Hospital (38 page)

My tablemate was Irving Pineiro, a doe-eyed young man whose job was to keep track of nurses and aides and help orderlies set up for surgery. He told me he had come to work at Maimonides as a janitor, nineteen years old, newly arrived from Puerto Rico, no English. Now he was an administrator, wearing a shirt and tie to work, dating the secretary who worked for Steve Lahey, chief of cardiothoracic surgery. The hospital had been good to him. He told me he believed he’d been chosen to become a Code Advocate because he had complained about nurses being rude to families of patients undergoing surgery.

Pam Mestel began. “We work in a high-stress environment,” she said. “We know it’s not one person’s fault a screw isn’t in a tray, the blood work isn’t there. The system isn’t what it should be, and we tend to take it out on the person who is there. The question is, how can we change the culture? And the doctor is the most notorious offender. We’re taking you out of work two days in a row, and David’s spending numerous hours with chairmen, talking them into giving up their precious M&M’s [morbidity and mortality meetings] once a month.”

“I know you’re sitting here thinking, ‘Oh, yeah, we did this five years ago.’ But this is serious. Will it happen in a week? No. But we’re calling people on the carpet. Our vision is that in the future you’ll be able to take care of these situations. It’s like Dr. Feldman said: ‘It’s just respect. Who doesn’t want respect?’”

Kathryn Kaplan asked, “Do you know how long a culture change takes?”

Someone called out, “One hundred years?”

Kaplan laughed. “Wow, this isn’t going to sound so bad,” she said. “Five or six years.”

The group learned that they would have to distinguish between rudeness, incivility, and bullying, which were Code of Mutual Respect matters, and sexual harassment and racial discrimination, which were union issues.

Paul McMurray, the consultant leading the sessions—chubby physique, preacherly style—told people to introduce themselves. Meanwhile, sitting at a table near the front, a taut man dressed in blue shirt, slacks, and necktie opened his laptop computer and began receiving and sending e-mails. Steven Konstadt, the new chair of anesthesiology, looked tightly wound as he typed furtively, his almost-hairless head glistening under the lights.

McMurray the consultant asked Elvia Johnson, a feisty nurse with long braids, “How do you stay in dialogue when a doctor has yelled at you?”

She laughed. “This happens to us all the time,” she said. “They yell at us, we tell the doctors to call Dr. Feldman. He calls us, we tell him what happened, he calls them, and then they are pussycats.”

Marion Contino, a nurse with short hair and “don’t mess with me” body language, chimed in, “They respect the doctor’s word more than the nurse’s, so we say, ‘Call Dr. Feldman.’ The doctor sees the doctor on the same level.”

Pineiro said, “I don’t personally have a problem with this, because I respect them, but I see what happens. If someone has a little higher rank than you, they’ll scream or yell. The doctors yell at the nurses. The nurses yell at aides. That’s how I see it.”

Konstadt kept typing.

Another nurse asked, “What do you say to a doctor who says, ‘I wish the patient would die so I could sue you’?”

Soon McMurray was barraged with lively examples of conversations gone wrong. The gripe session bubbled along, complaints flowing like champagne,gathering festive momentum until Elvia Johnson brought the proceedings up short with a nod toward Konstadt, still typing.

“I hear what you’re saying and appreciate that this institution is committed to this,” she said to McMurray, Mestel, and the other group leaders. “Then I see Dr. Konstadt sitting using his laptop through the whole thing, and I think that’s very disrespectful. I don’t want to sit here for two days if this is just lip service. There is still a hierarchy here. If this is to work, everyone should be committed, not just us front-liners.”

Konstadt froze, no longer typing, staring straight ahead. The incriminating laptop remained open.

McMurray jumped in with the enthusiasm of an acting coach whose student has just opened a vein. “Before I let him talk, let me respond,” he said. “What you see is a doctor with his laptop open. You see laptop open:
disrespect
. My path, I see something different! I see a doctor who says, ‘I can’t be here today. I have pressing matters beyond my control. I can’t be here.’ But he is here. If he brings his laptop, he can participate at some level. I’d rather have him semiengaged than not here. I tell myself I’d rather have a doctor with a laptop than no doctor at all.”

