Julie Salamon‘s new book, Hospital, chronicles a year in the life of the Maimonides Medical Center in Brooklyn, N.Y. She begins with two quotations that for me, having spent enough time in the E.R. as a volunteer rape-crisis counselor, resonate strongly.
Julie SalamonThe first is the Oath of Maimonides, a Jewish physician and philosopher.
The second is a quote from the film The Hospital:
“… a man comes into a hospital in perfect health … In the space of one week we chop out a kidney, damage another, reduce him to coma, and damn near kill him.”
Salamon’s book provides a vivid snapshot of the effects of the U.S. health-care system, where “cancer is a growth industry” and where first-year residents learn that Occam’s razor doesn’t apply to medicine.
Salamon is a bestselling author whose work has appeared in The New York Times, The Wall Street Journal, Vanity Fair, and The New Yorker, among others. Her previous books include The Devil’s Candy, The Net of Dreams, and Rambam’s Ladder, the last of which led directly to the writing of Hospital.
Before she answers our questions about her book, Salamon would like to ask a question of Freakonomics readers:
What has been your most memorable hospital experience — heartwarming or horrific — and what did it tell you about what works/what is broken in our health care system?
Post your answers and comments below.
Q: What have politicians said about health care reform that’s most accurate in light of the real-life situation you witnessed at Maimonides and where are they most off?
A: The politicians who acknowledge that the system is a mess and needs to be fixed are accurate. Certainly both Obama and Clinton recognized the need for universal health coverage. But that’s only the beginning. Look at the problems in Massachusetts, which has provided universal coverage without providing incentives to encourage people to go into primary care medicine — or without putting strong insurance regulation into place.
Well, I could go on and on about this, but here are my headline thoughts:
Medical and nursing education subsidized so our medical corps don’t enter the work force saddled with large debt. We need to entirely change the malpractice system. We need to encourage better health through prevention rather than procedures and medication.
It is time to make health care less of an industry and more of a national priority. Wouldn’t it be nice if the first thing your doctor’s receptionist asked you was, “What’s wrong with you?” rather than “What kind of insurance do you have?”
Pam Brier, president and CEO of Maimonedes.Q: How can the minimally paid cleaning staff and technicians at a hospital affect patient health?
A: Hugely. A few years ago the Institute of Health, which advises the federal government on medical matters, reported that a remarkable number of medical people in hospitals failed to regularly wash their hands. So now it isn’t unusual to go to a major medical center and find doctors wearing signs around their necks: “Ask me if I washed my hands.”
Dirty floors can also carry dangerous bacteria and the people responsible for the important job of keeping them clean are often the lowest paid employees.
Q: Which hospital’s emergency room would you go to if you had your choice of any in New York? Which would you avoid at all costs?
A: Right now I would probably want to go to the Maimonides emergency room simply because I know so many people there! Without a doubt, knowing someone on the inside helps a lot at any hospital. But more often than not, you don’t have much choice when it’s a true emergency; you’ll end up at the closest place to wherever you happen to be.
So a couple of pieces of advice: If you take any medication or have any allergies, keep a typed list with you at all times. Clear information is your best friend. Your second best friend is your actual best friend. It’s always better to have someone who can be your ally and protector.
A community dinner at Maimonides Medical Center.Q: The Jewish community has a huge sway over Maimonides and the way it’s operated. How are they able to hold their influence at Maimonides? Did this influence quality of care for non-Jewish patients?
A: While I was at Maimonides I met this amazing, tiny elderly woman named Miriam Lubling who was an immigrant nursery-school teacher — not a wealthy person. Yet she had become an associate trustee at New York University Medical Center because she referred so many Jewish patients to N.Y.U. from Borough Park in Brooklyn.
While other hospitals in New York try to cater to the city’s large Jewish population, Maimonides has a special relationship with the Jewish community. It was founded as a Jewish hospital and remains kosher. There is a “Sabbath elevator,” which stops at every floor so Jewish patients and visitors don’t have to push buttons on the Sabbath in violation of religious law. There is even a light that goes on to alert Cohanim — descendents of priests — that someone has died because the Cohanim are not supposed to be in the presence of the dead. Hatzolah, the Jewish ambulance corps, has influence in the emergency room; while I was there Hatzolah members vetoed the hiring of a nursing director they didn’t like.
