Implications of Graft vs. Host Disease in Modern Medicine

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You are listening to ReachMD XM-157, the channel for medical professionals. We all learned that graft verus host disease is a common complication in transplantations, how can this also be happening on an institutional level. Welcome to our special segment on public health policy.

I am Dr. Leslie Lundt, your host and with me today is author Julie Salamon. Julie has written best-selling books on the film industry and ancient scholars, but her most recent book Hospital, Man, Woman, Birth, Death, Infinity, plus Red Tape, Bad Behavior, Money, God, and Diversity on Steroids gives us a glimpse into her year-long journey through Maimonides Hospital in Brooklyn.

DR. LESLIE LUNDT:

Welcome to ReachMD Julie.

JULIE:

Hi, thank you for having me.

DR. LESLIE LUNDT:

Julie you have written about so many things in your wonderful book Hospital, but one of the most intriguing things to me was this concept of graft versus host disease in the institution, tell us about that.

JULIE:

Well, what I was talking about really was the hospital I wrote about Maimonides Medical Center in Brooklyn is a hospital that has, they like to say they have 67 languages spoken here and that applies to the patients as well as the people who work there and I think in hospitals around the country we have increasingly multicultural patient body and medical staff. People come here from all over the world to train and to then stay and practice medicine and at this hospital needless to say there are all kinds of programs in place to try and integrate the international doctors with the homegrown and sometimes it is hard and that is where the graft host analogy kind of came into being was, you know, how do you deal in the middle of all the other complexities of modern medicine people with completely different cultural attitudes and beliefs.

DR. LESLIE LUNDT:

How do you run a business with 67 different languages.

JULIE:

It is hard although I have to say what was interesting to me was I felt well may be this is Brooklyn, it is in New York, but one of the young doctors I followed around to was actually from Nebraska. His parents came to visit 1 day and I interviewed them and his dad was an anesthesiologist in Lincoln, Nebraska at a big hospital there and he was saying that even in Lincoln, they do not have 67 languages, but they have on a regular basis probably 8 or 9 and so I think in major cities around the country you are seeing people come to live who come from all different backgrounds and they have different attitudes towards being patients and different attitudes towards being doctors and nurses.

DR. LESLIE LUNDT:

So these problems aren’t unique to Maimonides, but may be they are amplified there?

JULIE:

I think amplified is a good way of splitting it. I mean one of the reasons I found this hospital such an interesting case study is that, I think almost every single issue that comes up in modern medical practice from regulation to malpractice to our pretty insane reimbursement system, it is all there, but it is there in a very intent environment and so it was a good place to kind of look at all the issues of modern medicine, sort of in a hot house and sometimes a hot-tempered house.

DR. LESLIE LUNDT:

So one of the titles of your book is Diversity on Steroids, where does that come from?

JULIE:

67 languages, you know this is a hospital founded 100 years ago to take care of the immigrant community of Borough Park in Brooklyn, which at that time was almost 100% Jewish and there is still a very significant orthodox Jewish population, so the hospital Kosher, but there is also a significant Chinese, Pakistani, Italian, Irish, Nigerian, you name it all kinds of different people, so now they have a Kosher kitchen that is run by a guy who was born in Jamaica and they also have Kosher Chinese food on the menu because they have so many Chinese patients.

DR. LESLIE LUNDT:

Now after spending a year immersed in this culture and you were given unlimited access, right?

JULIE:

I was.

DR. LESLIE LUNDT:

Do you see any hope for fixing the many problems that you outlined in your book that w are all painfully aware of with health care in this country?

JULIE:

You know what I saw is helpful is that, you know with all the problems and all the insanity and all the money pressures every single day I saw some incredible piece of medicine being practiced. The people even under very difficult situations rise to the occasion and when they are pushed up against the wall, and I think we are at that point now where we are pushed up against the wall, people start to think about change. The truth is I do think that people recognize at every level whether it is patients, doctors, even politicians that we have to bring some kind of rational thinking to the health care system and I think what it is going to mean is that everybody is not going to be able to have everything as some people have now and yet, but more people will get something and I think people are going to have to take more responsibility for their health. I think we are going to start believing more in preventive medicine and I do not think any of it is going to happen in the next 5 minutes, but I do feel hopeful. I mean I did not see a bunch of cynical burned out people, I saw people who were frustrated and angry sometimes, but I saw them caring a lot and that certainly is always a hopeful proposition.

DR. LESLIE LUNDT:

After looking back on this experience Julie, what do you think is the biggest challenge that we face in trying to deal with these problems.

