Hospital (23 page)

As Astrow told this story, he paused and grinned. “You might ask, ‘Why did I do this?’ I’m starting a new job. I’m trying to meet people. I’m trying to get along with everyone. Why would I do something which might get people all upset when I’m just trying to get started in a new job and have good relations with people? You might well ask that question.”

Before I could respond, he said, “But you’re not a psychiatrist.”

Biberfeld wasn’t either, but he was the hospital’s vice president for psychiatry. I had seen him watching me warily around the hospital. He was a thin, hovering man with a D.S.W., a doctorate in social work, whose function at the hospital was only partly indicated by his title. When I finally met him for an official (taped) interview, I said, “I see you play many parts here.”

He nodded. “Some of them are very tangible roles and some are not,” he said. “The largest department I run is the psychiatry department. It’s a full-time job, really. We have seventy inpatient beds. In any rural area, this would be a hospital by itself. The other big piece on paper is religious observance. All religious observances from Jewish, Catholic, Protestant, Muslim . . . Jehovah’s Witnesses. That reports to me.”

After offering me a bottle of water, he left the table we were sitting at for a minute and then returned with a piece of lined paper. He drew a Venn diagram and explained. “I sometimes draw a picture to explain Douglas and me,” he said. It took me a minute to realize he was talking about Douglas Jablon. I had heard that Biberfeld was envious of Jablon’s influence with the executive office.

“Douglas has a very specific area he runs, and there are a lot of areas we overlap.” He pointed to the area marked off by the intersection of the two circles. “This area, I spend at least almost as much time as the other. That is dealing with community-board members, community leaders, and rabbis at large. How does that differ from patient reps and stuff like that? In certain significant ways and certain ways that overlap. As a professional and a clinician, many of the people look to me in that level. That’s one aspect. The other level is just being in my capacity as community member living a block away, I’m convenient to come over and expedite something. I work through the patient reps, but as a senior management person you can get certain things done. Certain Orthodox board members call me about something dear to their hearts.”

Added to my mental Venn diagram: Both Biberfeld and Jablon were polite hosts. But Biberfeld offered his guests water, Jablon put out cookies.

When Astrow’s flyer found its way to Aaron Twerski, the dean of Hofstra School of Law and a member of the board, Biberfeld moved to expedite. He called Astrow to let him know that Twerski was upset, so naturally Biberfeld was upset, too. Not, as Astrow would have thought, about the presence of a Buddhist speaker. The name that caught Twerski’s attention was Rabbi Shai Held, summa cum laude graduate of Harvard University, former director of education at Harvard Hillel, adjunct lecturer in Talmud at the Jewish Theological Seminary, the academic arm of the conservative Jewish movement. Only one of Held’s pedigrees mattered in Borough Park, and it was the wrong one: He was a Conservative, not an Orthodox, rabbi.

Astrow’s first reaction was to get angry back, though he tried not to reveal his feelings to Biberfeld. He didn’t sleep most of Thursday night, trying to figure out what to do. He had run into this kind of problem before. At a conference at New York-Presbyterian, a prominent faculty person walked out on a pro-abortion Catholic speaker Astrow had invited. An Orthodox rabbi he brought in to speak at Sloan-Kettering irritated secular Jews in the audience. What did he expect? The world was inflamed—again—because of religion. Bringing religion into medicine had become controversial—even just religious thinking, not religious dogma. So he couldn’t complain if people were agitated.

A year later Daniel Sulmasy, Astrow’s collaborator in the spirituality series, the Franciscan friar who was a doctor, would write in
Tikkun,
a liberal Jewish magazine, “Even when I attended medical school in the early 1980s we were at least taught to ask a perfunctory question about the patient’s religious preference. Now, even that question has disappeared from standard textbook instruction in taking a medical history. Religion and spirituality have been effectively purged from medicine.”