Now, however, the majority of Maimonides patients come from all different cultures and ethnic groups (the hospital claims 67 languages are spoken there). The hospital does considerable outreach. I accompanied the hospital president to a mosque where she talked to Pakistanis about getting colonoscopies. Every month the hospital invites pregnant Chinese women to attend seminars in Chinese on pre-natal care (and the kosher kitchen has a Chinese menu). Thirty patient representatives speaking numerous languages help with interpretation. That’s what I meant in the subtitle of my book by “Diversity on Steroids!”
Q: How important to a hospital is the support of the community around it?
A: Remember that old expression, “pillar of the community”? Hospitals are supposed to be one of those. For most hospitals, community support is crucial — except for rarefied specialized hospitals that deliberately cater to national or international patients.
In New Orleans, because of divisive politics, the hospital system still hasn’t recovered from the devastation of Hurricane Katrina. In addition to humanitarian reasons, hospitals that want to succeed financially have to understand and cultivate their communities.
Q: In the book, a surgeon speaks about the bell curve of performance between different departments and teams — with some of them having exceptional outcomes, others with disturbingly poor patient results, and a large middle-ground. What does this mean for patients and why does this curve exist?
A: I first heard about the medical bell curve in a fascinating article Atul Gawande wrote in The New Yorker.
Only in recent years have companies like HealthGrades started measuring outcomes. But statistics only tell part of the story. What kinds of patients does a doctor or hospital treat? How much does the relationship between patient and doctor matter? What about location? Is it worth traveling across the country for treatment because a doctor has better outcomes? There are no easy answers.
As the medical director at Maimonides asked me, “What are the right statistics to use for outcomes? You treat a patient for pneumonia, and they go home and have a horrible course … the patients survive, so the mortality figures don’t look that bad.”
The curve exists because doctors are people and hospitals are places run by people, some of whom are smarter, more talented, and sometimes shrewder about gaming the system. Individual patients should make sure their doctors aren’t at the low end of the curve. After that, they have to take into consideration many factors.
Q: How does the way a hospital treats the uninsured affect operations and the care the insured are getting?
A: At Maimonides I saw constant tension between efforts to provide hospital care for the entire community and the desire to make enough money to be in the black.
That means for non-emergency care, such as elective surgery or cancer treatment, most uninsured patients would be referred to a public hospital. Yet many uninsured patients enter the hospital through the emergency room and stay a long time. I met one such patient whose bill exceeded $1 million — that would never be paid. The insured are affected by the money pressure this puts on the system.
Q: What was the biggest financial threat to the hospital?
A: The inequitable and convoluted reimbursement system.
Q: How do pharmaceuticals and insurance companies affect hospitals? How do individual doctors deal with this relationship? Is the relationship changing?
A: Enormous impact. The pharmaceutical companies are intertwined with hospitals and doctors, in positive and negative ways.
The drug companies sponsor seminars, introduce new medicines, do research, and sometimes provide free drugs for uninsured patients. But those same companies have a vested interest in determining which studies are supported, which diseases get attention, and which populations are served.
Some doctors and hospitals try to maintain objectivity by limiting the access of pharmaceutical sales people. Many have stopped allowing the drug companies to buy lunch for their staffs.
The relationship with insurance companies is even more fraught. I have yet to meet a doctor, nurse, or hospital official who has anything good to say about the current situation.
Q: What’s the first thing a hospital usually relies on to help bail them out of financial difficulties?
A: Judging from many hospitals, bankruptcy court. The lucky ones — the big prestigious academic centers — can turn to philanthropy.
Q: You write that whenever a patient is discharged the hospital saves at least $10,000. What incentives are used to get patients to leave sooner and how well do they work?
A: The main incentive is having a good discharge plan in place. So if the patient needs rehab or extended nursing care following surgery, for example, the hospital can help find a place or person who accepts that patient’s insurance and is available. This is very effective.