JULIE:

I think it is a 2-fold challenge, I mean on the one hand everybody thinks they are either for the single payer system and Universal Health Coverage are against it. I think whether you are for or against, I do think we have to have cost controls and that means there is just so much irrationality built into the system now that I had a young friend who a couple weeks ago, a student from another country, she got a fever in the middle of the night and her resident advisor in the dorm took her to the emergency room. The girl did not want to go, but she had a really, really high fever and that was the rule that, if they have a student. So she ended up getting 2 Tylenol and a bill of $1089 that was mailed to her home by a collection agency. In the scheme of things, not the worst horror story in the world, but I think symptomatic of a system that is in need of reform. I think if you look at the profits of the insurance companies, the pharmaceutical companies, they are out of wack, which does not mean that people should not make money, we shouldn’t encourage research. But Maimonides who is the philosopher, the hospital is named after always encouraged moderation in all things and I think we are way out of wack with moderation.

DR. LESLIE LUNDT:

To tell you one of the gasps that I had in reading your book was how much the hospital administrators made at Maimonides.

JULIE:

Oh and they are not really the most highly paid at all, but I was surprised as well that the CEO, when I was writing the book, so this was when I was doing the research which was a couple of years ago was making a $850,000 a year and that put her nowhere near the top paying hospital executive in New York, I mean there were hospital administrators making a million and a half, 2 million, 3 million dollars a year and you know on the one hand while for somebody running a company of that size that would not be such a huge salary, but these are not-for profit institutions and I think that you are raising a really good point that I think there has been a kind of inflation, built into the system that certain parts of medicine, surgeons make a lot of money, the top hospital administrators make a lot of money, the people doing sort of internal medicine, pediatricians don’t struggle to make a living really and I think it is not a very rationale long term view because if you are not paying people to teach us to take care of ourselves, then we end up with these high cost, high procedure services that cost a fortune.

DR. LESLIE LUNDT:

And you make another excellent point in your book about putting in these very expensive computer-cum-tracking systems for the hospital in trying to follow the patients and really the pivotal point in these systems is the lowest paid person in the whole link, that is the data entry person and if they don’t do it right, this fancy system is completely worthless.

JULIE:

I think you are making a very good point and yet on the other hand , I do believe that putting in not just computer systems, but just better systems of thinking and planning can be very useful for these big institutions because I think in order to make the more rational the system, than the more rational the delivery of care and yet again one of the things I tried to do in the book, was to you know, this isn't a book that is out to bash the medical profession. I think on the contrary what I saw over and over again were doctors, nurses, social workers all trying really hard to do the job they were trained to do and feeling frustrated by a system that seemed bent on stopping them from doing it.

DR. LESLIE LUNDT:

After spending this much time in the hospital, are there people that you continue to stay in touch with?

JULIE:

Everybody. It has been kind of overwhelming, I mean, I think for a lot of the people in the hospital, because a lot of the book is personal. I go into the personal stories of many people in the book partly to show people what happens if you are an oncologist and all of a sudden your wife has cancer, how does that affect your thinking as a physician and your sense of failure that you were unable to catch something in your own family. I followed doctors who have been promoted to management positions, but are still practicing medicine and they may be great doctors, but are having a hard time to adjust to their new role. I want to give the way the public a full cross section of the kinds of issues that medical professionals working in these big institutions face that people on the outside are not aware of and those pressures, the personal pressures, the financial pressures, and the institutional pressures, these are big, big. They are like big companies, except they are not-for profit and some of them in some states are for-profit institutions, so all those things would come into play in other professions ego, ambition, youth, money, expenditures, money lost, those come into play in hospitals as well.

DR. LESLIE LUNDT:

So I am dying to find out what happened to Davy, the ER resident.

JULIE:

Well, Davy the ER guy, this was my guide from Nebraska who actually ended up at Maimonides by accident, because he thought his girlfriend might go to graduate school in New York. She ended up staying in California where they were both in school and he came to New York. Well he ended up transferring to another hospital to be close to his girlfriend in California and I am happy to report they are still together, but they are actually moving again to Oregon. He is following her again because she got either a postgraduate or a teaching position up in Oregon, so he is going to do another medical, not a residency, but may be a post residency position up in Oregon so he is very faithful, I hope they get married.

DR. LESLIE LUNDT:

I hope so too. My goodness, thank you so much for being on the show.

JULIE:

Thank you.

DR. LESLIE LUNDT:

I want to thank our guest today, Julie Salamon. We have been discussing the complex cross cultural implications of 21st century American Medicine as illustrated in her book, Hospital.

I am Dr. Leslie Lundt your host and you have been listening to the Clinicians Round Table on ReachMD XM-157, the channel for medical professionals. To listen to our on-demand library visit us at ReachMD.com. If you register with the promo code 'radio' you will receive 6 months of free streaming to your home or office. If you have comments or questions, please give us a ring at 888-MVX-M157.

Thank you for listening.

You have been listening to public health policy in American, a special ReachMD XM-157 interview series with our nations top thought leaders in public health. This month ReachMD XM-157 will be discussing the many issues challenging public health policy in America. For a complete schedule of guests and programing information, visit us at ReachMD.com.