding and are actually so derogatory when they speak to you that you think, 'Remind me again why should I help you?'"
Hatzolah, a network of emergency medical service volunteers, specializes in helping Jewish patients, which means not just getting them to the hospital, but agitating for better care once their charges are admitted. Hatzolah have clout; they bring a lot of paying customers to the hospital. When the chair of the emergency department displeased a Hatzolah leader by hiring a nursing director the leader didn't like, he let himself in for a major headache. "Hatzolah didn't work for him, he worked for Hatzolah," is how Salamon characterized the lesson he learned from that particular contretemps. Even the hospital's diplomatically gifted V.P. in charge of patient relations -- the "favor bank," as Salamon describes him, and Orthodox himself -- says, mournfully, "The Gentiles come in, they love us ... The Jews complain. Someone gets stuck on a highway, they'll stop the car. But to get a pat on the back? Never!"
Yet all the Hatzolah are doing is insisting on respect for their charges in the only way they know how: by kvetching. Brier herself, a survivor (with her husband) of a horrific car accident, speaks of every patient's crucial need for an advocate: "You have to have someone with you to take notes, to ask questions, to hear. Even if you take notes, it's hard to focus. I hear so many patients say, 'What did he say?' when the doctor walks out of the room. That's why hospitals are scary. For all the care organized around you, when you are in the hospital bed, I won't say you're dead meat, but you're really in a vulnerable position."
Newer minority communities, like the Chinese and Pakistani immigrants that have streamed into Brooklyn in the last few decades, haven't fared as well in adapting to the American medical establishment. Maimonides, like many contemporary American institutions, aspires to "multiculturalism," by which is meant a prevailing ethos that treats all patients' cultures and languages respectfully (whether or not they happen to be good at wringing what they need out of the system) and that strives to accommodate the demands particular to each one. As described by a "labor-management developer" Salamon interviews, this still-unrealized dream is one in which everyone tries to "hold multiple realities so we can accomplish our goal while we are listening to each other and understanding how we are different from each other."
Not everyone at the hospital is sanguine about this goal. On the subject of multiculturalism, the cancer center's oncology fellows may have been unusually outspoken with Salamon because their tenure at Maimonides was inherently limited -- or they might just represent a younger, more international perspective on the virtues of assimilation. A young, much-traveled Malaysian doctor, exasperated by patients who he feels have made an insufficient effort to integrate into American society, tells Salamon, "I had to assimilate to this country. I had to assimilate to Switzerland. I had to assimilate to France. Wherever I went. This disrespect for our country is what I hate. And this is my country now. We cater to this disrespect. Our health care system completely embraces this kind of stuff. We can't expect these people to change because we do nothing to change them. When I was in France, they didn't bend in any way. You either learned French or else ... Here you get translators." (Later on, the same man is singled out by one of the social workers as an exceptionally compassionate doctor, so go figure.)
To read "Hospital" is to despair (if you haven't already) of the ultimate viability of the multicultural ideal. A Chinese-born doctor (who learned Spanish for the sake of his half-Jewish Puerto Rican wife) is one of the few residents able to appreciate the protective drive of the Hatzolah, but even he expresses exasperation at the notion that the hospital can successfully accommodate the mores of every immigrant group without a diminishment in the quality of care. "A lot of cultures don't have the concept of preventive care," he tells Salamon. "They don't go to the doctor unless they're deathly ill. That's the way the Chinese community is. We throw all this money at it -- and that's a good thing, to have people who speak the language and understand the culture. But it's only half the equation. If the patient has the mindset 'I'm only going to come to the doctor when I'm on my deathbed,' then they are going to die. I can't see that patient reps or having doctors that speak Chinese or making inroads in the community will change the mindset of these people. The only thing that will change the mindset is themselves. ... Whether the something that is preventing them from coming is our point of view or their point of view, it is reality."
Unruly, politically incorrect, riven by factionalism and petty quarrels, exhausted by the effort to sustain their humanity amid the turning gears of a vast, ever more relentlessly capitalistic industry, the people of Maimonides nevertheless have some of the more serious, meaningful jobs in today's America. Their work is often a matter of life or death, and almost always a battle against grievous suffering. At the end of her year at the hospital, Salamon leaves with the apparent belief that they can still find meaning in it, despite the infighting and the external pressures. For all the sturm und drang and unfinished business in "Hospital," that makes for a heartening conclusion. Because if these people couldn't do it, what hope would the rest of us have?