Problems arise when the patient is uninsured or has poor insurance. This makes it difficult to discharge the patient safely because there is nowhere for the patient to go. Universal health coverage would be very effective in solving this problem.
Q: You mentioned that cancer is a growth industry … what other industries bring in a lot of money for hospitals?
A: Lucrative areas are cardiac angioplasty, knee and hip replacements, and imaging (MRI/CAT scans). These are areas that certain insurers are willing to pay large amounts for. I don’t know exactly how this came to be, but now I am going to try and find out!
Q: As malpractice costs for private physicians rise, what has this done to a hospital’s staff of physicians?
A: Though rising malpractice costs hurt a hospital’s bottom line, there are some benefits — if you like silver linings! Many talented doctors opt to work for a hospital rather than private practice because the hospital picks up the malpractice tab.
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As part of my job supervising adults with cognitive disabilities, I accompanied a forty year old man with autism to the emergency room for heat stroke (he had fainted with a body temperature of 108). He received good care from an ER PA until it was time for a head CT. I was not allowed to accompany him into the CT room. The doctor and nurse there had no idea how to treat someone with autism.
The radiologist was shouting with gusto as though joking with a little boy, which overwhelmed his patient. He shouted, “We need to use this machine to look at the inside of your brain!” and cackled with artificial glee. I listened from the hallway to thumping and shouting and crying for ten minutes, and finally the nurse came to the door looking disheveled and asked for me to come in and help them.
The man we were entrusted with caring for had a look of utter horror on his face. The nurse told me that they were trying to strap his head down, but he wouldn’t let them, and he wouldn’t stop moving. The look on the man’s face told me that he thought he thought the nurse and shouting doctor were trying to crack open his head or kill him using the huge, noisy, strange CT machine. He was squirming around in an effort to escape.
I am not a miracle worker. I just talked to him. I took him by the hand, looked him right in the eye, and explained that he was hurt, and we were worried about his brain. I told him we needed to use this big machine to take a picture of his brain, he needed to hold still, it wouldn’t hurt him at all, and it would be over in two minutes. I told him that I knew he could do it, that I knew he was scared, but he was tough enough to do it and get it over with. He agreed with me. I wore a lead apron and held his hand and reassured him as the scan was taken. The man watched my face for reassurance the whole time. He was an adult with a genuine fear and concern, and instead of explaining the situation, his doctor treated him like a cranky toddler. He was fine and made a full recovery.
To me this highlighted how poorly people with disabilities are treated by the medical community-ignorance and poor attitude combine to equal bad care for people who desperately need it. People with disabilities use health care more often than other people, for some due to chronic disability-related health issues, for others because they cannot communicate to others that they have a health problem until it becomes severe. Health care employees who don’t understand people with disabilities are doing a great disservice to millions. I look forward to the day when people with disabilities are treated in a compassionate, understanding, non-condescending manner to best meet their medical needs.
My ex is a nurse. I was in the hospital recently with a broken leg… she came in to check on me, and to start an IV with some pain killers. By the time she was done, my arm and my leg hurt, as a result of being stuck seven times.
I can only imagine how many holes I’d have in my arm if we’d ended poorly.
Ok. The system is broken. Why exactly is “universal health coverage” the solution?
What has been your most memorable hospital experience.
I had a c-section with my first baby — a semi-emergency c-section after a failed induction. When I was discharged 4 days later, I got a bill in the mail, for $40,000. I was insured (PPO). Apparently, the original bill had been for $80K, and my insurance had paid $40K. When I asked for the itemized bill, I saw things that I had never gotten (drugs I was never offered, drugs I refused), things that were ridiculously overpriced ($20 for a 2oz. bottle of shampoo), and nursery care, even though my child was in my room the entire time.
The hospital ended up getting another $5K from me, in addition to the $40K they got from my insurance. But a c-section with no complications, and four days in the recover room should cost nowhere near that much money.
