Why was it when Polk said ‘Doctor’, it sounded like an insult?
Small beads of sweat formed on Carrie’s upper lip. “Well,” she hesitated, “alcohol has a direct damaging effect on the pancreas—and,” she faltered…
“Dr. Harris,” he began without trying to hide his contempt, “what are you doing in this program? Why are we wasting our valuable time with someone who is obviously unfit to be a physician?”
Bright red, embarrassed and humiliated, Carrie tried to explain, “Dr. Polk, I was awake all night with these admissions. I didn’t have…”
“Don’t make things worse with some lame excuse,” he shouted. “Didn’t they teach you anything in that second rate medical school?”
Carrie began crying while the group turned and looked away, sympathetic, but silent, paralyzed.
Finally, Sarah Jessup, the GI resident, pushed her way through the group and placed her arm around Carrie. She turned to confront Polk. “This is inexcusable. This is no way to teach anybody. Don’t you have a shred of decency left?”
Polk stood mute, stunned into silence as Sarah led Carrie away.
Joe and Marion Polk had been married for nearly thirty years and had raised two children. The family thrived as Joe’s practice and his stature in the community flourished.
Though she loved Joe, the marriage never gave Marion the love and intimacy she needed. Joe was charming and attentive, but he remained cool and distant. Early in their marriage, she had been concerned for his emotional health—so remote, so aloof. He had done and said the right things and fulfilled his responsibilities, but stayed uninterested in her or in anyone, except for Joe Jr.
Joe Polk’s muted reaction to the birth of their daughter, Vanessa, stood sharply in contrast with the extravagance of his response to the birth of his son Joseph. Marion was, at first, pleased to see Joe so emotionally involved with their son, but soon she discovered his fascination becoming an obsession. His inattention to Marion and Vanessa left a legacy of jealousy and resentment.
“It’s how I feel,” he replied when Marion confronted him. “I can’t change how I feel.”
Chapter Eight
By the time I arrived at the QA Meeting room, most of the docs had finished eating and were preparing to review the medical charts scheduled for presentation. The committee held its meeting in one of the hospital’s small conference rooms with tables arranged in a U-shape. The room had a street level view of the sidewalk. Pedestrians passed by in the midday sun heading for lunch.
I knew everyone attending the meeting, some better than others since I’d consulted for a few. Warren Davidson had chosen the members carefully balancing medical specialists, general internists, and family practitioners. Personality and character, more than training or experience, determined how effective physicians were in monitoring their colleagues.
When Warren Davidson put me on the committee, he said, “Most docs on the committee want to do a good job in QA, but when it comes to tough decisions, they’re all over the place. Some are willing to forgive everything, except murder. Others find the guillotine appropriate for the minor infractions. One thing surprised me,” he continued, “the women on that committee may have all the balls. They’re more willing to make the toughest decisions.”
Warren Davidson picked Arnie Roth as chairman. Arnie was honest, hardworking, and only a little too deferential to the specialists on his committee. Warren had gently coerced Arnie into this position and he had surprised everyone with his effectiveness.
Arnie was a thirty-seven-year-old family practitioner. He had been in practice for about five years. Arnie was a likeable guy and a hard worker. He was a large sandy haired man, bear-like and friendly. One rarely caught him without a smile. He was one of the few Family Practitioners, still in private, solo practice. He shared on-call coverage with several practice groups. Although they asked him to join them, he preferred to hold onto his independence for as long as possible and repeatedly declined their invitations.
Arnie purchased, renovated, and shared a converted private residence with a psychiatrist and an optician. He was beloved by his patients and staff who recognized his kind and caring nature. His patients received the best care, not so much based on his skills and knowledge as a physician, but for his willingness to refer to specialists and other outside resources, especially university specialty programs, when appropriate.
His careful examinations, time spent with each of his patients, and the outside referrals, did not match well with the expectations of the HMOs. They suggested he needed to see more patients each day and make fewer referrals. As a solo practitioner, the lowest man on the totem pole of power, Arnie recognized these suggestions for what they were, threats.
