by Gen LaGreca
“I’m aware that the patient would have died without my treatment.”
“I’m not disputing that. I’m talking about our new rule.”
“And I’m talking about Eileen Miller’s life.”
“Doctor, we agree that the patient should receive the best care. The new rule was made to ensure that. It’s designed to prevent people from flooding the ER to see specialists when their general practitioners haven’t authorize a referral. You know the drill. A guy gets an earache, and the general doctor gives him eardrops. But the patient’s not satisfied with that. He wants to see a specialist. So he goes to the ER, where he has all of the specialists and their tests at his disposal. Unfortunately, people abuse the system,” she complained. “How can we give them their right to medical care when they do things they have no right to do?”
“What does that have to do with Eileen Miller?”
“We can’t waste taxpayers’ money whenever a patient wants to see multiple doctors about the same problem. Under our new rule, if a patient goes to the ER for the same condition that his general doctor treated within the last ten days, we’ll pay only the amount allowed for the original diagnosis. In this case, Eileen Miller’s husband filled out the new ER admitting form. ‘What is the problem?’ it asked. ‘Migraine headaches,’ Mr. Miller wrote. ‘Was the patient treated for the same problem within the last ten days by a general practitioner?’ the form asked. ‘Yes,’ Eileen’s husband replied.”
“So?”
“So that treatment falls within the fee we pay the general doctor’s group practice for having the patient on its roster, and nothing more.”
“But Eileen didn’t have a migraine—she had a massive brain hemorrhage.”
“If you had waited until ten days after the general doctor’s visit—”
“If I had waited ten minutes longer, Eileen Miller wouldn’t be here.”
“Then the primary physician has to change the original diagnosis.”
“But the brain scan shows the hemorrhage, so who cares what anybody diagnoses?”
“Our computer cares, Doctor. The diagnosis has to be changed in our records. But only the general practitioner can make that change, because it involves the original diagnosis, which, I explained, is the only thing we’ll pay on now. This was described in last week’s BOM bulletin.”
She paused, as if waiting to hear an excuse or apology, but none was forthcoming.
“Eileen Miller’s original diagnosis can be amended, but the form to do that still requires the general doctor’s signature. Do you understand now, Dr. Lang?”
“I understand that Eileen Miller had a hemorrhage and needed surgery.”
“Yes, of course. But our payment has to coincide with the diagnosis, and that diagnosis has to be confirmed by the other doctor involved.”
“But I was the only doctor involved.”
“You may think you were the only doctor who counted, but we can’t agree. A second physician should collaborate with the first one and agree on treatment. We can’t pay over and over for the same case each time the patient feels like seeing another doctor. Perhaps you surgeons might learn to consider other viewpoints.”
“But if it weren’t for my viewpoint, Eileen Miller would be dead.”
She shrugged her shoulders. “Dr. Lang, we’re not disputing your actions; we’re only asking you to work within the system. Our new rule has decreased ER use by thirty percent,” she said proudly, “and that’s good for the people.”
“What people?”
“The public.”
“You mean the people who aren’t Eileen Miller?”
“You can, of course, challenge our ruling on that surgery. Just appear before the Appeals Committee and explain your position. If you give the new system a chance, you might find us quite reasonable.”
“If you’re reasonable, then redo your red tape, so I can get paid for the Miller case.”
“I can’t.”
“Why not?”
“That case is closed unless you appeal it.”
“Why?”
“I did what I could, but I found no way to pay you.”
“What did you do?”
“I asked Eileen Miller’s general doctor if she would amend her original diagnosis from migraines to a head injury, which matches your story. Then we could enter a correction and pay you for the surgery.”
“And?”
“The general doctor, your wife, refused to do it.” She smiled contemptuously. Her eyes followed him as he sprang from his chair. “Dr. Lang, I’m not finished! Where are you going?”
* * * * *
A patient in the waiting room of a nearby medical office looked up curiously when a man in a doctor’s coat stormed in.
