Peeking Behind the Curtain: A View From Inside a Hospital

When author and journalist Julie Salamon was introduced to Maimonides Medical Center in Brooklyn, N.Y., she found an institution that in one sense faced all the problems of a large urban hospital in the 21st century: reimbursement hassles, bed shortages, the pressure to invest in new technology to stay competitive. But there was an added element; Maimonides's patients and employees are a crazy quilt of cultures, religions, traditions, beliefs, and personalities that reflect the surrounding Orthodox Jewish community and the wider world. And its strong tradition of openness and accessibility puts all the conflicts right out in the open. In Hospital (Penguin Press), she chronicles the year she spent reporting at the hospital, where she had access to every perspective, from the residents' to the patients' to the administrators'. U.S. News talked to her about her experience. Excerpts:

Julie Salamon, author of 'Hospital'

(Sara Krulwich)

You describe Maimonides as "diversity on steroids," a place where patients speak 67 languages. What was good about that?
Just looking around and seeing the absolute mind-boggling diversity actually made me feel amazed about what good could happen in our country. Three or four years after 9/11, when everyone's nerves were still raw, in this hospital it was extremely routine to see [observant Jewish] men wearing skullcaps and religious Muslim women in head-to-toe coverings treating each other civilly. The hospital became a kind of DMZ [demilitarized zone].

And what was bad?
There's so much miscommunication, even if you're speaking the same language. A doctor [in the book] makes the point that patients have a lot of pre-existing conditions, and the language barrier is just one more. And there's all kinds of diversity beyond the multicultural dimension; there's class diversity—doctors are from one class, technicians from another, and yet they're all supposed to work together and have the same amount of concern for the patient on the operating table.

The book makes clear the tensions inherent in running a hospital and trying to make enough money to stay afloat. How could you sense that?
Where you could see it is that everybody seems to be rushing around all the time. In the last 20 years, led by Medicare, reimbursement became linked to something called diagnostic related groups. That means the hospital gets paid X for this disease, whether a patient stays six days or six weeks. If you stay six days, the hospital can break even. If you stay six weeks, it's costing the hospital every extra day. That may sound like an obscure insurance problem, but [as a result] the minute the patient gets into the hospital, the whole aim is to get him out.

You had the benefit of getting everyone's perspective. What's one thing about being a patient that hospital staff members should recognize?
When you're a patient in the hospital, so much can be very terrifying, but I saw over and over again how the simplest form of human communication—which can go by the wayside—makes a big difference. People want to be talked to, they want to be treated as human beings. One doctor would always make sure he sat down next to patients at eye level. When you're sick and frightened and fragile, that makes all the difference. I think that as an ethos, the hospital understands this, but it isn't always able to carry it out.

And what aspect of the doctor's perspective would you convey to patients?
Doctors may not always give clear instructions, but even when they do, it's not heard. In the cancer center, one patient was supposed to come in for radiation treatment and was told not to eat for X hours beforehand. Three times in a row, he came in eating a candy bar...and he got mad at them! He didn't speak English, but the interpreter made sure he understood it. Obviously, he didn't take it seriously. Patients, for their part, need to take more responsibility for themselves. You cannot expect miracles. If you don't take care of yourself in the most basic way, you can't complain if you're unhealthy.

Conventional wisdom says that the emergency room has become the place where the uninsured get their minor primary care. Did you see that?
I'd say the more common situation was for people to be really sick and without a primary-care doctor. One of the big problems, especially for the uninsured—especially immigrants—is that people would delay going to the doctor and then were very sick. A really bad cold that lasts for two weeks, you'd go to the doctor. But if you don't have one and wait, by the time you get to the ER, you have pneumonia. You actually did have fewer of the scraped ankles and headaches that are the regular ER problems.