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All over New York City, hospitals are shutting their doors. Some have already been repurposed into luxury condos; others are heading in that direction. I suspect I’m not the only one to wish in vain for a formal public ceremony before each transformation, enlisting perhaps a few clergy, a shaman, and a dozen bagpipers to desanctify the real estate and soothe the old ghosts.
If it is really true, though, that a large section of the great Bellevue Hospital is soon to morph into a hotel and conference center, such a ceremony would be impossible to stage. There are simply not enough dirges and incantations on this earth to exorcise all those spirits. Best to leave them alone.
Every hospital creates its own universe of larger-than-life personalities and narratives full of high aspirations, low comedy, good science, bad science, great kindness, and quantities of cruelty and pure stupidity. Bellevue provides among the biggest, the oldest, the best, and the worst of these mixtures, and over the centuries it has evolved into a symbol, a giant public institution larger than the sum of its parts.
Writers have been attempting to capture its universe on paper for decades. Most in recent memory have been Bellevue doctors brimming over with shaggy dog stories starring themselves; William Nolen’s The Making of a Surgeon, Laurence Karp’s The View From the Vue, Eric Manheimer’s Twelve Patients, and Danielle Ofri’s multivolume set of memoirs are just a few among them.
These books are full of color, suspense, and sentiment but, inevitably, they are all about the medicine. None of them dwells much on the historical, political, or social forces that conspired to let the medicine happen.
Now along comes a new book that is just the opposite. David Oshinsky’s Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital provides all the information on Bellevue’s social and historical context a person could wish for, although it comes up just a little short on stories of what actually goes on in there. A historian at New York University whose 2006 book, Polio: An American Story, won a Pulitzer prize, Mr Oshinsky is a careful, fluent narrator who has set himself the gigantic task of re-creating almost 300 years of medical and civic history.
Bellevue started out in the early 18th century as a tiny almshouse for New York City’s homeless. An outbreak of yellow fever soon transformed it into a crowded pesthouse (as repositories for contagious patients were then called). Over the next two centuries, the hospital’s medical wards brimmed over with the impoverished victims of one urban epidemic after another, as yellow fever yielded to cholera, then typhus, then tuberculosis. Then there was that deceptive lull in the middle of the last century until HIV/AIDS showed up to make sure we all understand that infectious diseases are far from obsolete.
Most other city hospitals were created to serve a carefully defined religious or ethnic clientele. All provided some general charity care, but always within strict limits. (The elegant New York Hospital was particularly straightforward in this regard, with a detailed “Do Not Admit” list that included drunks and vagrants and a charter stating that “Persons of Decrepitude” were not suitable for its wards.)
So the city’s poor, intoxicated, and decrepit trudged on over to Bellevue, where the door was always open. In the mid-19th century, New York finally unloaded Bellevue’s jammed wards into two large new public hospitals for the contagious and insane. Even so, an updated set of “Rules and Regulations for the Government of Bellevue” specified that all such patients would be triaged at Bellevue first, and that the hospital would accept “only patients who were unable to pay for their board and maintenance.”
Bellevue’s mission was grand but its budget was tight, and hospital conditions ranged from the spartan to, occasionally, the unspeakable. In 1860, a stillborn infant was gnawed by the river rats who roamed the hospital in droves. In 1989, a Bellevue physician was murdered by a psychotic patient who had been discharged from the wards but remained on the premises, a lapse traced directly to a grossly underfunded security department.
The hospital was also long accustomed to saving money on its attending physicians. In the 18th and 19th centuries, they were generally uncompensated and managed financially by bringing with them on rounds medical students who paid well for the matchless clinical experience. This arrangement ultimately evolved into a complicated academic affiliation system, with the faculty of several local medical schools charged with supervising the hospital’s wards. At its best, the affiliation system enlisted the city’s greatest physicians to care for its humblest patients. At its worst, it created a culture of absentee supervision, with disinterested attendings providing minimal house staff oversight, even as their medical schools inhaled quantities of city cash.
Bellevue would of course eventually acquire a stable, exclusive affiliation with New York University, as well as a dedicated full-time professional staff that included quite a few world-renowned physicians who provided superb clinical care. Even so, the hospital continues to this day to be a place where a close-knit house staff reigns supreme, fueled by a potent combination of pride, terror, and moral strength. All present and past Bellevue house officers will nod with recognition at the excerpts Mr Oshinsky provides from the diary of Bellevue’s first house officer, one Alexander Anderson, whom the city fathers hired during the yellow fever emergency of 1795. Anderson arrived at Bel-Vue, as it was then known, “in a state of confusion and perplexity,” found deplorable conditions, became (and remained) very depressed, was tempted to quit on a daily basis, but stayed and did his job.
Mr Oshinsky relates all of this in glorious detail, with long excursions into the evolving norms of medical care, and entertaining discussions of the often signally peculiar personalities of the doctors who called Bellevue home. No breaking news featuring Bellevue is missing from his account, not even the catastrophic 2012 surge of Hurricane Sandy’s floodwaters into the hospital’s basement, or the 2014 admission of New York’s first and, so far, only Ebola patient to its seventh floor.
And yet to my ear, the book is just a little too smooth, reading perhaps the way a celebrity’s authorized biography might read to that star’s psychotherapist. What it lacks may simply be the material all those other Bellevue books provide in abundance—worm’s eye depictions of suffering, triumph, and unremitting labor, accounts of exactly what it means for the average patient to be treated at Bellevue, or for the average doctor to work there.
Had Mr Oshinsky come to me for help with these details, I, like any other veteran of a Bellevue residency, could pick among hundreds of stories to tell him. Perhaps the one I’d choose would be this:
I was an intern, fatigued beyond all description, heading into one more sleepless night on call. I admitted a young woman with cancer for an overnight infusion of cisplatin. I remember nothing more about her: she was an easy admission. I did her paperwork, ordered her infusion, and went on with my night.
At 6:30 the next morning I came by her ward again to write her discharge orders. When I stopped at her bed, a vaguely familiar figure sitting in the bedside chair was patting her hand. He stood up, stretched, nodded at us both, and left the room.
It was the night janitor, the guy who mopped the floors. Apparently the patient had spent a hellish night vomiting uncontrollably. No one had called me: the nurses on that ward were always soundly, illicitly asleep after midnight, and I was all alone, covering dozens of patients scattered all over the hospital, all far sicker than she was. But the guy with the mop had spent the night checking in on her, comforting her, and holding her hand.
That was Bellevue in all its cruelty and kindness, just a little piece of sentiment to supplement all of Mr Oshinsky’s facts.
Corresponding Author: Abigail Zuger, MD (email@example.com).
Additional Information:Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital, by David Oshinsky. New York, NY: Doubleday; 2016.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported.
Zuger A. Bellevue Gets Its Biography. JAMA. 2017;317(5):460–461. doi:10.1001/jama.2016.20313
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