A lesson in advocacy
The last mile.
One of the encounters that has left an everlasting impression on me was my first meeting with Mr. Morris Steinberg, Director of Hatzolah in Kiryas Joel, Monroe.
On July 1st 2003, I started my career as an attending in Ezras Choilim Health Center, a beautiful clinic in the famous chassidish quarter of Monroe. At 27 years old, I was both nervous and excited to start this journey.
I was excited because I felt it was an opportunity to help a community that I was told needed more doctors. A community of ultra-Orthodox Jews, which reminded me of my charedi lineage. I remember the joy of my late grandfather, Harav Chaim Yitzchak Aryeh z”l who was delighted to hear the news that I was a doctor in Kiryas Joel. Personally, it was a fulfillment of a dream. Exactly a week before my wedding, I ventured to shop on 13th avenue in Boro Park. While strolling down the avenue, I looked at the faces of the children on the street and felt that they were missing some “Simcha” - happiness. On that avenue, on my last conversation with my soon to be wife (before we saw each other under the “Chupah” a week later), I told her that I wished G-d would allow me the opportunity to help bring smiles to their faces. Not a year passed and I found myself practicing among them (it turns out that the chassidish kids are very happy - and maybe it was just a cold October day in Boro-Park.)
I was nervous because I was not sure why the CEO of the Health Center, Mr. Nuchem Friedman was so interested in signing me on, and even more nervous when I saw that in my first few weeks at the center there were less than 30 patients visiting the Pediatric Department - which staffed 3 medical providers each day. I remember calling the CFO of the Health Center, Mr Jacob Friedman on one very light, boring day and asking him if he had any ideas that could help boost our patient load and our providers’ morale? He laughed and said, Dr. Simai, I noticed that you have a Mishna Brura book on your desk. Open it and learn, I am sure that the “Yetzer Harah” - evil inclination will send a patient to interrupt you!!!
And so, nervous and excited, I spent the first few weeks at the center trying to make good impressions, follow up with parents and hoping that the “Yetzer Harah” would keep on interrupting my learning…….
One afternoon, as I was sitting bored in my office, I heard a sudden knock on the door. When I opened the door, I noticed a man in his 50’s, with a short grey beard, wearing an EMS vest. Although he looked tired, he greeted me with a warm smile. He was flanked by a few EMS members and judging by their admiring gazes, it was obvious that he was their chief. With his warm smiling face, Mr. Steinberg asked me some questions about my medical education and training and informed me of the special services Hatzolah offers the residents of Kiryas Joel. We discussed head trauma and asthma protocols, and the strengths and deficiencies of the local hospitals. Throughout the conversation and subsequently, with every encounter, I noticed that Mr. Steinberg would go out of his way to complement me. I remember how he called me once to discuss a patient that suffered from severe anaphylactic reaction to eggs. I briefed him excitedly about how we managed to control the patient and safely transport him to a hospital, but Mr Steinberg started by saying the following words: “First, let me compliment you Dr. Simai for making such an elegant diagnosis. It takes a wise and experienced physician to make their diagnosis and manage it the way you just did.” I was bewildered why a person so experienced was so nice to me, literally buttering me up with so many kind words. I may have been young, but I felt he had an agenda. What could it be? Why was Hatzolah so interested in a 27 year old pediatrician?
It did not take long for that agenda to be realized. It turns out that Mr. Steinberg was a true public advocate. He knew how to go the extra mile to help a sick patient. The amazing thing about him was that he often insisted on going the extra mile. He would deliberately choose to transport patients to a children’s hospital 50 miles away from Kiryas Joel, rather than risk having them managed by an inferior hospital 5 minutes away. He would travel to emergency rooms past midnight and sign patients out against medical advice, in order to personally transport them to a better hospital.
