Hospital (9 page)

Stephen J. Lahey, another new chief, had been recruited from UMass Memorial Health Care, a large nonprofit healthcare system in central and western Massachusetts, and the University of Massachusetts Medical School. Boston bred, formerly a professor at Harvard Medical School, he had a noticeable Boston accent and an office full of Red Sox memorabilia. He was part of a delicate transition, replacing Cunningham as the head of cardiothoracic surgery while the hospital nudged the older doctor into a senior-statesman role, head of strategic planning. (Cunningham remained chief of surgery.) Lahey’s mandate from Brier was to improve not just medical practice but behavior among the physicians. “The intensity of the emotions was way more than I thought it would be,” he told me. “I’m dealing with the toughest thing in the world. Not changing atrial fibrillation but changing the way people think. That’s a zillion times harder to do. To change a procedure I can issue an edict. But I want them to look at these changes as change in the way we think. We’re going to think logically and collaboratively and that’s not the way health care works in Brooklyn. It’s rough-and-tumble. There are some pretty tough hombres here.”

It didn’t take long for me to hear about the two biggest fights in the hospital, both of them involving major players. One long-standing battle involved none other than Joe Cunningham, venerable chair of surgery, and his former medical partner, Israel Jacobowitz. Everyone referred to Jacobowitz as Izzy but Lili Fraidkin told me to be sure to call him Israel. He didn’t like Izzy. The other feud—Kopel v. Bashevkin—was the one to watch, I was told, because it was already affecting the start-up of the new cancer center. I would quickly learn how.

In mid-September, Alan Astrow, who had unwittingly lured me to Maimonides, and who by then had been the chief of hematologic oncology for six months, invited me to the first of what he hoped would be weekly interdisciplinary meetings. In this team approach, doctors from different disciplines considered whether the cancer under scrutiny would be best treated through surgery, chemotherapy, radiation, or some combination. The practice was not new to Astrow; he had begun attending discussions like this as a resident at Boston City Hospital, now merged into Boston Medical Center, more than twenty years earlier. But this was the first such gathering at the Maimonides Cancer Center, which was still under construction four months after the official opening.

The radiation-oncology floor in the basement had been open since May, though not many patients seemed to have noticed. The office spaces were sleek but not cold—wooden furniture, earth tones, and fish tanks. The hospital had invested $5 million in a linear accelerator for radiation therapy and the subterranean fortress needed to house it—a room that was surrounded by several-foot-thick concrete walls covered by several hundred thousand pounds of lead, plus plastic impregnated with boron to absorb radiation. Yet, despite the absence of windows, the feng shui consultants and architects had dispelled any sensation of being in a bunker. It was a pleasant place to face the prospect of life and death.

The small conference room quickly became crowded with about twenty representatives from the departments of hematology and radiology, a surgeon, and several young doctors enrolled in the hematologic-oncology fellowship program. They discussed a variety of cases: two patients with leukemia, one a forty-three-year-old man from Turkey and the other a twenty-five-year-old from Mexico. There was a forty-two-year-old African American woman with a brain tumor causing excruciating headaches, and a forty-year-old white man with lung cancer. Bernadine Donahue, the brilliant radiation oncologist recruited from New York University Hospital, a dark-haired woman in her forties, with milky skin and a soothing, husky voice, rattled off several studies in response to each case. Matching wits with Donahue, study for study, was Yiwu Huang, a hematologic oncologist who looked like a schoolboy and spoke English with a heavy Chinese accent. Huang, who had trained at Robert Wood Johnson, carried a library of medical information in a small portable hard drive that had become like an extra limb on his thin frame. Amit Schwartz, a self-assured young neurosurgeon, explained with exaggerated patience how he would approach the case. The oncology fellows, whose medical training represented India, Pakistan, South Africa, Russia, the Caribbean—and yes, the United States—were quizzed by the experienced doctors.

