First, Do No Harm (Brier Hospital Series Book 1)

by Lawrence Gold

  Arnie pushed on. “MRN 190010, the case of the gentleman with his abdomen full of fluid. You left him in the care of a novice nurse without experience or specific protocols to follow for the removal of this fluid. That patient nearly died of shock after huge amounts of fluid was removed so quickly and again no one could reach you.”

  “I told that nurse what to do. What more do you want? I never got any pages on that case. Maybe something was wrong with my beeper.”

  From the back of the room came an audible whisper, “Who does he think he’s kidding?”

  Enraged, Polk turned his head and stared in the direction of the whisper, but said nothing.

  Ross Cohen intervened. With a controlled and modulated voice, prototypical of a psychiatrist, he said, “You must understand, Dr. Polk, most everyone who has reviewed these cases sees problems with your behavior and your decision making. Why do you think that is so?”

  I suspected that I might take offense myself from this patronizing question presented in these tones, and I was right as Polk exploded, “On top of all this, I’m subjected to this bullshit psychobabble from someone who can’t recall the location of the liver.”

  Without hesitation, and still calm, Ross Cohen continued, “Whatever you think, there must be a reason you find yourself in this situation. Whatever you are doing is not working out well for you. Don’t you agree?”

  “What’s not working for me is my reputation has been dishonored because of a malicious nursing conspiracy. They were out to get me and they’ve succeeded beyond their wildest dreams.”

  Jason Phelps, Polk’s attorney had been watching the proceedings dispassionately, except to frown on occasion at Polk’s performance tonight. He interrupted. “None of this is relevant to this issue at hand. Dr. Polk’s position is clear; whatever deviations from standards of practice that may have occurred were inconsequential. Furthermore the termination of my client’s hospital privileges raises restraint of trade issues on which we are prepared to litigate.”

  Arnie was looking progressively more agitated. “Inconsequential? Are we looking at the same medical records?”

  Phelps pounded his fist against the packet. “We are prepared to present our own expert witnesses, who will concur with our position that these charges are far less damning then they appear in your committee’s descriptions and conclusions.” Phelps paused for effect. “I assure you, your recommendations, which appear to you to be so obviously justifiable now, will not be so clear or persuasive once we’ve had Dr. Polk’s version presented in court.”

  I held my hand on Laura Larsen’s chart. “How do you respond to the criticism of case 193777, the young woman with the heart attack?”

  “I see nothing wrong with the management of that case,” Polk replied.

  “To begin with,” I said, “Why did you refuse to follow CCU protocol for heart attacks? Why didn’t you request cardiology consultation in this case with extremely complex heart rhythm problems? Why did you ignore the prior EKG that showed signs of a serious acute heart injury?”

  Polk flared again. His eyes bulged. He scowled and blurted out. “How the hell did you get that EKG? That was private information from my office. Who gave it to you?” With his question unanswered, Polk continued, “Maybe you need a cardiologist on all your cases, but I’ve been practicing long enough to take care of these problems myself. The same goes for those damn cookbook protocols. They’re a crutch for those too stupid or too lazy to learn what to do.”

  “The point is, Doctor,” I responded, “you didn’t do what was appropriate in treating these heart irregularities and you missed an obvious imminent heart attack.”

  Polk turned to his attorney. “I’m sick of this crap, Jason. How much more of this crap do I have to take?”

  Jason Phelps tried again to calm his client, but after more whispered exchanges, Polk stood. He stared around the room. “You just try to make this stick! Expel me and we’ll finish this in court.” After starting for the door, he suddenly paused and turned to the group.

  Polk pointed his finger at Warren Davidson. “You must be overjoyed, you son-of-a-bitch.”

  Phelps stood and approached Polk. He spoke to the irate doctor in a near whisper.

  Polk managed to regain control. He took a deep breath and spoke with a calm voice. “Don’t forget I’ve been around here for a long time, long enough to know where all the skeletons are buried.” Turning, he walked quickly to the door, slamming it as he departed.

