Tell Me I Didn't Put it There

E

ven after forty-five years, memories of Simon continue to haunt me.  He was a simple man, so it seemed from the initial medical history.  A high school graduate, he opted out of college for earning a living as a salesman in one clothing store after another.  In an era of few working wives the family income was supplemented by his wife’s clerical job. 

Simon had no special interests or skills.  He was not a joiner. Having had no ritual training, he even avoided synagogue life, which further alienated him from potential friends.  He lumbered through his ten-hour workday, arriving home with no more energy than to eat supper, read a newspaper, and listen to the radio news.  (Television had yet to be commonplace.)  Conversation with his wife was sparse and usually concerned money.  He had little to say to his three children.   

 Yet, Simon was a likable soul.  Customers appreciated his gentlemanly behavior: he offered advice without pushing to make a sale.  In my office he was genuinely courteous.  He was embarrassed to admit that he had agreed to come to me only after a mutual friend had reassured him that I would charge a minimum fee.

He a big man who overflowed the sides of my office chair.  His clothes were crumpled, his thinning gray hair was combed but unruly.  Hesitatingly, he offered his reason for coming to me.  “I’ve been bleeding when I go to the toilet. It happens when I move my bowels … for three weeks.” 

He was pale; otherwise his physical examination was normal.  I hoped I would find bleeding hemorrhoids; no such luck.  The next day I performed a proctoscopy, which showed no abnormalities.  Had I missed something?            

At that point Simon asked if he might have cancer.  “What makes you think so?” I asked.

“Well, my father died of it at forty-seven (Simon was sixty-one). My brother died at fifty-five; we never knew his diagnosis but he lost a lot of weight and was in pain for months before he died.  I don’t think I could go through that.”

As he spoke each word I could sense my training being challenged.  My medical mentors, always peering over my shoulder, waited for me to stumble.  If Simon had cancer, would I be able to lie to him?  Of course I must for that was what I was taught only ten years before (in 1946).  Simon wasn’t one of the exceptions listed on the blackboard such as a wealthy corporation executive with an estate to protect.  I temporized.  “It could be colitis or polyps.  Maybe tomorrow’s X-ray of your colon will give the answer.”  He was not cheered but then again, I don’t think I ever saw him smile.

I gave Simon instructions for “cleaning” his bowel in preparation for the X-ray.  I called his wife, Rose to tell her that “the diagnosis might be cancer and if so …”.

Rose interrupted me.  “You mustn’t tell him.  It would kill him.  He’s been talking about nothing else since he finally admitted to me why he was seeing you.  He says he knows he’s going to die like his father and his brother.”  She began to cry. 

“Okay.  We’ll see.  Maybe you should come in with him.  We can talk after I finish the barium enema.”

What I didn’t tell either of them was that, as a resident though I had performed over a hundred X-ray examinations of the bowel, Simon’s would be the first in my new office. I saw no reason to mention my apprehension about the technical aspects of the procedure.  I didn't want to disturb my image as an infallible Harvard specialist.

The next morning my nurse, Pauline, had everything ready.  Simon lay on the X-ray table. A two-liter bag of chalky barium suspended three feet above the table was connected via a tube inserted into Simon's rectum.  I motioned to Pauline.  “Let’s begin.”

  Pauline released the tubing clamp.  As I turned on the fluoroscope to watch the barium enter the rectum, I was chagrined to see barium spreading on the table.  “Stop,” I said to Pauline.  She snapped on the lights. 

“Oops.  The enema tip came out.  Simon, I’ll reinsert it deeper.  Sorry.”  I  couldn’t be sure but I think Pauline was blushing. 

With the lights out again, we resumed.  Barium was entering freely.  All was normal in the rectum and deeper into the sigmoid until “Oh my God!” resounded in my head.  “Look here,” I whispered to Pauline.  The X-ray motor drowned out my voice.  There was a huge mass, which allowed only trickles of barium to advance beyond it.  I took a few X-rays to show to a surgeon.  “Finished,” I said to Pauline and Simon. 

