Hospital (39 page)

Marcel Biberfeld mused, “Maybe so few doctors do this because they don’t want to do it either,” to which Minkoff replied, “They don’t want to get shot. There used to be more of them, but they didn’t want their homes to be picketed or to be shot.”

Yet Minkoff said freedom of choice included the right not to participate. “It would be a Pyrrhic victory to tell nurses they have to be there when they object,” he said.

Biberfeld tried the other side of the argument. “Isn’t that a slippery slope?” he asked.

Kidney answered. “I agree it’s dangerous to have nurses object to one procedure or another, but this is unique.”

The final decision came later, an agreement to compromise. Next time the hospital would hire nurses from outside to assist in the procedure. Quirky, rambunctious Maimonides managed—this time—to find a reasonable arrangement that respected opposing views without forcing one to capitulate to the other. They agreed to live with unease, with the recognition that fairness and mutual respect meant struggle and uncertainty.

Five years earlier the hospital had brought in a group of airplane pilots to talk to surgeons about how to reduce errors, making comparisons between the mistakes and miscommunications that led to runway collisions and mistaken amputations. They talked about the importance of emergency checklists and an atmosphere that encouraged communication. The pilots told stories of an airplane en route to Florida trapped in a circling pattern because of a thunderstorm. When air traffic control told the plane to return to Atlanta for a forced landing, the pilot threw a tantrum. But the copilot remained calm and brought the plane down.

The surgeons hadn’t been convinced. “It’s a beautiful analogy, except the captain can control it,” Richard Lazzaro, a Maimonides surgeon, told me. “That copilot was this cool guy. He said, ‘You have to be cool, you’re the captain, you take it up, you fly, you land.’ But if you’re in the middle of an elective case and the carbon dioxide tank goes out and your circulating nurse isn’t in the room and you’re putting a stitch in some big blood vessel and the belly’s totally deflated, a minute might seem like an hour. You have this pause that’s beyond your control, and then you find out someone is out talking to their boyfriend on a cell phone—you want to drill them. But if you drill them, that person is going to say, ‘God, what a prick.’”

Lazzaro was one of the hospital’s bad boys, a surgeon known about equally for his fierceness on behalf of his patients’ well-being and his nastiness in the operating room toward those who dared to show less enthusiasm for the work than Lazzaro thought they should have. His father and grandfather had been doctors, and he grew up in their offices, knowing this was what he wanted. “I feel there’s no greater glory than what we do, and I expect that from my team,” he told me. “Our job doesn’t end at five o’clock. You have to be willing to say, ‘I can’t go to that wedding or some family event,’ or you’re not going to help your patients.”

Lazzaro was one of five brothers in a Brooklyn Italian family who pounded one another playing football and basketball and then forgot about it. Still chubby-cheeked and impish in his forties, he described his own behavioral flaws with the same sheepish charm he probably beamed on his mother when he announced he’d knocked out the living-room window with a baseball.

Lazzaro had become an expert in laparoscopic surgery, using tiny cameras that allowed surgeons to do precision work, reducing the area that had to be cut, sutured, and stapled. It made hospital stays shorter and recovery faster, and the procedure had become commonly used for gallbladder removal, hernias, and cancer. But as Americans got fatter and fatter, the fastest-growing field for laparoscopic surgery was gastric bypass surgery, which reduced caloric intake by shrinking the size of the stomach and the length of the intestine. In 2006 the Public Health Service estimated that medical spending averaged $29,921 for obesity surgery (and as much as $65,031 if there were complications that required hospitalization) and six months of follow-up care.

When Lazzaro was at about 120 cases, he told me, and very comfortable with the procedure, he was operating on an obese patient—huge, a body-mass index (BMI) of more than 40, meaning the man was carrying at least a hundred extra pounds. The surgeons had penetrated the dense flesh and the camera was in place when the senior resident asked a question:

“Why are we here?”

Lazzaro, trying to concentrate on the tiny incision, couldn’t believe his ears. This was not the moment for existential angst. The resident elaborated. He’d read a paper that had come out of Long Island Jewish Hospital reporting that in twelve out of forty cases where patients had a BMI of over 40, the cases took too long and patients suffered a lot of complications.

Lazzaro recalled his reaction. “I said to him, ‘To be honest with you, that’s the stupidest thing I’ve ever heard, because if it were true and you knew it prior to the operation, why didn’t you bring it to our attention beforehand?’” he said. “You’ve got to be an idiot if you think something that important, grade-one evidence—you should be shouting it from the rooftops, saying, ‘Guys, you shouldn’t be doing this!’ But not in the middle of the case to try and impress somebody.”

