Chapter 47: The Woodshed

September 11, 1989, McKinley, Ohio

"Jesus, Petrovich!" Clarissa exclaimed while we were having lunch just after 1:00pm on Monday afternoon.

"Tell me I'm wrong or that anything I said to Doctor Mertens, Doctor Gibbs, and Doctor Gabriel was wrong."

"You probably aren't wrong, but you know people are going to assume you're sleeping with her."

"Let 'em," I replied. "I know it's not true, you know it's not true, and most importantly, Kris will know it's not true. If someone says it to me, I'll demand proof, and if teaching a student, even remedially, is 'proof', I'll get the new rule implemented before you can say 'Jack Robinson'."

"Where did that phrase come from?"

"No clue. It wasn't one of the ones Mr. Black took time to explain, which, I suspect, means there is no verified origin story of which we're aware."

"Back to your Quixotic quest — what now?"

"Nora Mertens has a meeting with Doctor Northrup in about an hour. I don't see how he can reject the request without risking outside intervention. Krista isn't an idiot, and all she has to do is say that the doctors demanded she sleep with them or they'd blackball her, and someone she turned down is blackballing her."

"That's true?"

"Does it matter? It wins because it could be true. Think about a jury, told about doctors banging medical students, told about the fact that she's being held accountable but the doctors aren't, and told that she believes she's being punished for not having sex, or for having sex, or both, while the doctors all skate."

"Ugly."

"Exactly. This isn't an issue of medical training, and you know how I'll testify."

"That she's an average but competent clinician who appears to have been treated unfairly."

"And that I have no knowledge about her relationship with any other doctor except for me. What do you think happens if someone accuses me of sleeping with her at that point?"

"Scorched earth. But you'll screw yourself."

"Will I? What's Doctor Roth's position? And Doctor Strong's? And Doctor Gibbs'?"

"And if you're wrong about her?"

"Then I give her a substandard grade or fail her, and neither she nor anyone else can legitimately say a thing about it. Similarly, if I give her a passing grade, who could legitimately argue with it? Think about why they assigned Felicity and Tim to me. And, honestly, why they assigned Krista to me."

"There has to be some potential downside."

"Yes, if I'm wrong, it will harm my reputation and create impediments in the future. That said, I can mostly mitigate it by admitting I was wrong. The challenge would be if I'm wrong, and then there's a future student who needs my help. It would harm them more than me. But you know I can't sit idly by and allow an injustice to occur."

"No, you couldn't. Isn't Jake going to be upset?"

"I'll have two Fourth Years. I'll simply see more patients because I can have each of them do a workup, then see the patients in turn."

"You actually might be onto something to speed up how quickly patients are seen."

"Possibly, but that's not the main point."

"Obviously, but it might be part of the solution. Of course, there are a limited number of Fourth Years, though I know there are some who would like to have multiple emergency medicine Sub-Is but who can't because of limited slots."

"The challenge, of course, is finding Residents who want to teach and are able to teach multiple students at a time. But we'll worry about that in the future."

We finished our coffee, and I returned to the ED while Clarissa returned to Internal Medicine. Jake, Heather, and I saw four patients and just after 3:00pm, Nate let me know that Doctor Northrup wanted to see me. I checked with Doctor Gibbs, then went to the administration wing.

"He's expecting you," Mrs. Andrews said.

I went into the office and saw Doctor Mertens and Doctor Warren as well. I greeted them, then sat down at a nod from Doctor Northrup.

"This entire situation is very irregular," Doctor Northrup said. "I'm concerned about significant disagreements amongst my Attending and Residents over a medical student and the dissension it seems to be causing. I'm also concerned about the claims of unfair treatment and double standards. And I'm also concerned about the rumors that are flying. Doctor Loucks, you've put me and the medical school in a very tricky situation.