“Where’s Marie?” David almost shouted as he slid open a plastic partition at the front desk to peer at a startled receptionist.
Without waiting for an answer, he rushed through a door into the clinical area. The late hour had reduced the traffic in the back corridors of the group practice to a few weary doctors entering and leaving compartments along a maze of numbered cubbyholes. He found his wife alone in her office.
“If you’re so proud of how you treated Eileen Miller, why can’t you admit it for the record?”
“Quiet! The whole office will hear you!” she whispered angrily, shutting the door behind him. “What do you want me to do? Admit to a misdiagnosis in the patient’s record? Please, David, be reasonable. Out of the thousands of cases I handle, I can’t get every one right.”
“Then handle fewer cases so you can get them right.”
His eyes caught on something disturbing—a shiny pin on the lapel of her white jacket.
“I did what I could. It wasn’t my fault!”
“Then why can’t the record state that you misdiagnosed the problem, so I can get paid?”
“What if the Millers get curious? What if they request the patient’s records and discover my admission in writing to the misdiagnosis? What if they hold me responsible for not acting sooner? What if they hire an attorney to bury me in court? I couldn’t live through that! Not again!”
David’s eyes landed on the gold pin on her lapel, inscribed Distinguished Caregiver.
“You don’t care if I’m disgraced. Do you, David?”
“That pin disgraces you! It’s letting you lie to yourself!” he said harshly.
She lowered her head sadly and did not reply. He watched the red-chocolate folds of her hair flow over her face. She looked younger and more vulnerable, the way he remembered her when they had first met. He wondered if she were hurt by his remark. His voice softened with a tone from their past, as if he were trying to recapture something—and someone—whom he had once valued.
“Marie, you’re paying a terrible price for that pin, aren’t you?”
Her eyes seemed to widen in fear, staring through the carpet to a disturbing image of their own.
“Marie,” he continued softly, “you’re upset, aren’t you?”
“I’m . . . tired, that’s all,” she said unconvincingly. For an unguarded minute, her confidence vanished and her face looked troubled. “I sometimes feel I don’t know what to do. I don’t trust myself to decide. It torments me at times.”
He recalled the frightened student who had sought his help years ago in choosing a field of medicine. “That pin is pressuring you to make some questionable decisions, isn’t it?”
“Why no, that’s not true, David. I’m a good doctor.” Her voice did not share the sentiment of her words; it trembled.
“Marie, I think you’re upset, and I think it’s because that pin is putting your patients in . . . danger.”
“Danger?” she repeated, tasting the bitter word but not spitting it out.
A buzz from the phone interrupted them.
Marie pressed a button. “Yes?”
The receptionist’s voice sounded through a speaker. “I’m ready to leave now, Dr. Lang, so I want to remind you of your photography
shoot at eight tomorrow morning for the new recruiting ad. Marketing is in a rush for that ad, so they can place it in the national trade magazines in September.”
The owners of Marie’s group practice had chosen her as the ideal doctor to represent them in their campaign to attract new physicians, an assignment Marie coveted as a stepping-stone to a partnership.
“Yes. Thank you, Sally.” The uncertainty in Marie’s voice was vanishing. “You can tell our marketing people that I’ll be there.”
She turned to David. With the speed of a door slamming on an intruder coming too close, she snapped her hair back into place and her eyes once again narrowed in anger.
“Did you say I put patients in danger? How dare you? I’m a good doctor. Everyone thinks so but you! It’s your reproaches that upset me, that’s all. If I hadn’t earned this pin, then which one of us could pay the bills?”
Her words silenced him.
“How much are you making after paying your fines?”
He had no reply.
“I’m trying to be practical. One of us has to be. I’m pleading with you not to make trouble with the Miller case. That wouldn’t accomplish anything, would it? Please, David, forget it.”
