Chapter 31: You're Quite the Subversive!

August 2, 1989, Circleville, Ohio

"Jesus, Petrovich!" Clarissa exclaimed. "What did she say to that?"

I'd called Clarissa from a payphone before I'd left Lou's, and she met me at the house just after I put Rachel down for her afternoon nap.

"Nothing, really. I didn't expect an answer because I wanted her to think about it."

"You're not concerned she'll change her mind about the hearing for Angie?"

"I'd say she's less likely to do so now because she's on notice about how badly she's screwed up."

"Don't you think you were a bit harsh?"

"Seriously, Lissa? Who else would speak to her that way? I simply took my cues from how Residents and Attendings have spoken to me over the past four years. Think about the situation — she's in independent practice, so who really watches over her? Even the Chief Attendings at Moore are accountable to the Medical Director and their peers in an M & M."

"The Medical Licensing Board."

"Tell me another bad joke! Look how difficult it is in a clear-cut case of malpractice with regard to Angie! And you know what happens to most complaints."

"Closed with 'no further action'. But are you saying nobody should be permitted to practice independently?"

"No, but some kind of oversight is necessary, and the Medical Licensing Board does not have the resources to do it properly. That's why the majority of disciplinary cases are handled internally at the hospital. Egregious cases are forwarded to the Medical Licensing Board, and they do take action, but that's because the reports come from other doctors or the hospital administration.

"Consider Angie's situation and how well THAT works with no actual oversight. The insurance company paid the malpractice claim with no admission of actual liability or error by Doctor Greenberg. That means other than in the records of his malpractice insurer, it never happened so far as the public record is concerned. We're remedying that, but only because Lara is providing the money to mount a complaint with actual teeth.

"And think about the end result — there is no additional money to be had, as all current and future claims were covered by the payment from the malpractice insurer. So there is no benefit to Angie from the process. The Stephens wouldn't have funded it because they don't have the resources, and it would have been foolish to spend Angie's settlement to go after Doctor Greenberg's license.

"The system we have, and not just for mental healthcare, is rigged in favor of doctors, and despite the strict licensing regime, there is little actual oversight because the process is designed to limit the ability of the public to hold doctors accountable. I absolutely agree there needs to be a way to limit baseless or frivolous claims, but the current rules make it difficult to address even legitimate complaints."

"Would you be willing to have that kind of scrutiny?"

"So long as we work in a hospital, we will. And it's incumbent on us to ensure that our peers hold us accountable and we hold them accountable. And lest you think I'm tilting at windmills again, I did consider asking for an M & M for my 'alien encounter' patient but rejected it because it had little chance of success and was not the right battle to fight at that time."

"But isn't it similar to Angie?"

"Somewhat. I made the point the best I could, given the circumstances. It's also the case that Mr. Alien Encounter was off his meds. I didn't know that at the time, but Lydia Samson let me know when she was in the ED for a consult. That distinguishes it from Angie's case because being off her meds improved her situation, whereas that wasn't the case with Mr. Alien Encounter."

"Did you know he was taking medication?"

"No, and he wasn't exactly forthcoming. According to Lydia, he claimed the drugs were part of the government conspiracy that includes Area 51, Wright-Patterson Air Force Base, and anything else to do with the aliens who are among us."

"Just out of curiosity..."

"Do I think there is life on other planets? Probably. Have they visited us? Unlikely. And if they have, they took one look around, shook the dust off their feet, and beat it for a planet with actual intelligent life!"

Clarissa laughed, "There might be something to that."

"But in all seriousness, the cases are distinguishable in that Angie was showing signs which contraindicated her diagnosis, while Mr. Alien Encounter was showing signs that confirmed his diagnosis."

"What was that?"

"Paranoid personality disorder. I don't know enough to have a medical opinion, but his behavior did fit the basic DSM criteria. Once he was back on his meds, he became more rational, but it's a good bet he won't remain compliant. It's a similar problem to Angie's in that way. She has always tried to avoid taking the prescribed drugs. And that is likely to be one of Doctor Greenberg's defenses."

"So, how do you counter that?"

"That when she revealed to me that she was not taking her prescribed drugs, I insisted she take them and speak to Doctor Mercer about modifying the treatment regimen, and she complied with my request. She was only taking mild sedatives at the time, not the antipsychotics, and she was perfectly lucid and was making plans. And her approach was VERY different from how she approached it at Taft."

"Either 'do not touch me' or 'fuck me right now'."

"Yes. She was fully aware of her situation, and her goal of regaining her driving privileges was a proxy for regaining the right to consent so she and I could marry and have kids."

"Are you actually going to say that?"

"Yes. It's in the statement I signed for Tom Kirkland, the attorney from Stefan's firm who's handling the case. And I'll repeat that before the Medical Licensing Board at the hearing."

"But as a private citizen, right? Not as a doctor?"

"Correct. I won't wear a medical coat, and I'll make it clear I'm speaking simply as Angie's friend and won't address anything other than directly observed behavior."

"But you just said something that's not directly observed."