  I returned to my consultation room and sat in my expensive, high-backed chair.  “Look at me.  What a great doctor I am!”  But almost simultaneously I thought, “Oh, my God!  Poor Simon.  Until I found the tumor, it didn’t exist.  Tell me I didn’t put it there!”  Irrational?  I don’t even have to ask.  I guess it was a form of denial; I didn’t want Simon to have cancer and I dreaded handling all that was bound to follow. 

After Simon had dressed, I invited him and Rose into my consultation room.  They could tell from my expression that the news was not good.  “Bad and good,” I started.  “Good in the sense that we’ve localized the problem and good in the sense that there is a large polyp inside the sigmoid."  I drew them a picture to show its location.  "That’s where the bleeding is coming from.  Bad in the sense that you need to have it removed, Simon, to stop the bleeding.”  I didn’t think it was necessary to add the threat of bowel obstruction if he were to procrastinate. 

“Then, it’s not cancer.”  Rose made it a positive statement.

I lied.  “It doesn’t look like cancer but to be honest, only the pathologist will be able to tell us for sure.  If it turns out to be cancer, I'm sure that the surgeon will be able to remove it all.  You’re not your father, Simon.”  He fought back tears.  “You have reason to cry, Simon, but more reason to be optimistic.”  (See the chapter “Down with doubletalk to cancer patients” in my memoir, “By All Means, Resuscitate.”)

Simon wasn’t convinced nor was he wrong.  Within the week he was operated on.  The bowel cancer had spread to his liver.  The huge mass was removed but only to prevent the hideous complication of obstruction.  Since I had nothing good to offer Simon (those were the days before chemotherapy), I told him that he had a "benign (noncancerous) adenoma" and that it had been totally removed.  (With Rose I was truthful.)  Simon felt better after receiving two units of blood but this didn't last long.  His condition rapidly deteriorated as the flesh fell away from his body. 

Simon never returned to work and he never asked questions even as his skin became yellow from progressive liver failure.  He had very little pain.  Oddly, though he had no medical insurance he never expressed concern for the hospital bills that Rose would have to contend with after he was gone.  Two months following surgery and after a three-day coma, Simon died at home.

  So I didn’t kill him, but in my mind he didn’t have cancer till I found it.  That's an ironic way of looking at what happened in Simon's medical story. I was proud of myself for having suspected and proven his true diagnosis but, then again, how could I feel gratified if I was the one who brought out a verdict of death?

Taking Roy for a Swim

Danny: The following is taken from my late father's autobiography "BY ALL MEANS RESUSCITATE!". I'm posting it here in honor of Martin Luther King Day. Our children, who think it wonderfully normal to have an African American President, need to know history, and some of the brave (or stupid) things that many people, including my father, did to try to change the world. The term "African American" was not part of my father's generation lexicon, and I've left his original wordings.

My hometown, Aliquippa, should have been a true example of the melting pot which characterized the American dream. Though numerous ethnic groups settled the town, the Jones and Laughlin Steel Corporation (J&L) which enticed them from Europe and from the USA’s deep south, segregated them by nationality and color by selling each group houses on the various hills. The inhabitants did come together somewhat as mill workers: mid-Europeans were laborers while office and foreman jobs generally were assigned to Anglo-Saxons. Mixing of cultures was more complete in the public schools though a small number of students went to Catholic schools. By 1956, when I returned with my family to live in Aliquippa, most neighborhoods had become integrated except for the continued exclusion of Blacks. It took well more than a decade for that particular wall to come down.

From the days of my childhood to the year of my return to Aliquippa, three public swimming pools existed in the town. The largest was in Plan 12, a predominantly Anglo-Saxon neighborhood, serving several other Plans within a mile or two – for me, about a mile. There was a second pool across the railroad tracks in West Aliquippa, which housed predominantly Poles and Italians. The third pool in Plan 11 Extension, was exclusively for Blacks. The latter were not to be found in the other two pools, at least not until the seventies. There was also a small private pool for more affluent residents of Hillcrest.

Private neighborhood pools were becoming fashionable in the fifties. Soon after we moved into our house on Hospital Drive in 1958, my neighbor, Ed Nanasi, and I approached the DiMattias, builders of all the houses in the neighborhood, to request a parcel of ground for the purpose of building a pool. They made the gift on condition that the pool be named for their son, Daniel, who was killed in an accident not long before. We promised; the honor was ours.

