Julie Salamon’s “Hospital”

GUEST: Julie Salamon
VTR: 07/21/2008

I’m Richard Heffner, your host on The Open Mind … and it was decades ago here at this table that the former head of one of America’s greatest and most prestigious teaching hospitals told me that every sophisticated American should know that going to the hospital is bad for one’s health.

Well, I don’t really know whether today’s guest would agree … but Hospital, best-selling writer, journalist, dear friend Julie Salamon’s admiring, sad, funny, exhilarating, compassionate, frightening new Penguin Press book about a year she spent with an unprecedented level of access to the inner workings of a modern American hospital – Maimonides Medical Center in Brooklyn, New York – may just provide a clue.

Now, whenever Julie Salamon has joined me here on The Open Mind, I’ve insisted that the pen with which she writes simply must be made of a quill from the wings of an angel. It’s true now, she writes beautifully.

Tom Wolfe describes Hospital, my guest’s new book, as “this real, true-life drama of the barely controllable chaos that actually rules in a huge metropolitan hospital, written by one of America’s best fly-on-the-wall reporters…”.

And Dr. Jerome Groopman, the distinguished author of How Doctors Think writes that in Hospital my guest “…goes beyond the sharp conflicts of ego, culture, and competition in a hospital and finds a community still rooted in compassion and caring. A unique and revealing book that captures the tensions and triumphs of today’s medicine.”

Which leads me to ask Julie Salamon how, indeed, these tensions and triumphs tote up for HER.

After all, after a year as a “fly on the wall”…I want ask, does she think going to the hospital is bad for one’s health? Julie?

SALAMON: Well, I’m going to give you a terrible answer … Yes and No. Or rather Yes or No. Because we talk about the health care system, that’s the big buzz word today. But the truth a health care system is made up of a lot of individual institutions and a lot of individuals within those institutions.

And if, if you’re lucky enough to go to an institution that’s well run and within that institution to be on a floor that’s well run and you find there the doctors and nurses that are doing what they’re supposed to do, being in the hospital can be … I won’t ever say a “fun” experience. But it can do what it’s supposed to do. And most often does.

However, if somebody doesn’t do their job well … even if they do their technical job well. But then aren’t compassionate, aren’t treating you like a human being, it can be a terrible experience … either medically or psychologically.

HEFFNER: So you do come back to a shrug of the shoulders. I don’t know … depends upon whether you go to the good hospital with the compassion and care, or not.

SALAMON: Well, and I think that one of things I see though that hospitals, I think, in a lot of ways … are in many ways better than they used to be. The big “to-do” is that they’re worse.

But, in point of fact, medical care is better now in terms of advancing health than they used to be. But what’s been lost in the equation is like so much of our modern world … we can do more faster and better. But we’re doing it so fast to get better that we forget why we’re doing it.

And I do think there are levels of healing and of care that fall between the cracks because there’s no time. And there’s no time because of many, many reasons having to do with reimbursement systems and bad systems and pressure of time. Everything’s about time because time is money and in a hospital you would think that wouldn’t be the number one priority, but very often it is.

HEFFNER: Why do you say “one wouldn’t think”, how naïve do you have to believe that there is any place, anything in American life where “time is money”, isn’t the major factor.

SALAMON: Well, I think you could argue that in medical care … sometimes … more time will mean the expenditure of less money. If you have a good primary care doctor … if you have a doctor who listens to you, who knows you, who understands you … then maybe instead of sending you in for the, you know, $50,000 MRI … they might see something else. So I think time sometimes is wasted money.

And what I tried to do in the book was to take these issues, which can be somewhat abstract sometimes, or sound too much like policy issues or economic issues, which they are, and bring them down to the personal stories of people trying very hard to do their jobs well.

HEFFNER: And you do … I was interested in, in that in particular. You’re talking about the personnel of a hospital, you’re talking about the doctors and the nurses … and the administrators. You’re not talking so much about the patients.

SALAMON: That was a deliberate strategy.

HEFFNER: I gathered that.