"She told me her goal, Lissa. One that was obvious to everyone, including Doctor Mercer and Father Stephen. And Tom Kirkland has a statement from Father Stephen to that effect, so even if I don't say it, it'll still be entered into the record. And you know it was Doctor Greenberg's declaration that marriage was impossible that caused Angie's relapse. That's a fact, and there is nothing Greenberg can do to counter that fact. It really is a question of what punishment will be meted out."

"You know Lawson is going to come gunning for you."

"He can't really do anything to me despite his threats. Remember, the facts are all on my side, and his buddy settled a malpractice claim AND is being brought before the Medical Licensing Board. I didn't try to treat Angie, and I sent her to Doctor Mercer as soon as I discovered she was non-compliant with her meds. What is Doctor Lawson going to complain about? That I show love for my friend? That I'm concerned for her welfare?"

"What about your policy violation?"

"Iffy at best, because I didn't prescribe any treatments, I simply made a recommendation to the Psych Resident. I humored Mr. Alien Encounter so I could perform a physical. In that way, it's no different from how we sometimes handle kids."

"Your candy bribes?"

"They work and don't violate policy. If I'd done anything other than perform the physical and recommended humoring him, then Lawson would have a leg to stand on. As it is, he doesn't. And I have the ultimate out."

"Elizaveta?"

"As one component of extreme stress for which I've sought counseling. What is he going to say? I haven't made any medical errors, and I've had perfect scores on my evaluations. So, even if my judgment about the best course of action for Mr. Alien Encounter was off, the combination of stress and my concern for Angie put Lawson in an impossible situation. I bet he does nothing, even if Greenberg is disciplined."

"You're counting on him to be rational?"

"Yes. What does he gain by gunning for me? His implied threat didn't work, and Doctor Mercer, Doctor Hoffman, and another psychiatrist hired as an expert witness will all testify to the same things I am. I'm not the lone voice crying in the wilderness. Rosenbaum and Mastriano are a bigger threat, but she's more or less defanged because she tried to contradict Northrup and Cutter."

"You don't think the 'adulterous bitch' will try revenge?"

"How will it look when I stated to Doctor Nielson that I agreed with Doctor Mastriano on how to handle the court order for a blood draw?"

Clarissa laughed, "Not good; for her, that is. I'm curious about that."

"About?"

"Your take on it."

"I have an ethical problem with court-ordered procedures in any instance, and in this case, there was a simple solution — transport him to the lockup and have the nurse and deputies there draw the blood. Can you imagine if the patient fought us and had to be subdued in a trauma room? I can't see that ending well."

"I agree. What about the situations we discussed in Practice of Medicine? Jehovah's Witness parents who refuse blood transfusions that will save their kid's life?"

"I'm guided by the Orthodox understanding of medicine, but I also cannot let my faith determine what is or isn't acceptable for someone to believe. It's a difficult call, given the competing interests, but in the end, I think I'd err on the side of giving the transfusion. That said, if the kid were old enough to give their opinion, I'd take that into consideration as well."

"What about a court-ordered abortion? Like the one performed on Liz."

"I refuse to perform elective abortions, period. In my view, mental health is not a consideration. That said, you know I don't believe that decision can ever be up to anyone except the woman and her doctor. I simply can't, in good conscience, impose my views on others with regard to medical procedures which are legal under our system, and the Supreme Court has made it clear that a specific medical procedure cannot be made illegal, at least during the first trimester."

"Do you agree?"

"Does it matter? I have a say about my body, not about yours or anyone else's. When I can get pregnant, then it will be up to me. I believe I have the right to give my opinion but not the right to decide. And that's how all medical procedures are handled. We can't force any patient to accept any treatment, nor can we be forced to provide it, except in very limited circumstances and with an appropriate court order. But even with the order, no individual physician can be compelled to perform the procedure.

"With regard to medically necessary abortion, it's one thing for me to say that I'm willing to die for my faith; it's a very different thing for me to say a woman should die for my faith. That's the error the Romans make in the way they handle abortion both theologically and in their hospitals. Orthodoxy objects to abortion but treats it as it does any other act of 'missing the mark' — based on the totality of the gravity of the act and the circumstances."

"I've read that some Orthodox bishops want it made illegal."

"And they are within both their legal and canonical rights to advocate that. In the end, though, it comes down to having a responsibility to shepherd their flock, and that includes a proper response to 'missing the mark'. But we're WAY off topic!"

"Yes and no," Clarissa replied. "We will have to face all manner of ethical dilemmas, and Mr. Alien Encounter was the first of many."

"You're forgetting my encounters with some young women from Saint Michael."

"The ones you fucked or the ones you encountered in a medical setting?" Clarissa asked with a smirk. "And I think those two sets overlap, if I read the tea leaves correctly!"

"Smart ass!" I chuckled. "No comment."

"Uh-huh."

She was correct in that I'd encountered Irina at the Free Clinic and had also been intimate with her after Elizaveta's repose.

"Whatever, Lissa! That's all in the past now."

"How much does Kris know?"

"Very little, by her own choice, as I think you and I discussed."

"Yes, I was just curious if that had changed. You know I won't say anything."