His head dropped, and with it, his spirits. The person whom he was seeking from a more innocent past had eluded him. Her anguish seemed to be dissipating, he noticed. He wondered if she had intentionally summoned her new ally, the one that was appearing more and more frequently to silence him and to end their arguments: his growing sense of guilt.
“Please, David, be flexible.”
He whispered tiredly, “All right, Marie. You win.”
“You won’t dispute the case and force me to change my diagnosis?”
“No.”
“Now that’s better, isn’t it?” She smiled.
He felt an exhaustion strange to him, as if a wound were draining his blood, not in one great hemorrhage, but more slowly and painfully, drop by drop. He could recall only vaguely the boundless energy with which he had started his career and the exciting world of medicine that he had expected to find. Far more vivid were the loose flesh of the inspector in the OR, the incessant knocking on his door by Pamela Varner, the whining of Marie, and the other jabs pricking his skin.
“Why don’t you come home early tonight, David? I’ll help you with your speech for the board of directors’ meeting tomorrow, the speech that will make my husband the chief of neurosurgery!”
David did not go home early that evening or prepare his speech. He went to the Taylor Theater to watch Nicole Hudson dance.
Chapter 9
The Threat and the Promise
Although it was a sunny day in Albany, vapors were rising from the hot summer ground to sully the blue sky with strands of dusty gray. Within hours, the harmless dark wisps could grow into menacing storm clouds whose pressure could be released only by the violence of a thunderstorm.
A limousine ascended a road that swirled through a grove of sugar maples to the top of a small hill. There the car stopped at an imposing white structure with classic Doric columns: the governor’s mansion. The secretary of medicine emerged from the vehicle, waving to reporters gathered at the entrance. The ready greeting—partly humble, partly patronizing—gave him the air of a next-door neighbor who was also a diplomat.
As he was escorted to a meeting with Governor Burrow and his aides, the secretary felt a quiet excitation at passing a gallery of oil paintings of New York’s governors. The leaders graced both sides of a wood-paneled walkway, arranged in a procession from the first colonial magistrates to the current holder of the state’s highest office, Malcolm Burrow. The secretary walked through the display with the authority and pride of the mansion’s resident rather than of a visitor. He permitted himself a moment’s furtive hope that the suspicions concerning the lieutenant governor would be proven true. Then he would likely emerge as Burrow’s running mate in the upcoming election. After serving a term as lieutenant governor, he could achieve the post that put the personages around him on canvas. He had come a long way, the contented look on his face seemed to say. How much further could he go? the ambitious eyes seemed to ask as they noted the empty space on the wall next to Burrow, the spot awaiting his successor.
The secretary’s father had been a manufacturer of kitchen gadgets, his mother a tireless volunteer for charity. Although his father’s work had made possible all of the family’s possessions, the children’s education, the employment of one hundred workers, the products enjoyed by countless customers, and tax revenue in the millions, his mother was the one whom everyone had admired as a “good person.” When his father died, the local newspaper ran a small announcement on the obituaries page. When his mother died, the same paper ran a two-page spread. The son was influenced by both parents. In choosing a career, he sought to combine the profitability of business with something that would bring him more esteem in the eyes of others. Medicine seemed fitting. When he started his medical career, the popular television shows, movies, and novels portrayed doctors as heroes. Patients were appreciative and news reporters respectful of the highly skilled, small-business entrepreneur who was the American doctor.
He was a good doctor who performed untold heroic acts to save patients. He restarted stopped hearts and forced air into dead lungs. Early in his career he enjoyed filling his study with mementos of his achievements: a scrapbook of thank-you notes from patients, an announcement of his appointment as a clinical department head of a hospital, a picture of him performing surgery, a magazine interview about one of his cases. He was proud of being a doctor and pleased with the rewards it brought him. He bought a new home, a luxury car, and a mink coat for his wife.
But over time, public opinion about medicine changed. A more recent movie depicted a cardiologist murdering patients in order to sell their organs on the black market. A novel portrayed patients given fatal drugs in a get-rich-quick scheme contrived by doctors and pharmaceutical executives.