SALAMON: And there were a couple of reasons. One, because I want … the book was about a hospital and, as crazy as it sounds, patients come and go … but all those other people you mentioned before … they stay. They are who the hospital is. And I feel we know a lot about patient stories. Many patients write their own stories, doctors write stories about triumphs and failures with patients. And I feel there’s a whole body of literature written by people who know better than I do on what’s that like.

But I felt very few of us understand what the institution is and really what the community of that institution is. And so, writing about institutions is hard, because they’re institutions, but they’re also made up of people. And I thought for me to see the dynamic of how people take responsibility, don’t take responsibility … how they manage their lives and the world that they’re operating in … which happens to be a world where people are often at the point of life or death was very fascinating to me.

HEFFNER: Why in the world did Marty Payson and the others say, “Yes” to allow you to spend a year as a fly on the wall?

SALAMON: Well, I could tell you all kinds of things about what a brilliant negotiator (laughter) I am and how smart I am. But honestly I believe a lot of it was luck, and my biggest point of luck … there were several pieces of luck.

One piece of luck was that Pam Brier who’s the President of the hospital had read a couple of my previous books and had ideas of her own about writing a book some day. So when I sort of stumbled into Maimonides Hospital, she liked my work and she had her own desire to write a book, but she was busy running a hospital. That was one piece of luck.

The second piece of luck … Marty Payson, who you mentioned, who’s the Chairman of the Board of the hospital, comes out of Hollywood, he was the Vice Chairman of Warner Brothers Pictures and then Time Warner. And I think he’s of the school that “there’s no such thing as bad publicity”. Even though he didn’t put it in quite those terms.

And then I think the third, and most important piece of luck was, the hospital did not have a head of public relations when I stepped in …

HEFFNER: To say “No.”

SALAMON: … to say “no”. And the guy who was hired eventually … six months later … there was a gap … somebody had been there. She had left and they just hadn’t filled the position when I came wandering in the door. And so, there was nobody to say “No”. And much later … Barry Ensminger who is the head of PR, who kept very far away from me at that point (laugh), during the writing of the … because I was already there for several months … told me when it was all over … he said, “I was never worried that you wouldn’t tell the truth, I was worried that you would tell the truth.”

HEFFNER: Well, that’s really what I meant Julie. And in a sense I must say, as I read the book, and it is absolutely fascinating. I think I’d be uneasy, too. Not about what you might do, but about what you did. Because the truth isn’t all that pretty.

SALAMON: It’s not all that pretty and what’s been fascinating to me is … how different people read the book. You know, there have been many reviews of the book and I’ve written a lot of books at this point. And usually … there are sort of a similar batch of good reviews and a similar batch of not as good reviews.

With this book, all of the reviews, whether they are good, indifferent or the couple who were kind of mean … they have very different takes on it and what I came to realize is, is that … this is a subject that terrifies and fascinates a lot of people and is very personal to them, because almost everybody’s had an encounter … either personally or through somebody they love with a hospital.

And so when they read my book, they’re not just reading my book, they’re injecting a lot of their own feelings and fears … I think … because, because of the diversity of the reviews. And because a hospital is a complex place. And this one is particularly complex because it’s a hospital that was started to serve a Jewish community, still has a very strong Orthodox Jewish community, but also has a huge growing population where 67 languages are spoken here. So there’s a lot going on.

HEFFNER: Was it the cancer … the new cancer pavilion, the new involvement that attracted you to Maimonides?

SALAMON: Ahemm, it was one … it was the thing that made me think I could write a book about it.

What attracted me was the clashing cultures, were the … was the, the community hospital. What does it mean to be a community hospital when you’re now a 705 bed hospital that does all kinds of modern medical procedures, but you’re also trying to deal with patients who are … not the poorest, it’s not a public hospital, it’s a voluntary hospital, but patients who by and large are middle class and working class.

What does it take to be a pillar of the community in today’s very complicated world? That was the thing that initially drew me to it … was just the, the clash of issues.

Also having met the President and several of the Administrators, it’s a … it’s in Brooklyn, so these are sort of a wild bunch of people, and I thought they’d be great characters.

