Silent Treatment

Chapter2

'Green Dolphin Street.' The Wes Montgomeryarrangement. The tune started up in Harry's head almost as soon as he hadsettled into a seat in the last row of the amphitheater. 'Green DolphinStreet.' Harry tapped out a riff with his fingers on the metal armrest. Heloved music of all kinds, but he was a fanatic for jazz. He had played basssince junior high school and still sat in with a combo when he had the time.Over the years, he had come to appreciate that 'Green Dolphin Street' tended topop into his head when he was keyed up — tense, but ready for action. He hadhummed it heading into organic chemistry exams, and later on throughout hisfamily practice-boards. And of course, during the war, it seemed he was alwayslistening to it either on tape or in his imagination. Now, for the first timein a hell of a while, it was back.

'Full house, Harry,' Doug Atwater said,gesturing toward the rapidly filling amphitheater. 'You'd think they weregiving away free stethoscopes.'

MMC was the largest of the three hospitalscontracting with the Manhattan Health Cooperative. As the vice presidentresponsible for marketing and development of the rapidly expanding HMO, Atwaterhad an office at each of them. He had come to the company six or seven yearsbefore from someplace in the Midwest. There were many, including Harry, whobelieved that without Atwater's creative energy and business sense, theCooperative and its hospitals might well have gone under some time ago.Instead, Manhattan Health had captured a decent share of the market and becomea real force in the business. Like Harry, Atwater was a devoted jazz fan,although he didn't play himself. The two of them managed to hit a club everythree or four months. And from time to time Doug would stop by C.C.'s Cellarwhen Harry was sitting in with the combo that regularly played there.

'Did Sidonis or anyone on his committeespeak to you about all this?' Atwater asked.

'Of course. Dan Twersky, the psychiatrist, got assigned to interview me. You know him? He couldn't havebeen more pompous or condescending if he had tried. He wanted to know how MarvLorello could have sewn up that guy's thumb so badly. I told him that as far asI could tell, Marv didn't sew up anything badly. Twersky asked why Lorellodidn't call in a hand surgeon. I told him that all anyone could do was clean upthe gash and suture it closed. The most skillful hand surgeon in the worldmight easily have gotten the same unfortunate result Marv did. Sometimescirculation to a wound isn't all it should be, and there is some tissue loss.He said I sounded a bit defensive of GPs. I told him that a thousandtimes out of a thousand I would choose to repair that cut without calling in ahand surgeon, and that nine hundred and ninety nine of those times the twohalves would heal perfectly. Twersky just sat there and smiled. It was an anythingyou say, Doc, as long as you don't count on ever fixin' my thumb kind ofsmile.'

Atwater reached over to give him asupportive pat on the shoulder.

'Harry, you're a hell of a doctor,' hesaid, 'and nothing Sidonis or his committee can do is going to change that.'

Steve Josephson maneuvered down the row,nodded a greeting to Atwater, and settled into the seat next to Harry.

'They just took Clayton Miller up to theunit,' he said. 'The man's doing great. A save of the highest order. After youleft, once his breathing was back near normal, he started talking baseballnonstop. He was a pro — a teammate of Satchel Paige in the Negro baseballleagues. And get this: apparently his son works for the Yankees. He says thatany time you or I want tickets, we've got 'em.'

'My kind of patient,' Harry said.

'What gives?' Atwater asked.

Harry deferred to Josephson, who detailedthe event with all the drama of a fighter pilot recounting a dogfight. Atwaterlistened, enthralled.

'Too bad Sidonis doesn't know what youdid,' he said.

'He does. I don't think he's impressedenough to call off the vigilantes, though. In fact, I don't think he'simpressed at all.'

'Well, just the same, you guys are reallysomething. I listen to you and I honestly wish I could be on the front linesinstead of sitting up there pushing pencils. Say, Harry, what's the story withEvie?'

'She's coming in later this week. Probablythe day after tomorrow.'

Atwater pulled out a black memo book andwrote down Evie's name and Flowers.

'She's a hell of a gal,' he said. 'I knowshe'll do great.'

Evie's headaches, which she had firstattributed to allergies, then to stress from her job, and finally to stressfrom Harry, had proven to be caused by something far more structural andvirulent. Harry spent several frustrating weeks trying to convince her to see adoctor and get a CT scan. Finally, she ended up on the neuro ward, with thickspeech and a weak right arm. The tests revealed a large berry aneurysm on heranterior cerebral artery, which had bled and then sealed over. Evie was lucky.Rapidly, her neurologic symptoms had resolved. A period of rest coupled withserial CTs was her neuro-surgeon's recommendation. Now, it was time for thebulge in the vessel wall to be repaired.

'Harry,' Atwater said, 'be sure and let meknow if there's anything Anneke or I can do to help the two of you out.'

'Anneke?'

Doug's smile was mischievous. When he andHarry went out to hear music, he invariably showed up with a date — always adifferent one, and each, it seemed, younger and more attractive than the last.

'She's half Swedish and half German,' heexplained. He thought for a moment, and then added, 'I guess it's the top halfthat's Swedish.'