When he was a child, other boys rebelled against going to Hebrew school, but Astrow loved the Bible stories with their violent, lusty narratives and their ethical riddles. Connecting body and soul, medicine and theology, had been the centerpiece of his academic pursuits for much of the previous decade, beginning with the first spirituality conference he organized in 1998 at St. Vincent’s. The hospital auditorium couldn’t hold the crowd. More than 250 people came to listen to four people—a Jew, a Jesuit, a Muslim, and a Protestant—discuss “What does it mean to be a healer in your tradition?” Over the next six years, more than twenty conferences took place in different hospitals, drawing as many as four hundred doctors, nurses, chaplains, social workers.

Astrow was contemplative and often seemed lost in an alternate universe of thought, beyond matter. He was in his fourth year of medical school before he discovered he had a lisp. Strange as it seemed to him, now a parent, he had gone through life mispronouncing his
s
’s and no one had done anything about it—or even seemed to notice. But in medical school he became friends with the family of his roommate’s fiancée, whose mother taught public speaking. One day she told him he had to do something about his lisp or no one would take him seriously as a doctor. He decided that by the time he went to Boston for his training at Boston City Hospital, where no one knew him, he would speak a different way. That’s what he did. He went to a speech pathologist and diligently did his exercises. He lisped his way through the rest of medical school until he became an intern, and then he stopped.

No one could accuse him of acting in haste, but he did eventually take action.

Now he wondered if the most decisive action would be to follow the path of least resistance and move the conference to St. Vincent’s. He took a poll. Bill Camilleri said the whole thing was ridiculous, that of course they should have the conference at Maimonides, but the decision was Astrow’s. Douglas Jablon just laughed and said he planned to be at the conference. Kopel told him not to worry but urged him to call Twerski. McDougle agreed and offered practical advice. He told Astrow to explain that the event was a secular, medical conference for physicians and nurses, who could get continuing-education credit for attending. It was never intended to be a public forum for the community.

The affirmation didn’t make Astrow less nervous. “They may be supportive,” he told me. “But administrators don’t like problems. They have budgets to meet. They can be supportive but also annoyed with me because I’ve caused a problem.”

Astrow put off calling Twerski until the following week. He wanted to be calm when they spoke, not agonizing over why he always felt compelled to stir things up in the name of doing what was right. The distinction between righteous and self-righteous was perilously fine, he knew that.

Astrow was a product of the Long Island suburbs, post-World War II, a particular moment of naiveté and optimism in U.S. history, at least among the new professional classes. Born in 1954, he was the middle child of Depression-era parents who bought into the mythological view, who preferred to link technological advance with hopefulness and a promising future rather than with the horror of the recent past, the efficient wholesale slaughter of European Jews and millions of other people worldwide, or with doomsday scenarios of nuclear meltdown and environmental catastrophe. They believed generally in the progress of humanity and specifically in their right—their duty—to participate in the then-popular vision of the American dream. They moved to Woodmere, part of the Five Towns on the south shore of western Long Island, where former residents of cramped apartments in Brooklyn, Queens, and the Bronx spread out in suburban manors, with easy access to bowling alleys, the beach, drive-in movies, and amusement parks. The hardscrabble life associated with immigration, the urban shtetl, was behind them. Martin Astrow was an engineer, a rocket scientist—literally, for Sperry Gyroscope, manufacturer of Sparrow air-to-air missiles. Ruth became a teacher. Unlike their parents—his father a florist, hers a tailor—they were professional people, modern Conservative Jews, observant but flexible. Ruth bought kosher meat until she had an argument with the butcher. Even then she still forbade pork or shellfish to enter her home. Shrimp cocktails and lobsters eaten in restaurants, however, were given special exemptions from the dietary laws, according to her (nonrabbinic) interpretation.

The Astrows appreciated the chance to live well while endorsing social responsibility within the confines of respectability. In other words, they wanted the child designated the brightest one to become a doctor, an ambition widely shared by the other Jewish parents in the Five Towns. The desire was expressed openly and often. In fact, Ruth, a slender, long-legged woman from the Bronx who posed like Betty Grable in seductive girlhood photos, once said, “I used to joke to Martin, my husband. Martin, I said, you’ve acquitted yourself as the perfect Jewish husband. You got me a mink coat. We have a Cadillac. We have a son who’s a doctor. You’ve done everything you’re supposed to do.”

