Polk reddened and glared back. “Look, missy, I know what I’m doing. Mind your own damn business.”
Doctors had been rude to her before, but nobody had overtly ignored and disrespected her. Her shock left her unable to respond.
Helen’s condition deteriorated.
When Mary Oakes arrived for Saturday morning nursing report, she faced an irate Barbara Nolan, the shift supervisor, “Mary, if we don’t do something about Helen Martin, she’s not going to be with us much longer. I’ve tried everything I could think to get Polk’s attention, but he remains adamant. He refuses to reconsider or ask for a consultation. The guy has his head up his ass, Mary. We have to do something.”
She’s right, Mary thought. They’ve all been right. I can’t let this go on for another moment.
“You’re not telling me anything that I don’t already know about Joe Polk. I won’t go through this again, watching passively as he injures or kills another patient. The man doesn’t give a damn.”
Mary picked up the phone, dialed a number and waited.
“I’m sorry to bother you at home, Mrs. Davidson. This is Mary Oakes at Brier. I need to speak with Dr. Davidson. Tell him it’s urgent.”
Chapter Six
My alarm clock clanged sending pain and shock to my system. It had awakened me during REM sleep. Two or three hours of sleep felt worse than no sleep at all. When I had the time, I’d invent an alarm clock that could detect rapid eye movements and awaken me only in their absence.
I dragged myself from bed, showered, shaved, dressed, and arrived at my office by seven a.m. I spent forty-five minutes reviewing records of patients scheduled for that morning.
The great East Bay and San Francisco panorama was visible through the west facing ICU windows. The view was mesmerizing and despite seeing it each day, I paused for a long moment. The rising sun streaming over the East Bay hills made the view spectacular, especially this morning with clear blue skies.
The monitor tech looked up and smiled. “Good morning, Dr. Byrnes.”
“Good morning,” I replied.
I picked up Mrs. Archer’s chart to review her progress. When I finished and moved to her bedside, I found her awake and alert.
“Who the hell are you?” Mrs. Archer said. “I don’t see any reason to spend my hard earned dollars for another damn doctor. I’m just fine.”
Coma and confusion do have their advantages, I thought.
“Dr. Phillips asked me to see you last night.”
She stared at me, sneered, and then said, “I’ve never seen you before in my life, and I hope never to see you again.”
I retreated with her chart to the nursing station and entered a consultation note then ordered more lab work for later in the day.
When you practice medicine and depend on patients or their families for ego gratification, you’re on a fool’s errand. Results and personality triumph over knowledge and ability every time. My former roommate, a particularly gifted physician, complained, “I do something simple and they think I’m a genius. I do something great and they ignore it. I can’t win.”
It’s a bittersweet lesson that’s easy to understand intellectually. The megalomaniacs of the world don’t need reassurance or feedback, but I hope to reach a more secure plane someday, where my ego doesn’t live in suspension over an abyss of doubt.
It troubled me. Why after all these years and all my accomplishments, did I still suspect I was faking it—living in fear of exposure? It was all too clear to me, but understanding the causes of my problems did not insure their elimination.
My mother was cool and demanding, and she endured, without grace, the frustrations of her heightened expectations for herself. Later in her life, she focused on her own limited definition of success for her children. My two brothers had somehow seen the light, while I suffered the withdrawal of her interest and affection. Initially, this was because she couldn’t recognize that my misbehavior was only childhood exuberance in an energetic, highly intelligent, and creative boy, and later by my overt rebellion. Rebellion aside, I knew that I’d remained the embodiment of her perceptions, a ghost never seen, but shaped by her lowered expectations and the denial of her affection.
Anyway, this was a good start to my day. Agnes Archer had returned to her usual irascible self, and her chemistries were heading toward normal. I’d round on her for two days more, enduring her ire, and then gracefully bow out before outlasting my welcome.
Dealing with unhappy hostile patients and their families is an essential skill not taught in medical school or in training. It was a clash of worlds and perceptions.
“Jack, I need your help with Emily Roberts, one of my diabetics,” said Forest Hastings, a general internist with a specialty in diabetes. “I’m fresh out of tricks.”
“I’ll do what I can. What’s the problem?”
“What isn’t the problem,” he said. “To say that things have not gone well for Emily Roberts, a fifty-six-year-old insulin dependent diabetic would be an understatement of all time. She’s been my patient for years, and I have the scars to prove it. I’ve tried everything to get her to control her diabetes starting with attempts to convince, then to cajole, then onto threats, rants and raves. I threatened to resign from her case, but that failed, too.”
“You can’t live your patient’s lives for them, Forest.”
“I know, Jack, but we clicked from the first day we met, and I was sure that I could help her.”
I examined Forest’s office records on Emily His work impressed me with his attention to detail and his fortitude in dealing with Emily Roberts, one of the world’s worst patients. Her chart recorded Forest’s repeated attempts at controlling her diabetes; the formal letters to the patient regarding the consequences of inadequate diabetic control, threats of resigning from her case, and a list of diabetes specialists with whom she might consult. His office notes reeked with frustration.