  “Well” Warren said, shaking his head in disbelief, “That sure worked out well.”

  Chapter Forty

  Joe Polk stared back at the closed boardroom door with disbelief. His future, his life as he knew it, lay beyond that door. Somewhere deep inside his psyche were the murmurings of a truth, a reality he’d kept at bay.

  He walked through the hospital’s grey-carpeted lobby, glancing at the paintings, awards, and dedications he’d observed a thousand times before, looking but not seeing them.

  He found himself at the medical records room, and decided to kill time by bringing his medical charts up to date. Like most physicians, he hated the constant pressure to complete his charts, a process strewn with the traps of the medical records librarian’s arcane demands. He went to the shelf bearing his name, grabbed an armful of charts, and placed them in the small cubicle containing forms, progress note sheets, and dictating equipment.

  He picked up the first chart and began the tedious process of signing the orders he’d given by phone, the transcribed H & P, and the discharge summary. Required by law, it was difficult to see how exercising his pen did anything to improve medical care. It was a mindless activity, but his thoughts churned as he reflected on where his life had taken him.

  From early childhood, Joe Polk suspected he was different. Somewhere, deep in his mind, the earliest of memories, he remembered the loving embrace of his mother. He relived the transformation, from the feelings of warmth and security to stifling oppression, disgust and the strong desire to escape her grasp at all costs. From then on, he remained untouched by the reality of others. He had not understood why, when books, movies, music, the loss of a pet, so deeply affected others, he felt nothing. As he matured, Joe Polk came to the understanding that in a competitive, cutthroat world, his sensibilities had its advantages.

  The one event that awakened any vestige of emotion was Joe Jr., a loss that created in Joe Polk a rage that had yet to subside.

  Why don’t they understand what I’ve been through, Polk thought. Why don’t they see it?

  Like most intelligent people, Joe wanted to know what made him tick. He’d read extensively about the entire spectrum of personality and psychopathology, little of which applied to him. For a brief period after during his residency, he’d considered a career in psychiatry, but the softness of that specialty offended him. Polk couldn’t stand a ‘science’ where professors considered any opinion, however stupid or ill informed to be ‘interesting’ or ‘insightful’. In addition, he felt uncomfortable joining a group whose mental health appeared to be barely a half step above the level of their patients.

  He concluded that as in most biological systems, the ability to feel emotion, to have empathy, varied across a broad range from those who’d cry during commercials to others like Joe, who were less responsive, less sensitive.

  See a psychiatrist; go begging to the physician support committee. They’re out of their fucking minds! Once I get this mess straightened up, they’ll regret their attack on me.

  Joe was in no mood now to complete the charts. He returned them to his shelf and headed to Sunshine Manor, the one safe haven in his world of despair, unfulfilled promise, and intractable sadness. He’d been finding every available opportunity to spend time at his son’s bedside.

  After his client’s abrupt departure from the boardroom, Jason Phelps stood and turned to leave. He paused for a moment, faced the committee, and with a calm and controlled voice said, “If I were you, I’d think carefully about supporti
ng this recommendation for the expulsion of Dr. Polk. Removal from the medical staff of an esteemed physician is an extreme action, unjustifiable, in our opinion. There will be consequences you may well live to regret. On strictly legal grounds, your case is weak and you are looking at a public relations disaster for the medical staff and the hospital. Please consider these factors and take into account the possibility there may be more creative means of addressing these problems.”

  Chapter Forty-One

  After the attorney’s departure, Paul Morris said, “Well at least Joe’s consistent. Mr. Phelps, on the other hand, has given us a realistic foretaste of what might lie ahead. Should we take a break or push on with discussion?”

  With the general agreement to forego a break, Paul continued, “Before I open the floor for discussion, I’d like to share with you my own reaction to this situation.

