Hospital (37 page)

He had to face the mother. He offered her options: They could do the operation and use banked blood or close the wound and do it another time. She said close the wound. Strongwater did the case a month later at the Hospital for Joint Diseases. “So look at the mess,” he said. “Here I am with all this experience, all this education, all this training, and look at this
twit
in the pipeline, the clerk who never made the call to notify me. You are relying on people with all levels of training, all levels of skill, all levels of commitment.”

So why didn’t he want to sign the code? In theory, the system of confrontation and conversation was meant to help prevent situations like this from happening. The hope was that the code would force a discussion, illuminate the weak links, improve the system. The case he used as illustration, which took place in 1999, had led the hospital to tighten its procedures for segregating designated blood.

“I didn’t sign it initially because I thought it made a comment on the medical staff at Maimonides, that it was so bad it needed a written document for behavior,” he said. “I thought it was atrocious the physicians needed it.”

Then he changed his mind. “I told David [Feldman], ‘This is great.’ People needed to know the organization was serious about working conditions. Not just OR, not just doctors, but across the board. This only works if you implement this across the board,” he said. “That means the guy who does six thousand cases a year has the same responsibility to that charter as the guy who does two. That’s hard to do from a financial standpoint. I have a running bet with Kathryn Kaplan [the development specialist who worked with Feldman on the Code]. The first time one of the high rollers crosses the line, the organization will back down.”

I heard that same skepticism many times, including from Pam Mestel, the executive director of perioperative services, Feldman’s nursing complement. Mestel’s father was in the garment business, and she had a streetwise sense of how the hospital’s sociological system produced perfect conditions for spikes in foul language and rude behavior.

“I have nursing attendants who make twenty-eight thousand dollars a year working elbow to elbow with these attending doctors who come into work in Jaguars and take these magnificent vacations,” she said. “When you’re in the room for three hours, you chat, you get to know someone. Some of the nurses have been here twenty years and knew these doctors when they were residents.

“Think about it,” she continued. “You can’t do surgery without your instruments. Our instrument techs make thirty thousand dollars a year, and we expect them to be these highly skilled, ambitious people who are going to make sure the tray is going to be built exactly the way the surgeon wants it. But they don’t have the same drive the surgeon has. It’s not the same drive even a nurse may have. I say this to doctors all the time when they tell me these nursing attendants aren’t working hard enough or fast enough. I tell them, ‘They’re not going to work like you work. They’re not going to stay for twelve hours for the good of the cause or the good of the patient or ‘This is why I came into health care.’

“How do you motivate someone who makes twelve dollars an hour? By saying, ‘Your next raise you’re getting another twelve cents’?” she asked. “I think what beats them down is the hierarchy, the respect they’re given or not given. Everyone beats down on the one below.”

While Mestel had been eager to help Feldman with the training program, she was both hopeful and doubtful. “There’s a lot of skepticism,” she said. “The nurses say, ‘Sure, they’re going to tell Dr. Cunningham to stop being rude. Sure, that’s going to happen to Dr. Felicia. He does almost three hundred hips a year. Sure, he’s going to say to the nurse, “Fuck you,” and they’re going to do something to him. Sure.’”

I first heard about the Code of Mutual Respect four months earlier, at the beginning of my sojourn, on September 12, at a “leadership team” meeting in the conference room next to Brier’s office. Much of the discussion was devoted to housekeeping and various plans—ranging from new solvents to new management structure—that could improve cleanliness. Brier reported on a meeting she had with a group of environmental workers, aka janitors.

“They specifically talked about doctors,” she said. “They didn’t say they were pigs that throw things on the ground—”

David Feldman interrupted. “Yes they are.”

Brier continued, “But they are not-nice non-pigs throwing down things and getting grouchy and maybe a little retaliatory. We need to work on this. This is not the hallmark of a mutually respectful workplace.”