“I understand the problem,” he told his wife Lois, “and I’m willing to compromise, but not at the cost of my soul or the best interests of my patients.”
Lois had two young children at home and managed to fit in the role of office manager. “We’re out on a limb, honey. We’ve overextended ourselves with medical school loan repayments and our investment in the building and the practice. If they drop us from the HMO’s list of approved providers, I don’t think we can make it.”
“As a solo practitioner, the HMO couldn’t care less about us. Eventually, that reality will force me into joining a group practice or association of practices. That arrangement should give us a little clout. Meanwhile, I’ll just do what I can to keep the HMO happy.”
“I’m calling the meeting to order,” Arnie said.
He reviewed and had approved the minutes of the prior meeting, and each physician in turn presented the charts reviewed.
Chart review served to screen the hospital records for problems. Brief hospitalizations were a cinch to review and they dealt with them on the spot, while long and complex ones took much more time than they generally had available and were frequently set aside for detailed review.
Jim McDonald, an internist, began, “I’ve reviewed ten charts today and found all in good shape except for minor omissions in the history and physical exam. I’d suggest a brief note to the involved doc, a reminder to include these in his H&P.”
Several other presentations went this way until it was time for Sharon Brickman, a cardiologist, to present her cases.
Sharon was tough, maybe too tough for my taste, but her judgments were right on point. She’d had her training at John’s Hopkins, an east coast cardiology mecca where confrontation and debate were the rule. Sharon took substandard practice as a personal affront, particularly if it happened more than once. Often her punishments did not fit the crime.
The committee conducted chart review blindly in an attempt to prevent bias. They maintained this anonymity until an individual physician’s work came to the committee too often or when the infractions were more than minor. Then they needed to look globally at that doc’s work over time, with a view that something more dramatic might be required. Eventually, they drew back curtains of anonymity and revealed a face and a name.
It had to be more than fortuitous that personality and appearance matched so well. Sharon was short, solid and with close-cropped chestnut hair, looked robust. Her bright blue eyes sparkled with determination and an element of mischief as she freely expressed her views.
Sharon began, “I’ve reviewed eight charts and all are okay, but I have problems with the ninth. I’ve seen this problem before with physician #34546 and it’s obvious that he won’t learn. It’s the same old problem. This physician has not kept himself available to the nurses when his patient is in ICU or CCU. Nothing drives a nurse crazier than putting out a stat call to a doc and not having it returned. This physician had a patient with a dangerous irregular heart rhythm, and he did not respond to his pages for ninety minutes. This is ridiculous. It’s unacceptable, and since it’s happened before with this doc, it’s time we did something. I suggest we restrict his privileges for the ICU/CCU and require him to have a specialist on these cases.”
“That’s
a little Draconian,” Ernie Charles, a family practitioner said. “Can’t we lay it out more forcefully this time, and maybe it’s time Arnie for you or Warren Davidson to whisper not so sweetly into his ear.”
“You must be kidding, Ernie,” Sharon growled.
After a heated discussion, they finally agreed to Ernie’s suggestion.
Sharon, still fuming said, “One more time with this doc, and my Draconian recommendation will seem like a walk in the park.”
I considered bringing the case I’d seen today to the committee, I but decided against it. The nurses would refer the case here soon enough and I didn’t want the committee to see me as too eager or hypercritical.
As I left the committee room, the loudspeaker sounded, “Dr. Byrnes, extension 5123.”
The ward clerk on fifth floor medical answered. “Dr. Polk wants to see you on the ward Dr. Byrnes, and excuse me sir, but he said, right now.”
What was that all about?
I’d met Joe Polk once, and had no other direct dealings with him.
Polk stood at the nursing station, red-faced and berating a young nurse. “Follow my orders. Is that asking too much?”
“Dr. Polk…” she tried, but he turned and walked away.
Spying me did not make him any happier.
