When A Doctor Tries To Be Robin Hood

It was not one of my better days when Don came to see me.  I had agreed to his request to see him after office hours when no one else would be present.  He sat heavily into a chair opposite my desk.  Saying nothing, within seconds his eyes watered.  I had absolutely no idea what was to follow.  As fellow internists Don and I had been friends for over ten years, frequently substituting for one another on weekends and extended vacations.  He was devoted to his patients and they, to him.  Though generally passive, he could be counted on to support any hospital policy innovation that would improve patient care. 

I waited for him to begin the conversation.  “Dave, you know I’m a good family man.”

“Oh, my,” I thought.  “He’s having an affair.”  I really didn’t think of Don as having much libido.

“And I go to church every Sunday.”

Again to myself, “that could mean all kinds of sins.”

“I’m in trouble, big trouble.”

Now I knew the answer.  Though I wasn’t his doctor, he had mentioned his being a diabetic.  This plus the fact that he was a heavy smoker and a sedentary chubby added up to coronary heart disease.  Surely he was going to tell me that he had developed angina pectoris, chest pain typical of that diagnosis.

Was I wrong!  “You know I’m a political conservative.”  How well I knew that!  A year after I started my practice in Aliquippa, Marcia and I invited Don and his wife to our home to watch the Democratic Convention on television.  Adlai Stevenson to our delight was to be nominated.  Don thought him to be a liberal “egghead.”  Within minutes we politely, though reluctantly, shut off the TV.  “And you would be right to think that I agreed with our medical society which opposed doctors being involved with Medicare.  Once we had little choice but to go along with their fee schedules, I knuckled under.  But it annoyed me that there was a significant deductible fee that patients had to pay out of their own pockets.”

“Don, I’m at a loss to know what’s upsetting you.”

And then came the confession.  “I got caught trying to beat the system.  I’m being accused of committing fraud.”

I was still in the dark.  “Well, did you commit fraud?”

“Yes and No.  When I did an electrocardiogram, I billed Medicare for two examinations which compensated me enough that the patient didn’t have to pay me anything.”

I was irate but managed a poker face.  I had to keep remembering that Don had come to me as a friend, as a confidant.  I couldn’t turn on him.  “But, Don, even if your reasoning might be politically understandable, in a climate where doctor after doctor is being found guilty of bilking the government for services never supplied, how could you be so naïve to think that you could get away with it?”

How well I knew the paranoia of the system. Only three months before, I had received a letter requesting (that is, requiring) chest x-ray films of ten specific patients for whom I had billed Medicare.  In addition I was asked to send for each of the ten patients the indication for the x-ray study and a copy of my written report.    Subsequently, my x-ray films were returned with a note thanking me for my participation.  Not all doctors were similarly praised.  A few received court summons; either they were unable to produce the requested films or chest x-rays were fraudulently produced as proven by testimony of patients who denied under oath of having x-ray studies performed.

Don had no answer for me.  Instead he anticipated the shame of having his crime sensationally disclosed in large print in the local newspaper.  “Can you imagine how the newspapers will rake me over the coals?”  A defense that he tried to help protect his patients’ finances would be ridiculed.

And then Don spewed one catastrophic scenario after another.  “Will I be put in jail?  Will there be an open court trial?  Will my kids be ashamed of me and will their classmates taunt them?  Will I go bankrupt?”  And finally, with chin touching his chest, “Maybe I should just kill myself.”  At that moment my anxiety took on a new dimension.  With Don’s permission I called his wife, Beverly, and asked her to come to my office; she had been too humiliated and terrified to accompany Don. 

“Do I have to, Dave?”  It was obvious that she was crying.

“I’m sorry, Bev.  You don’t have much choice.”  Then to Don I began proposing a plan of action.

“Is your friend, Lionel, also your lawyer?”

“Yes.”

“I suggest that I call him now and arrange an urgent meeting today.  OK?”  With resignation, Don nodded approval.  “Then I think you should set up a meeting with your tax consultant.  If he’s also your financial advisor, so much the better.  I think you have to sit with him with a sharpened pencil and see exactly what you have to worry about in case your income should drop.  And don’t hide any assets from him.”  I made both calls.

By the time all was arranged, Beverly arrived.  In contrast to Don, Bev was slender, looking even thinner as she sat in the chair, a twin to Don’s.  There was no question that their ordeal, which was just beginning, had taken its toll.  She was wearing a wrinkled housedress and no make-up; her hair hadn’t felt a comb since the court summons had arrived early that morning; normally every hair was in place.  She sobbed continuously.  “What are you feeling,” I asked?

“I wish I were dead.”  It was quickly made evident that Don would have no support from this quarter.  All I needed was a double suicide.  A vision of their two orphaned children flashed through my mind.  I needed help.