A few minutes later, Feldman and Kathryn Kaplan, the organizational specialist, introduced their strategy for giving the Code of Mutual Respect some bite—or at least some recognition. For the pilot program, they selected perioperative services, in part because Feldman ran it and also because it was a hospital epicenter for frayed nerves and robust tempers (vying for top place with labor and delivery and the emergency room).

Feldman and Kaplan had been trained in Crucial Conversations, the trademark of VitalSmarts, a company based in Provo, Utah, that specialized in helping organizations—mainly corporations, a handful of hospitals— instill what might be considered rudimentary social skills in managers and employees. Clearly, the World Wide Web, with its magnificent, instantaneous transferral of information and ideas, had not made it easier for people to communicate. VitalSmarts published two handbooks,
Crucial Conversations
and
Crucial Confrontations,
both of which were
New York Times
best-sellers and had been translated into eighteen languages.

Feldman and Kaplan laid out the plan.

In January they would begin a customized version of the training for the perioperative staff. The department chiefs had agreed to relinquish one Friday a month, for a total of eight sessions, one of the weekly morning slots reserved for surgical conferences. The training sessions were the theoretical part. The practical application: Those who misbehaved would be called in for an accounting with Feldman, along with the person who felt offended. Each could bring an ally. The sessions sounded like a cross between an administrative law proceeding, couples counseling, and a nursery-school time-out.

There would be two preparatory stages. Four days after the leadership meeting, on Friday, September 16, at the quarterly perioperative-services meeting, Feldman, Kaplan, and Pam Mestel would introduce the plan. Most important, they felt, was that Brier would come to the meeting to endorse the Code of Mutual Respect.

In December, they explained, forty-five volunteer members of the hospital staff—including nurses, clerks, and physicians—would receive training that would allow them to be Code Advocates—the “influencers,” Feldman called them, chosen because they were believed to have the respect of their peers.

The marketing jargon grated, inviting uncomfortable associations from the wider world, past and present, raising a Stalinist specter of institutionalized snitching. But then Feldman said something that made me think again. Did bullies always have to win? “People know something is happening, but there haven’t been any major changes,” he said. “The people who yell and scream are still yelling and screaming.”

“Code Violators,” someone wisecracked.

Feldman smiled. “I like that. Yes. Code Violators. I want to put up a plaque with this quote—it isn’t mine: ‘Respect is like air. When you lose it, nothing else matters.’”

Brier muttered, “No plaques.”

That Friday Feldman addressed a packed house in Schreiber. He reminded the audience that the Code of Mutual Respect had been endorsed by the hospital’s medical council in 2004; all members of the medical staff were given a copy and asked to promise to abide by it.

Facing a wall of blank faces, he asked, “How many of you have heard of the Code of Mutual Respect?”

Six people raised their hands.

No one responded when he asked, “How do you feel about doctors’ respect for one another? If you’re a clerk, how do you feel about how doctors respect nurses and other doctors? How do they respect you?”

No one responded when he projected the Code of Mutual Respect on the big screen at the front of the auditorium.

“Other institutions call it a code of behavior,” he said. “I think that’s too punitive. It is not a bylaw or a policy but a way of life.”

The crowd did come awake when he asked, “How many of you have been treated disrespectfully in the last week?”

Encouraged by the noticeable ripple in the sea of scrubs and suits, Feldmancontinued. “Sounds like an epidemic,” he said. “How many times have you been in a situation where someone starts yelling or insulting?”

A wave of appreciative giggles.

He told them how, earlier in the year, a court had ordered a doctor to pay three hundred thousand dollars for bullying.

Another wave.

He played a video showing two nurses talking.

“Remember Dr. So-and-So’s parting shot?” said one of them. “He said baboons could take better care of his patients. I see one of the good doctor’s patients has an elevated temperature. Ninety-nine point five. Maybe I’ll call him.”

The other nurse widened her eyes with the exaggeration of a sitcom character. “It’s two A.M.!” she shrieked. “You wouldn’t!”

The other nurse picked up the phone, and the screen went dark.

By then the mood in the room had shifted from dutiful to interested, from listless to attentive.

