Chuck stood for a moment and turned to face the office window. In a moment, he turned a fixed and angry gaze on me saying, “If this is Polk’s doing I…” He let the words trail off.
“Let’s focus on getting Helen through this. We’ll see what the consultants have to say.”
The woman can’t catch a break, I thought.
“I’ll see you later.” I left to complete my rounds.
Like any large institution, gossip and rumor were the life’s blood at Brier Hospital. Joe Polk, and his handling of Helen’s case, was the main topic of discussion around water coolers and coffee tables. Unfortunately, many felt it was their obligation to share with me an opinion on the matter. They offered many creative suggestions, some injudicious in nature, regarding an appropriate fate for Dr. Polk. It was easy to understand these heartfelt expressions of frustration and disappointment.
“I can’t talk about it,” worked well for most, but not for Warren or Beth.
Warren lived in a world of politics and intrigue, so filled with subtleties and complexities that it kept me unsure of what he expected of me. He would clarify this tonight when we were meeting for dinner.
With Beth, it was simpler. “We’ve finally got that bastard where we want him. This time he won’t get away with it.”
Beth and I had grown closer.
I had trouble making the distinction between wishful thinking and fantasy when it came to Beth. I tried to pace myself, to hold back, to be careful. Don’t make a fool of yourself was sage advice I gave, but wouldn’t take. Beyond the physical attraction, Beth made me feel good about me, about us. Around Beth, I could be myself and say anything. Opening myself to another person, as many of the best things in life, involved a risk, one I was more than willing to take for Beth. I had misgivings about everything that happened recently and I wanted to share them with her, however, Beth’s feelings regarding Polk were so strong as to discount her objectivity and her sensitivity to my dilemma.
“A lot’s at stake here, Beth. No question, Polk’s a menace. The medical staff and the hospital need to act decisively. It’s my role in all of this that’s troubling.”
“What do you mean your role?” she snapped. “You didn’t ask for this case nor did you ask to be on the QA committee.”
“I don’t want the docs to think that I’m the force behind the persecution of poor old Dr. Polk. Amazingly, in some circles, that will be the spin. I’m still new to this community and that puts me at risk if I succeed in pissing off enough old timers.”
“Look, Jack, I’m not telling you what to do, but you’re in it pal, even though you didn’t ask for it. Act on your conscience first, and be concerned about the rest later.”
I felt flushed. “That’s easy for you to say. I have years invested in getting here, and at the least, whatever I decide to do requires some thought, not some knee-jerk response.”
“Do what you like, Jack, I don’t give a damn,” Beth shouted as she raced out, slamming the door.
Well handled, I thought. Maybe it’s time to reconsider being a solo practitioner in some small town, answerable only to my patients and my conscience.
I completed my rounds and returned to the office. My mind remained preoccupied with my first fight with Beth and with the Polk situation.
My appointment book provided me each morning with a degree of foreboding—a crystal ball’s insight into what the day might bring. Like anyone providing personal services, I looked forward to some patient’s visits, and dreaded others.
Today, I was glad to see that John McPherson would be in for his monthly appointment. John, a celebrity by longevity, had lived one hundred four years, and though frail, he still had his intellect combined with a century of refined southern manners. His hearing was bad and his raised voice left no doubt of his presence, observations, and opinions. Friendly and flirtatious, he chattered away regarding every aspect of his life, his opinions on modern culture and with pride, and the specific descriptive details of his bodily functions.
The overall effect was to charm all. I especially felt the pressure to do well with a man at this age who recently entered my practice. If John lived one hundred four years without my help, and died shortly after coming under my care, it would be at least disappointing and might be bad for the practice.
Janet and I could hear John coming as the elevator bell nearby pinged on its arrival, “Give me a hand, Margaret,” John demanded. “It’s time to see young Dr. Byrnes.”
John, once fully six feet tall, had lost several inches of height from the degeneration of his spine and bending forward. As usual, he wore a bright yellow tie and a dark tweed coat smelling of mothballs. Margaret Atkins and her sister Patricia Moore were John’s daughters and main sources of support. John lived with Margaret, but Patricia was every bit as involved in John’s life.