Ed and I invited neighbors to my house one evening. From this meeting grew an organization with elected officers and committees. Membership grew to include first-and-second-generation Italians, Poles, Ukranians, Greeks, Serbians, Croatians, Germans, and Irish – all Caucasian. There were also Jews, Roman and Eastern Orthodox Catholics, and Protestants. Knowledge of democratic process was well-known since many of those involved were active in the steelworkers’ and teachers’ unions. At one meeting I had my comeuppance after making what I thought was a suggestion to streamline our proceedings. A coarse-looking steelworker shouted, “I don’t know who you are, but you’re out of order;” he was correct.

The organizational details escape my memory except for several significant incidents. Mother’s Day in 1960 was never to be forgotten. Volunteers assembled to construct the pool clubhouse. The foundation had been laid; it was now a bricklaying job. There were Ed, a paint chemist, and I, a Harvard internist, making cement (mud) – my only relatives who did this were delivered from Egypt by Moses – carrying it in hods to five professional bricklayers.

We had considerable difficulty keeping up with the demands of “More mud! Get a move on!” After about forty-five minutes of me being pilloried with expletives, one of the bricklayers, an elderly, old-school Italian gentleman, discovered that I was “Dr. Chamovitz.” His embarrassment, his mortification (no pun intended), were touching. To him I was the Professor Doctor equal to a priest in stature. It took a while for me to reassure him that I loved the anonymity and the sharing of this venture, like homesteaders of bygone days raising a neighbor’s barn on the wild prairie. After this dramatic interlude, construction progressed, though at a slower pace out of respect for the doctor.

Marcia served on the bylaws committee. As to membership she suggested the phrase, “regardless of race, creed, or color.” Resistance was heated. “Why bother with ‘color’ since no Blacks live in our area?” was the response.  Residing within walking distance of the pool was a substitute precondition. Marcia kept pushing but to no avail. The committee decided, “We’ll handle the matter when a problem arises.” Marcia was not reassured.

When Roy Hart and family, a Black family with two sons, moved within a stone’s throw of the pool, they applied for membership. Their application was summarily rejected. The father Roy was a steelworker as were most of the pool members. “You know he was accused of using J&L telephones for personal calls,” hardly a capital offense among speeding ticket fixers, numbers writers, and God knows what else. It seemed to Marcia and me that our dream of neighborliness was being vandalized.

These were the dreadful years of the sixties when Detroit was burning from race riots. During an annual Brotherhood meeting I rose to confront the political leaders and clergy who were spewing forth platitudes that had characterized so many fatuous showpiece gatherings.

The following day I was confronted by phone by a Black steelworker, James Downing. “Did you mean what you said last night or are you just another smooth talking White liberal?” That was the moment “to put up or shut up.” I could hear Dad saying, “Just be a good doctor,” as James and I planned our first interracial meeting. It was to be held in my living room. “You bring six Whites and I’ll bring six Blacks.”

One of my six was Eric Garing, my high-school teacher of American Civics. To me he was the epitome of morality, a preacher of excellence in scholarship and justice in human behavior. All that had been twenty years earlier. He was dumbfounded at the opening meeting when he heard angry Blacks attacking the City Council, the schools, and white society in general. His naiveté reminded me of my own childhood acceptance of Negroes sitting upstairs in the theater balcony. Mr. Garing’s reaction paralleled that of visitors to the Holocaust Museum in Washington. They shake their heads from side-to-side in disbelief and say, “I didn’t know.” He was humiliated by these same Blacks who had been his admiring students or so I had assumed.

The most enlightened member of my group was Father Phil Schaffer, a young pastor of the Episcopalian Church. Shortly after we began our deliberations, Father Phil was inspired to remove his clerical garb and go to live for two weeks in a Chicago slum. The experience for him was earth-shattering; he now had a new calling. And for these efforts his congregation ran him out of town. “We want a minister who will devote himself to religion,” was their excuse. I wish I could say I never heard such a remark in a synagogue.

I don’t recall that our group accomplished anything of significance other than meeting alternately in White-and-Black homes. Many Whites had never been in a Black home, let alone been to Plan 11 or Plan 11 Extension, a mix of low-to-middle-class homes bordering the town’s garbage dump. If Blacks had been in a White home, it would have been only with mop and pail in hand. But one of our group’s Blacks was Roy Hart who, as previously mentioned, had moved into a house near the pool.