“In spite of my best efforts, futile ones I see now,” Forest wrote, “over the years, Emily Roberts had suffered the consequences of moderate kidney damage, blindness, severe vascular disease, heart failure, and damage to her peripheral nerves with persistent leg pain.”
I put down his notes. “Short of declaring her incompetent and institutionalizing her, thus depriving her of the right to abuse herself, she’d had the best medicine could offer. Few docs I know would have gone so far for a patient. It’s sad, but she’d made her decisions and now she’s suffering the consequences.”
This was the forty-fifth day of Emily’s hospitalization, and I suspected that she was not long for the world.
The hospital environment around this patient was psychopathological. The dedicated staff had come to hate the patient and her husband for how they had been abused.
She hated them in return. Her husband hated the world.
I’d been on Emily’s case for seven days, but it felt like a month. Each day, Emily Roberts and her husband Ernie, bombarded the staff with waves of hostility, a test of one’s patience that Mother Theresa might fail.
Maybe it was kindness and sympathy, or a sense of responsibility, but the staff continued to subject themselves to abuse. Ernie Roberts was the worst of the lot and today he was in full form. “What do you guys get off on, torturing Emily? I’ve called the Director of Brier Hospital and if I don’t get action, I’m reporting the lot of you to the State Department of Health.”
I prepared myself for the next confrontation knowing my patience was nearly gone. It was a lost cause, but I’d try again.
Ernie stood, hands on hips, girded for today’s battle.
“Mr. Roberts,” I said, “Tell me what’s going on, and maybe I can help.”
“I’m sick and tired of all your damn promises. Emily’s not eating. She can’t move her bowels. She’s in constant pain, and she’s not being turned and positioned. All we get from you guys is attitude and disrespect.”
“Look, Mr. Roberts, we’ve been over this time and time again. These nurses have
reviewed the treatment plan several times. We’re doing everything possible for Emily.”
“You’re all full of shit,” he spat, face reddening.
“Calm down for a minute, please and I’ll explain again,” I said. “Emily has end stage diabetes, the result of a severe disease made worse by twenty years of neglect. All those years of her refusal to abide by Dr. Hastings’ recommendations have come home to roost.”
“Blame the patient, that’s all you guys ever do. I know Hastings has tried to get rid of her before, and I’m sure nobody around here would shed a tear if we transferred to another hospital and physician. We should have fired you a long time ago, but Emily’s too old and sick to start again. You’re not getting rid of us so easily.”
“Look, medically and psychologically, this is a difficult situation. In my opinion, you only have two choices; to keep things going as destructive as they are, or try to make things better.”
“There you go again, blaming Emily and me.”
“I’m way past blame, Mr. Roberts; I’m trying to find a way to make things better for all of us.”
“The first thing you can do is to get rid of that bitch Mary Oakes. She’s the worst of the bunch.”
I can’t approach this guy, he’s so angry, I thought. “If we’re to have a civil conversation, I’d appreciate a change in tone. Mary Oakes is about the best nurse I’ve ever worked with, and if you can’t see that, there’s something’s seriously wrong with you.”
“Fuck you, Doc.”
I rarely felt as angry as I did now. I counted to ten. “This is what is going to happen; you will stay out the way of the doctors and nurses caring for your wife. You will let us treat Emily in the manner we feel is best or fire us and go to another hospital. Finally, and hear this clearly, if you do not change your abusive behavior, and soon, I’ll have you barred from this hospital and you won’t be able to see Emily at all. We’ve had it with you! Am I getting through?”
I had prepared myself for the worst, but not this. Ernie Roberts collapsed suddenly into his chair, head in hands, weeping.
One second I could kill the guy, the next I’m feeling sorry for him.
I sat beside Ernie and placed my hand on his shoulder. “Nobody can truly understand what it’s been like for you all these years. All the worry, effort, and frustration can take a toll on the strongest of us. I’m not sure I’d have been as capable and as caring as you have been all this time. We all can understand the anger as you face a situation that’s not likely to turn out well.”
“I’ve never done this before, Doc. I don’t know what’s wrong with me. I can’t conceive of losing Emily. I’ve never been this frightened before.”
After wiping his eyes and blowing his nose, Ernie Roberts continued, “Let me apologize to you, to Dr. Hastings, the nursing staff, and especially to Mary Oakes. My behavior has been inexcusable.”
“Let’s put all this behind us,” I said. “I’ll set up a meeting with you, the Docs, and the nursing staff. Let’s try and put all our heads together and work out the best plan for Emily’s care.”
The next five days passed uneventfully, and after completing morning rounds, I returned to my office a little after nine.
The fresh coffee smelled great, so I poured a mugful, sat at my desk picked the first envelope on top of the three-inch pile of mail, and I began reading.
Janet, my office manager stuck her head in. “I’ll give you a minute to settle down, and then I need to talk with you.”
“Don’t start my day with another problem, Janet.”
“Sorry Jack, but I’ve tried several times to get approval for John Jacobs’ hospitalization for a kidney biopsy, but no go.”
“What’s the problem?”
“His insurance requires prior approval before the biopsy, and they’re refusing his hospitalization.”
“What kind of crap is that? Get me the authorization clerk and let me talk with him or her.”
