Hospital (46 page)

Cunningham had been wary of me from the beginning. The first time we talked, he explained why he thought I should make the book a work of fiction. “Who wants their dirty laundry hanging out there?” he asked. He told me that after he’d been at Maimonides a few years,
Esquire
magazine had assigned a reporter to do a story about him. They met two or three times, in Cunningham’s recollection, and then the conversation got personal. “I’d been married before, and I gave him crap about that stuff,” Cunningham said. When the writer refused to agree to let Cunningham preview the article, the surgeon pulled out. “It became important to me that there were certain things about myself I didn’t want exposed to the world,” he said with a look I took as a warning.

I understood that this was a man who wanted to control his own mythology.

Cunningham told me he got a call from Edward Lichstein, Maimonides’ chief of cardiology, who would become the chief of medicine, asking the heart surgeon if he would come to Brooklyn. Lichstein was the same man who, twenty-three years later, would deliver roughly the same message to Alan Astrow, just substituting cancer for heart disease: Too many patients were crossing the bridge toward Manhattan; Maimonides wanted to reverse the traffic flow.

Sitting in his big, masculine office with its sportsman’s trappings, including the portrait of Hemingway and the boat, the
Swamp Fox,
Cunningham told me he had been intrigued by Lichstein’s invitation for two reasons, one personal and one entrepreneurial. “I had been at NYU almost ten years, and I was forty-two,” he said. “I had aspirations to be my own boss, to run my own show, to build something I could call my own. In your early forties, that’s your first opportunity. Then, in your mid-fifties, you realize you’re either going to stay or make yet another move. Where I am now, I can’t go sixteen different places. At forty-two you are fearless because you have many avenues.”

Assessing the situation at NYU, he recognized that his boss, Frank Spencer, was at an age where he wasn’t going anywhere for a decade or more. Besides, Cunningham wasn’t the only hotshot in the pipeline; he knew he wasn’t going to jump in front of Wayne Isom, two years ahead of him. (Isom also left NYU. In 1985 he was recruited to become chair of cardiothoracic surgery by the New York-Cornell Medical Center, which would become New York-Presbyterian Hospital after the merger of the New York Hospital and Presbyterian Hospital.)

Cunningham told Lichstein he wanted to be not just chief of cardiothoracic surgery but chief of surgery as well. Lichstein agreed to his terms.

There was ego gratification on the one hand, profit potential on the other: Cunningham saw the chance to earn a good deal of money. “It was the glory days of reimbursement,” he recalled. “We were all making nice bucks.”

As he saw it, the situation was no-lose. “Maimonides had a failing cardiac program doing a hundred twenty-five cases a year with twenty-percent mortality rate,” he said. “What made it easy was that I was already doing a lot of patients from Brooklyn, so I didn’t have to come here and develop a new practice. The pie was so big you could slice it fifteen ways and everybody could still have plenty.” By 2006,
Crain’s Health Pulse,
a newsletter reporting on the health-care business, reported his annual compensation at just over $1 million. The mortality rate for coronary bypass surgery was well below 2 percent, not among the very best in the country but significantly better than the national mortality rate.

The doctor who introduced Lichstein to Cunningham was Israel Jacobowitz, who had trained as a resident at NYU under Cunningham and joined his surgery practice. In Brooklyn they thrived—until, like Sam Kopel and his former partners, they quarreled and disbanded. By the late nineties, Maimonides cardiac surgeons were doing as many as twelve hundred major cases a year, with Jacobowitz as the biggest producer. In the early eighties, Maimonides had also hired Jacob Shani, a former resident who had gone on to train at Beth Israel in Boston, to build cardiology. The hospital’s heart program prospered, and eventually Maimonides was designated one of the country’s “Top Ten Heart Hospitals” by Solucient, another company whose business was measuring cost, quality, and market performance of hospitals.

Like the Kopel-Bashevkin contretemps, the Cunningham-Jacobowitz split may or may not have been about money but it was certainly about the things that they believed money measures. “It wasn’t money, it was principle,” Cunningham told me dryly. “Izzy’s the Rodney Dangerfield of cardiac surgery. In his mind he don’t get no respect. No one can ever stroke him enough.”