  “Standards for dealing with issues of professional competency and unprofessional behavior are poorly enforced in this country. In fact, reports to the State Medical Boards have fallen while the number of complaints against physicians has continued to rise. For example, in California, with over 500 hospitals, there are over 250 hospitals never reporting a problem physician in the last 10 years. This would be a joke if it weren’t so serious a problem.

  “Doctors can’t complain,” Paul continued, “about the decline of medicine, and at the same time fail to deal with the Polks. We have that chance tonight.”

  “Warren,” Harvey Ross said, “you’ve been on the frontline with this situation and I’d appreciate your take on Joe Polk and your specific recommendation.”

  Warren stared at the ceiling for a moment and then took a deep breath. “Polk’s been a pain in my ass for years. I’m sick and tired of fixing his mistakes and apologizing to the nursing staff for his actions and his behavior. If you think my little talks with Joe were fun, you’re out of your minds. I know it won’t be easy to get rid of him, but nobody with a conscience can let him continue to practice at Brier.”

  Harvey Ross continued, “I appreciate all that, Warren, but isn’t there anything, short of expulsion, which will protect patients while giving Joe another opportunity to get his act together? Even someone as hardheaded as Joe must be impressed by now that we’re serious.”

  Ross Cohen found amusement in his internal dialogue. Both the public and the profession hold psychiatric treatment and the discussion of mental health problems in contempt. Psychobabble, shrink talk were only a few of the kinder phrases used dismissively until they need me for themselves or for one of their patients. I’ve been working long enough to understand the problems in practicing psychiatry, but I sure see something distinctive in Joe Polk’s behavior.

  Ross began, “Let me lay it out for you about Joe Polk. He disregards the welfare of his patients, fails to conform to the rules of the hospital, lacks remorse for his behavior, disrupts the nursing staff and many physicians, and blames others for his behavior. I don’t have the DSM-5 criteria for behavior disorders in front of me, but I’m willing to bet that he’s a textbook example of the antisocial personality disorder or sociopath. Someone said facetiously, he doesn’t get it, that’s an accurate characterization.”

  “If you’re right, Ross,” Warren asked, “what difference does it make?”

  “It explains his behavior. Something’s missing in the man. He can’t see how his actions affected others and, frankly, he doesn’t give a damn. It’s as if he’s color blind to this part of human existence. Incidentally, treatment is nearly impossible.”

  Warren continued, “We’ve stepped over the line to protect each other. I could tolerate the wall of white coats, like the Blue Wall of the police, if behind that wall we handled problem physicians. I can’t condone a wall for its own sake that protects the guilty. Protecting doctors in this way demeans us all.”

  Warren scanned the room. “You may still feel sympathy for Joe Polk, but, I’m fresh out.

  “We complain about government, insurance providers, HMO’s, and lay committees poking their noses into our business when it’s our own fault. If we don’t police ourselves, others will. They’ll make the decisions about how we work and who can practice medicine, and what we’re seeing today, we’ll be calling the good ole days.”

  Harvey Ross responded, “That may all be well and good, Warren, but we’re not talking in the abstract. Today an outstanding professional career is in jeopardy. Before I vote for expulsion, I want two things, certainty that we’ve exhausted the possible remedies, and a high likelihood of success in making Joe’s expulsion stick.”

  “Damn it, Harvey,” Sharon Brickman said, “that philosophy leaves us so paralyzed we can never fulfill our responsibilities.”

  “Cool it for a moment, Sharon,” Harvey said. “I’m as offended by Joe Polk as you are. I’m just entering a plea for a reality assessment. Let’s look at alternatives before we kick him out. Warren or Paul, what do you think?”

  Paul and Warren looked at each other hoping the other would respond first, until finally Paul said, “I’m not ducking the question Warren, but anything short of expulsion will find its way right back onto your plate.”