"I'm sure you're aware that the training program for medical students is far from perfect, but it does work. Can it be improved? Yes, of course. And you benefitted greatly from one of those improvements — Preceptorships. That said, what we cannot have is a specialized training program targeted at a single medical student. That's simply not sustainable. In addition, it's also not practical or reasonable to assign two Fourth Year students to a Resident.

"I've listened to what everyone has to say, and off the record, I believe we've handled this situation poorly, and it reflects badly on the hospital. That said, there is no easy solution to the problem before us. I'm reluctant to support any plan which does not conform to our standard practices because I do not want to set a precedent that either allows students to pick their Residents or Residents to pick their students. That is a recipe for trouble similar to the issue at hand.

"Doctor Loucks, if we were to accept your proposed solution for Miss Sandberg, it would, of necessity, mean swapping her shifts with Mr. Green, something he expressly rejected. I don't believe it wise to, in effect, punish him to benefit the wishes of another student or even of a Resident. What that means is, despite the agreement of Doctor Gibbs and Doctor Casper, I have to reject the proposed solution.

"Doctor Warren, Doctor Mertens, and I had a lengthy discussion on how to address the specific complaint. Doctor Mertens proposed a solution on which the three of us agreed. Miss Sandberg will repeat her emergency medicine rotation starting in December, and her grade for that second rotation will be her grade for both rotations. No record of that specific grading standard will appear in her transcripts.

"Her next rotation is Internal Medicine, and I spoke with Tim Baker right before I called you upstairs, and he will instruct his Residents to treat her as they would any other Fourth Year. He's confident that will happen. This change would cause her to give up her rotation in Pedes, but that's the price she'll have to pay if she wants to attempt to improve what would be a sub-par or failing grade.

"As for assignment, I will ask, but not require, Doctor Gabriel to match Miss Sandberg's schedule to yours as best he can, provided it fits within the normal scheduling guidelines. Scheduling of student hours has always been delegated to the Chief Resident, and I'm not of a mind to change that, nor to undermine their final authority on the matter. We'll inform Miss Sandberg of her options, and Doctor Mertens will modify her schedule for December and January if Miss Sandberg agrees."

"OK," I replied, absolutely positive Doctor Northrup was not interested in a debate.

"Now, to you, Doctor Loucks. Everyone here believes you are an excellent clinician, but you are irreverent with regard to policies, intemperate with regard to demanding change, and impatient with the process. If you do not get control of those tendencies, you won't make it to an Attending position. We all see things that ought to change, and we all get frustrated from time to time, but that is not license to disrupt the operation of the Emergency Department. I'm going to ask Doctor Gibbs to closely mentor you on that, and your evaluation as a Resident will depend on it."

I was tempted to simply say 'bullshit' but held my tongue and silently repeated the Jesus Prayer forty times.

"OK," I said evenly.

"Go back to work, Doctor," Doctor Northrup said. "Doctor Mertens will speak to Miss Sandberg."

"Yes, Doctor," I replied.

I got up and left the office, more frustrated than I'd been in a long, long time. I decided to take advantage of being excused from the meeting to go to Internal Medicine to see Clarissa.

"Uh oh," she said as soon as she saw me. "18 is empty, so let's go there."

I nodded and followed her into the empty patient room.

"What happened?"

"I said the Jesus Prayer forty times to prevent me from saying 'bullshit' to Doctor Northrup when he basically told me to shut up and do my job and not rock the boat."

"I think before we discuss that, I need to ask what happened with regard to Krista Sandberg?"

"Swapping a pedes rotation for a second emergency medicine rotation, with her grade on the second rotation being her grade for both rotations and nothing in her record about that grading system. That'll be in December, but no guarantee she'll be assigned to me. Her next rotation is Internal Medicine, and Doctor Northrup said he'd call Doctor Baker and ensure Krista is treated the same as any other Fourth Year. I hope you'll keep an eye on that and let me know if that doesn't happen."

"Sure. Now, tell me how much trouble you're in."