Yet, as usual, the trigger point had been division of the spoils. Cunningham and Jacobowitz had a third partner. No one disputed that Jacobowitz was the hardest worker; it wasn’t unusual to stand outside the hospital at nine-thirty or ten at night and see him walk out and drive away in a pale blue Mercedes convertible. Nor did Jacobowitz resent Cunningham’s smaller caseload, understanding that official hospital duties cut into his surgical volume. It was the proportion paid to the other partner, a friend of Cunningham’s, that irked Jacobowitz. “It was an ultimatum: ‘Either get rid of him or I’m out,’” said Cunningham. “Blood is thicker than water, so I said, ‘Well, Izzy, see ya.’”

Jacobowitz left the hospital for a few years and then came back. Bygones were never bygone, however; every slight was recorded and remembered. The lines were drawn through the ranks: doctors, nurses, technicians, and administrators. Some were loyal to Jacobowitz, others to Cunningham. By the time I arrived at Maimonides, the heart doctors were in the midst of their own palpitations. Cardiac surgery, once the fastest-growing procedure, had dropped by 30 to 40 percent, giving way to less invasive remedies like angioplasty. The feud didn’t help.

Jacob Shani, the cardiologist, became the heart star (he would be adopted by Brier as a personal friend), designer of the “Shani Right,” a specially angled catheter used in angioplasties, the process of clearing clogged arteries. The Shani Right was designed to make a tricky journey, from the groin— where the catheter, a tiny tube, was inserted into an opening of a couple of millimeters or so—through the entrance to the right coronary artery, about a yard away.

Shani, an Israeli who didn’t mind feeding gossip about the feuding doctors, cheerfully described the relationship between his group and his surgeon colleagues: “We were eating their lunch.”

Cunningham had been replaced by Stephen Lahey as chief of cardiothoracic surgery, but the older doctor remained a power center of the hospital, with a full contingent of friends and enemies eager to adorn or desecrate the legends that grew around him. Remaining head of surgery and the hospital’s senior vice president for strategic initiatives, Cunningham commanded respect and fear as he prowled the hospital in his cowboy boots, exuding king-of-the-jungle bravado, even as his allies and antagonists wondered when he would be ready to lay down his scalpel. “One of the most tragic things is to watch a great surgeon at the end of his career become a cranky old man,” said Lahey. The new cardiothoracic chief of surgery continued to have a difficult time asserting his authority in Cunningham’s old territory, a year after he’d been imported to Brooklyn from Massachusetts for a hefty price tag (
Crain’s Health Pulse
reported him in the $1 million-plus category as well).

“Joe is a great figure—a phenomenal figure,” Lahey told me. “I’m not saying he’s a great man. I don’t know about that. He is a tremendous character.”

I replied, “But those things are quite different.”

Lahey nodded. “They are quite different.”

He added carefully, “I told him I respect him tremendously. But now it’s my turn to put my imprint on this. He understood that.”

That understanding didn’t stop the feuding, which remained corrosive, Lahey said. “I still hear doctors in the community say they won’t send patients here because there’s feuding, and ‘If I send patients to one guy, the other one is going to call me up and say, “Why are you sending patients to him?”’ ”

The feuding surgeons were almost perfect archetypes. Cunningham was Alabama molasses; his jabs were coated in sugar. (“It’s a shame about Izzy, too, because he’s a hardworking guy who’s very talented, he just has this problem. . . .”). Jacobowitz was Brooklyn pastrami, salty, spicy, and apt to cause heartburn.

“If he were polished and slick and political, this wouldn’t have happened,” said Mark McDougle of Jacobowitz, whom the executive admired because he was a good and a fearless surgeon but who also was exasperated with his temper tantrums. “Izzy makes himself an easy target,” said McDougle. “He gets angry, loses control, he’s emotional.”

Like Sam Kopel (and Jacob Shani), Jacobowitz was a product of the Holocaust, born in a refugee camp. He was wired, wounded, defensive. “I don’t think I’d be off base saying Marty Payson and Pam Brier feel they owe some debt to Joe Cunningham,” he said accurately. “I don’t understand it. They weren’t here since 1982. I have been. Maybe it’s my ego, but I think Jacob Shani and Israel Jacobowitz have had as much to do with the growth of cardiac as Joe Cunningham. I think Joe is a good administrator. He can be charming. I guess along the way he developed the allegiance and support of a number of people from within the institution and the board.”