With a knowing smile, Janet said, “It’s your funeral. Here’s the number and the patient’s insurance information.”
It took me ten minutes to get beyond the busy signals and into the voice-mail system, then another ten minutes to work my way through the prompts in the attempt to reach the authorization clerk. After listening to Feelings and several similarly soothing musical pieces, the line went dead, and I had to start all over again. When I finally got back to the operator, I said, “I’ve been on this line for twelve minutes. Don’t make me start from scratch.”
“Sorry sir,” I heard as she switched me back into the waiting queue just in time to hear Feelings all over again.
Finally, the music ended, and after five or six clicks, a voice came on the line. “Ms. Harper speaking. Your provider number, please.”
“Where’s our provider number?” I yelled at Janet.
“It’s your corporation ID number.”
I gave the number to the clerk, who continued, “Patients name, insurance number, date of birth, and requested service, please.”
I read the requested information from the patient’s data sheet.
Following the data entry keyboard clicks, she said, “I’m approving Procedure 88448-21, Biopsy, Kidney, Percutaneous (pronounced incorrectly as per-kut-anus), but I’m denying hospitalization,” she read obviously from her instruction manual.
“What do you mean, hospitalization denied? Hospitalization is an absolute requirement following a kidney biopsy.”
“Denied.”
“If you deny the hospitalization, then you’re denying the biopsy, since it can’t be done without hospital follow-up,” I said, becoming more agitated.
“Denied.”
My head throbbed. “Perhaps you don’t understand. A kidney biopsy is associated with a significant incidence of bleeding after the procedure, bleeding sometimes so severe that a patient could lose a kidney and could die. Patients must be in the hospital after a biopsy.”
“Denied.”
“I don’t know what’s wrong with you people.”
Ms. Harper, replying in kind to my exasperation, said, “Doctor, sir, I’m reading from our prior approval manual and that’s all I can do sir, and I don’t appreciate the attitude.”
“This is crazy. There must be some appeal to reason in this system?”
“You can talk to Dr. Ghupta our medical advisor. I’ll transfer you.”
Before I could utter a word, the phone clicked and they queued me up again to more elevator music. Ten minutes later, they connected me with Dr. Ghupta who spoke with a heavy Indian accent and immediately requested the identical information I had just provided to the authorization clerk.
“Mr. Jacobs,” I pleaded, “has mild kidney failure and needs a renal biopsy. Your clerk authorized the biopsy, but denied hospitalization. Please tell me, this isn’t the policy of your company that would, in essence, prohibit biopsies.”
Gupta turned the pages as he looked through his authorization manual. “Something must be wrong here Dr. Byrnes, our manual only permits outpatient kidney biopsies, this can’t be true. How many days do you anticipate needing?”
“Two days would be fine, absent complications.”
“I’ll give you one day and you can apply for additional days, if necessary.”
Apply for additional days? Go through this again? I’d shoot myself first.
I had many more things I’d like to say about this company’s approval process, but I’d only be indulging myself, venting on poor Dr. Ghupta, powerless, a cog in the wheel of a corrupt system, just trying to do his job.
I hung up the phone with new insight into Ted Kosinski, the Unabomber, and his rage against modern culture.
I nearly finished the second cup of coffee when my office door flew open and Warren Davidson plopped himself in the chair in front of my desk. Janet tried to explain, “He just got by me and got in before I had a chance.”
Few people slipped past Janet, who in the short time she worked for me, proved her willingness to s
acrifice her body by throwing it into the path of anyone trying to get to see me without clearing it first with her.
We’d been through this before. Certain forces of nature were immutable. Warren Davidson was a good example.
Warren was sixty-three, overweight and always a bit disheveled. He stood at six feet. You knew when he came or he’d been there by the unforgettable accompaniment of stale cigar smoke emitting from his pores and/or the fabric of his clothes. His appearance and demeanor belied his status as an Emeritus Professor of Internal Medicine and the Chairman of the Department of Internal Medicine.
Warren was a primal force in this medical community and had recruited me. I owed him for my current position.
Without direction or encouragement, Warren assumed he’d be a physician like his father and grandfather. While he had limited contact with the life of the first old Doc Davidson, his grandfather, he knew well enough the respect he’d earned from the community.
The professional life of Warren Davidson senior, his dad, was a videotape played out before him, some of his earliest memories. Dad’s medical practice, with long hours, hard work, dedication, and responsibility were, contrary to one’s expectations, accompanied by the pure joy. “Believe it or not, son, I’d do this job if I had to pay for the privilege, I love it that much.”
With that kind of enthusiasm, role modeling, and his passionate love for his father, Warren raced forward to his own future as a physician.
In medical school and through residency training, it became obvious that Warren had the intelligence, personality and temperament to be an academician, a teacher. However, in his heart, he knew he could never abandon the practice of hands-on medicine.
Through the early years of his professional life, Warren remained focused on his practice and his medical community. Gradually, with the donation of his time to the education of medical students, interns and residents, he began taking a more active role in the administration of the university’s teaching program.
First, Do No Harm (Brier Hospital Series Book 1) Page 5