I sat next to Samuel Kopel, the medical director, whom I had met briefly but hadn’t yet seen in action. Kopel was also a hematologic oncologist; he and his former partners had run the hospital’s faculty practice for many years. He seemed to be enjoying the colloquy, offering examples from his long history with patients, interjecting proverbs in fluent Italian. He was a formidable figure—balding, lean, and tall. His precise diction implied authority; his intense alertness indicated wariness. I would learn that both the slightly stilted manner of speaking and watchfulness were residues of his ruptured childhood. Born somewhere in Europe (he didn’t know the place) in 1946 (there was no record of his birth), he lived with his family in a refugee camp in Germany until he was eleven years old. I had first seen him at the cancer center’s opening, where Brier had singled him out as the person responsible for its creation. I wondered why he hadn’t been invited to sit onstage. My interest deepened when I overheard someone whispering that Kopel’s wife was quite sick—an advanced case of ovarian cancer.

When the discussion was over, I looked for Astrow. I found him deep in conversation with a gray-bearded middle-aged man wearing a yarmulke who had sat quietly during the conference. I overheard the words “Talmud” and “anger.” Astrow spoke in a conciliatory manner, but the man he was talking to seemed too distressed to listen.

That was my introduction to Michael Bashevkin, Kopel’s former medical partner, protégé, and friend—more than a friend, close enough to have once bought Kopel a piano, a gift that seemed both intimate and extravagant. Bashevkin’s current partners included two other Kopel protégés, including a cousin of his and a friend who was close enough to sign the
ketubah,
the Jewish marriage contract, of Kopel’s daughter when she got married.

Kopel and Bashevkin ignored each other during the conference, as usual. Bashevkin and the two others had split up with Kopel five years earlier but had continued to share the same office space for two years. They tried to avoid each other in the corridors. But the corridors were narrow.

The Bashevkin-Kopel fight never fully made sense to me, no matter how many people I asked about it, including the participants. Recollections were clouded by self-interest and the passage of time.

“Let me put it to you this way,” said Sharon Kopel, Sam Kopel’s wife, so weakened by cancer when we talked that she could barely sit up, but still able to muster lively indignation. “People who were supposed to be honorable weren’t.”

“It was personal,” said Michael Bashevkin. “It didn’t have to do with our greed. We felt we were treated like chattel.”

“It was absolutely money,” said Sam Kopel. “Yes! Oh yes. I don’t think it, they said it.”

“Bashevkin is a stubborn man,” said Stanley Brezenoff, who tried to broker a peace and managed to make it worse. “He’s not a bad guy but he’s a stubborn man. And Sam [Kopel] is a stubborn man.”

By the time I talked to Brezenoff, those negotiations were part of a vague memory for him. He was at a bigger place with bigger problems, and besides, he was a master deflector. “Honestly,” he said, “all the cancer center at Maimonides needs is a surgical star or two, and that changes everything. Patients come to the surgeons. Remember, you don’t need everyone, just a certain percentage to make it viable.”

By then he was ensconced at Continuum headquarters on the nineteenth floor of a high-rise building on the West Side of Manhattan, with grand views of the working piers on the Hudson River.

He smiled slightly as he talked about the quarrels at Maimonides. “I spent a lot of time on that feud,” he said when I asked him about Bashevkin and Kopel, but then he quickly demurred. “I can’t remember all the details of it.”

It
was
generally agreed that the fight involved neither charlatans nor thieves, but rather respected oncologists considered to be good and caring doctors and decent men, whose bad behavior was hot-linked to self-righteousness and pigheadedness—to being human—not chicanery.

This quarrel between former partners, between a mentor and his students, between cousins and friends, was petty perhaps, but it was no minor rift. Kopel, as medical director and driving force behind the cancer center, represented the institution. The Bashevkin group’s hematologic-oncology practice covered a substantial portion of Maimonides cancer patients. The hospital relied on private practitioners like Bashevkin and his partners to keep the beds full.

The breakup began when Maimonides, at Kopel’s urging, began seriously exploring the possibility of building a cancer center. By that time, in the late 1990s, Kopel had become medical director but was still in partnership with Bashevkin.

Dr. Bernard Salick had become interested, and that was significant. Salick, an entrepreneurial physician who grew up on the Lower East Side of Manhattan, had moved to California and opened a national chain of cancer clinics, including the one at St. Vincent’s, Alan Astrow’s former hospital in Manhattan. All Bashevkin recalled of the Salick episode, however, was “a very insulting meeting” with Brezenoff at which he and the other partners— besides Kopel—were asked to articulate their terms to participate. They asked the hospital president for an amount of money he dismissed—in a letter—as “totally outrageous.” Bashevkin said he was offended by Brezenoff’s response and, even more, by how it was delivered.