"He said that I'm 'irreverent with regard to policies, intemperate with regard to demanding change, and impatient with the process'."

"He's not wrong."

"No, he's not. But it's what he said next that's the concern — he said my frustration isn't license to disrupt the operation of the ED and that he's instructed Doctor Gibbs to monitor me, and my evaluation will depend on not doing that. It's, in effect, an order to shut up and do as I'm told."

"Or a request to back off in the only way you, who needs to occasionally be whacked on the nose with a rolled-up newspaper, would understand and take to heart."

"Maybe," I admitted.

"There's no 'maybe' about it, Petrovich. You'd accept a reprimand or rebuke such as that from your bishop if it was accurate, and Doctor Northrup's description of you is accurate."

"Except what he's saying is that nothing is going to change. It's exactly the problem with the OB chief at Good Samaritan that Doctor Kelly and others identified — an unwillingness to accept necessary changes for the overall benefit of the practice of medicine. In effect, he's saying he's OK with doctors sleeping with medical students AND is OK with sex in on-call rooms."

"I think you might be reading a bit too much into it."

I shook my head, "Why rebuke me as irreverent, intemperate, and impatient about policy and changes if that's not the case? Think about the things I asked for, and apply the response to those."

"We did say we would have to wait until we're Attendings to make real change. You pushing now would qualify as impatience."

"So we just ignore it? And what happens when the sexual harassment complaints are made? You know they will be."

"The hospital quietly settles to keep it out of court."

"And won't change policy to avoid looking guilty."

"You're in one of your moods, Petrovich. What did you say?"

"Four words. I said 'OK' twice, then 'Yes, Doctor' when I was dismissed."

"What are you going to do?"

"Practice medicine. But this is going to blow up, and you know it. And someone is going to come to me, take a deposition, and all hell is going to break loose because I won't lie to cover their sorry butts. That said, I am going to push Doctor Mertens to make having sex in the hospital while on duty an ethics violation, with dismissal recommended. She was receptive to that idea."

"Neatly cutting the Gordian knot."

"And I'll get grief for it, but Lissa, it has to stop before something really bad happens and courts or the legislature impose rules on us that are not conducive to good patient care. No judge and no politician has a freaking clue about it unless they're medical doctors, and those are few and far between."

"Don't you think they got it right in New York?"

"Do you think a hard and fast rule, with potential civil and criminal liability, is in the best interest of patients? Or is flexibility a necessary component of good medical care? And what happens when they get it wrong, but the change sounds good to the public yet needlessly makes medical care more difficult or more expensive? I'll answer — the politicians blame the doctors and hospitals and get zero blame for the problem they created.

"It's the same problem with shifting away from insurance to government programs — there is no actual accountability. Yes, you could argue that insurance companies avoid accountability, but that only proves my point — they use the courts and the regulations to escape responsibility and liability. A bureaucrat is going to be even MORE insulated from the public because, as was made clear in Civics class, you can only sue the government with its permission, and the remedies, if there are any, are generally weaker than against a private company."

"You must be pissed! You're discussing politics and political theory."

"You're a safe ear," I replied. "I can rant to you without worrying that someone will rat me out. And Doctor Gibbs has been assigned to be Chief Rat, in addition to Chief Attending."

"Jesus, Petrovich."

"That was made clear by Doctor Northrup. Which means her butt will be in a sling if she doesn't rat on me. And that means I can no longer be honest and speak my mind to my first mentor. What was left unsaid is what Doctor Northrup is going to say to Doctor Cutter."

"Because you're officially on the Surgical Service. What about Doctor Lindsay? She seems sympathetic, and I believe she agrees with you. And she's Doctor Roth's star pupil."

"I don't want to drag anyone else into this mess at the moment."

"Besides me?"

"You signed up for this when you decided to take me in as a stray and began whacking me on the nose with a rolled-up newspaper! Little did you know you were boarding a high-speed train to Crazy Town."