And then came the other pieces of it, the sort of medical pieces … the modern world we live in. And so, I think it was … and the cancer center was … became sort of … to me … the news. It was new and it represented many things.

It represented to me the ultimate conflict in modern medical care which is on the one hand, there was no comprehensive cancer center in Brooklyn, so it had a vital pillar of the community reason to exist.

But, cancer is now a huge growth business, to put it in very vulgar terms, in the medical field. So 20 years ago, it was heart … that was the new frontier. Now cancer is the new frontier. And cancer … while many kinds of cancer have been … become chronic diseases … which is an amazing advance, there are many, many kinds of cancer that we still can’t cure or even make better for a little period of time.

And yet the cost of treating cancer is enormous. And so I thought that sort of reality of how we spend money on health care could sort of be shown through the difficulties of starting this. And, and the difficulties and I should say, successes of starting this cancer center.

And where does compassion, where does the kind of end of life discussion come up? Where do all those things fit into the modern medical world?

HEFFNER: Where does end of life discussion fit in anywhere?

SALAMON: I think a lot of doctors don’t do it very well. I think …

HEFFNER: A lot of doctors don’t do it.

SALAMON: And a lot of doctors don’t do it because they’re afraid to do it. When you ask how … why … the role of the cancer center … the other role it played for me is that one of the people who becomes a major character in the book is Dr. Allan Astrow who is an oncologist, who’s a lovely man and a very, very good doctor … who thinks about these issues all the time because he’s somebody who has to deal, in his practice, with helping patients get better, but also helping them die better. And he takes that role very seriously.

And it’s a, it’s a tricky situation because a doctor isn’t your Rabbi or your priest or your spiritual advisor on the one hand. But on the other hand, in certain … many times the doctor has to take on some aspects of those roles because your fate is in that doctor’s hands and many doctors don’t have the training or even the personal inclination to handle that aspect of being a doctor.

HEFFNER: You know there’s one aspect of, of that “etc.” that I, I really … it, it’s at the end of the book that you’re talking to Marty Payson and you’re asking him about … “what about the big picture, national health care policy” and I thought in a sense we were going to start off on that. And then you quote … you’re quoting Payson … “I believe eventually we’ll have a single payer system because this system is insane.” What do you think?

SALAMON: I think it is insane. And, what do I mean by that? I, I mean that time and time again you see that through a process of bureaucratic craziness … you know you start a bureaucracy and allow it to get bigger and bigger. Even though many of the, the rules and ideas and pricing that are put in place start with the best of intention, they start to take a life of their own. And we’re at the point now where it’s taken on … it’s like some kind of monster movie where the system has evolved into some kind of Frankenstein.

And what I mean by that is very simple examples where the cost … the cost of going to see your primary care physician, who should be somebody who kind of knows you as a patient and knows that if you come in, Dick Heffner, with one kind of symptom, it may mean something in this case, it may mean something else with you, with your history … with the kind of person you are. Are you a hypochondriac, are you not a hypochondriac? There are all kinds of …

HEFFNER: Sorry, you’re 15 minutes are up. Doesn’t the doctor have to say that?

SALAMON: That’s right. That “sorry your 15 …” and to know who that patient is, that consultation will only be paid a very small amount and then your 15 minutes are up and out the door. What gets paid a lot is a procedure … “Ah, Mr. Heffner, let me cut you open.” And that will get reimbursed a lot of money and so, you could spend the time talking and trying to find out what’s wrong with this person, or you can cut … because in 90% of the cases that cut may be the right thing to do.

And that’s putting it in very crude terms, but that’s one example. Another is years ago Medicare changed its system of reimbursement to hospitals, saying that … it used to be … you came to the hospital, you stayed until the doctor said you were discharged and the hospital got paid for every day you were there.