"Nothing has changed. In that way, she's more mature than Elizaveta, who was always trying to figure out who I'd been with. It still bugged Elizaveta even after two years of marriage. That said, Kitten was exactly who I needed at the time, and I wouldn't do anything differently."

"Your relationship with Kris is very different."

"It is, and it's more of a partnership with shared goals, which is exactly what I need now. I think the past month has proved much of my thinking about relationships to be correct, and only a strong, independent woman could deal with the situation. Elizaveta would have struggled but found her way through. Kris doesn't struggle."

"Because she still lives what amounts to an independent life," Clarissa observed.

"Yes and no. She's accepted responsibility for Rachel, and you know full well from the past two years that parents don't have a life independent of their children. Rachel is the most demanding person in my life, and everything I do has to consider her, even if the demands of medicine interfere. The balance is difficult."

"Which is my main reason for waiting to finish my Residency before I have our baby. I'll make an appointment with a fertility specialist in about eighteen months to work out a plan with the goal of having our baby about three-and-a-half years from now."

"Perfect timing, given Kris and I will have two kids in the next three years, assuming nature coöperates."

"Circling back to the reason you called, how did you leave it with Doctor Mercer?"

"That we'd speak again after the hearing on the 23rd. Fundamentally, I don't trust her at this point, and it will take time and effort on her part to regain the trust."

Clarissa looked at her watch and said, "Tessa's shift ends in fifteen minutes, and I want to be home when she arrives."

We got up, and I walked Clarissa to the door, we exchanged a hug, and I watched as she walked to her car and drove away. I had some time to simply relax, so I put on music, put my feet up and chilled until Rachel woke up from her nap. I'd just finished changing her diaper when Kris arrived home.

"How did things go?" she asked after we exchanged a hug and a kiss.

"About as I expected," I replied. "Clarissa was here this afternoon, and we talked it through."

"That bad?"

"I basically read off Doctor Mercer and wanted Clarissa's opinion and advice. I want yours, too."

"Let me change, and then you can tell me."

She went upstairs and came back down in short shorts and a tight white T-shirt, obviously not wearing a bra.

"And I'm supposed to be able to think coherently with you dressed that way?" I asked with a silly smile.

"Given you're male, coherent thought is difficult under the best of circumstances!" Kris teased.

"Yeah, yeah," I chuckled.

We sat down on the couch with Rachel playing on the floor in front of us, and I described my conversation with Doctor Mercer and the debrief with Clarissa afterwards, though I had to finesse the situation with Samantha.

"She would have objected to us marrying, wouldn't she?"

I nodded, "I'm positive she would have. Her arguments would have been slightly different but along the same lines."

"How is it that she can only seem to apply what she considers to be 'normal' without considering the individual?"

"It's the training," I replied. "While she's not an MD, she was trained in a way analogous to our clinical rotations, and doctors are repeatedly reminded that the 'standard of care' is how they'll be judged. That means if you follow the guidelines, you will never, ever get into serious trouble because 'standard of care' is a sufficient legal and ethical defense. That's how Doctor Mastriano avoided any liability for the death of the patient."

"But she was disciplined!"

"For substituting her judgment about my training for that of Doctors Northrup and Cutter."

"So she killed the patient, and that's OK?"

"No, it's not, but because of the way the system is set up, discipline in cases where you follow the standard of care has to be limited. There are competing impulses, mostly driven by malpractice claims — what's called 'defensive medicine' and rigorous adherence to the standard of care. And 'defensive medicine' has costs, both in terms of resources expended and in subjecting a patient to what might be unnecessary tests.

"For example, in the Emergency Department, the standard is to run a full trauma panel on patients brought in by ambulance. I had a patient for whom that was totally unnecessary, so I didn't order it. If something had gone wrong, I could have been held responsible for not running the tests, even though it made perfect sense not to run them. I believe I could defend not running them, but nobody would ever question me if I did, even if they were unnecessary. My beef with Doctor Mercer is she relied too heavily on 'standard of care' as a defense, but as I said to her, that's a product of our training and of the environment in which we work."

"So you're a rebel?" Kris asked.

"Only insofar as I'm looking out for the best interests of my patients or identifying flaws in the system. And it's not that I would ignore the standard of care because I wouldn't. But it's only a guideline, except in one instance — malpractice. Going beyond the standard of care might get me a talking to about expending resources, but my concern is, and always will be, the best interest of my patient.

"As for defensive medicine, it takes resources which could be put to better use. I understand why it happens, and unless there are real reforms to the system, it's not only going to continue but get worse. Once somebody has a condition where a CAT scan might have saved their life, and their family sues and obtains a settlement, we'll be doing routine CAT scans, which are far more expensive than a trauma panel by at least an order of magnitude, if not significantly more."

"You know my answer!" Kris said with a smile.

"And you know my response! We already have 'socialized medicine', what we don't have is single-payer or complete government control. And I'm not sure either of those would improve things overall. It all comes down to one thing — are the doctor and patient allowed to determine the best course of treatment without any interference by bureaucrats, be they employed by the government or an insurance company?