Johnson was not impressed. “You see, he gets away with it and I don’t!” she said with a theatrical shrug.

McMurray changed tactics. “What is going on here?” he asked rhetorically. “Why is the doctor more important than me?”

Contino said, “We did confront. We went to Dr. Feldman during the break.”

McMurray continued, “You can see from body language and tone: ‘I am here, I don’t count, I’ve got emotional issues and work issues, but I am frustrated as hell. I am pissed and want to bring a computer tomorrow.’ Or maybe he doesn’t want to be here either, but he can do what he wants because he’s a doctor.”

Konstadt clutched his knees and then absently pecked at the computer while McMurray went off on a long story about his fears of riding the subway. Pineiro leaned over and whispered to me, “Do you see what’s so bad about him being on the computer?”

Lunch.

After the break, before doing damage control with Konstadt, Feldman discussed the mechanics of how the mass training was going to be conducted, once a month in Shreiber.

A nurse asked, “There will be attendance taken?”

Feldman looked pained. “There are hundreds of people,” he said. “I’m not sure. The idea right now is, we passively support bad actions. If they see everyone else talking differently, we hope they’ll change. I have Pam Brier’s support. I run the OR. We don’t want to get to the point where I say, ‘I won’t book rooms for you.’ We don’t want to do that, but we want that threat to be there.”

Konstadt was back on the computer.

McMurray nodded at him. “Now we’re going to hear from the other side.”

Konstadt stood and spoke. “I want to apologize to anyone who took my computer as a sign of disrespect,” he said mechanically. “I’m going to be here four days this week, and I have things to do before the weekend. My beeper is disruptive, so I arranged with my secretary to e-mail me things. Seven years ago I finished an executive M.B.A. program, and I was looking up my notes about negotiations. For
this
. On a personal note, I have a psychology that could be called multitasking or ADD; it’s part of my learning style. I don’t want to be disrespectful, and I apologize if this ancillary tool is causing any disruption.”

Feldman explained that Konstadt had already been involved in a trial crucial conversation involving an anesthesiologist and a gastroenterologist. Each of the doctors brought the chairs of their department to meet with Feldman. “That’s the first problem,” said Feldman. “To put five doctors in a room takes three weeks of scheduling.”

The case involved a patient who spoke only Italian, who entered the hospital with a minor problem and ended up with a cardiac stent, very sick. The anesthesiologist began to discuss the case with the gastroenterologist immediately after the surgery, but he said, “I can’t talk about this now,” and left without explanation. The anesthesiologist was upset and complained to Feldman. He forced a meeting. At this conference, the doctor explained that the patient’s family was sitting outside and wanted to talk to the gastroenterologist. “It didn’t help that one is Syrian with a thick accent and the other is Chinese with a thick accent,” said Feldman.

They discussed the Maimonides Method: “One of them screams at me, and I scream back louder, and he says, ‘Why are you screaming?’ and I say, ‘When you stop, I’ll stop.’ ”

Class dismissed.

M
aimonides had a history of freewheeling behavior. Old-timers spoke nostalgically of the giddily righteous tumultuousness of the 1970s, when a group of social workers from psychiatry, angry at cutbacks, stormed the executive office and took the hospital president hostage for several hours. The young union mental-health worker who led the charge, a striking African-American man named Clarence Davis, wasn’t punished but was recognized as a leader. Now, thirty years later, Davis was an executive, director of hospital safety and security, still trim and muscular, still on the move. Every time I saw him, he was racewalking from building to building. I would run to catch him and ask if I could schedule an appointment to talk about emergency preparedness.

He always nodded and then pulled ahead, leaving assurances in his wake. “I can’t do it right now,” he said. “Later.” And I would make a note in my calendar for the next month, when the scenario would be repeated. My calendar was filled with notations, spaced about a month apart:
“Call Clarence D. re evacuation plan, weapons of mass destruction, biological warfare, chemical disaster, etc.”

Davis was always dressed in a smart suit, the picture of officialdom. When I heard of his earlier, rebellious history, I was reminded again of the words of Carol Kidney, the nursing director of obstetrics
:
“Everybody believes they can and should speak up.”