Then Medicare said “there’s abuse”. So they said, “if you have X disease, you’re allowed six days.” If you stay seven days, that’s fine, but the hospital gets paid for six days, so out you go. Now in many cases that’s good, because hospitals are filled with germs and you’ll get sick and it’s probably better to get out sooner rather than later. But sometimes you’re not ready on the seventh day. And so there’s a pressure to get you through the system. And that pressure affects everything. It affects the kind of care you get, it affects the thought process of the people from the technicians to the surgeons. Everything has to be done fast and speed is not always the best thing when you’re trying to find out what’s wrong with somebody.

HEFFNER: What’s your solution?

SALAMON: My solution is … I think you know everybody’s worried that if we have a single payer system, that we’ll have a two tiered medical system. Guess what? We have a two tiered medical system now because how many people do I know, including myself … my gynecologist years ago went off insurance. I still go to her. I pay for it out of pocket. And so it’s a two tier. If I couldn’t afford to do it, I wouldn’t do it.

And many, many people I know do the same. Or they pick and choose … “I love this doctor”, not on my insurance … “this is the doctor I’ll pay for out of pocket”, but for something I’m not as worried about, I’ll, I’ll go to the one recommended by my insurance.

And so I think if we had a single payer system … but that’s only the beginning because you have a single payer system, you still have to have cost controls, and that’s what people don’t want to accept … is that now it’s a free-for-all.

If you have certain insurances you can get a zillion things done that will get paid for. If we have a single payer system there’s going to be more tightening of costs, which I think is ultimately going to be a good thing … as much as it doesn’t sound like it off the bat.

Because I think now … once you step into the medical industrial system then, the push to take more and more tests … irrational, irrational tests … giving colonoscopies to … it just happened to a friend of mine … she had an 80 year old mother who was on dialysis, on regular dialysis … and her doctor sent her in for a colonoscopy. And it did not have a good result. Was that a … was that really thinking through … even though the protocol is “colonoscopy every ten years”, don’t you look at the whole situation of the patient?

HEFFNER: What did most of the doctors … what do most of the doctors whom you dealt with in that … over that whole year … the thoughtful ones. Where are they? Where are their heads in terms of this single payer system?

SALAMON: I think all of them felt the single payer system was a good first step. But then, then you need the second step, you need the second step of … okay, you have a single payer system. You cover everybody in the country, a universal health coverage. That’s something else people believe in … right? You have universal health coverage.

But then who are the doctors who are going to take care of all the new people coming into the system? It’s already happened in Massachusetts. They have universal coverage. You can’t get in to see a doctor because there aren’t enough of them.

And I think this is an old drum I’ve been beating for a long time. I think we’ve lost the idea of public service. We’ve lost the idea of going into professions to serve a public need. I think many of the doctors and nurses I met felt that very strongly and they felt the system was mitigating against it.

HEFFNER: Now wait a minute, wait a minute, let me, let me understand … are you saying your experience over this year indicated that many or most doctors no longer have that public service …

SALAMON: I feel they have that desire but I feel like it’s squeezed out of them little by little every day …

HEFFNER: By the system.

SALAMON: By the system, by the fact that they can’t spend enough time with patients, by the fact that they’re ordering tests that they know sometimes are probably not necessary, but they’re afraid if they don’t order them … then …

HEFFNER: Malpractice.

SALAMON: Malpractice. Even though it’s a tiny percentage of doctors ever get sued … and I think one of the things that was quite interesting at Maimonides that head of the hospital, Pam Brier instituted the Code of Mutual Respect which was partly to encourage the medical practitioners themselves to talk to each other in a respectful way with the hope that that eventually would, would work down the chain to the patients. But also to prevent errors. To get people to, to step back and communicate with each other.

HEFFNER: I didn’t get the sense from the book that that Code of Mutual Respect worked quite as well as she hoped it would.

SALAMON: Well, I think that was the first year … it’s interesting, three years later, you know, was everybody walking down the street hand in hand singing tunes together (laughter)? No.

HEFFNER: (Laughter)

SALAMON: But I do think it has raised the level of awareness. But I think until the system changes somewhat to give people a little bit more of a … the cushion of time, I think it’s going to be hard to institute across the board.