Kopel, on the other hand, felt his former partners were greedy.

The Salick talks fell apart. “Bernie would show up and be dazzling and very Bernie-like and talk about how he was a street kid from New York and Stanley’s soul mate and a few other things, but we couldn’t figure out how to do a deal that left us with a modicum of something and not turn it all over to them,” Pam Brier recalled. “So we moved on.”

But Kopel, Bashevkin, and their other partners were not able to move on. Their split was final, and it would have ongoing repercussions for the hospital.

How specifically? Kopel had helped to convince Jay Cooper, a renowned radiation therapist, to come to Brooklyn after Cooper’s twenty-seven-year career at New York University ended on a sour note. Cooper brought along a team—including Bernadine Donahue—with strong credentials and reputations. In addition, there was the $5 million price tag for the linear accelerator and its accommodations. The expenditure was rationalized by the understanding that radiation would be the economic engine of the cancer center; reimbursements for radiation therapy were far more lucrative than those for chemotherapy. But without patients, there would be no reimbursements, and radiation cases came through referrals.

Referrals came from other doctors—primary care physicians, oncologists, or surgeons. Patients never knew whether referrals were based on an assessment of competence and results, or on relationships. Cooperation among clinicians, I was learning, was a deceptively simple concept. Hospitals were interlocking systems. Just as medications produced harmful side effects as well as cures, notions of progress resulted in distrust and anger as well as a sense of hope. Insurance companies paid for procedures, not bedside manner, but when it came time for one doctor to refer to another, personality often mattered as much as (and often more than) ability.

After the new cancer center opened, the Bashevkin group referred only a handful of patients to the radiation group. And it hurt. Business was slow.

Bill Camilleri, who had been hired by Brezenoff to build the cancer center—six weeks before Brezenoff announced he was leaving—described the Bashevkin-Kopel battle like this: “It’s a great cultural feud,” he said. “In my inappropriate way I compare it to why there will never be peace in the Middle East. To work with doctors who walk around believing that if one of them gets struck by lightning it’s the other one’s fault, it’s shocking.”

Not so shocking, considering Camilleri had his own private, internal feud simmering with Pam Brier. She hadn’t been consulted when Brezenoff hired him, and Camilleri believed she simply did not like him. He thought she was high-handed and egocentric. He couldn’t get over the fact she had chosen May 4 as the day for the cancer center’s opening, and had locked in the mayor and other politicians, knowing that Jay Cooper, the director of the center, had a conference in Barcelona the day before and would have to scramble to get back in time.

Even worse, in Camilleri’s view, Brier had never recognized the coup he had pulled off just getting the place built. When he’d arrived in March 2003, the hospital had a vague agreement with Health Insurance Plan of New York (HIP), the occupants of the Chinatown building that would become the cancer center. There was no written plan, no lease, no drawings—and a structure that would have to be completely overhauled. By being a bulldog in negotiations with the landlord, with contractors, with everyone, Camilleri reached the deadline. The new cancer center was ready in less than two years.

The achievement was all the more heroic—or foolhardy—considering his health. He had been a “blue baby,” born with tetralogy of Fallot, a congenital, life-threatening heart defect. His parents were told he would live a year, but he tricked the odds and survived. At twelve he had open-heart surgery; in 1969, as a teenager, he had a pacemaker implanted in his chest. Short, bearded, and chubby, always panting a bit, he seemed bent on defying his heart’s weakness; he kept jars of M&M’s, pistachios, and Pepperidge Farm Goldfish cheddar crackers on his desk, and he worked from early morning until late at night.

Now that the center was built, Camilleri’s job was to create a serene, efficient, and friendly atmosphere that would help take the edge off cancer, not the deadliest but perhaps the most dreaded diagnosis. He knew what it meant to be deathly ill. He believed he was running the most important program in the hospital, and yet he had never had a one-to-one meeting with the president. That rankled.