As with disease (and goodness), finding the root cause of choices we make is often hard to untangle from misleading symptoms and wishful thinking. But Alan Astrow always returned to his father. During the Vietnam War, when Astrow was in high school, he and his father had many heated discussions about the ethics of earning a living from the military-industrial complex. The arguments never diminished Astrow’s love for his father, nor did they stop the future doctor from having his education financed by said military-industrial complex.

But the dilemmas posed by those discussions would always reverberate for him. Later he would direct the same fervor at debates about a new enemy of idealism, the
medical
-industrial complex, accused of preventing universal health coverage to benefit corporate coffers, of imperiling basic health care by creating a profit motive to focus on costly procedures. Yes, there had been tremendous advances in remedying heart disease and certain cancers, but Astrow found it hard to defend the millions spent on cosmetic surgery, the financial disincentives that discouraged young doctors from going into primary medicine, pediatrics, obstetrics.

How was an idealistic physician supposed to contend with the pharmaceutical companies that, with the insurance behemoths, had come to dominate medical treatment? The drug companies sponsored research that produced the drugs that cured previously fatal diseases and lifted the death sentence off so many others, like AIDS and certain cancers. They paid for speakers at educational conferences. They helped physicians filter the mass of information that was churned out by medical researchers in overwhelming volume. A diligent social worker could
hondle
with them to obtain free drugs for indigent patients. But those same companies had a vested interest in determining which studies were supported, which diseases got attention, which populations were served, how many drugs they could sell. Their executives made unconscionable amounts of money.

Those questions continued to bother him. “I was thinking this morning about Leslie Wexner,” he said. “Do you know who he is? He funded this deluxe Jewish adult-education program, and he gave all the people in the program a talk about how his father had owned a department store in Columbus, Ohio, and how he, Leslie Wexner, got his M.B.A. and came back to work in his father’s store. He noticed the only department that really made money was women’s sportswear. He said to his father, ‘You know, the only thing making money is women’s sportswear, and that is what we should focus on.’ His father said, ‘No, we’re a department store. We have to do everything.’ So Wexner raised the money on his own and opened a chain that sold women’s sportswear, which is the Limited, and became a billionaire as a result.”

He shoveled a piece of pita piled with hummus into his mouth and then apologized. “My wife says I have terrible eating habits,” he said, hastily rubbing a napkin across his lips before getting back to his retailing analysis.

“That’s fine in the department store, but what’s happened in medicine is that people have applied the same reasoning to hospitals,” he said. “They are almost like department stores, where some departments make money and some don’t make money or lose money. If you decide to take a profit-and-loss mentality for the whole system, you focus on the things that make money. That’s why people have opened these cardiac hospitals or orthopedic hospitals. If you’re looking at the system in that way, how you maximize profits, that makes sense. But you would think that in health care you wouldn’t want to look at it that way. But the whole market ethos has become so dominant that people don’t really have another way of understanding what health care is all about, and it causes all kinds of problems.”

Astrow liked to argue and debate, but he wasn’t at heart a rebel. He reconciled himself to working within the system. “I don’t really have any solutions,” he said. “You have to focus on the individual patient and hope that someone is looking at some of the larger policy issues in a way that really reflects the public interest,” he said. He hoped to develop clinical trials to use what he and others at Maimonides learned from individual cases for greater knowledge, but mainly his focus was micro. “As a doctor you have to do the best you can for every patient,” he convinced himself. “You get involved with these larger social issues, and you can’t.”

He sometimes wondered whether medicine had been a calling at all, or whether he had simply complied with what was expected of him. In eighth grade Astrow asked his father, who was widely read, for help with a school assignment, to write a report on three books with related themes. The books his father suggested were
Arrowsmith, The Citadel,
and
Of Human Bondage,
all novels with protagonists who were physicians. The message was readily received by the sensitive boy. A year later Astrow was sitting in his friend Jason’s basement, vehemently arguing that medicine was different from other fields because it wasn’t primarily about making money. Being a doctor was about being an ethical person—someone like his father, who was so honest he insisted on paying full price for Alan at the movies the instant his son turned twelve.