With new confidence, Feldman became fervent. “We need a culture change,” he said. “Our patients are savvy. They see what’s going on. You can’t tell me they won’t get better quicker if the staff is more respectful. This is Day Zero. It is no longer okay to act disrespectfully in the operating room.”

He paused and looked out over the room. “I know what you’re saying,” he acknowledged. “This is the way it’s always been here, and it isn’t going to change. Well, this is like psychic surgery.”

He explained about Crucial Conversations, and Kathryn Kaplan explained that sometimes the conflicts would be among peers. “We’re going to have interventions when there’s an unfriendly exchange between a physician and an anesthesiologist,” she said.

Someone in the audience muttered, “An anesthesiologist
is
a physician.”

Feldman accepted the challenge. “How many of you think this is
not
going to work?” he called out.

Almost every hand in the room went up—the converse of the showing for who knew about the Code of Mutual Respect.

Feldman decided it was time to introduce Brier. She peered into the auditorium and noticed Enrico Ascher, the $3 Million Man, who had walked in late wearing a sleek suit, sitting in the back of the room. “Dr. Ascher,” Brier called out to him. “Don’t be afraid to come to the front.”

She then turned her gaze to the room at large. “What is a good workplace?” she asked. “It’s a place where people know they’re going to be treated respectfully. Without it you’re sunk. We’re piloting this program here in the OR because it is the hardest. It’s a tough one. But let me be really straight with you. No one in this hospital is so good, so special, so talented, that this doesn’t apply to you.”

Big round of applause.

“Hopefully, it won’t come to that, where people don’t get it and don’t get it,” she said. “You can hold us accountable.”

Everyone was asked to fill out a survey. Then the session was over.

Survey results: Almost 85 percent of the respondents felt that the Code of Mutual Respect would positively enhance the workplace, though only 76 percent said they had a clear understanding of what it was. Thirty-seven percent believed that leaders handled disrespectful behavior effectively, and 62 percent felt that physicians were held to the same standards of professional behavior as were staff. Almost 90 percent of the respondents felt they treated others with respect, but only 61 percent felt they were treated with respect by fellow workers.

Sixty-seven percent of the people in the room answered the survey; of these, 53 percent were physicians, 27 percent were nurses or technicians, 3 percent were ancillary/clerical staff, and 17 percent were “other.”

Doctors were the worst offenders in every category. It was believed by 46 percent of the respondents that doctors treated other doctors with respect; only 39 percent felt that doctors treated nurses and technicians with respect.

My acquaintance with the Code of Mutual Respect deepened three months later, in early December. On a drippy, gray morning, I trudged through the slushy residue of the previous night’s snowfall to the hospital’s “learning center.” It was located ten blocks from the main campus, on a weary residential street of small houses stuck behind elevated train tracks. Antiseptic fluorescent-lit classrooms shared the building with the Maimonides ambulance corps employed by the hospital, not to be confused with Hatzolah, the Orthodox volunteers.

Waiting for the train that morning, I’d heard a woman tell her companion why she loved her doctor: “I saw this old lady on the street, and her skirt and underpants fell to the ground. Dr. K. was walking by, and he just reached down and pulled up her underpants and buttoned her skirt,” she said in a Caribbean accent. “He’s an old-lady magnet. They all love him. He’s gay, but all the old ladies come to him. You have bad news to hear, you want him to be the one to tell you. He is kindness itself.”

I was ready for Phase Two, training the forty-five Code Advocates, the “influencers,” the missionaries enlisted by Kaplan and Feldman to spread the Gospel of Mutual Respect. I joined one group of these influencers—doctors, nurses, techs—for the first day of what would be a sixteen-hour cram course in the art of Crucial Conversations. Each of us found a Crucial Conversations Participant Tool Kit on our tables. There were chapters on “How to Spot the Conversations That Are Keeping You from What You Want,” “How to Speak Persuasively, Not Abrasively,” “How to Listen When Others Blow Up or Clam Up.”