Is that really what he had said?

No, said Lazzaro. “I screamed at him and called him a fucking idiot, and then I sent him out of the room,” he said with a grin, remembering for an instant how satisfying it was to take that smug idiot to task for asking a question appropriate for a naïve college student, not a senior resident.

But the explosion didn’t make Lazzaro happy. He was aware of his hothead reputation, and he didn’t like it. He had heard that people who worked with him in the hospital said they respected his ability and would send their families to him for surgery, but they also thought he was a jerk. “I was a mean person,” he said plaintively. “It wasn’t me, it was part of me. They never saw me outside of the hospital, with my patients in the office, with my family. They knew me from a surgery standpoint, and they thought I was a nasty guy.”

Something was wrong. He was forty-two years old, the proud father of the adorable children whose photographs sat on his desk. He had a job that was also an avocation, a passion—and yet he wasn’t happy. He smoked. He was overweight. He was tired all the time.

It didn’t make him feel better to know that others were nastier than he was. He recalled the surgeon who said to his residents, “Your mom must have taken thalidomide when you were born,” suggesting they had no arms and their hands were like flippers. At least he’d never been that bad.

Maybe it was because his wife was nagging him to get some exercise. Or because he got tired of people telling him he looked like he hadn’t slept in a week. But Rich Lazzaro decided to change. He began doing yoga. He quit smoking. He lost weight. So he was primed for the perioperative-services meeting on Crucial Conversations that met January 13. Lazzaro was sitting just a few rows from Alan Astrow when the surgeon stood up and said, “Hi, I’m Rich Lazzaro, and I have to say, from my standpoint, sometimes we don’t think about the view of the team.”

Not exactly a thunderbolt from beyond, but startling enough for Lazzaro to be surrounded by colleagues after the meeting was over, asking him to sign their copies of
Crucial Conversations,
and only partly as a joke.

“I felt if I’m the poster child for being the tough person, and I wanted to make change, I needed to stand up and say so,” he told me later. “So I did.”

Lazzaro’s enthusiasm was infectious. Astrow raised his hand for a microphone and spoke in a humble tone of recognition. “There’s a part of the Jewish liturgy where you ask forgiveness,” he said. “And at St.Vincent’s I’d hear the Lord’s Prayer over the loudspeaker: ‘Forgive those who have trespassed against us.’ To have a conversation, you have to recognize your own fallibility and to forgive others from that place.”

By then hosannas wouldn’t have surprised me. None erupted, but many people did applaud. On the way out, I bumped into Steve Davidson, still smarting from his misadventures with Hatzolah and Jablon and the executives. I couldn’t decipher the odd expression on his face. “It’s so reenergizing to have someone like Astrow bring that kind of thinking back to this place,” he said, and disappeared into the crowd exiting the auditorium.

Strange that in all this talk about the Code of Mutual Respect, no one ever mentioned the Oath of Maimonides. It was displayed on the wall next to the receptionist’s desk in the Gellman Pavilion, alongside a brief historical accounting of Maimonides, the twelfth-century philosopher and physician for whom the hospital was named. Sometimes, especially when sleep deprivation left my emotions raw, I would find in these noble sentiments from long ago an exquisite connection to the people surrounding me in the small lobby: the family murmuring in a mixture of English and Russian about a parent’s prognosis; a black man reading a book on Islam; a Pakistani woman in bright silk pajamas running after the little boy playing hide-and-seek by the cash machine.

When I asked Feldman about the oath, he said he had a copy in his office, a gift from an aunt, but he thought of it as décor more than inspiration.

During my year of immersion, a new biography of the medieval scholar was published. It was written by Sherwin Nuland, another physician and author, who focused on the sage’s place in medical history. He explained the significance of the prayer of Maimonides: “the testament of the ideal—and idealized—healer. It has rivaled the Hippocratic Oath as the statement by which a young physician pledges fealty to his art, his principles, and the trust of his patients.

“Unfortunately,” continued Nuland, “it is also like the Hippocratic Oath in that it was not written by its putative author.” Scholarly research indicates that the prayer most likely had been written in the eighteenth century.

Nuland decided not to let the question of authorship stand between him and his desire for illumination. “The prayer’s final paragraph elevated my sense of worthiness to the task I had chosen,” he concluded. “Had Maimonides ever read it, I feel certain it would have done the same for him. I would have preferred that these were indeed his words, but it hardly matters. This prayer is a credo for the life that was his, and has been mine. Any thoughtful physician might say the same.”

Ten

A Good Death