'Hail, Caesar, we who are about to diesalute you,' Steve Josephson said, gesturing toward the small stage at thelower end of the amphitheater. Caspar Sidonis had just taken his place at themicrophoned table in the center of his six-member committee.

'Could I have your attention, please,'Sidonis said, tapping at his microphone. 'Let's get started. We have a gooddeal of important material to cover. . Please, would you all take your seats…'

'If people keep talking, I wonder if he'llstart throwing things like he does in the OR,' Josephson whispered to Harry.'I've heard he's had enough complaints filed by scrub nurses to fill the phonebook. The hospital doesn't do anything about his tantrums because they'reafraid he'll take his act somewhere else. The guy brings in millions ofdollars.'

'Whatever Caspar wants, Caspar gets,'Harry sang to the 'Lola' tune.

'I don't have very good vibes about thisat all, Harry.'

'I can't think of any reason you should.'

Caspar Sidonis, in his early forties, hada matinee idol's good looks, which he augmented by being impeccably andexpensively dressed at all times. He had been first in his class at Harvard Medand never, ever let anyone forget it. He had also won MMC's tennis and squashchampionships several years running, and was rumored to have been a collegiateboxing champion.

'Green Dolphin Street' intensified inHarry's head. Funk or no funk, he did not want to be told what he could andcould not do as a physician — not by HMOs, not by insurance companies, andespecially not by a pompous, overblown, crank-'em-through super-technician likeSidonis. He glanced around the hall at the other GPs, thinking about all thoseyears of study, the countless hours of continuing-ed courses, their willingnessto endure the low prestige and even lower reimbursement that went with being afamily practitioner. They deserved to be rewarded, not restricted.

'Harry, for chrissakes, say something.They're crucifying you.'

Doug Atwater, seated to Harry's right,clenched his fist in frustration as, one by one, the Sidonis committee'srecommendations were presented to the medical staff. To Harry's left, SteveJosephson was shaking his head in disbelief. He had tried arguing against thefirst of the committee's proposals, which required that a board-certifiedobstetrician be present for all deliveries. Josephson had once made headlineswhen, as a passenger stuck in a disabled subway car, he had successfullydelivered the twins of one of the other passengers. Now, it seemed possiblethat deliveries in such situations would be the only ones he would be allowedto perform.

The vote, despite Josephson's emotionalarguments and well-publicized heroics, was nearly unanimous. Only the three GPswho still did deliveries voted nay. The rest abstained, perhapsbelieving that the staff would conclude they were responsible enough to policethemselves, and back off from supporting the other restrictive resolutions.

'There goes the new refrigerator,' Harrysaid.

The next resolution, requiring GPs to turnover their Coronary Care Unit patients to a cardiologist or internist, passedeasily. The cardiologist who had taken over Clayton Miller's care was one ofthe few dissenters who wasn't a GP. Then came the vote to limit surgicalparticipation by GPs to first assisting only. Again Sidonis's committeeprevailed.

'History will refer to this next one asthe Marv Lorello Proviso,' Harry whispered as discussion began on the last ofthe committee's proposals.

'It is recommended,' Sidonis began,adjusting the Ben Franklin reading glasses that Harry sensed he wore more forhis image than for his vision, 'that all suturing done in the Manhattan MedicalCenter emergency ward by a non-surgical specialist be approved in advance bythe senior emergency physician on duty.'

The murmur around the amphitheatersuggested that many were surprised by this final, and perhaps most humiliatingproposal. Harry had had advance warning, but the words stung nevertheless.

'There have been,' Sidonis went on, 'anumber of cases reported to our complaint committee, and to our liabilitycarrier, in which improper technique was used or faulty judgment displayed bycertain non-specialists. Mrs. Brenner of our risk-management office has assuredme that developing some sort of internal pretreatment screening policy couldsignificantly reduce the number of claims against our non-specialty staffmembers.'

He glanced vaguely in Marv Lorello'sdirection, and several dozen pairs of eyes followed. Lorello had joined thestaff just a few years before after serving three years on a reservation in theIndian Health Service. He had impressive academic credentials and a refreshingidealism about practicing medicine. The malpractice suit — his first — and thesubsequent fallout from it had hurt him deeply. Harry did his best to remainexternally placid. But 'Green Dolphin Street' was playing on, up-tempo now andlouder.

Then suddenly, the music stopped. It tookseveral seconds before Harry realized he was on his feet, his six-one frame thecenter of attention of everyone in the amphitheater. He cleared his throat. Thefaces stared up at him, waiting.

'If it's all right with the chairman,' heheard himself saying, 'I… um … I guess there are a few things I need to getoff my chest before we vote on this last — and for the family practitioners,most degrading — proposal of this commission.' He paused for objections andhalf felt Sidonis was about to voice one. The silence, however, was total.'Okay. Thanks. It's not my intention to belittle anyone's specialty by implyingthat someone with less training might be able to do exactly what it is they do.But I do want to stress that we generalists are well trained to do some ofthose things. We are board-certified in family medicine, not half-assedmedicine. We went to medical school just as you did, we had residencies just asyou did, we care about our patients and continue our education just as you do,and most important, we recognize our limitations, just as I hope you do.