Both daughters were in their late seventies, and though they loved the cantankerous old man, Margaret said to me, “I spend all my time worrying and caring for dad. Who’s taking care of me?”
It’s a dark secret, unspoken, in the care of the chronically ill or the old-old; a sense of ambivalence, a sordid mélange of sorrow at the loss of a loved one, and relief when caregivers are finally unburdened, done with the old guy. It’s a human emotion, understandable to all but the saintly, and a common thread in the genesis of guilt when the loved one finally departs.
Janet looked into the heavily wrinkled, brown spotted face, and the brightest set of blue eyes. “Miss Janet, how wonderful to see you this beautiful morning.”
“Great to see you too, Mr. McPherson. Doctor will be with you in a few minutes.”
“Not to worry, darling, we’ll just make ourselves comfortable in your lovely waiting room. Maggie, get in here now,” he shouted. Margaret Atkins dutifully pushed her father into the waiting room, covered him with a plaid blanket, and got him a magazine.
John, while particularly charming and courteous to his physicians, nurses or to anyone not his family, managed to be abrupt, demanding and totally unappreciative of his daughters’ efforts and sacrifices. To John, their efforts were his entitlement.
John McPherson attracted and repelled Janet me. He charmed us by his age, manners, good humor, and sharp-as-a-tack mind. We were appalled by the way he treated his devoted daughters.
It was a lost cause, but I’d brought it to the old man’s attention anyway. “John, you should be a little more appreciative of Margaret and Patricia and all the help they’ve given you.”
John stared blankly at me as if I’d spoken to him in Martian.
“That’s a right handsome woman you got there for a secretary, Doc,” he said.
I nodded then called Margaret into the office and explained some minor changes in John’s medication and arranged for tests. With these two women at the helm, I knew that they’d carry out every order and every test. With John’s genetics and their attention, who knows how long the old-timer would live.
After finishing with the last of my morning patients, I headed for the cafeteria and the physician’s dining room.
Osgood Hodges, or Ozzy as they called him familiarly, if not affectionately, was unavoidable. The seventy-plus family practitioner was a fixture every noon in the physician’s dining area where he held court from the same seat. He looked normal, benign, and grandfatherly, but Osgood’s behavior, both odd and mischievous, bordered at times on malevolent. His bright wide ties and oversized sport jackets, looking as if he slept in them, lent color to the otherwise conservative medical staff.
I prayed that other tables were in use so I could sit elsewhere and not offend Ozzy, a bullfrog sitting there with a long tongue ready to snap up any insect within range. Ozzy loved grilling newcomers, especially specialists, with questions like, “Tell me everything you know about Lupus” or “How do you know how much potassium to give to a patient?” The answers required a lectern, slides, pointers, and a fistful of antacids. In addition, his questions had the flavor of ‘prove to me how smart you are�
�, while others took the form of a curbside consultation, a chance to extract specific information from a specialist in lieu of asking for a consult. God forbid the specialist might earn a few bucks.
In commiserating with other specialists, I said, “I never mind helping docs with curbside consults, especially if those docs actually refer a patient from time to time. If I had to depend on Ozzy for referrals, I’d starve. To top it all, I’m uncomfortable with his use of advice that came from me to treat his patients, when I never saw them and can’t verify his observations.”
Blessed today, or so I thought, I sat at another table with Warren, Arnie Roth, Maddy Kumar, and several other docs I knew well.
“Good to see you, Jack,” said Maddy Kumar; a Bombay trained OB/GYN. Everyone called her Maddy, since no westerner could pronounce her real first name.
“I just called your office for a consult,” she said. “After lunch, if you have the time, we’ll walk up to the postpartum ward and I’ll introduce you to my patient.”
“I’ll always make time for your patients,” I said, smiling.