One morning without any advanced planning, without consulting either the American Civil Liberties Union (ACLU) or any other civil rights group, I called Roy to ask if he felt like taking a swim. Without hesitation he accepted an invitation to be my guest at the Daniel DiMattia Swimming Pool.

Accompanied by Marcia and Danny and attired in bathing suits, Roy and I drove to the pool, walked through the gate, and within minutes, were in the water. Little did I realize that for us it was hot water. But why should that be? Wasn’t I Dr. Chamovitz, physician to many of the members? Wasn’t I one of the pool’s founding fathers? How vindicated I felt not seeing any bather jump out of the water. Nor did any mother haul her child from infested waters. Surely my action would be universally approved.

Hardly! It and we were universally denounced.

That afternoon with only Amy at home, I was visited by three members of the pool board. Poor Amy, sitting on the stairs outside the living room, heard them threaten me “If you ever to do this again, ...” The threat to do what was open-ended. I dared not ask.

When they left, Amy rushed into my arms sobbing, “Daddy, can’t you do something?” Like call the police? How could I explain to my daughter that most of the police were friends and relatives of my attackers? I was paralyzed with the shock, the embarrassment at my naiveté about how far my patients’ goodwill would carry me. It really was sheer arrogance that I hadn’t done my homework to prepare a plan of action, or to consult with the ACLU, for example.

That same afternoon the pool board canceled all guest privileges. Soon after, they were restored, though to blood relatives only.

Almost everyone was scornful in varying degrees of my blatant move to integrate the pool. Marvin Neft, a member of our Jewish congregation, called to offer endorsement. Only Steve Plodinec, an older Serbian friend and businessman, called, saying, “Call me if there’s trouble.”

I remember having visions of burning crosses in the yard. Poor Amy must have suffered even worse fantasies. Raina remembers only being proud of her parents. We had anonymous threatening phone calls but there were no dirty tricks. We did feel isolated from our neighbors. For months I could not escape the feeling that my family and I were in physical jeopardy.

A few days after the event my sister-in-law Irma was having her hair trimmed in Sewickley by a former Aliquippian. He asked Irma if she had heard what her brother-in-law had done. “Yes,” she knew.

He continued. “Can you imagine the kind of Negro he took to the pool, a real shady character?”

Irma replied, with tongue in cheek, “He tried inviting Ralph Bunche, (a famous American United Nations diplomat and Nobel Peace Prize laureate) but he was busy.”

The hairdresser asked, “Who’s Ralph Bunche?”

Did we accomplish anything worthwhile? One teenager, a stranger to us, related some years later that she got into an argument with her parents when she expressed admiration of us. Did we liberate her? Are Roy Hart’s sons less prone to be racists because of one white family’s courage? Did we delay integration that might have come from more considered action? The Plan 12 pool did become integrated several years later when economics forced the closure of the pool on Plan 11. By this time there were a number of neighborhood pools that presumably siphoned off a significant number of politically strong opponents of integration.

Our standing at the Pool had hardly been enhanced by a poolside discussion regarding intermarriage with Marcia participating. This was prompted by the elopement of our baby-sitter, Donna. She had run off with a local Black after prolonged and futile attempts to have her family accept him. Her father was a devoted cardiac patient of mine, an Italian immigrant whose self-image was already marred by a congenital clubfoot. Marcia posited that a shared philosophy of life was more important as a basic ingredient to a happy marriage than was matching skin color. A Catholic worrying about his soul burning in hell would find little solace from a Jewish spouse for whom the concept had no meaning. Similarly, a couple harboring strong but opposing political opinions might tangle over them. Marcia’s conclusion: “Better for a white Jew to marry a black Jew than a white Christian.” So much for intellectual pursuit of the good life. Word went around town that the Chamovitzes were “nigger lovers” and Christian haters.

I did have the shallow satisfaction of confronting my neighbors at a dinner in 1980 when I received the Aliquippa Chamber of Commerce Brotherhood Award. Dad had been the recipient in 1960. (Dad’s fourth-grade English bested many of the college-educated speakers on the program.) He and I were the only Jewish Brotherhood awardees since its inception in 1958.

