Hospital (10 page)

Sondra Olendorf, the head of nursing and hospital operations, remembered being surprised when she first met Camilleri. “Stan met him—no one else had—and hired him on the spot,” she said. “He didn’t match anyone’s physical view of what we thought the administrator of the cancer center would be. It’s horrible to say, but true. I think Stan was compelled by what Bill had overcome in life. Bill wasn’t expected to live after a year of his birth. When Stan heard that story and saw what this guy had done, clawing and kicking and fighting his way through life and love and work, he figured this was a guy who would claw his way to success here.”

When Daniel Sulmasy heard about the political situation at Maimonides, he understood why the hospital administration would be interested in hiring his friend Alan Astrow to become chief of hematologic oncology at the new cancer center there. “He’s a calming influence,” he told me. “I couldn’t imagine Alan screaming or stamping his feet in a temper tantrum or throwing over an IV pole in a fit of anger at a nurse—that’s not his style. He can listen to people attentively, make a reasonable judgment, let people think their case has been heard.”

There had been full disclosure; in an early interview, the chair of medicine had told Astrow about the Bashevkin-Kopel feud, and how it might affect the cancer center. Hiring Astrow made sense for Maimonides but, Sulmasy wondered, did the move make sense for his friend? Astrow had a thriving practice at St. Vincent’s in Manhattan and a warm feeling for the Catholic hospital where he had spent most of his career. When the morning recitation of the Lord’s Prayer came crackling over the loudspeaker, Astrow actually listened, taking the Christian prayer (“
Forgive us our sins as we forgive those who sin against us
”) as a daily reminder to be humble. Life was comfortable. He had the freedom to organize his conferences on spirituality and healing and to teach. He had enjoyable and satisfying relationships with his group of nurses and physicians’ assistants. On nice days he rode his bicycle from his apartment on the Upper West Side, down the bike bath along the Hudson River, and over to St. Vincent’s, which was surrounded by streets full of interesting restaurants conducive to long discussions and debate.

I saw what he was giving up when I visited Sulmasy in the old wing of St. Vincent’s; the old-fashioned main hall had the hushed feeling of a monastery. Astrow had told me he wasn’t that worried about losing the amenities. It was the loss of a whole history of relations. “Suppose I’d forgotten to call a doctor I’d done a consult for,” he said. “At St. Vincent’s, I had a whole history of giving good service, a wellspring of goodwill I’d built up over twenty years. If you’ve done things for people you know and like they’ll cut you some slack. If you lose your temper or don’t say the right thing, they’ll know it wasn’t quite you. At a new place, everyone is sizing you up.”

Sulmasy told me his concerns for Astrow had to do with the job itself. Sulmasy was a clean-cut, handsome man who appreciated fine food and appeared to choose his wardrobe carefully. But he was consumed by higher callings. He was a Franciscan friar and chair of the bioethics committee at St. Vincent’s, and he couldn’t understand why a thoughtful, sensitive person like Astrow would want to become an administrator in any hospital. “One of the problems of being a leader of a section or a department in medicine these days, so much of it is running a business,” he told me. “It’s about cash flow, marketing to communities, coming up with gimmicks to get patients in. It almost sickens me in terms of what medicine should be about, part of that medical-industrial complex. I have no interest. I was worried in some ways about Alan pursuing that.”

Sulmasy was a seeker. He had trained as a physician at Weill Medical College of Cornell University, done a fellowship in internal medicine at Johns Hopkins Hospital, and then completed a Ph.D. in philosophy at Georgetown. He thought of Astrow as a companion intellectual and a genuine healer. On the day Sulmasy arrived at St. Vincent’s, seven years earlier, in 1998, Astrow was conducting a symposium called “Spirituality, Religious Wisdom, and the Care of the Patient,” where scholars from different religions spoke to physicians, nurses, and social workers about the role of religion in medical treatment, particularly with very sick people. Astrow had invited Sulmasy, and though he wasn’t able to attend, Sulmasy was impressed by Astrow’s intention.