I consulted regularly for Maddy. She was so busy delivering babies and rushing from clinic to clinic, that at the first sign of any non-OB/GYN medical problem, she’d call for a consultation. I liked working for her, since most referrals had uncomplicated medical problems and I was free to do whatever their condition required.
While I chatted with Maddy, I tried to avoid the energetic discussion going on around the table. I’d heard only fragments of the conversation, but had already filled the blanks. I’d only been here for nine months yet had heard ad nauseum, all the shallow exchanges, and institutional griping.
Maybe visiting with Ozzy wasn’t all that bad.
Today it was reimbursement:
“Piss poor, a fraction of what it was in the past…”
“Billing, a nightmare…”
“Sick of justifying treatment to stupid clerks…”
“Won’t be able to accept Medicaid or Medicare patients…”
“Will need to lay off staff…”
“Can’t fund pension plans…”
“Sold out by medical associations and hospital administration…”
Early on, I made the mistake of trying to participate in those conversations, but it didn’t take long for me to conclude that what I initially thought to be conversation, was, in reality, group psychotherapy.
To be fair, some days the conversation was light, interesting, and sometimes riotous as the best jokes found their way to the lunch table. It was especially interesting to hear the views of our senior docs, the ones who’d been around for a while. While they suffered from the transformation of medicine, they maintained their perspective, their antiquated values about caring for their patients, and, most essential, their sense of humor.
“Did any of you see this morning’s paper?” Warren asked.
“No, I haven’t had the chance,” I said. “What has your attention now?”
“Well, on the next to last page of the local section, was a report that one of Brier’s most illustrious physicians shot one of his neighbor’s sheep. The county sheriff arrested the doc on the spot.”
Astounded, nobody said a word.
“Our own beloved crackpot physician, Robert Blankman, had been having an ongoing dispute with his neighbor about the sheep kept on the property next to his home. He reported the sheep to police, zoning commission, department of health and the CIA regarding their risk to the health of the community and the noise, their baaing and bleating, all day and night.”
Warren unfolded his newspaper, turned to the article and began reading, “After three months of bureaucratic delay, Dr. Blankman took things into his own hands, executing his greatest tormentor with a .38 magnum. ‘I just lost it,’ he said as the police rushed to the field next to his home, confiscated the weapon, cuffed him, and took him to jail.
“I needed this on top of all the other problems I’ve had with this nut-case,” Warren said. “He’s had several suspensions and alterations of his privileges due to psych problems, but this one takes the cake.”
“I see the police are categorizing this arrest as a crime of passion,” I said, looking impassively at Warren, and then joining him as the table erupted into laughter.
After lunch, I walked with Maddy to the post-partum ward and met her young patient. She’d delivered her baby two days ago, but her blood pressure remained elevated.
Dealing with obstetrical patients was pure pleasure and stood in sharp contrast to many of my other referrals. Medical and surgical patients, due to their illnesses, were stressed and depressed while OB patients were cheerful and relaxed. After completing the consult, I ordered medication to control her blood pressure and planned follow-up.
The rest of my day went by smoothly.
I visited Helen Martin again before leaving to meet Warren. She was in good spirits, sitting up in bed chatting noisily with friends.
She smiled warmly as I approached the bedside. When her friends tried to excuse themselves, I said, “No, don’t leave. This is a social call and to let you know I’m transferring you back to the ward, unless you’d like to spend a few more days up here?”
“You’re kidding, right? Get me out of here now.” she said in a voice too loud. “ICU is great for the comatose, but it’s not a place for anyone aware enough to know what’s happening. The nonstop level of activity here makes sleep virtually impossible and there’s no such thing as privacy.”
“You’re out of here when the bed is ready downstairs. See you in the a.m.”
I asked the nurses to call Chuck so he would avoid that frightful experience of arriving at ICU and finding Helen’s bed empty.
It was a warm, clear evening, the fog now well to the east. Warren was waiting for me at Jake’s, a local pub, and restaurant. With Warren, eating out, like eating in, was another sign that business was at hand. Why was so much of the world’s business associated with eating?