"I suppose that's better than a Highway to Hell!"

"Actually, I retract that because of the implications with regard to mental health. Make it a 'highway to the danger zone'. Anyway, I need to get back to the ED."

"Dinner?"

"I'll call you when I'm free. If you don't hear by 7:00pm, assume I can't get away."

"OK."

We hugged, and I left the room and headed back to the ED. I found Jake and Heather, and we began seeing walk-in patients. I knew, at some point, before the end of the day, Doctor Gibbs would ask to see me, and that happened about 4:00pm.

"I warned you," she said firmly. "And so did Pete and Ghost."

"I just want you to answer one question with complete honesty," I said. "Off the record, do you, or do you not, think it's inappropriate for doctors to sleep with medical students?"

"That's neither here nor there," she countered.

"I'd like an answer, Doctor Gibbs," I said formally.

"Mike..."

"The only thing I have to say is that I'm happy this isn't the Soviet Union, where I'd be shot for pointing out the flaws of the Party."

"You're being overly dramatic."

"Answer the question, then, Doctor."

"I'm not the enemy," Doctor Gibbs replied.

"No? Doctor Northrup made it clear that you're his «стукач» (stukach)."

"Translation?"

"Stool pigeon or snitch. I was told to shut up and desist, and you were going to monitor me and base my evaluation on my fidelity to the Party."

"Mike, please..."

"Please what? Keep quiet when an injustice is being perpetrated? Look the other way when someone is blackballed either for taking advantage of the policy or for refusing to? I don't know which, but either one is wrong. And the Old Boys Club is closing ranks. Every single department head is male. You're the only female Chief Attending. Tell me how it looks to a neutral observer."

"Mike, I don't want to fight with you."

"You don't have to. I recall a PGY2 admonishing a First Year about something exactly like this. She said, 'If you believe you are right, you STICK TO YOUR GUNS, Mister!'. She also said, 'Speak your mind and do not keep your mouth shut'."

"Context, Mike," Doctor Gibbs replied.

"I disagree. Answer my question, please, Doctor, or allow me to go back to work."

"That's it? We're no longer friends?"

"Beyond this conversation, I can no longer speak my mind to you without risking it getting back to Doctor Northrup and ruining my career. We can discuss clinical issues, but that's it. I can't risk being dismissed for crimethink."

"What do you expect me to do?"

"Stand up for your Residents," I replied. "Look, let's be clear. I will follow the directive, and I won't cause trouble. But, you know as well as I do, at some point, this will blow up, and someone will come to me and ask difficult questions, and I'll answer them truthfully. And if anyone instructs me or advises me to lie, obfuscate, or dissimulate, I'll make sure that's known publicly. Anyone who expects different doesn't know me."

"You realize you're putting your Residency at risk, don't you?"

"That's the same thing Doctor Lawson said when I backed my friend Angie against her psychiatrist. I was not only justified but proven right when he accepted a suspension without putting up any real fight."

"You're putting me in the same category as him?!"

"If the shoe fits..."

"Go back to work, Mike. We'll discuss this when you calm down."

"I'm the very picture of serenity," I countered. "I'm calm, cool, and collected."

"Exterior? Yes. Interior? No."

"Believe what you will, Doctor," I said. "Unless you have some clinical matter to discuss, I'm going back to work."

"Shit," she swore under her breath.

I wasn't sure what that meant, but in the end, I was going to do my job to the best of my ability and within the guidelines. That was, in the end, the only way to not be dismissed from the program, which was the clear threat Doctor Northrup had made.

"Mike?" Nate called out. "Paramedics three minutes out with an MI. Trauma 2 is free."

"Thanks, Nate."

I gathered Jake, Heather, and Kellie, and the four of us went to the ambulance bay to wait for EMS to deliver the patient, which they did two minutes after we had entered the ambulance bay. The patient was having a non-STEMI, so after evaluation and a cardiology consult, he was admitted.