Hospital (12 page)

“You know she’s a striver, that she’s good, that she is doomed by illness,” Kopel was saying. He was talking about Violetta, the main character in
Traviata
. “In the first minutes of the overture. Those high violins, those dissonant notes, go home and listen to it. That is a musical depiction of tuberculosis, of disease. It’s perfect.”

His initial interest in starting a cancer center, in the early 1990s, was purely professional, a desire to implement at Maimonides the idea of multidisciplinary cancer care that had emerged in the 1980s. An ambitious surgeon named Rene Khafif recognized the financial potential, and he and Kopel drew up a business plan just as Brezenoff came in. The potential may have been there, but the new president said no, unable to justify making an investment that would take years to recoup at a time the hospital was in financial trouble. By then, Kopel was medical director, part of the administration, and he took Brezenoff’s side. Khafif left Maimonides and sent Kopel a letter, accusing Kopel of not fighting for something that would provide better patient care.

That goad alone would have been enough to trigger Kopel’s competitive instincts. But additional, painful incentive came later that year. In August 1996, Sharon felt a lump in her breast. A biopsy was pronounced negative— the wrong diagnosis, it turned out, a too-common oversight with youngish women with dense breasts. But a second biopsy was deemed suspicious; she had an extensive lumpectomy and then radiation.

Even with Kopel, the medical director, pulling strings it took six weeks of utter frustration to get Sharon’s treatment organized. He didn’t need
La Traviata
to touch his emotions then, from this new vantage point on the other side of cancer treatment. Watching the psychological toll on his wife, he said, he now saw the radiation therapy room as a “disgusting little hellhole.” He became determined to resurrect the cancer center dream. Finally, when the hospital reached financial stability, Brezenoff agreed, though he would leave Maimonides and Brier would become president before construction began.

On the very day the groundbreaking took place, on September 26, 2003, Sharon Kopel received a new—more ominous—diagnosis. Kopel knew she might not live through the time the construction would take. But she was very much alive, though she had been too sick the day of the official opening in May to leave the house. Sharon was tough, and told Sam she planned to be there for the next dedication, of the Lena Cymbrowitz Pavilion, scheduled for the end of September 2005—and she was.

After I had been hanging around Maimonides for several weeks, I bumped into Astrow near the front entrance of the hospital. By then I recognized the expression on his face, just as I had become accustomed to noticing the difficulty he had keeping his shoelaces tied. He looked worried. As the usual Maimonides mix of rebbes, women wrapped in
hijab,
and various others walked by, I said, as a joke: “You must feel like a stranger in a strange land.”

Astrow snapped. “Don’t call me Moses.”

I was startled by his vehement, almost angry, response, because he rarely showed anger. When I first met him, he told me, “I’m almost pathologically concerned about saying things that will be hurtful to other people.” It hadn’t taken me long to discover why his patients loved him: That compulsive worrying was an admirable trait in the person in charge of your destiny. He had empathy to spare. By then I had watched him reveal the most hurtful facts to terminally ill patients, but in a manner that mitigated the harm as much as humanly possible. He practiced what he preached: “Medicine should not be caveat emptor. You should be watching out for the patient.”

When I invoked “stranger in a strange land,” I had been referring to the science fiction novel with that title by Robert Heinlein. Astrow went straight to the source, Exodus 2:22. This biblical passage takes place after Zipporah, the wife of Moses, gives birth to their son, whom Moses names Gershom, derived from the Hebrew verb
garash,
“to drive out,” referring to the Israelites’ exile in Egypt. Moses explains, “I have been a stranger in a foreign land.”

Later, during another, calmer conversation, I asked Astrow why he’d reacted so strongly.

“Moses in the Torah, he had a direct relationship to God,” he said. “He’s seen as the person who’s supposed to solve every problem and ends up being lonely and isolated. I’m not God, I don’t have a direct relationship to God, and I don’t want to end up lonely and isolated. That’s one reason.”

