By Thomas Cullen
Association of Health Care Journalists
Julie Salamon has written for prestigious news outlets, penned several books and was a Kaiser Media Fellow for 2006-07. Here, she answers AHCJ questions about her new book, "Hospital: Man, Woman, Birth, Death, Infinity Plus Red Tape, Bad Behavior, Money, God, and Diversity on Steroids." Salamon discusses what reporters can do to maximize their coverage of health care, the new administration's challenges with the system and what she saw at Maimonides.
How did you get the extraordinary level of access that you received for this book? Did you have to agree to any conditions or stipulations? Does it seem likely that other journalists could do the same or was this a unique situation?
I think it was a particularly lucky situation. Sometimes there’s just a confluence of circumstances that work to your advantage as a journalist. A couple of things work in your favor. The president of Maimonides, Pam Brier, had been interested in writing a book but had never gotten past a few journal pages. She had also read some of my work and liked it. She also believed in a kind of openness as well. Also, the hospital had, a few months before I showed up at their doorstep, their public relations person had left and there was no one there to block the door. They said no restrictions really. The only thing that they were concerned about was HIPAA. And basically, I signed a document that transferred their HIPAA responsibility to me.
Is there one overall lesson that came out of this for you about health care? What about an overall lesson about writing this book?
I would say that, in terms of writing about health care, there’s sometimes a danger because people aren’t on the ground. It’s hard to find what the real stories are. Certain kinds of verities become the truth. One of the things I found on the ground that lay people are not aware of is that they think of a hospital as a big anonymous force, but it is actually based on day-to-day decisions made by individuals. The system can actually work better or worse according to the people working within it. For instance, certain floors [of the hospital] ran better than others because of who was in charge. And also, there’s a lot being done to improve the system as well. I think people may not be aware of the huge crush of business that goes on at a hospital that makes it hard to provide the quality of care. Some of the regulatory stuff that is good can also impact care. I think if there’s a villain in the piece, it’s the way the insurance companies have evolved over the years. Now hospitals are dealing with significantly more companies, and each one has restrictions. Plus, Maimonides is a hospital that is running at 99 percent capacity.
Describe the day-to-day reporting for such a protracted process.
The year in the book was the year I spent there, but there were months of negotiating and pre-reporting and follow-ups. The management of the information is one of the things I’m most proud of about this book, because I’m not necessarily a structured person. Also, I wanted to go in with as open a mind as possible. I knew that I would be sort of auditioning people for the first couple of months to see if I would focus on them. And there are lots of meetings at hospitals. I tried to go as many of these organized meetings as I could to learn about the workings of the hospital. This is a big hospital. So, early on, I focused on learning the lay of the land. In a week, I would go to several meetings or classes of students or people I could follow. Then, as I began to meet people, I would start making appointments with people I wanted to spend more time with.
The process was basically broken down into two blocks. The first one was the observational reporting, and being around every day I became a bit of a fixture. I would set aside one or more days a week just for transcription. By the end of the year, I had 5,000 single-spaced typed pages of notes, and a part of the task was keeping up with my notes. So, I spent a day or two a week for transcription or note-taking. By the end of the year, I had pretty organized files. I used dates to organize my observations. At the end of the year, I had a drawer full of these notes and folders, and, before I started to write, I spent three weeks just reading them, and then I created an index. If you’re doing a magazine piece or a book, for sure, I actually found having a little flip-through notebook that matches with your computer is helpful.
Did your experience leave you with any thoughts on the presidential candidates' plans for health care? Did you see or learn anything that would be relevant to that?
I think I might betray my bias here, but I definitely think that the Democratic position is better. And it’s not just universal healthcare versus not universal health care or single payer versus not single payer. How the health care system evolves from now on involves a shift in attitude. We’re seeing in Massachusetts the difficulties in moving from a system of multitudinous insurance to single. Whatever party comes in to power, there will be a change in health care, and the system is on such tenuous ground. I think we need an open system, but we’ll see the same push pull. Will we be willing to have a system with limits on it? The challenge of the next administration is to not be didactic about it but to really look at the system and break it down to its individual parts and try to make some changes. For example, there is almost no financial reward for many aspects of primary health care, and that needs to be addressed.
What about immigration? You were in a place that served a large immigrant population. Do you feel immigrants' health care needs are being met? Did you see anything in place at that hospital that was unique in how immigrants are handled and treated? Any lessons or initiatives that could be applied elsewhere?
Every hospital has to deal with people from different cultures. It’s not just language; it is attitude toward sickness and what you think will improve your stay at the hospital. At Maimonides, they have a huge patient representative staff of 30 people, and they provide help in situations where interpretation or religious or customary differences might come up. At the cancer center there, the fellows have a weekly session called Bio-Psycho-Social. Every week during rounds, young doctors look at sociological, psychological and cultural issues that affect that patient. Is it perfect? Not at all. But even having such courses raise awareness. Communication is incredibly important. They may understand the words you are saying, but it’s very important for medical people treating people from different backgrounds to try to understand who they are. Now, that sounds great, but, in ERs, everyone is under incredible stress. So having cultural understanding is extremely difficult. Hospitals could hire volunteers or, if they could afford it, have paid professionals who could be advocates for patients.
Hospitals are places of incredible triumph and unparalleled defeat. Describe the toll that the experience took on you.
I think I was an altered state of reality for almost three years if you take in the whole project. I think for me in a lot of ways I found it to be a very deepening experience. I thought I would be very depressed, but I often found myself very exhilarated to be there. A lot of times, as reporters, we move fast, and we don’t allow ourselves to get the depth because there isn’t time. I felt very grateful to be there because I was being allowed, as a writer, to deepen my thought process about some of the most important things in life. Just watching ordinary people, some extraordinary but mostly ordinary, smart, flawed people trying to do a good job.
As a result of your time in the hospital and writing this book, do you see any lessons for journalists? Any stories that aren't getting covered or aren't being covered adequately? Anything you would advise journalists to look for in their local hospitals?
I think one thing that would really be great for people to do, is I think that my sense in reading a lot of health coverage, a lot of it good, is there’s kind of a dismissal of the people who run the hospital. People think, “Oh, they’re just suits,” but most of these people have been medical people in one capacity or another. Another thing to consider is what are the real issues that make things happen at the hospital? Take a look at the medical care given and the financial ramifications of what happens. That said, the medical role of hospitals shouldn’t be forgotten.
Also, look at both sides of the coin, like for the issue of patient responsibility. A hospital has to be a good hospital, but there are better ways to be a better patient too. Try to find things that are not as obvious. Who plays a role in care that you wouldn’t think of? What does the technician do? Being on the ground and talking to the people in the not so “important” jobs, although they are important, would be interesting too.
Read more about Julie Salamon and her book at www.juliesalamon.com.