Polk did the come here gesture with his index finger, then used the same digit to point me in the direction of the dictation room. When we entered the small room, Polk refused my outstretched hand. “I see Warren had you consult on Mrs. Martin today. I wish he’d mind his own business and keep off my cases. I’m sick and tired of second guessing by that guy, especially since he’s only a lot smarter through his retrospectoscope.”
I quickly retracted my hand.
Polk straightened his bow tie and continued, avoiding direct eye contact, “I don’t know how I missed the peritonitis. Mrs. Martin had been doing well. Her belly was soft and the nurses, especially those new grads, were just hysterical. Thanks for your help, I’ll take over now.”
Abandoning this case to Polk would be a mistake—no worse than a mistake, it would be a disaster. He’d lied about Helen Martin’s abdominal findings. The nursing notes over the last four to five days were full of complaints of her pain and their findings of abdominal tenderness. Clearer, in the nurse’s notes, were repeated statements: Notified Dr. Polk of the patient’s abdominal pain and tenderness, No orders received.
This guy is intriguing, I thought. How can a man so intelligent think he could get away with this blatant lie?
“You must know, sir, this is not the way I’d hope we’d meet. The situation is awkward for me, but Warren instructed me to follow Mrs. Martin for the next few days if it’s okay with you.”
Polk grudgingly uttered his acquiescence. This was clearly not okay, but he grunted, “All right, but just indicate your suggestions on her chart and leave the writing of all orders to me. Pay attention to how I care for patients; you might learn something.”
Learn something? He must be kidding.
Since I had nothing more to say, I nodded and left the room with a disquieting sense that Mrs. Martin stood at the precipice in the unsteady hands of the esteemed Dr. Polk.
I knocked on Mary Oakes’ office and entered. She waved me to the chair next to her desk and poured me a cup of coffee. “What happening with Helen Martin?”
“I’m still on the case, but Polk will be writing the orders. I’m still consulting, and if your nurses don’t get what they need from him or Mrs. Martin begins to go downhill again, have them call me immediately and I’ll come in to see her.”
Mary stared at me intently. “Something’s wrong with a system that permits the Polks of the world to practice. Do you know what it does to me and to my staff to work with that man? It demeans and demoralizes us. We don’t need this additional aggravation and frustration at a time when all the other pressures of managed care and hospital cutbacks are taking their toll.
“If you want to know what I’m talking about, let me give you a good example. It happened two weeks ago…”
Polk arrived on the fifth floor medical ward at seven fifteen in the morning. He stood at the nursing station, hands on hips, scowling and waiting for service. His angry eyes darted back and forth in a search pattern. When Polk did not get the attention he deserved, he became irate and barged into the nurse’s lounge, ignoring the Do Not Disturb sign. Spying Mary Oakes, he began, “I’m sick and tired of waiting for assistance on this ward. Where are all your damned nurses?”
Though she hated to admit it, Mary Oakes had accustomed herself to Polk’s rudeness and demands. “We’re just completing Nurses’ Report for change of shift. How can I help you, Doctor?”
“I need to perform an abdominal paracentesis on Fred McDonald right now to remove some of his fluid. He’s short of breath, or perhaps you didn’t notice?”
Angry, but controlled, Mary responded, “Yes, Doctor, as I recall, his nurse called you three times last night about Fred’s breathing problem.” Mary stood. “Come with me, Dr. Polk; let’s check the chart for your orders.”
He ignored her gibe. “That won’t be necessary. Get me a paracentesis tray, size six gloves, and collection bottles for abdominal fluid. If it’s not asking too much, I’d appreciate assistance as well.”
“You did say size six, didn’t you Doctor?” she said smiling.
He stared at her.
What a jerk, Mary thought.
“The next time you plan a procedure, Doctor, please give us prior notice, so we can bring your equipment to the ward and I’d have time enough to plan for someone to assist you. It will take a few minutes to get the tray here and I’ll get one of our nurses to help.”
“Well I don’t have all day—get moving.