With my second son, also a c-section, I talked to the hospital beforehand. I walked with them through my insurance coverage (still the same insurer). After 4 days, I was billed $2K. My insurance was billed & paid $25K.
So what was the difference between kid#1 and kid#2? I filled out paperwork (lots of it) and spent two hours making arrangements ahead of time. Crazy.
Socialized medicine is NOT the answer to our health care woes.
Providing “free” health care for all Americans is a bad idea for multiple reasons.
First, there is the very clear example of the Canadian health care system and the disaster it has become. Because it is “free at the point of use”, people demand more health care and services than they would if they actually had to pay for the services they receive. This leads to what we call a “shortage”. (Sort’ve like rent control on a nationwide scale and on a much more important issue) We’ll lose quantity and quality if we choose to centrally finance our medical system through a third party payer. Plain and simple.
The incentives in a socialized system are all wrong. You’re going to have bureaucrats deciding how much to doctors should be paid (regardless of performance) how much of which drug to purchase, who can get see the doctor when, etc. It’s a bad idea all around.
We have a lot of problems with this country’s health care system, but socializing is not the answer. I don’t have time to offer some other potential solutions now, but if people are interested, I might be able to lay some out there later.
emergency physician here.
Most satisfying: resuscitation of near-death babies/children back to stable vitals on purely clinical clues.
The greatest financial return in medicine comes from the low tech/no tech dollars. The rest of the money chases the defensive bunkers.
Most unsatisfying: being spit upon and insulted by the hordes of entitlement beneficiaries.
When health care is free, people do not value it. They can destroy their own health with impunity, and demand restoration of that health, with nary a Thank you to the 11th hour providers.
To the author: You question the lucrative areas for insurance and CMS reimbursement. Easy: lobbyists for the related medical technology companies to CMS. CMS establishes reimbursement.
Your answers re: impact of malpractice on hospital staffs was weak. Better: physician migration from no punitive damage caps states (Illinois) to states with punitive damage caps (Texas and Indiana).
As an emergency physician, I’d prefer single-payer system , but most physicians do not trust CMS, and the insurance companies will fight it.
I had a great experience with appendicitis while being a graduate student. The emergency room took 4 hours of waiting, but then again I wasn’t the one bleeding from the head as a result of a fight. They did the standard stuff to figure out if I had indigestion, appendicitis, or something else (MRI, blood tests). Got my surgery, spent the night, etc. Luckily, I had decent insurance, the whole ordeal cost me a couple hundred instead of the $14,000+ medical bill from the hospital. Granted, I can see how being hit with $100 there and $200 there (post-hospital visit insurance fall-out)over several months might be difficult for some, but the pain killers were sweet and the surgeon and hospital staff was nice. So my 1 (out of 1) emergency room experience was perfectly tolerable. Nothing broken there, maybe faster triage? or knowing up front what might not be covered by insurance (not that I would have opted out of any of the medicines or procedures…) so I could prepare financing for the bills that come in the post-op months?
I have been a caregiver for my mother who has battled cancer for 15 years (and so far winning), as well as for my mother-in-law who we lost to pancreatic cancer.
My memories of hospitals from a caregiver’s perspective highlight how important PEOPLE are in health care. We spent a grueling day in a surgical waiting room during my mother-in-law’s extensive surgery for pancreatic cancer. We knew the prognosis would be grim. When the PA came out to tell us that my mother-in-law was terminal, and had only weeks to live, the PA was a good friend from high school whom I’d lost contact with. We were surprised to find each other in that waiting room, but he treated us with such compassion and kindness, I will always be grateful to him.
Similarly, my mom was in a clinical trial 12 years ago for a new bone marrow transplant treatment for her breast cancer. The program assigned one doctor at the cancer center to be her primary caregiver and advocate. This doc served on a TEAM of doctors and specialists who discussed each patient’s case weekly to provide the most exceptional care I’ve ever seen. Further, the patients were in isolation together on a floor, and later in an apartment complex attached to the hospital, and the patients not only became close friends, but two couples from out of the country lived with my family for several months post-treatment and would carpool back to the hospital for check-ups.