In the spring of 2005, I made an impudent proposal to the president and board chair of Maimonides Medical Center in New York: Let me spend a year roaming free in your hospital and then write about what I learned. Amazingly, they agreed to let me bear witness to the inner workings of this venerable hospital, warts and all.
What I found was an immensely complex institution. There were disturbing and uplifting medical stories, insurance quagmires and financial pressures. Those I expected. But time and again I was struck by the importance of human connection and communicationqualities that often threaten to get lost in the quest for technological advance and the pressures that arise from budgetary concerns. Too often, peopledoctors, patients, nurses, technicians, administrators, community membersfelt they didnt get the respect they craved. In a hospital, disrespect isnt simply a matter of manners, but can actually result in harm to patients.
I had been drawn to Maimonides initially for cultural reasons. This 705-bed institution contends with the usual travails of any large, urban hospital. But its location in Brooklynan epicenter of immigrationadds another crucial component into the mix of financial, technological, actuarial, ethical and scientific considerations. Founded 100 years ago to serve a community made up largely of Jewish immigrants, the hospital remains kosher, and Orthodox Jews maintain a strong presence20% to 25% of the patients. But the rising majority is from everywhere: 67 languages are spoken by patients and staff in this hospital.
It didnt take many visits to see the hospital as a place where the most significant social issues converged, including questions of community identity and responsibilityin other words, questions of mutual respect. Cultural matters weighed mightily on medical decisions.
The medical director of this teaching hospitals wildly busy emergency room told me, It is great training for your young residents to understand that when you walk up to a person from another country who speaks another language, that is a riskperiod, he said. Its as much of a risk factor as diabetes or anything else if you had an internal point system to admit the patient, you should add 25% of risk.
One important way Maimonides helps its polyglot patient body cope is through its extraordinary patient representative department. The hospital has more than 30 patient reps speaking numerous languages. They help calm families, arrange for interpreters, and discuss do-not-resuscitate and health-proxy orders. Sometimes they simply listen, a courtesy that can seem like a lifeline to patients who are frightened and alone.
The administrators at Maimonides recognize that miscommunication is a major pitfall of hospital lifeand not just the most obvious kinds of misinterpretation that occur between people who speak different languages. Specialization has led to superior technical results but also to a fragmentation of care that has injected elements of distrust into even the friendliest of relationships between doctors and patients. Patients often feel incidental, like inconveniences to be dealt with between computer entries. Nurses and technicians on the front line of patient care feel underappreciated and underpaid. Insurance regulations have put everyone under pressure.
To address these problems, Maimonides President and Chief Executive Officer Pamela Brier and the medical staff instituted a program called the Code of Mutual Respect, a series of training sessions designed to improve the behavior of the perioperative department. Attendance was mandatory for the entire staff, from physicians earning $3 million-plus a year to nursing attendants earning less than $30,000.
The hope was to make people sensitive to disruptive behaviorverbal abuse, yelling, profanity, she said. Why do we care about it? Because bad behavior ruins communicationand communication problems are what cause mishaps that can harm patients. I mean communications between doctor and nurse, nurse and clerk, housekeeper to nurse or doctor, everybody. The idea of the Code of Mutual Respect for me was to make the place safer and medical care better.
The importance of civil discourse seems to be catching on in the medical field. The New York Times reported recently that some prominent academic medical centers are promptly disclosing medical errors and offering earnest apologies and fair compensation, diluting the anger that often leads to lawsuits and opening up the chance to learn from each mistake.
I learned in my year at Maimonides that much more is needed to improve our medical care. The healthcare system is undeniably tainted by callous disregard for decent and equitable care, by corporate influence, by lack of political will and by too much concern for money. Individual doctors and nurses and clerksand patients and their familiesdo behave badly on occasion. People make mistakessome honest, some careless. Yet I was constantly struck by the sense of urgency that accompanied desires for fairness, for efficiency, for compassionate medicine.
Almost every day at the hospital, I was reminded that the system is the sum of individual human successes and failures, each of which can build or destroy. Hospitals are paid for procedures that statistically help prolong life and improve health. But just as important are matters that cant be measured and for which there is no insurance reimbursement. Hospitals must promote the understanding and empathybetween colleagues as well as between caregivers and patientsthat require genuine conversation and mutual respect.