I can’t stand that man.
Ten minutes later, Mary entered Fred McDonald’s room with Andrea Green, one of her young nurses. “Dr. Polk, this is Andrea Green, one of our new grads. She’ll be assisting you today.”
“Nice to meet you, Dr. Polk,” Andrea said.
Polk ignored her greeting, “Just pay attention and follow my orders to a T, and everything will go as planned.”
Fred McDonald had managed to reach age forty-seven in spite of his alcoholism and advanced liver disease but at a price. He’d spent the last year in and out of the hospital.
He had a career as one of the area’s most successful real estate salesmen and brokers. Social drinking was an intrinsic part of his work and Fred never considered it a problem until he received his final divorce papers.
Everyone knew that Fred could mount a train from San Francisco to LA, and by the time he reached Modesto, he would know everyone in his car by name and a good part of their life’s story.
The worst part of Fred’s divorce was the loneliness. He couldn’t stand the quiet of his empty apartment and the sudden surplus of time on his hands. Depressed and feeling sorry for himself, Fred filled the void with martinis, spiraling into an alcoholic abyss.
He’d done it all, reached bottom, had his family intervention, and had graduated, three times, from the alcohol rehabilitation program as their star performer. Nothing worked until that day when he stared in his mirror and got the first good look at himself naked in years. The once powerfully built man had disappeared. In his place was a stick-figure, shadow-thin everywhere but his abdomen. Its enormous size gave a bad name to the phrase, beer belly. Something about that image in the mirror, still branded in his memory, had done what friends, family, physicians, social workers, shrinks, and AA failed to do–it got him to stop drinking.
Although Fred no longer drank, and without the solace of the bottle, his alcohol related medical problems persisted.
It’s shutting the barn door after the horses are gone, he thought.
Fred’s personality contrasted with many alcoholics, and the nursing staff liked him. They enjoyed his jovial moods, off-color jokes, and sincere appreciation for their efforts. Moreover, unlike many alcoholics, he refused to blame anyone but
himself for his predicament.
Friends and family found it difficult to believe the transformation of this once vigorous and athletic man. He had become the stereotypic alcoholic with a ruddy complexion, prominent facial veins, red nose, and generalized muscle wasting. Above his stork-like lower extremities, sat an enormously swollen belly. He looked ten months pregnant. The massive amount of fluid in his abdomen had pushed his diaphragms northward, interfering with his breathing, and leaving him gasping and struggling for each breath.
Polk placed his hand on Fred’s belly. “We’re going to remove fluid from your abdomen to relieve your shortness of breath.”
“Go to it, Doc. I can’t hardly take a breath,” Fred said with difficulty, straining for air and barely getting the words out.
Polk went to the sink and began scrubbing up for the procedure. Andrea opened the paracentesis tray and organized the equipment for the doctor’s use. Mary supervised her, and then left the room saying, “I’ll be right back. I have to check a few patients.”
Fred McDonald’s breathing worsened. He struggled and strained for each shallow breath as his color reached a mottled dark blue.
Polk faced away from Andrea as he mechanically continued his scrub, first one hand, lather, brush, rinse, then the other hand, lather, brush rinse. He kept scrubbing one arm, then the other. Just before the mirror before him fogged over, Andrea saw Polk’s face staring with unfocused eyes into it. His tongue, moving slowly and caressed his lips. Finally, the water, hot and steamy, completely obscured his reflection.
“He’s been at it for ten full minutes,” Andrea said when Mary returned. “What’s he up to?”
Bewildered, Mary raised her shoulders in question. “He’s scrubbing up.”
They waited ten minutes more, and then Mary said, “Dr. Polk, we’re ready for you, any time now.”
“Just a few minutes more,” he said as he rinsed his red, raw hands under the water.
Finally, after nearly thirty minutes of scrubbing, unheard of for this procedure, Polk said, “I’m ready.”
First, Do No Harm (Brier Hospital Series Book 1) Page 7