I will say something else. I also think we are a complaining people. The US. I think that we have, in many cases, I felt that the patients were also unreasonable many times. And I felt that people often don’t cut each other any slack whatsoever.

HEFFNER: Impatient and unfair, perhaps, in their relationship with their physicians and with the other workers in the hospital?

SALAMON: Yeah. I mean I just think that everybody … I mean, you know, look, you have to cut patients a lot of slack, they’re scared, they’re sick. So they deserve incredible amounts of leeway. Having said that … I think that there is a kind of … there’s almost a … I won’t say “hostility” but wariness on all parts. You walk in and everybody feels a little wary. And I think that it was amazing to me. Because time and time again in the course of the year I saw wonderful interactions between patients and doctors, patients and nurses. And I would say in 95% of the time those interactions were non-medical. But I think they made a huge difference in terms of how everybody felt about the system at the end of the day.

HEFFNER: But weren’t the tensions, to a large extent, because of the neighborhood in which the hospital you were the fly-on-the wall …

SALAMON: That’s what I would think. But as the book has been getting read by people around the country I’ve been getting emails … I now have a website so I can get instant reaction – and I’ve been getting calls and emails from people from all over the country saying, it may manifest itself in a slightly different way, but I feel these tensions, this same thing is happening here.

HEFFNER: The human condition?

SALAMON: The human condition.

HEFFNER: Well …

SALAMON: The human condition.

HEFFNER: … that makes me ask whether you ever could expect anything different? Either from the nature of the payment system or from the nature of the doctors or the nature of the patients?

SALAMON: Absolutely you can expect something different because you do see … as I said, even within one hospital, one floor could be wildly different from another floor because there’s a nurse/manager on the floor that looks at the situation and figures out a system with the same personnel, the same budget … that works better. That, that provides for spaces in time so that there’s maybe an overlap of shifts so that people can talk to each other for five minutes before they hand off the patient. For even the way people communicate with each other, to have meetings once a week to talk about some of these issues apart from medical issues. Or how the medical issues are affected by a patient’s sociological … their, their money issues, their insurance issues. There are health issues apart from the thing that the person’s in the hospital for … to give time for the doctors and nurses to actually discuss the patients in a different context than just “quick, quick, treat, treat”. And different floors made a difference. I do think that certain systemic changes … there can be changes in these systems to make them more human.

HEFFNER: You know, most of the doctors I know … when I ask them “what about Suzy or Joey … their children … are you recommending that they become doctors?”. Quite the contrary, they say. If we could we’d prohibit it. How did you feel about that?

SALAMON: Would I want my children to be …

HEFFNER: Yeah.

SALAMON: … you know, I have the opposite feeling. I actually think that with all the troubles and all the difficulties of it, it’s an incredible profession. That at the end of the day … in fact a young nurse asked me that same question at a reading. She stood up, she said, “Everything you’re saying, I’m in first year nursing school … should I change? Should I drop out?”

I said, “Absolutely not.” I said, “Let me tell you something. No matter what business you go in, you’re going to come home at the end of the day fuming about something. You’re going to be upset and angry. At least if you’re in this profession, you have the chance to help people.”

HEFFNER: I think that has something to do with the fact that your father was a physician.

SALAMON: That’s right. And he was under a lot of time pressure. We lived in a small town, he was the only doctor. He worked incredibly hard. I felt that with all the difficulties of his profession it rewarded him in ways way beyond money. I think that it gave his life some purpose and I felt that with many of the people here.

That if you went beneath the complaining and the kvetching and the, you know, the bad feelings about everything and you really … and it happened over and over again … you would see a sense of pride. And you would see a sense of fulfillment that people had. The sad part is they rarely have time to really bask in it, and society doesn’t give it back to them.

HEFFNER: Well, you didn’t become a doctor, you became a writer of beautiful, wonderful books. And, again, as I do each time you do a book and we do a program, I can’t help but recommend Hospital by Julie Salamon. Thanks so much for joining me again today, Julie.

SALAMON: Thank you.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. If you would like a transcript of today’s program, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.