The other reason was my fault. I had told him that Pam Brier had heard him speak at a cancer center gathering and said she thought he was “luminous.”

What I thought would be reassuring turned out to be fuel for more worry.

“I got in a lot of trouble, I think, at St. Vincent’s for being seen as this spiritual ethical person,” he explained. “If you’re seen as a little too interested in religion and spirituality and ethics, you’re seen as a nice boy and not a particularly effective person, and if you have a real problem, you go to someone who is a tough person interested in power. This nice one is seen as just interested in ethical issues, who nicely just puts a window dressing on everything, but that’s not the person you go to if you really have a problem. I think I got into problems in that way at St. Vincent’s and was underestimated as a result. I think I really have to watch that.”

I said, “I don’t think she meant it that way.”

He replied, “It’s like being seen as a nice Jewish boy.”

“God forbid,” I said.

“It’s problematic,” he explained. “If you’re seen as being too nice, you cannot accomplish very much. You can’t be too nice. You can be honest and principled and respectful of other people, but that doesn’t mean you can’t make a decision and tell people when they aren’t doing their jobs and be effective. That’s your job.”

World-class worrier that he was, he couldn’t finish the conversation without completing his thought. “Seeing yourself in terms of Moses is also being totally grandiose, isn’t it?” he said. “I was talking to my wife about this. If you really want to do anything, if you want to accomplish anything, you have to be slightly grandiose. If you’re writing this book, you must have some grandiosity behind it, large ambitions—you probably have large ambitions for every book. However you fantasize, it never turns out quite the way you fantasize. You haven’t really transformed the universe. But that’s what keeps you going. When people point out your grandiosity, you can feel a little bit foolish about it.”

He laughed. “That’s the Jewish religion! Our hero is Moses, who has a direct relationship to God, and we’re supposed to look up to Moses and aspire to that somehow, but then Moses is praised for being very humble. He speaks directly to God, but he’s the everyday Joe; he’s very humble. Well, I’m not Moses.”

Then he smiled and said slyly, “Of course my father’s name was Martin, and his name in Hebrew was Moses—
Moshe
.”

It was the kind of discussion people had at Maimonides—at least those who thought about such things—the hospital named for the man who was, for Jews, the other Moses. “From Moses to Moses,” the rabbis said, tracing the line from the receiver of the law to the codifier. But the biblical Moses— the dashing man of action who defied Pharoah—was the primo Jewish leading man, not the bookworm Moses—Moses ben Maimon, Maimonides, the medieval philosopher and physician. Moses the Egyptian slayer may not have been Hollywoodized as many times as Jesus, but he was indisputably an icon, both religious and pop.
The Ten Commandments
had remained a perennial favorite for half a century, televised each year around Passover and Easter. The story had legs. Who doesn’t know some version of it? Moses led his people out of bondage and became spokesman for God. What a hero! All the more compelling because he was flawed—human—subject to miscalculations in carrying out divine will, his honorable intentions frustrated by ego and impatience. In the end he was ordered by God to pass the torch, before his journey was completed, to his successor, Joshua.

Speculating about Moses in the context of the hospital and the cancer center, it wasn’t Alan Astrow who brought to mind the uprooted child who became a dogged, uncompromising warrior, the man who led the people to the Promised Land but then was forbidden to enter. Maybe the more fitting surrogate was the behind-the-scenes man, Sam Kopel—the medical director who had willed the cancer center into being but whose feud with Bashevkin was damaging the new enterprise. “I feel I have a life sentence here at Maimonides,” Kopel once told me. “I love it and hate it.” No matter how much he achieved, he remained the displaced person, the immigrant boy who spent most of his life feeling rootless, stateless, not belonging anywhere.