After a few weeks on the job, I started getting interesting phone calls from Mr. Steinberg. Most of them had been requests to call-in patients to Columbia Presbyterian Hospital ER. These were not patients of our center, but apparently, their doctor was not responding quickly enough, and without a call from a referring doctor, the patients would sometimes spend hours upon hours in the waiting room. The other calls were consultations. Mr. Steinberg would call me randomly, at any hour of the day or night, and ask for a second opinion for a member of the Kiryas Joel or Williamsburg, Brooklyn community. Mr. Steinberg seemed to like LIJ -Cohen Children’s Hospital and wanted me to introduce him to some pediatric specialists there.
Not only did I not mind being “taken advantage of” when asked to help Mr. Steinberg, I felt that he was helping me fulfill my mission - to increase the smiles on the faces of as many children as possible. This relationship grew stronger as our practice, with G-d’s help, experienced exponential growth.
In 2005, I moved back to the Woodmere and started a part time private practice in Cedarhurst. For the next 4 years, I traveled back and forth to Monroe to work there 4-5 days a week.
It was literally 3 am in the morning, when I heard my phone ring. On the other side, a familiar voice - Mr. Steinberg. This time, an 8 year old boy from Williamsburg was in distress. He was diagnosed with severe pneumonia at a local Brooklyn Hospital and was in significant respiratory distress. A CT scan showed that he had a large amount of fluid in his lungs. Mr. Steinberg was paged by the Brooklyn Hatzolah members who asked for help. They felt that he needed a pediatric surgeon to evaluate him ASAP and possibly drain this fluid. The local hospital did not have any pediatric surgeons on call. The patient’s pediatrician was not available and therefore the patient could not be transferred. LIJ had an emergency transport team, which I never used, so I agreed to try my best to arrange the transport. Mr. Steinberg and I were both surprised and delighted that within 30 minutes the ambulance was on its way to Brooklyn. I was even more surprised to find out how quickly I fell back asleep…..
I woke up the next morning remembering very little. I sometimes worked so much that I felt it was a clear miracle I made it home at night. But the following night, I was paged again - this time at 4 am. It was Cohen Children’s Hospital letting me know that little Simcha had undergone surgery to drain the fluid from his lungs was now exiting the Pediatric ICU.
Since I was officially his doctor, I would have to see him daily and monitor his progress. For the next 10 days, I would travel to the hospital between shifts in Monroe, on Saturday nights and Sunday afternoons. The thought of charging the parents for this extra work crossed my mind once (since I was not their PCP I could not bill their insurance), but I quickly decided that it would be nice if I could spare them the added stress.
At first, I was so excited that Simcha underwent the seemingly life saving surgery, and that I had the merit to facilitate it. But Simcha had a very rocky postoperative recovery. He continued to have fevers for 9 days and required oxygen during that time. His lung sounds were horrible. 3-4 days after surgery I was so concerned about him that I insisted the surgeon re-examine him. The surgeon told me that this was normal and reassured me that there was nothing else to do. This surgeon was a senior member of the team and his stellar reputation preceded him. The infectious disease team was following Simcha as well.
Being that Simcha was still feverish, requiring oxygen and had horrific lung sounds on day 7 and 8 post-op, I decided that Simcha would benefit from continued IV antibiotics at home via a Pic line, after his eventual discharge. I asked the special nursing team to arrange prior authorization from the insurance for this and within 24 hours it was approved.
On day #10, I received good news. Simcha was fever free and off oxygen for 24 hours and in his opinion, he could be sent home. “Really?” I asked. I listened to him yesterday and he looked and sounded so bad. “Yes,” he replied, “there is no reason to keep him here any longer.” Great, I thought. I guess this was the best news of the day!!! But here came some criticism - David - the doctor said - I feel that the Pic line is a total waste of time. After all, the fluid from the lungs did not show any organisms, so I do not think you know what you are treating. This specialist was one of my mentors, so although I worked hard arranging the Pic line, I felt that arguing with such an experienced specialist would be a mistake. “High dose amoxicillin is sufficient in my opinion,” he added. I reminded him of Simcha’s rocky post op course, the fevers, the lung sounds and the oxygen. He will be fine with amoxicillin was the answer. I replied “I am happy to hear that you are optimistic.” I was not about to argue with my mentor and Simcha was sent home that day.