After introducing my family and giving the perfunctory “Thank Yous,” I lashed out: “And where were you when I needed you, when I ran for Democratic delegate in the Presidential year meant to bring down Richard Nixon (I came in ninth in a field of twelve aspirants beating one Governor Wallace and my two fellow Senator McGovern candidates) and where were you when Roy Hart and my family went for a swim in the Daniel DiMattia Pool?” By then Roy was a county detective; I had him stand up. Dad used to quote a Harry Truman supporter who shouted, “Give ‘em hell, Harry!” That’s what I was doing, but for whose benefit? Surprisingly the award wasn’t rescinded. Only Racheal, Marcia, and Danny acknowledged my remarks.

Soon after, we resigned from the pool, but only after Danny stopped using it. We are still awaiting the refund of our building assessment fee as mandated in the bylaws. In January 2000 I wrote a letter to Roy to remind him of that epical moment in our lives. In return I received a video cassette, a promotional message advocating Roy’s candidacy for the United States Congress. He presented the image of an elder statesman. I doubt that it would have helped his case for membership in the DiMattia Pool.

Better than Money

One of the delightful aspects of adopting a new life in Israel was the move from a fee-for-service payment system to a fixed salaried one, delightful even though entailing a drastic reduction in my income. It was like returning to the days of my medical training when hospitals paid minimal salaries while providing years filled with rich doctor-patient encounters, unencumbered by that ugly word, money.

Whatever the reasons, I was uncomfortable having a patient put money directly into my hands or even discussing fees. I avoided these whenever I could by referring the patient to my secretary. Did I feel guilty thinking I was rewarded enough just by being allowed to provide my services? Or was it my worry that maybe my fee was too high or maybe that I had misjudged the patient’s ability to pay. Or maybe I was tapping into the ill-conceived notion that just talking with a patient didn’t merit a fee. One surgical colleague didn’t charge a patient for his consultation unless it was followed by an operation. He rationalized, obviously incorrectly in my opinion, “If I didn’t operate, I didn’t do anything for the patient.” Matters were greatly alleviated for both the patient and me, when insurance carriers, Blue Shield and Medicare, began paying most of my fees. The following patient put me to the test.

Roland Jasper at age 53 had an attractive, debonair flair as he offered a firm handshake across my desk. “A born salesman,” I thought. In answer to my opening question, “What can I do for you,” he replied, “Not much. It’s just that I’m going across the country to promote and sell encyclopedias to families and schools. It’s very profitable but also very exhausting work. Though I’m feeling fine, I wanted a general checkup to make sure.” At the conclusion of my study, which included routine lab work, a chest x-ray, and an electrocardiogram, I suggested that because of borderline high blood pressure he should lose ten pounds, go easy on salt, and, by all means, quit cigarettes. The multitude of oral medications now popular for hypertension was not in vogue at that time. He agreed to try to comply – he didn’t display much enthusiasm – and said, “See you when I get back in a couple of months.”

On the way out, he stopped at my secretary’s desk and gave her ten dollars as the initial payment on his $110 bill. For the remainder he gave her a post-dated check, cashable two weeks later.

At the appropriate interval the check was deposited. Lo and behold, the following day the bank manager called to inform me that the check had bounced “for insufficient funds.” He continued, “Let me tell you, David, this Jasper guy is a con artist. He’s passed bad checks all over town. I even lent him a few hundred dollars on the basis of his previous year’s tax return, which I later discovered was a fake. Welcome to the club.”

Approximately six months later Roland, without an appointment, popped his head past my office door saying he had palpitations and a severe headache. “Please, can you help me?” The patient I was examining was startled by this rude intrusion. I excused myself to her and went into the waiting room.

“Yes, but on condition that you pay up your old bill and put down another fifty dollars toward your next bill.” I didn’t like myself, sounding so mercenary, but I wasn’t going to let him take advantage of me a second time.

“I can give you fifty dollars now and another fifty tomorrow. The rest, I really can’t say.” That bit of honesty was a step forward.