“He was thinking about getting scholars talking to doctors and nurses about the role of religion in the care of patients beyond simply complaining this person’s religious beliefs won’t let me transfuse them, or this person’s religious beliefs lead them to denial, or complaining that religious beliefs won’t let us get the DNR [do not resuscitate] order we want,” said Sulmasy. “He wanted doctors to take religion more seriously, to acknowledge that the fear of dying is not new, and these traditions have dealt with them for centuries and still might have something to say.”

Sulmasy and Astrow decided to continue the discussions and obtained funding for them from the John Templeton Foundation, which had been founded by John Marks Templeton, a Wall Street financier from Tennessee, who became a naturalized British citizen and was knighted by Queen Elizabeth II for his philanthropy. The foundation, based in West Conshohocken, Pennsylvania, was giving away about $40 million a year to projects concerned with exploring the benefits of cooperation between science and religion. In the late 1990s, Templeton had been giving medical schools grants to begin courses on the subject of spirituality and medicine. With the grant, Astrow and Sulmasy put together an all-day colloquium that drew five hundred participants. A few months later, with another foundation grant, they began a year’s worth of monthly discussions, including the session I attended at New York-Presbyterian Hospital, which they videotaped and hoped to distribute to medical schools.

Sulmasy explained what attracted him. “Part of this groundswell of interest in spirituality comes from a sense of alienation that is not just experienced by the patient anymore. The past few decades, patients have been saying, ‘I feel I’m just a machine, a widget on the assembly line.’ But lots of doctors are now beginning to experience that, because of the medical-industrial complex that treats doctors as another widget. It’s all interchangeable parts, and the chief virtue becomes efficiency rather than caring, compassion. Lots of physicians are feeling a sense of emptiness, alienation: ‘Is this why I went into this? Is this what it’s all about? If we’re addicted to technology, is this the way out? Is there more to this than just thinking about how many colons I can put a scope up per day and how many polyps I can remove and how fast I can be and how few complications I can get?’”

He continued. “People have speculated that the Baby Boomers just don’t want to accept the fact that people are going to die, and technology can’t give us the solution. It’s everybody’s obsession. Of course, physicians can’t be exonerated from this. We’ve been telling people we’re going to win the war on cancer for decades, since [Lyndon] Johnson, and now they’re playing the tape back: ‘Why are we losing this war after spending so many billions on it?’ It’s hard, when they are playing back what we told them, to say we aren’t to blame for patients’ misconceptions.”

Astrow thrived on this kind of debate, and he was aware of the pitfalls of becoming an administrator. But he had been determined to try it, and if the job at Maimonides hadn’t come through, he would have gone somewhere else.

The stakes for him were high. He was fifty years old, with two young children, one in middle school and one in elementary school. He was tossing aside a secure job for an uncertain future at a hospital in Brooklyn in a brand-new enterprise that could fail. As a cancer doctor in New York, he was always acutely aware of status. Memorial Sloan-Kettering was the behemoth that always had to be dealt with. His own mother had lung cancer and chose to be treated by an oncologist at Sloan, even though Astrow had recommended NYU, where everyone knew him.

Nice he may have been, but not naïve. He knew that taking over the department of hematologic oncology at Maimonides would be much more than a simple matter of exchanging crosses on the walls for mezuzahs on the doorposts. He would be stepping into a charged situation—the feud. But, even without that, Astrow was aware that bringing in outsiders automatically set up a kind of class struggle within the discipline. He understood firsthand what it is like to be the old guard in a situation like this. A decade earlier St. Vincent’s had contracted with Salick Health Care—which had been franchising for-profit, state-of-the-art cancer centers around the country. Salick invested millions in equipment and architectural niceties, and it was clear management felt that marquee-name doctors were needed to complete the picture of superior medical care.

Astrow realized he would never run a division at St. Vincent’s, no matter how capable he was, no matter how much he was loved by his patients, no matter how much he was respected by his peers and superiors. He’d been there almost nineteen years, ever since he completed his training. “If you’re in a place your entire career, you’re seen a certain way,” he said. “I’m a different person than I was eighteen-plus years ago. I was immature. People who have known me all along tend to see me that way. To do something different, you have to leave, so people can see you in a different way.”

He realized it might not seem logical, his wanting to leave. Not only was he comfortable at St. Vincent’s, he hated change. “I drive my wife crazy,” he warned me when we first talked about letting me shadow him. “I like doing the same things all the time.”