“Medicine is tainted by the profit motive. The public must be protected from doctors lining their pockets at the expense of the sick,” was the battle cry of ambitious politicians who enacted laws claiming to revamp medicine to serve the public good.
The secretary was caught off guard when the climate for medicine changed. His profession was somehow in crisis, and he had caused it. People no longer paid him homage. He felt a growing sense of guilt about his work. When a patient, Bob Martin, whose life he had saved, bought a new sports car instead of paying for his medical treatment, the secretary hired a collection agency. Bob Martin, adopting a helpless air and claiming poverty as an excuse, contacted the press to complain about his doctor’s bill collector. To the secretary’s dismay, the local newspaper, hungry for a cause célèbre, ran Martin’s story as a Sunday feature. It portrayed the secretary as a villain who gouged the disadvantaged while he lived in luxury. This started a biting public attack that the secretary found unbearable. The curious stares by colleagues, the questioning eyes of patients, and the lowered heads of neighbors avoiding him had the dark power of an impending storm. Thus, he ran for cover. He thought that somehow he was wrong, so he stopped trying to collect his fee, and the waters of his life calmed.
When a local agitator, Charles Fox, and his group, Earthlings for a Simple Planet, vandalized the secretary’s experimental laboratory, alleging that his research was polluting the environment with noxious chemicals, the secretary sued them. But he did not fight for long. The press depicted him as a monster whose self-serving experiments recklessly introduced hazardous material into the air and water. People reading the media accounts shunned him. His alma mater withdrew a speaking invitation that it had extended to him; friends excluded him from a golf meet; patients cancelled appointments. Although the Earthlings’ accusations were false, the secretary, capitulating to public pressure, dropped the lawsuit and abandoned his research. He was afraid to oppose people claiming to protect the planet.
Events like these changed the secretary.
He came to believe that he was too selfish in loving medicine and profiting from it. Over the years, the topsoil of his life eroded, leading him to plant a new crop. The kinds of mementos that he collected changed. They no longer marked achievements from his medical practice but from other activities gaining in importance to him: a hat from a charity fair at which he manned a hot dog stand, a newspaper clipping about him giving money to a poor person, a photo of him sweeping trash from the street in a campaign to help the city’s garbage collectors. The secretary included among his new souvenirs a framed thank-you note from a family whose dog he had rescued from a ditch, while he omitted an impassioned letter of gratitude from an executive whose life he had saved in the hospital—and who had paid a handsome fee.
He sold his luxury car for a jeep, asked his wife to wear a wool coat instead of a mink, and canceled a major remodeling of his house. He gave up his medical practice for what he considered a more public-spirited role. He became president of the state’s medical association, where he made political contacts. Ultimately, he was appointed to head the state’s Bureau of Medicine and to administer the governor’s new program, CareFree. The post of secretary of medicine lifted his guilt. CareFree was a kind of atonement.
When asked to describe his job, the secretary would say humbly, “I work for the people.” Gradually, the luxury car, the mink coat, and the home remodeling returned to his life, along with an arsenal of new treats: the limousine, the extravagant parties he threw, the hobnobbing with the prestigious, the entourage of press, the celebrity status. No one seemed critical of his posh lifestyle now, because he worked for the people.
One morning a week, he opened his office to any citizens wanting to discuss their medical problems and their difficulties with the system. One afternoon a week, he conducted hearings against those whom he called “medical delinquents,” the doctors who broke the rules. The press hailed him as medicine’s savior.
With the lieutenant governor and other officials under investigation for accepting costly gifts from contractors awarded government projects, the governor’s administration was wounded. Burrow needed a running mate untouched by political scandal. Should the heat on the lieutenant governor increase, the secretary would likely be chosen. As he approached the meeting room, the secretary’s ready grin, authoritative gait, and impeccable grooming suggested that he could win the public’s confidence for the office he so ardently sought.