Something about his expression told me “Con man or not, I believe him and besides, this time he looks sick.” I said, “OK. Hold on for about ten minutes until I finish up with my last patient.” As I turned around I noticed him handing a fifty-dollar bill to my secretary. I mused, “I bet it’s counterfeit.”

As Roland sat on my examining table, I was tempted to begin by discussing his morals. His fearful facial expression dissuaded me from that. Instead I took his blood pressure. 230/130! I checked it repeatedly, in the other arm as well, without noting any significant difference. Among other findings were warm, moist skin and a heart rate of 125/minute. I said to myself, “So what if I’m conned out of a couple hundred dollars! This case is my meat.”

I immediately thought of a severely overactive thyroid, causing “thyroid storm.” Untreated, this can be quickly fatal. Against this was the absence of either a goiter or protruding eyes.

My second choice was an adrenal tumor called “pheochromocytoma.” (The adrenal glands sit on top of the kidneys.) I listened with my stethoscope over his kidney regions and sure enough, there it was: a murmur suggesting the tumor’s increased blood flow. I didn’t have time to congratulate myself for in the next few moments Roland began gasping for breath. Liquid in his lungs was audible without a stethoscope. Sitting him up helped somewhat as did an oxygen mask. I gave him an intravenous injection of a strong, rapidly acting diuretic. Roland was considerably improved by the time the ambulance came to take him to the hospital.

Within two more days urine chemical testing and computerized tomography confirmed the diagnosis. Conservative medical treatment resolved Roland’s symptoms but cure would come only from surgical removal of the tumor. For that I wanted him to be in a medical center for the operation requires a team of experienced, highly qualified surgeons, anesthesiologists, and specialists in hypertension. I had already learned that Roland had hospital insurance but like me, his doctors would have to enjoy the medical experience for monetary remuneration would exist on paper only.

The surgery was successfully performed in a Pittsburgh hospital. Other than the discharge letter from the operating surgeon I lost all track of Roland. Statements of money owed to me were returned, “addressee unknown.” We gave up. Seeking the aid of a collection agency long ago in other trials had lost its appeal for me; it was an angry, fruitless gesture. Satisfaction from a quick diagnosis and cure of a rare disease were to be my reward.

It was five years later that the man with an attractive, debonair flair walked into the office. Roland told my secretary that he just wanted to say, “Hello.” She escorted him into my office. We shook hands and, without any greeting, he handed me a brown paper heavy bag. “Look inside,” he ordered. To my chagrin there were a several handfuls of silver dollar coins. “This is a first payment,” he said. “Believe me (I didn’t) there will be more.” Then, departing, he called back over his shoulder, “And thanks, Doc.”

After the door had closed, I took one of the coins and bit it. Though it stood the test – I wouldn’t have been surprised if it had been chocolate – I thought I should do the same for the whole collection. In today’s competition of “one upmanship” both Roland and I were “one-up,” he for recovering his health at a bargain price and I for having a story to tell my grandchildren.

Just Try to Change a Surgeon

Though doctors' medical licenses generally indicate permission carte blanche from governing medical societies to practice both medicine and surgery; it is generally accepted that surgical procedures will be of a limited nature; it is given to the individual staffs to mandate which procedures and under what conditions an individual doctor may perform an operation. A surgeon may not just walk in to an operating room and perform an appendectomy, e.g.,without his credentials having been been closely scrutinized by a committee of his peers.

Hammering out these rules caused many hard feelings especially when turf battles were involved. A surgeon may say, "I've been taking out tonsils or appendicies before you were born. Why must I stop now?" The answer is easy: he need not stop. He must just prove his qualifications..

I remember one particular surgeon who was irate when the head OR nurse stopped him at the operating room door and refused him admission. Our staff president asked our pathologist along with a significant committee to review the surgeon's previous 10 appendectomies. Tho' each case was diagnosed by the admission surgeon to be an "acute appendicitis," in actuality only one showed evidence of infection.  It was further made clear that the surgeon did not understand the disease as he blatantly wrote in the chart, "Schedule for appendectomy in 2 weeks when I return from my vacation"; surely at least one of the appendicies would have ruptured during that 2 week period if the diagnosis were correct. The reviewing committee decided to require the admitting surgeon to obtain a consultation on every new case of suspected appendicitis. Result? He gracefully stopped treating patients with abdominal pain.

