“Hospital: Man, Woman, Birth, Death, Infinity, Plus Red Tape, Bad Behavior, Money, God, and Diversity on Steroids”

Major medical centers in the United States have their own minicultures; various people stream through them, some receive care, some render the care, and others run the systems that allow the care to happen. Hospital, by Julie Salamon is a well-written piece of investigative journalism that emerges from a year-long study of Maimonides Medical Center in Brooklyn, New York. It provides an unvarnished look at how a major medical center comes to terms with the patients, families, and community it serves, as well as with the health professionals and administrators who run the institution.

Salamon, a journalist and book author, is able to chronicle the serious and the ridiculous elements that often characterize a busy city hospital. She spent a year with near-total access to Maimonides executives, medical staff members and trainees, various hospital staff members, and community members. Salamon used that access to provide readers with fascinating insights on such serious issues as the transition from one CEO to the next, the launching of a newly built cancer center, and the personal and professional experiences of several hospital executives and physician leaders. She even finds an emergency medicine resident who keeps an episodic email journal during his first year of training at Maimonides. In Hospital's 363 pages, a number of characters who are human, hard-working, and exceedingly candid about what they do in and around the medical center stand out. The book is grounded in emotion, science, and in the financial realities of today. The candor of the people discussed in this book is refreshing.

Maimonides Medical Center in Brooklyn, New York, was originally an institution that served a primarily Jewish population. Demographic changes that have occurred over the past decades have turned Maimonides into a melting pot, with patients speaking 67 languages (hence the portion of the book's title that refers to “diversity on steroids”). As you read Salamon's rich description of the various ethnic and religious groups, you almost start to see and feel a part of the different cultures she describes, prominently including Hasidic Jews, Pakistanis, various Hispanic groups, and Asians. A labor management consultant whom Salamon interviews notes:

We focus so much here on diversity, but in this country people do not have the smallest idea of what diversity is. They think it is black and white. But you have culture, you have race, you have age, you have position, you have education, you have so much to it. (pg. 166)

Later the consultant adds:

The community here changes every three blocks. The Hasidic, the Hispanic, the Asian–even between Latinos you have different types of culture and they are right here, and they are segregated … Walking here from patient accounts upstairs, I passed a Mexican group, a Dominican group, a Cuban group, a Puerto Rican group.(pg. 167)

As the consultant notes, the differences in the population served by Maimonides are both subtle and profound.

Salamon also paints a portrait of a staff that has a passion for getting it right, and a commitment to keeping the institution vibrant so that the 80,000 plus patients who come for care in the Emergency Department (ED) can find it when they need it. The overcrowding in the ED and the tight bed situation come to define the “chaos” at Maimonides, but it rings true for many other busy urban medical centers that face similar challenges throughout the American health care system. For anyone who has worked at a hospital and has sat through a meeting on what we euphemistically call throughput, Salamon's book will strike a familiar chord. For example, she offers the following assessment of patient flow and bed management: Patients would be scheduled for discharge, and then the doctors wouldn't pick up the lab work in time for the social workers to reach family members to pick the patients up. It was taking the cleaning staff eight and sometimes ten hours to get a bed washed, when the actual washing took about twenty minutes. Nurse-to-patient ratios on many floors were one to eight, requiring Herculean effort on the part of every nurse; if a patient was discharged, there was little incentive to rush to fill that eighth bed too quickly. (pg. 99).

Salamon details the multiyear effort to address this perennial hospital management problem. She describes a series of fixes, including a computerized bed-tracking system as well as the implementation of “bed management” nurses. Even though the problem doesn't seem to get much better after 5 years of effort, Salamon is able to convey how the spirit to keep trying to improve seems to be in the DNA of the workers and leaders at Maimonides.

Salamon is not shy about highlighting some of the negatives as well. Like any complex, modern organization, there are performance issues among the staff, occasional political infighting, and office gossip. Says Maimonides' otherwise optimistic, customer friendly vice president of patient relations,, “ … gossip was the hospital's most vicious enemy. That's why God gave you teeth,…the cage to hold in the serpent tongue.” (pg. 47).

Professional break-ups and feuds, backroom politics, and even failed business ventures do not escape Salamon's observations, and she gives the reader a perspective on just how hard won occasional successes really are for people working at the medical center.

In extensive interviews with individual staff members, Salamon describes how career choices were made, how one's family factored into decision making, and what the professional came to understand in terms of their values and accomplishments. For example, Salamon follows the story of Dr. Alan Astrow, who was recruited away from another New York institution, St. Vincent's Hospital in Greenwich Village, to lead a program at Maimonides:

… [He] realized he would never run a division at St. Vincent's, no matter how capable he was, no matter how much he was loved by his patients, no matter how much he was respected by his peers and superiors. He'd been there almost nineteen years, since he completed his training. ‘If you're in a place your entire career, you're seen a certain way,’ he said. ‘I'm a different person than I was eighteen-plus years ago. I was immature. People who have known me all along tend to see me that way. To do something different, you have to leave, so people can see you in a different way.’ (pg. 59).

Astrow's trials and triumphs at his new position provide dramatic tension throughout the book. Salamon effectively keeps the reader's attention riveted as Astrow struggles with whether he should have left his previous position.

Julie Salamon's Hospital will not provide any great answers to the significant problems that face America's health care institutions. It will, however, give readers a unique look into one institution's challenges and how its executives, professional staff, workers, and community members try to make it work. It will reassure some readers that things aren't that bad at their own institution, but it might challenge others to examine their own behavior to see if they are part of the problem or part of the solution within their own organization. What is clear is that Maimonides is an adaptable organization that is reinventing itself, because the times and the environment are changing around it. It appears that the leaders and their staff are up to the task and, frankly, that is all a community can ask of such a large and venerable private institution. Perhaps Salamon can visit them again in a few years and give her readers a progress report now that we are so familiar with the people surviving – and some who are thriving – at Maimonides Medical Center in Brooklyn, New York.