  “My plate’s full-up with Joe Polk and it’s giving me a bad case of indigestion. You want it, here it is. We can’t allow Joe Polk to practice at Brier without direct, hands on, minute-to-minute supervision by our staff. This means anytime, day or night, when Polk admits a patient, one of us must go to the hospital to make sure he’s not screwing up. Every time he writes an order, someone will have to sign off on it. Think of the logistical problems. Where and how does it end? Should he go back for more training? Should he be shrunk?”

  Warren continued, “Should we keep him on staff without practice or admitting privileges? Would he accept these limitations? What would this sham action say about us and our willingness to deal with problem physicians? Look at the message we send to a nursing staff that has watched Joe Polk injure patient after patient with little or nothing done in spite of their best efforts to bring his destructive behavior to our attention. What message will be delivered to the next bad actor and to our own professional sense of self if we fail to deal with a physician who time and again has proven unworthy of our respect or the trust of his patients?”

  Phil Banks entered the discussion. “This whole thing is moving too fast for me. Right now, he’s practicing under direct supervision, and we’re keeping patients safe. We have ample time to see what’s wrong with him, if anything, and to independently evaluate his charges of bias. I’d suggest we table this motion until we have had a chance to investigate.”

  The room filled with groans.

  An agitated Arnie Roth replied, “Christ, Phil, if you give any credence to these charges, you’re not listening. Read the charts and the nurse’s notes. Talk with docs and the nurses who have worked with him. Talk to Helen or Chuck Martin, among others, and talk with your colleagues on the QA Committee who have spent innumerable hours with these cases, then tell me this motion is unwarranted. I’m not unsympathetic to the effects of this proposal on Joe Polk. However, for whatever reason, the physician he has become, can no longer practice in this hospital.”

  Ernie Charles, a respected family practitioner and former Chief of the Department of Medicine and Family Practice, and a former president of the medical staff, rose to comment. He was in his early eighties and slowing down in his practice. He’d served as a medical staff leader and as a practitioner. He survived the politics of medicine and each transformation of medical practice, yet never lost sight of his responsibilities, his integrity, or his joy in caring for patients.

  He brushed back his few remaining strands of white hair from his freckled scalp, scanned the room and said, “Somewhere during each stage of my personal and professional life, there came a time when I convinced myself, ‘Ernie, you finally get it’. It never lasted long. Along the way, I learned to find value in life’s uncertainties, which were unavoidable, and in change that was inevitable.

  �
�The public held physicians in high esteem, not so much for what they could accomplish, hell, even the worst practitioner today is light years ahead of the best old-timers, but for being a professional. It’s paradoxical, but the better we got at the technical aspects of medicine and the more we had to offer our patients, the worse the public thought of us.”

  Pausing for a moment in thought, Ernie continued, “What I’m saying here may resonate with some of you while for others it will be an anathema. Acting as a professional had virtue. Physicians were trusted, respected, and appreciated for their efforts at caring for patients, almost without concern for the outcome. We knew with certainty our doc would do what he thought best for us without concern for profitability, convenience or the risks of malpractice litigation.

  “Who does the physician work for today? We’re not sure. Is it the patient, is it himself? Is it the HMO or managed care organization? Who does the physician fear? Is it hospitals, State and Federal Governments, HMOs, malpractice attorneys, or their own patients?

  “These uncertainties weaken the profession and undermine the practitioner, not only as a political force, but also most perniciously, as the guardian of his patients’ interests. Our reluctance to deal with Joe Polk, in my opinion, is a manifestation of this weakness.”

  “Respectfully,” said an angry Sharon, “That comment reflects antiquated and paternalistic attitudes of the past, gone and deservedly so. We are not responsible for patients. They are responsible for themselves. Patients need to fight the battles with government and insurers, since it’s their asses on the line. I’m sick and tired of fighting with insurers and filling out their goddamn forms, begging for permission to provide services my patients need. It’s their lives, let them do the fighting.”