Problems concerning surgical privileges generated much hostility and were a bane of contention in the opening months of the Aliquippa hospital. To the credit of the Aliquippa surgeons and to those general practitioners who for many years had included minor surgery as their domain, Final decisions were, eventually assigned to, board certified surgeons. The very loose rules acceptable for years to the older staff at Beaver County's three hospitals were summarily overturned by Aliquippa's Staff and soon adopted almost overnight in the three other county hospitals. It was not only a significant advance in medical care but also the prevention of potential malpractice suits.

It took longer to eliminate "ghost " surgery. A "surgeon" would be gowned as he said "hello" to his patient at which point another surgeon unbekownst to the patient would walk in and perform the operation. The referring surgeon would collect a major portion of the fee.

“You’ll make no friends serving on the Quality Control Committee,” my brother, Jerry, cautioned me.  It was to be the first of its kind at the Aliquippa Hospital.  At Jerry’s hospital tempers raged during their first attempts at quality control; a couple of meetings ended as members stormed out.

My reaction?  “What!  A Harvard man shirking the responsibility of teaching colleagues and protecting patients?”  “It’s not arrogance,” I mused.  “Rather a solemn obligation to my profession.”  Whatever my noble or immodest motivations, I let myself be maneuvered even to the committee’s chairmanship.  Jerry wished me, “Happy hunting.”

In truth at our first meeting I successfully sidestepped one land mine after another, maintaining a full complement of friends.  It could just as easily have gone otherwise.
 
At first glance a layman or a physician-reviewer might not fault the first patient record to be reviewed.  On the patient’s history page Larry, the orthopedic surgeon, had written: “This forty-five year old male came to the E.R. with a fractured femur.”  End of history.  Then on the physical examination page: “There is marked swelling and deformation of the region of the upper right thigh.  Heart and lungs, normal.”  On the pages meant for progress reports Larry wrote: “Performed closed reduction of femoral fx under gen’l anesthesia.  Cast applied.”  And lastly, three days later: “Patient walking on crutches.  Home.”  The chart furthered included the minimum blood tests required for giving a general anesthetic.  Completely impersonal, not once did Larry indicate that the patient’s name was Carl.
 
“No problem here,” said a member of the committee.
   
“Not so fast,” said another member.  “It just so happens that I’ve been Carl’s family doctor off and on and I know for a fact that he’s quite a heavy drinker.  The history makes no record of this and I see the surgery took place four hours after admission to the E.R., time enough to obtain liver function tests.  None were done.”
     
The first physician, who thought the chart passable, minimized the criticism.  “Carl got through the surgery well enough.  What’s the problem?”
          “C’mon.  Though you’re right, we’re not here to whitewash our colleagues.  The surgery was successful but if the history of alcoholism had been elicited and if liver function tests had been performed, a different anesthetic might have been indicated.  And you know what else?  Mention is made in the nurse’s notes that Carl fractured his leg when he ‘fell down the stairs at home.’  No written comment by Larry.  Listen.  I know this guy’s son.  He’s a violent kid who’s always fighting with his Dad.”
       
“So, you’re saying that the chart is lacking in liver function tests and information as to how the fracture occurred,” I summarized.
   
“I’m saying that as much as I like Larry, apart from making the right diagnosis, he did the work of a carpenter.  I hate to make an example of him but I got out the hospital record of two years ago when I admitted Carl for pneumonia.  Look at what I wrote on the discharge summary: ‘1. Pneumococcal pneumonia.  2. Chronic alcoholism.  3. Aortic stenosis, possibly from rheumatic heart disease.’  Did Larry ask the record room for old records?  Of course, not.  ‘Heart and lungs, normal’, my arse.  Any second year medical student would have heard Carl’s heart murmur.”
     
I added fuel to the fire.  “I doubt that Larry had ever sat down with Carl to ask about work-related financial concerns – nor did he call for a social service consult.  Furthermore I would have given him a gold star if he had verbalized the known myth in patients’ minds that equates a fractured leg with impotency.  So, what are your recommendations?” I asked, looking at each member of the committee.
     
