Hospital, USA

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?

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