The right to disagree was as basic a tenet in the hospital as any principle in the Hippocratic Oath. This belief and practice led to the eruptions creating the need for a Code of Mutual Respect but sometimes resulted in a remarkable willingness to accommodate. Coincidentally, Carol Kidney turned up in scenarios illustrating both aspects of the hospital’s unruly persona, one side bent on contention, the other on compromise. Kidney had signed on to be one of Feldman’s Code Advocates. She also found herself part of a national battle over a late-term-abortion procedure being fought by some with acceptable partisan fervor and by others with unpardonable nastiness.

Kidney and Howard Minkoff, the physician chair of obstetrics, brought the abortion issue to the Maimonides bioethics committee. It involved a procedure called D&X, dilation and extraction, usually performed after the twentieth week of pregnancy. The method, recommended by the American College of Obstetricians and Gynecologists in certain cases, requires the person performing the abortion to dilate the woman’s cervix, pull the fetus through feetfirst, and then puncture the head so the skull won’t cause damage as it exits the cervix. “Certain cases” might involve a fetus that was so damaged it was no longer viable or a teenage mother who, through ignorance or denial, didn’t realize she was pregnant until late in the game. The procedure was almost always reserved for instances when the alternative— pulling the fetus out whole—could be dangerous to the mother’s health, causing severe blood loss and cervical damage significant enough to prevent future pregnancies.

It was a procedure rarely used at Maimonides or nationwide. In 2000 it was used in only about 0.2 percent, or 2,200, of the estimated 1.3 million abortions in the United States, according to the Guttmacher Institute, a nonprofit research and public-health-policy organization that focuses on sexual and reproductive rights. Though the procedure was rare, its mechanics made it a powerful visceral weapon for antiabortion forces, which dubbed the method “partial-birth abortion” and vilified the physicians who terminated pregnancies in vivid, gruesome language, like “baby killers.”

Pop-ups on the National Right to Life Web site:

In 2003, President George Bush signed the Partial-Birth Abortion Ban Act, a bill that used the politically charged and nonscientific name for the procedure. The bill had twice been vetoed by his predecessor, President Bill Clinton. However, since Bush’s endorsement almost three years earlier, the procedure was still legal because of numerous court challenges that were keeping the ban in limbo.

That was the political situation when a physician newly affiliated with Maimonides scheduled a D&X and Carol Kidney could not find a nurse in the hospital willing to participate. She and Minkoff brought the matter to the monthly bioethics meeting. Alan Astrow and Carl Ramsay were among the nurses, doctors, and legal people gathered in the boardroom as a bright, early-morning winter sun illuminated the Empire State Building in the distance.

Minkoff, a vocal advocate for the rights and health of pregnant women, had clear opinions and let them be known. For example, when local Orthodox women proposed a doula program for the hospital, Minkoff agreed, but only if the doulas operated strictly on a first-come, first-served basis, regardless of whether the new mother was Arab, Chinese, or Jew. In Minkoff’s view, Maimonides had an ethical obligation to offer legal abortions to its patients, even if a particular method offended someone on the nursing staff.

“The procedure is much more humane for women,” he told the group. “You dilate the cervix, and instruments extract the fetus in pieces. More humane for the patient, less pleasant for the nurse. I don’t object to individual objections. I do object to institutional objection.”

A nurse at the table spoke. “Many people don’t object to patients’ right to have an abortion, but this involves the removal of body parts of a human body. Whether you are pro or against abortion, it is an unpleasant landscape. It is a scene many have trouble with.”

Carol Kidney elaborated, “It’s pulling the fetus out in pieces.”

The ensuing conversation covered moral and aesthetic objections, medical and ethical rebuttals. Alan Astrow expressed sympathy for the nursing staff and suggested that greater effort be made to explain why the procedure was necessary. Minkoff acknowledged sympathy for the nurses’ reluctance and then commented that some people might think it was unethical to keep elderly people alive in a persistent vegetative state on ventilators. An Orthodox doctor whispered, “It’s not at all the same.”