Four

Safety Nets

Picked up my ID at Maimonides a week after Hurricane Katrina knocked the stuffing out of New Orleans. Charity Hospital, the city’s big public hospital, refuge of the poorest people, was shut down. As I rode the D train across the Williamsburg Bridge and squinted at the early-morning sun coming in through the window, I experienced one of those weird movie moments, a dissolve, Manhattan skyline beyond the East River fading into gruesome television images: bloated corpses floating in dirty water, dazed people climbing on buses bound for safety or maybe exile, blundering president, sickening mold, weeping mayor, clueless head of Federal Emergency Mismanagement. Major systems breakdown, assuming—big assumption— that the systems were ever in place. Barbara Bush, presidential mom and former first lady, was quoted all over the place saying people forced to leave their homes, possibly forever, won’t really mind, because they are so poor anyway. Later Googled and found replay on Internet of
Marketplace
[the public radio show].

What’s the word they use in Borough Park?
Shanda?
That’s it. Shame.

There are many ways to be dispossessed—hurricanes, wars, poverty—and of course disease, the great disrupter, mercurial and unsparing as weather. In modern society we rely on complex systems to protect us when the winds sweep in, when planes attack, when we can’t pay the rent, when we fall ill. At Maimonides the desire to take responsibility was great, to provide a safety net for people who were sick, but the system was overloaded. Sometimes people fell through the holes, despite the best of intentions.

Dr. Gregory Todd and a patient called Mr. Zen arrived on Gellman 7, a general-medicine floor, within a week of each other, in August 2005, a week or two before the levees broke in New Orleans. Although Todd was the older of the two, his arrival marked a new beginning, while Zen was at the beginning of the end.

Zen was one of Todd’s first patients after he became a member of the hospital’s in-house staff of salaried physicians, called “hospitalists,” who treat patients only while they are in the hospital. This type of medical practice had grown significantly in the past decade, as insurance paperwork and malpractice costs have made private practice less and less appealing for primary-care doctors. Also, the hospital job required a more limited commitment: regular hours and patients whose demands would become someone else’s problem once they were discharged.

Todd had grown up in Henderson, Kentucky, a small city on the Ohio River, onetime home of John James Audubon, the wildlife artist. Todd became a lawyer and came to New York to work in securities law, for an investment banking firm. At the age of forty, he decided to become a physician. By the time he completed his training at Maimonides, and then was hired as full-time faculty and met Zen, Todd was forty-nine years old. Along the way he had become a Buddhist. Zen was an atheist, but he indulged his doctor’s enthusiasm for Buddhism and discussed it with him, as far as the patient’s English would allow.

Hard cases, including a sizable number of patients subsisting on ventilators, went to Gellman 7. Todd was not sanguine about his patient’s prospects. “My biggest concern with him was his unwillingness to come to grips with his diagnosis,” he said. “It was the scariest thing for me, because I knew the outcome of this. It was never going to get better; it was only going to get worse. When I met him, the tumor was already too big to be surgically removed. Urology had said it would probably kill him to remove this tumor. Sarcomas do not respond well to chemo or to radiation, and this we proved.”

Todd cared for Zen through an entire chemotherapy regime plus twenty-eight cycles of radiation therapy. “There’s a fine line between acknowledging you’re never going to cure the cancer versus getting the cancer to remit to a stage where someone can continue to have a pleasant life for a period of time,” said Todd. “We were trying to extend the comfort of his life, though ultimately the finality would be determined by the tumor, and everyone collectively sort of knew that. No one held out false promises for him, and everyone was very clear about what they were doing, but I’m not sure he interpreted it that way, even though that’s what he was told. Hope and faith are powerful things, and to a certain extent you don’t like to get in the way of them, because they do keep the person motivated and their spirits strong.”

One day I asked Chris Kam, the social worker assigned to the case, how to spell Zen’s name, as it appeared in various ways throughout his medical record, a voluminous stack of notations contained in a thick binder. Only the emergency room was fully computerized.

“However you want,” Kam said, then lifted a dark eyebrow as he added, with a smile that wasn’t a smile, “That may not be a correct name, of course.”