Through the smoke-filled room, Warren appeared in a rear booth. He smiled and waved as I approached.
“Whatever you want, Warren, it’s okay with me,” I said smiling in return.
“Oh ye of little faith.”
We ordered drinks and Warren rambled on about hospital politics and his favorite subject, the deficiencies of the modern practitioner.
“Let me tell you a story,” he said. “Mary Smith, eighty-five, has been my patient for the last twenty odd years. She’d become frail and forgetful. When she came to see me last Tuesday, my day off, the nurses told her she’d have to return another day. Poor old Mrs. Smith became upset and tearful saying, ‘It’s impossible for me to leave the house and get here. Please, can’t someone else see me today?’”
“The office nurse took pity on the old lady, and approached the doctor of the day, name to be withheld. The nurse explained the situation with poor old Mrs. Smith, especially her difficulty in getting to the office, asking the doctor if he might see her. It took two seconds for him to refuse. After all, this doctor’s obligation was to see patients every ten to fifteen minutes and the schedule allowed no room for her.
“I would never permit that to happen,” Warren said, “nor would any of my colleagues in practice twenty years ago. Whatever it took, they would have squeezed that lady into the day’s schedule. Something’s wrong with some docs today who have lost their perspective and their humanity.”
“Don’t generalize, Warren,” I said. “I’m of that generation and most of the docs I know, share your concerns about patients. Moreover, docs of my generation have their professional careers before them, not a rosy prospect, based on what’s happening to medicine today.”
“Maybe I’m getting old, senile, or full of outdated ideas, Warren said, “but patients admired and respected my father and grandfather for their work and their concern for their patients. How can physicians, particularly young physicians, feel like my dad did, when government, insurers, and attorneys, to list a few, rob docs of their i
ndependence? It’s demoralizing and may explain the Joe Polk’s of our world.”
“I don’t buy that for a second,” I said. “We’ve always had arrogant, uncaring, and stupid physicians. The professional environment today surely hasn’t helped. Moreover, our major problem at Brier, and I suspect many other hospitals, is we find it difficult to get physicians to police themselves. It’s inexcusable. The reasons are obvious. We have sustained real losses; independence, status, and economics, to name a few, and the result is confusion about what it means to be a professional.”
“How have you been doing out there in the spotlight?” Warren asked.
“I’m disappointed. They did not design the QA process for the bright light of day. Politics and personality shouldn’t be part of this equation, but they are. I’m only a cog in the wheel, but thanks to you, I’m in the middle of it. Involving me in these cases and appointing me to the QA Committee sent the word around the hospital, right or wrong, that I’m a prime motivator.”
“Sounds a little paranoid to me, Jack. I’d watch it.”
“Maybe so, but I like this community and want to stay.”
“Look, I’m not going to try to finesse this situation with you because I like and respect you. This is what I’ve been up against; I’ve had to intervene on Joe Polk’s cases at least a dozen times in the last ten years. Sometimes, it was simply because of his talent in pissing off the nurses by his disrespect and disregard of their thoughts and observations. Most often, Joe just screwed up.”
Warren took a sip of his drink and continued, “I’ve tried to be his pal, no easy undertaking for me. I’ve tried to be suggestive, directive, and finally threatened to throw his ass off the staff, but he’s still here and if anything, his behavior is worse. He has many powerful friends on the hospital board and in the community. The best I could achieve was a slap on the wrist. The current situation offers us a chance to do the right thing. Let’s not waste the opportunity.”
Warren took a deep breath. “Times are a changin’ ma boy. Many changes I find disquieting such as managed care, hospitals having to function constantly in survival mode because of reduced reimbursement, and the encroachment of non-physicians into the practice of medicine. What I do like, is the arrival of young, well-trained physicians and the increasing empowerment of nurses. Young nurses have turned part of their newly discovered assertiveness toward making things better for their patients. With this combination, maybe we can do something.”
First, Do No Harm (Brier Hospital Series Book 1) Page 16
