A hospital's characters and its stagecraft

It is commonplace to see the drama of the medical profession portrayed in the popular media. But Hospital, a new book by Julie Salamon, is remarkable for the way it captures the life of a hospital in all its confusing, infuriating and inspiring complexity.

For one year Ms. Salamon had virtually unlimited access to Maimonides Medical Center in Brooklyn, NY – its people and its facilities, day and night. Pam Brier, the President and CEO of Maimonides, knew Ms. Salamon was an experienced writer, the author of other books, whose journalism credits include the New York Times and Wall Street Journal. Nonetheless, it took courage for Pam to give a reporter carte blanche at her hospital.

Pam Brier ends up as one of the characters in Hospital. We see Pam on stage, and we sense her presence even off stage. She addresses the men in a mosque to discuss Maimonides’ cancer center. We see Pam in day and night staff meetings as she demands spending cuts. One night she rounds in the emergency department. We overhear her fretting about patient volume. One manager sulks, thinking he’s been ignored by Pam. A doctor thinks she plays favorites.

I serve with Pam Brier on the Board of the New York eHealth Collaborative, but I do not know her well. I was fascinated to see her, through Julie Salamon’s eyes: someone with personal courage, a bit eccentric, plenty of worries, fully engaged in the life of her hospital and its difficult relationships.

But Hospital is not just Pam Brier's story. There are 69 other characters in the book – doctors, nurses, residents, patients, social and community workers, environmental aides, executives. We see them as the author does, as complicated, interesting, flawed, and worthy individuals.

Hospitals are political environments, as are all places where human beings work together and compete for resources, satisfaction, and respect. “Political intrigue and turf wars,” writes Julie Salamon, “were not unique to Maimonides; struggles for space, equipment, staff, and money were part of the hospital life.”

Beyond the politics and the professional jealousies, the book tells something about a hospital's stagecraft. We see the importance of medical record coding, length of stay management, case mix, and health insurance contracts. There are neighborhood politics. There are donor politics. These are unseen forces that shape a hospital world, and they help give this book its fascinating reality.

Despite financial pressures, despite individuals who give or take offense, despite various ethnic tensions, an undercurrent of hope buoys Hospital. At one point Dr. Alan Astrow, Associate Director, Medical Oncology, reflects:

In the contemporary world, when we speak of an invisible hand that drives us, it is often assumed that we are referring to the marketplace and the invisible hand of economic self-interest. But most physicians and nurses, I think, want to see themselves as more than simply one party in a financial transaction. Why do we do what we do? What keeps us going? Not just that we ought to care but why? Faced with a suffering or demanding patient whom we might prefer to avoid, where do we find the strength to enter the patient’s room?

Here is the author herself, summing up:

Depending on the day or night, life in the hospital could seem full of exquisite promise or pointless despair…Yes, individual doctors and nurses behaved badly, sometimes inexcusably so. Clerks were rude to patients and to each other. People made mistakes. Yet I was constantly struck by the sense of urgency that accompanied desires for fairness, for compassionate medicine, for efficiency, for meaning – and yes, for cleaner rooms. Both Pam Brier and Margie Morales (a member of the environmental staff) struggled to sort the unwanted from the wanted, to make the hospital what it should be. They needed their lives to matter.

Thank you, Pam Brier, for giving Julie Salamon the ability to research and write Hospital. I'm not sure I would have been as brave.

Hospital patients who can't (or won't) leave

“Immigrants Facing Deportation by U.S. Hospitals” reports today’s New York Times about the extraordinary efforts of one Florida hospital to find continuing care, both in this country and in the patient’s native Guatemala, for an illegal immigrant who had become a de facto ward of the hospital.

Last week the Wall Street Journal reported that a Los Angeles’ ordinance makes it illegal for city hospitals to discharge to “skid row” homeless people who no longer need to stay in the hospital – this is called “patient dumping.” See “L.A. Law May Keep Homeless in Hospitals.” According to the Journal, many homeless patients simply “refuse to leave” a hospital.

Hospital, a new book by Julie Salamon, which is highly recommended, recounts the efforts of discharge planners at Brooklyn's Maimonides Hospital to find a place for a Chinese immigrant who, dying of cancer, no longer needed hospital-level care but otherwise had nowhere to go.

Hospitals nationwide deal with such situations all the time. Once a hospital has successfully cared for an individual’s acute care needs, that person may end up with nowhere to go because of deficiencies and inconsistencies in health care and social service systems.

A family may drop off an elderly parent in the emergency room, then leave on vacation or refuse to take the parent home after discharge from the hospital. If no nursing home will accept the patient, that individual becomes a border in the hospital, sometimes indefinitely.

Hospitals often help patients and families with nursing home placements by assisting with the complex Medicaid application process. It is not unusual, however, to find an individual or a family unwilling to disclose financial assets – unwilling even to sign a Medicaid application. This often means a nursing home will not accept the patient, who then remains inappropriately in the hospital.

These are called placement, transfer, or discharge problems, and few know about or understand them. As a result, such problems generate no political consensus toward a solution.

As a humane society, how do we assure appropriate levels of care for the homeless, for illegal immigrants, for the mentally challenged, as well as for those who may be willfully irresponsible?

According to the Journal: “[A]bout half the hospital’s homeless patients won’t sign discharge consent forms. ‘We can’t force them,’” says the discharge planner at one California hospital.

The Times reported that the Florida hospital’s care amounted to $1.5 million for the Guatemalan patient, but when it came to paying for nursing home or rehabilitation care, the hospital declined “to take out…[its] checkbook.” Why was that expected to be a hospital responsibility? Hadn't the hospital already discharged its (uncompensated) responsibility for acute care? Where is the nursing home industry's responsibility for continuing care? Where is the US government’s responsibility? Where is the responsibility of Guatemala for one of its citizens?

Government rules and media scrutiny are inconsistent among the sectors of the health care system. Thanks to unaligned incentives and inconsistent requirements, our disjointed health care system yields paradoxical results, as reflected in these stories from the Times and the Journal.