'Most of us can handle being treated withthe sort of disdain I've heard expressed here today.' He looked pointedlyacross the auditorium toward Sidonis. The impressive silence continued. Not acough. Not a clearing of a throat. Not a creaking of a seat. 'We can handle itbecause we believe in the specialty of medicine we have chosen. Now, we'vebecome something of a convenience to the insurance companies and HMOs. Theycall us primary care physicians. By that they mean medical traffic cops,screening the mundane and insignificant complaints so that the much moreexpensive specialists won't have to deal with them. And that's okay. Most of ushave adjusted to that new order, too. Just as we'll adjust to first assistingon simple appendectomies and other operations we have performed dozens of timesourselves, or turning our coronary care patients over to someone they don'tknow.

'But this — ' Harry gestured to the hugescreen behind Sidonis, on which was displayed the last of the committee'srecommendations. 'This I simply cannot accept. You know, we doctorspersistently lay the blame for the malpractice crisis on lawyers. There are toomany lawyers. The contingency system is wrong. The way they advertise isinflammatory. Well, that may be so. But that is hardly the whole story.Patients don't know us anymore. We don't portray ourselves as partners in thebusiness of keeping them healthy. Instead, most of us come across as just whatwe are — specialists, interested only in making sure that the body part we havebecome expert at works properly. Hey, lady, I'm sorry you have to get toBrooklyn, I never drive past Forty-second Street. Well, I know how to suture.I've sutured wounds you wouldn't believe in situations you wouldn't believe.I'm damn good at it. So is Dr. Josephson, here, and Marv Lorello, and every oneof the rest of us who chooses to sew up our patients when they cut themselves.I don't need to be told what I can and cannot fix. None of us does.

'So I say, enough. The return tothe kinder, gentler days of the rumpled, overworked family practitioner makesfor great conversation around the medical cocktail party circuit. But when thechips are down, no one s ready to challenge the great god science, and to saythat there's still a place for doctors who know their patients as whole people,and want to care for them regardless of what is wrong. I wish that instead oflimiting this session to medical staff members you had invited some of thosepatients to be here. Once you understand what having a doctor means tothem, perhaps you will remember what being a doctor should mean to us.These proposals are all humiliating and unnecessary. But this one is even worsethan that. Don't pass it.'

Harry hesitated and then sank to his seat.The heavy silence continued. Finally, Steve Josephson reached over and took hishand.

'Thank you,' he said hoarsely. 'Thanks fortrying.' Then, from across the amphitheater, the applause began. It spreadquickly around the hall until nearly everyone had joined in. Then they werestanding. Several of them cheered out loud. Others rapped on the woodenseatbacks in front of them. Caspar Sidonis sat rigidly in his seat, crimsonbeneath his perpetual tan. The other members of the committee shifteduncomfortably.

'It appears there is a great deal ofsentiment surrounding this proposal,' Sidonis said after he had finally managedto reestablish his authority. 'I would suggest that perhaps we should tablefurther discussion until our committee can meet again with the risk-managementpeople and reconsider this issue.'

'No, let's vote!' someone shouted out.

'How about another vote on all thoseproposals,' another yelled.

Suddenly the entire medical staff seemedto be talking and arguing at the same time. Sidonis, bewildered and unsure ofhow to handle the situation, looked about for help. He was bailed out by thechief of the medical staff, a burly orthopedic surgeon who had twice been anAil-American linebacker at Penn State.

'Okay, everyone, cool it!' he barked out.'That's it. Thanks. I want to thank Dr. Sidonis and his committee for a jobwell done. It seems this last issue is controversial enough that we ought tosit on it for a while. I know this whole business of who does what is not easy,and would like to praise the staff for its courage and the nonspecialtypractitioners for their understanding.' Two physicians booed. 'Come on, growup,' the chief snapped. 'We gave Dr. Sidonis and his committee a mandate, andthey have lived up to it. Now, I think we owe them a round of applause.'

Grudgingly, the staff complied. Thesession ended with a word of praise for the hard work of the Sidonis committee,and a plea for understanding and unity among the staff.

'You primary care physicians are still thefoundation of our medical delivery system,' he said. 'Never forget that.'

Harry accepted the handshakes andcongratulations of Doug Atwater, Steve Josephson, and a number of the otherstaff members. But he knew that while he had helped the GPs save face, theirloss of stature was severe. The groundswell of support following his speech hadnot changed that. He worked his way free and headed down toward the exit by theamphitheater stage. He was nearly there when Caspar Sidonis stepped in front ofhim. For a moment, Harry thought the former boxer was going to take a swing athim.

'Enjoy your little show while you can,Corbett,' he said. 'It's not going to make a bit of difference around here. You'vealways been a wiseass. But this time you've picked the wrong person to fuckwith.'

He whirled and stalked away.

'Asking you over for tea?' Doug Atwaterasked.

Harry recovered and forced a smile.

'There's something going on with that guyand me.

Something beneath the surface that I don'teven know about,' he said.

'Forget about him,' Doug replied. 'Comeon. Let me buy you a Coke. You're a hell of a guy Harry. A hell of a guy.'