I knew that Don and Beverly were active members of their church.  Furthermore I admired their Pastor, enough so that he had been a guest at our Passover Seder the previous year.  “If you feel up to it, I would like Reverend Walters to see you now while you are waiting for your appointment with Lionel.  He could see you in the privacy of my office or his, whichever you prefer.”  The idea pleased them.

“Call Reverend Walters and we’ll do whatever he wants.”  As it turned out, Reverend Waters was free and chose to have them come immediately to his study.  For the time being I felt that I had covered the major components of the support system that Don and Beverly would need.  Surely psychiatric help would come later.

Don rose first and helped Beverly stand; there was almost no tone in her body.  Don and I embraced, but distantly.  Beverly gave me a limp hand handshake.  They shuffled to the door and departed.

Predictably, the next day a front-page headline read, “Government Accuses Local Doctor of Fraud.”  The reporter raised cogent criticisms: “Why didn’t the good doctor just absorb the loss of the deductible himself?”  (“The good doctor” is always spoken with derision.)   Or, “If he didn’t approve of Medicare, why did he participate in the first place?”  (Doctors had the option of billing patients directly and letting them collect what they could from Medicare.  The guaranteed payment, albeit partial, was too tempting to ignore.)  The writer had done his homework, choosing to link Don with the growing number of doctors convicted of lining their pockets with money by fraudulent Medicare claims.  There was no defense on Don’s behalf or any mention of his stellar medical training or professional skills.  There were no quotes from his loving patients, only comments of townspeople anxious to spew their contempt for doctors and their inflated incomes.  Don had been warned in time by his lawyer not to speak to the press. 

When I went to the hospital that morning, I inquired of the nurses if any of Don’s patients needed help from me.  They informed me that he had made rounds at 5:30 AM.  That was a good sign.  As soon as I had finished tending my hospital patients, I called Don’s office.  The secretary informed me that Don had her cancel all his appointments for the day.  I then called his home.  After at least twenty rings, I hung up. I couldn’t blame him for not answering.

I drove to his house. A television station vehicle was pulling away as I approached.  The only indication that Don was home was a car parked in his driveway with a clerical symbol on its windshield.  I knocked. After a brief delay, a child’s voice asked, “Who is it?”

“Dr. Chamovitz,” I replied. There was another pause before the door opened. Reverend Walters was the first to greet me. 

“I’m so glad to see you. Don’s not feeling very well. He wouldn’t let me call you.”

Don was sitting in an easy chair, smoking a cigarette, “to soothe my nerves. Dave,” he said apologetically.  Beverly sat next to him, her hand on his.  “I’m OK. Just a little indigestion from all the turmoil. The phone never stops ringing.”

“Then take the phone off the hook,” I said for starters. “Now tell me about the indigestion.”

“Oh, it’s nothing new. I’ve had it before. Maybe too much to drink before I went to bed. I just couldn’t get to sleep.”

“Don, please stop being your own doctor and tell me your symptoms.”

“Well, you know. I just had this vague feeling in the middle of my chest last night. A few good burps after Alka Seltzer and I felt better. It came back a couple of times but I’m feeling alright now.” I paid attention that Don did not run his fingers up and down the middle of his chest as he described his discomfort; that would have reassured me that his problem was related to his esophagus and not his heart.

“Don, I know you don’t want to be seen in public but I’m taking you to the hospital now for an electrocardiogram and blood tests.”  He followed me without protest; Reverend Walters remained with Beverly who just stared into space.

Suffice it to say that Don spent the next two weeks in the hospital recovering from a mild heart attack, doubtlessly precipitated by the stress of the impending criminal investigation.  A “No visitors” sign on the door of his private room shielded him from casual spectators wanting to gloat over the downfall of a pillar of the medical community.  I did permit members of his professional support system to visit freely but no one from the prosecutor’s office.  I was pleased that his minister didn’t interpret the heart attack as divine retribution for Don’s “indiscretion” though Don did. And he knew full well that this wouldn’t be the end of his punishment.  “Maybe since I’m recovering from my heart attack, I’ll manage with whatever else is thrown at me, God willing, not a jail sentence.” 

And survive he did. An out-of-court settlement imposed a fine of triple the amount of money Don had received illegally from Medicare and a one-year ban from Medicare payments. A few of his very loyal Medicare patients paid his fees out of their pockets; most transferred to the care of other doctors.  Fortunately, I never benefited from Don’s loss; had I done so, our relationship might have been tainted.

Although not outgoing by nature, Don thereafter avoided all social contacts. He fulfilled his medical obligations and came only to mandatory meetings. No one asked him to prepare conferences or to give a lecture, not wishing to impose upon his flagging energy level.  He did give up cigarettes and took walks late at night, timed to avoid his neighbors. He declined a psychiatric consultation. For the next five years before leaving town for good, he continued to express to me his feeling of having been abused by the community he was committed to help. “After all,” he persisted, “all I did was try to protect my patients from an abusive payment system.” 

Robin Hood to the very end.