Regarding Cunningham and Jacobowitz, Mark McDougle, the calm man from Ohio, had the diplomat’s desire for a dispassionate approach, a rare attitude that made his office an oasis of reason. “There’s a lot of bullshit in all the stories,” he said. “In my opinion there’s enough validity in what Izzy says for me to conclude he was unfairly treated. Whether it was unfairly this much”—he placed his index fingers an inch apart—“or unfairly this much”—hands wide apart—“I’m not going to quibble. These little games of personality are, in my opinion, truly pathetic. I know ultimately we’re here to take care of the people who live here. Five years later, maybe ten, pick a number, we’re all going to be gone. The idea is to set the place up to make it better than it is now.”

No matter what actually transpired, that was almost always the idea, the aspiration, the hope: to make the place better. When Cunningham arrived for work in 1982, the Eisenstadt Pavilion was a construction site; Schreiber Auditorium was being built, and so were the cafeteria and the medical library. The office he’d been assigned was a mess. “Everything was pretty much a shell, plaster hanging off the walls,” he told me, leaning back in the chair behind his big wooden desk, drawl caressing every phrase. “I remember the first day I got here, I walked into this office and there was an old desk here, a big cabinet that went ceiling to floor where the prior chief had kept everything from his liquor bottles to his textbooks. He’d been dead five or six years. I open the cabinet, and all this stuff falls out.”

Cunningham unspooled his yarn with the patience and timing of the fisherman he was. “There was no welcome reception,” he said. “I remember I went to the desk and I wrote in the dust, ‘I . . . am . . . here.’”

Jay Cooper, the compulsive, aloof chairman of radiation oncology and director of the Maimonides Cancer Center, was there and not there. The cancer center’s location, almost a mile from the hospital, made life difficult for the hematologic oncologists and surgeons who treated cancer patients in both locations. The radiation therapists, tied to their machines, rarely needed to visit the main hospital. Cooper seemed to like the separation, the clean slate, the ability to build an idealized institution removed from the hospital’s grit and hurly-burly.

The radiation department in the basement reflected his desire for a calm, orderly process. His six medical physicists sat behind computers measuring the shapes and sizes of tumors and customizing the angles and intensity of radiation beams for each patient. It was like a temple down there: quiet and serene, unlike the bustle upstairs in hematologic oncology, crowded with patients coming for consults and chemotherapy.

Cooper, a thin man who always complained that he was getting fat, could seem uptight and out of touch. He was most at home with theory and analysis. But he did care about patients. I realized that one day when he had paused after an extended dissertation about something; I idly asked him whether it really was that big a deal for patients to go to Manhattan from Brooklyn—lots of people, including him, made the commute in reverse every day.

He cut me off. “You don’t understand because you’re well,” he said impatiently. “If you’re well, the trip, whether on the D train or by car, is an annoyance. If you’re sick, if you’re anorexic, if you have no will to live, if you’re dizzy, if you’re nauseous, if you’re in pain—I could go down a longer list— then that trip is impossible.”

At that moment his obsessive meticulousness seemed noble. And I couldn’t discount the fact that he surrounded himself with good people. He had won the loyalty of someone like Bernadine Donahue, the radiation therapist whose talents were uniformly praised. It was hard not to like Donahue, who was as warm and natural as Cooper could be cold and awkward. She was that lucky combination of brains, compassion, and common sense, and she had been willing to follow Cooper from NYU to Brooklyn.

The cancer center was approaching its one-year anniversary. Many pieces were in place, many were not. The Breast Cancer Program covered prevention and treatment, from mammography to surgery; the children’s oncology service was expected to move in over the summer. The radiation-therapy group was getting more patients but was not busy enough—despite the excellent medical credentials of Cooper and his team. Referrals remained slow, and the intensity modulated radiation therapy function remained on hold, as testing and analysis continued at Cooper’s insistence. Despite the setbacks he kept repeating, “The good news is we’re a lot further on than we were a month ago, and the bad news is we’re not nearly where we want to be.”

Lahey had recruited Joseph LoCicero III from the University of South Alabama, where he was chairman of surgery, to be director of surgical oncology. LoCicero came with a weighty résumé, studded with prestigious research and impressive academic credentials, including Harvard Medical School, director of the surgical clerkship program.