Not 3 days passed and again, I was paged on my cell phone. It was Simcha’s mother. I was sure that she was calling to thank me, so with a huge smile, I picked up the phone and gave her a hearty greeting!!! But on the other end of the line was a very concerned mother, informing me that Simcha appears to be as bad as he was before his operation!!!
My throat went dry as I was scrambling for answers. I decided to arrange for an immediate visit with the Infectious Disease specialist and the Pediatric Surgeon. Simcha saw both specialists that day. They conferred and suggested to bring Simcha back to the operating table. They felt that the fluid had re-accumulated and that the problem was not infectious but more mechanical, so the antibiotics were not helping at all. At this point, the mom spoke with me in tears, imploring me to make the final call.
I was holding the phone and trying to stay calm and collected, but my heart was going through tumultuous phases. Initially I felt great anger in my heart, anger towards people that I trusted and humbled myself to. Frankly, I was angry at myself for not insisting, maybe the stronger antibiotic Pic line would prevent this.I felt confused - How could this be? How could Simcha crash like this again? Then, there was doubt - maybe they are correct, maybe right now, nothing else will help Simcha other than surgery. I felt desperate and confused, and extremely disappointed.
And then, G-d delivered the solution. Maybe we need a fresh set of eyes to examine this case? I decided to get a second opinion. I went through my head to find a specialist that would see Simcha, and I decided this time, I would not schlepp him out of Brooklyn. I remembered that there was one Pediatric Pulmonologist that I encountered in one of my rotations in Maimonides Hospital and decided to immediately call him. With G-d’s help he was available to speak with me. I described all the details of the case to Dr. Michael Marcus and then proceeded to ask: “Do you think that we could control this infection without surgery at this point? Could we just re-order the Pic Line?”
Dr. Marcus did not reject the idea. He agreed to see Simcha that day and evaluate him. After examining Simcha, and looking at his X-rays, Dr, Marcus decided to place Simcha on two strong, oral antibiotics simultaneously, and he continued monitoring him as an out patient. With G-d’s help, this was all Simcha needed. After 2-3 weeks of treatment, Simcha’s lungs were crystal clear. I truly feel that Simcha transformed my approach to practicing medicine. I hope that G-d willing, I will bring a few examples of subsequent cases where I put these lessons to work. But to sum it all up, these are the conclusions I arrived at:
The first lesson I learned, was that no matter how much I respect a doctor, we are all human, we all have our moments in the sun and we all go through dark days. In retrospect, the trust and confidence I had when I heard that Simcha was managed by top notch specialists should have been directed instead to sincere hope that G-d would direct these specialists in the right direction.
The Second lesson I learned was that we often feel that the right physician for our illness may require us to cross many bridges and states, but G-d often shows us that the best doctor for is right in our backyard.
The last critical lesson I learned is that in order to help my patients, I had a lot to learn from Mr. Steinberg. Instead of nodding my head yes in awe of others, I should have realized that I was the only person who checked Simcha every day and as such, I should have insisted on having the last word. I failed to go the extra mile, to have that “chutzpa” to argue with my mentor. I should have realized that there was a message that Mr. Steinberg was sending me through all the elegant compliments that he showered upon me. I do not think that Mr. Steinberg chose to wake me up at 3 am that night just because I was a nice guy, but because he truly believed that I could and would be the right messenger to advocate for this precious soul.
I thank you Mr. Steinberg for your kind and warm words. For your ambitious and relentless work, and most of all, for allowing me to see Simcha come marching down the hallway of Eras Choilim Health Center on the eve of Shavous in 2007 to present me with a platter of tasty chocolates with a beaming smile.
The sight of Simcha’s glowing face took me back to that cold October day in Boro Park when I wished that someday, I would be able to bring a smile back to Simcha’s shining face.
I assure you Mr. Steinberg, that I will do my utmost to continue your legacy of going the extra mile - until the last mile!
Wishing you and yours many happy, smiling days!
David Elazar Simai M.D.
With sincere appreciation to the exceptional Hatzolah members of our community and Kiryas Yoel, who devote their lives to ensure our safety and happiness.