Larry’s critic spoke up.   “Well, I agree that the outcome was satisfactory.  But I think Larry fulfilled only half of his responsibilities.  No disciplinary action is indicated but I believe that the minutes of this review should be given to him.  He’ll be mad as hell.  Put him on the committee next year.”
     
With a unanimous vote we did approve a recommendation that charts of all previous hospitalizations be provided the attending physician as expeditiously as possible.
   
That’s not the end of the story.  After receiving our report, Larry asked to be invited to the next meeting of our committee.  More accurately, he asked for an immediate opportunity to face his critics.  We accommodated him.
   
“What do you guys want from me?  You all trust me with your orthopedic patients.  Dave, I operated on your cousin’s knee and Jim, you let me operate on your wife’s back.”
   
I called a halt.  “Hold it.  No one has challenged your surgical competence.”
   
“Well, at least, thanks for that.  Okay.  Let’s go point by point.  Carl’s alcoholism.  Listen, he eats three meals a day and is as strong as a bull.  The anesthesia was brief, no more than fifteen minutes.  I set the fracture and took an x-ray to see if all was in place and finish.  There wouldn’t have been any ill effects even if he had alcoholic cirrhosis.  You may not know it but the anesthesiologist hasn’t had a great deal of experience with the new less liver-toxic agent.  And if Carl wants to announce that’s he’s a member of AA, that’s his privilege.  Why should I write it in the chart for busybody eyes?  It’s nobody’s business.”
   
The orthopod certainly had a point about privileged information.  We all had struggled with this dilemma.  I remember wanting one particular patient’s history to be complete; I felt smug substituting “sexual identification problem” for “homosexual,” hardly much of a ruse these days.  In an effort to direct others involved in the patient’s care I had divulged privileged information.
     
As chairman of the committee I took the liberty of concluding at the point: “I find little or no fault with your reasoning.  If no one disagrees, let’s move on.”   One hand went up.
     
“Okay.  So I missed the heart murmur.  As I said, Carl is as strong as a bull.  If he could run up three flights of stairs, I couldn’t care less if he has a heart valve problem.  It’s true that if he had had an open wound, I would have known better to prescribe antibiotic therapy to prevent endocarditis.  In that situation I might well have been negligent.  So what do you guys want?  That I have an expensive medical consult on all my cases?”
     
A committee member took me, a medical consultant, off the hook.  “No, you have a good track record for using consultants.  But if you had taken the time to review the discharge summary of the previous admission, you would have been a lot farther ahead.”
   
“No disagreement there and I do like your recommendation that old records be made available with all due haste.  You guys earned your keep with that one.”  (He was being sarcastic since he knew we received no compensation for the committee’s work.)  “As to how Carl broke his leg, I took him at his word that he tripped on the stairs.  If his son pushed him, that’s between them.”  The reader must remember this was in the 1970s before doctors accepted the responsibility for preventing violence in the home.  None of us in the room was sensitive enough to take up the gauntlet.
       
“Lastly.  ‘Sexual impotence?’  You got to be kidding!  No patient is ever going to admit he’s worried about that.”
     
Again, none of us was equipped to give a lesson in the psychodynamics of trauma.  All I could do was to say, “Well, maybe once in awhile you might just ask.”  And I did add the well-known adage that “the patient knows how he feels but not what he’s got; the doctor knows what he’s got but doesn’t know how he feels.”
 
“So now the committee will recommend routine psychiatric consultation on all my fracture cases?
 
I closed the meeting thusly.  “I’m in line to be Staff President next year.  You can make that question your first agenda item as the new chairman of the Quality Control Committee.”
 
Years ago I took a course on “Psychiatry for Internists.”   It was given by a friend, Bob Plesset; I enjoyed it thoroughly.  After the last session, I thanked Bob and added that it would be wonderful if he could repeat the course, but for an audience of surgeons.  He replied, “Listen, Dave.  If I have emotional problems, I’ll go see my internist and if he can’t help, I’ll go to a psychiatrist.  But if I have a surgical problem, I want to be operated on, not by someone who will waste precious anesthesia time by deliberating on all the implications of what he’s doing, but rather by the best man for the job, an out and out bastard.”
 
Maybe we should have left Larry alone.  If Dr. Plesset were right, we would have achieved nothing by trying to change him.  Who knows?  If successful, we may have created an impotent surgeon.