Yet his résumé revealed ambition: Yale University for his undergraduate and medical degrees, residency and fellowships at Boston City Hospital and NYU Medical Center, organizer of symposia, pursuer of grants, and contributor to academic journals. “I’ve felt very capable of organizing things, running things, motivating people to do good work, recruiting people, building a good program, and the only way you can do that is if you are the leader of the division. And it wasn’t going to happen for me at St. Vincent’s.”

The first few months at Maimonides were very hard for him. No one told him exactly what he was supposed to be doing. Despite the fanfare of the cancer center opening, the floor where the heme-onc (hematologic oncology) group would be practicing wasn’t ready. Astrow and his colleagues were stuck in the old building—in the old Kopel-Bashevkin practice space—until the end of September. Camilleri had just fired the billing person, a holdover from the old group practice, which infuriated Kopel. The lab was still under construction so patients had to wait longer for test results. The bright young woman he and Camilleri had hired to manage the department had arrived over the summer and immediately alienated almost the entire support staff by letting the nurses and technicians know she thought they were incompetent. At the same time, he was trying to ingratiate himself with the hospital administration and other doctors by showing his face at meetings at the hospital and at charity functions in the community.

He was always tired.

Jay Cooper, the radiation oncologist who was director of the center, kept himself aloof, disconnected from the daily operations and not showing much interest in doing public relations or worrying about his colleagues’ anxieties. Meeting him reminded me of something Howard Minkoff, chief of obstetrics, told me he learned in medical school:

“We got assigned to a patient who was dying. Part of the course, you had to be in the room when they were told, up to the day they died,” Minkoff said. “They asked, ‘What does death mean to you?’ The humanities people would say, ‘Death is the loss of everything all at once. It’s like losing a family member.’ The science major would say, ‘Death is the cessation of all spontaneous electrical activity.’ So some people come to medicine because they use science to get to people, and some people come to medicine and use people to get to science.”

Cooper seemed to belong to the latter camp. He told me he chose cancer as a specialty because the minute he saw a tumor under a microscope— experimenting on the thymus of a mouse while at New York University’s medical school—he knew that whatever he did in medicine was going to have something to do with tumors. He was a monologist, the kind of person who would say, “Don’t get me talking about photography,” when what he meant was, “Let me tell you about photography” as long as you’d listen, then do the same for computers and the difference between CAT scans, MRIs, and PET scans, as well as the Tao of tumors.

“We live in a sea of radiation,” he told me enthusiastically when we first met. “When you walk in the street, you get radiated with cosmic rays. When you fly in an airplane, you get more radiation. You have a granite counter-top?That’s mildly radioactive. We live in it, we’ve adapted to it through evolution. It’s merely a question of dose. If you give any living thing a dose, you can kill it with radiation. The other half of the equation is that if you give enough dose to any normal tissue, you’ll kill that as well. So if you had some magic way of differentiating normal tissue from neoplastic tissue and keeping it out of normal tissue, you could cure every cancer.”

That, of course, hadn’t yet happened, but technology had refined radiation treatment dramatically. Cooper had convinced Maimonides to purchase two linear accelerators, one equipped to do intensity modulated radiation therapy (IMRT); the other could offer basic radiation therapy. IMRT machines can alter the shape of beams to conform to the shape of certain tumors, making the radiation more effective. IMRT therapy also happened to have a reimbursement rate that was at least three times higher than that of regular radiation therapy. However, the IMRT function had been idle because another hospital had reported an irregularity in a machine made by the same manufacturer; until Cooper had tested and retested the IMRT, he wasn’t going to use it.

He claimed not to be worried that the patients weren’t lining up at the door for the sophisticated radiation therapy that was available. He believed in the
Field of Dreams
business model: Build it and they will come. “The way to do it is through education of doctors, and the way you do that is provide a level of care for the patients they’re not used to,” he said. “That’s beyond what they could have gotten in Brooklyn up until now. We’ve seen already the patients we’ve treated have gone back to their communities and said to their physicians, ‘Wow, you can’t believe how well I was treated.’ I think to some degree it’s important we go back to the idea that quality is our most important product.” The implication that the cancer center operated at a different—higher—level than the rest of the hospital wasn’t lost on his colleagues.