Chapter 41: Differences of Opinion

September 12, 1988, McKinley, Ohio

"How was your weekend?" Clarissa asked when we met in the surgical lounge on Monday morning.

"Fairly typical," I replied. "Besides the usual band practice and grocery shopping on Saturday, and attending services at the Cathedral on Sunday, Kris and I spent time looking at furniture and other furnishings for the house in Circleville. I have a budget, and we were getting an idea of what things will cost."

"How did that go?"

"Our tastes are similar, in that we both prefer a modern look, and my budget appears sufficient for what we need. Obviously, I could spend more if I had to, but I'd prefer to keep as much as possible for a down payment on our own house sometime after you and I finish PGY1."

"Just out of curiosity, have you and Kris..."

"Not even a kiss on the lips," I replied.

"You're joking!"

"No, I'm not. Kris is open-minded, socialist, and traditional. I suspect that she, like certain other Russian girls of my acquaintance, understands her sexuality, and knows the associated risks."

Clarissa laughed, "Tasha and Lizochka were very passionate!"

"And I expect Kris to be equally passionate! And we'll have our first kiss after the crowning."

"You're a nut, Petrovich!"

"As if that were news!" I chuckled.

"Is there anything you need help with at this point?"

"According to you, Jos, and several others, I always need help!"

"OK, besides being a guy!" Clarissa teased.

"No. Our moms are handling the reception in Columbus, and we're not taking our honeymoon trip until June. We're discussing going away for a week in January, but planning to drive any distance in January is an iffy proposition because of the weather."

"What about Rachel?"

"My mom offered to take her for a few nights in January. We may take her with us in June."

"Of course you would! But you should have it out of your system by then, anyway!"

"Never!" I chuckled. "But I understand your point. And you know what it'll be like starting in July."

"I've prepped Tessa to basically not see me awake for days at a time."

"You'll at least get some sleep during your thirty-six-hour shifts. I could have to go the full thirty-six with zero sleep. Fortunately, I'm a good napper, so if I can catch twenty minutes here or there, I'll manage."

"What do you have today?"

"A lap-chole and a partial colectomy."

"Laparoscopic or open?"

"Open. Right now we're only doing cholecystectomies laparoscopically. They're getting the procedure down and getting comfortable with it. What about your team?"

"Lung resection and a total hysterectomy."

Doctor Rafiq came in, so I got up, and Debbie and I went with him to do our pre-op prep. When we brought Mr. Paxton, the lap-chole, to the OR, and he was put under anesthesia, I asked Doctor Roth for permission to teach Debbie how to intubate. Doctor Roth granted permission, and Doctor Rafiq's eyes telegraphed a frown of disapproval, which was hidden by his mask.

"What do I do?" Debbie asked.

"You studied the procedure and read my notes, right?"

"Yes."

"Do what you learned. I'll guide you if you need me to, but just remember the steps and do them."

Debbie nodded and picked up the laryngoscope and began the procedure.

"Don't rock it," I advised gently. "You could break his teeth."

"Sorry," she said.

"Just smooth and careful. He's not in any respiratory distress, so you have plenty of time."

She followed the steps I'd outlined in my notes and inserted the endotracheal tube, which had been selected by the anesthesiologist.

"Check breath sounds in both lungs and tell me what you hear," I said.

She did and shook her head.

"Only left side."

I listened and nodded, "Slide the tube back about 5mm."

She did and listened again.

"Good bilateral breath sounds," she said.

I listened to verify and nodded, "Connect the ventilator."

She did, and reported, "Good tidal volume."

"Thanks, Debbie," Doctor Roth said. "Doctor Lindsay, let's begin."

Debbie and I moved to our observation positions and watched what was becoming a routine procedure using laparoscopic instruments. There were no complications, and as was our usual procedure, Debbie and I escorted Mr. Paxton to Recovery and waited for him to come out from under anesthesia. When he did, we returned to the lounge to wait for lunch.

"Doctor Rafiq didn't look happy," Debbie said.

"Ignore him," I said. "If you noticed, Doctors Roth, Lindsay, and Taylor are all sidelining him and giving him what amounts to med student scut. He can't affect our evaluations in any way, so we honestly don't have to worry about him at all."

It was telling that Doctor Rafiq didn't join us for lunch, and was relegated to pure observation during the afternoon surgery, which was routine. At the end of the day, I retrieved Rachel from daycare and headed home. We had our dinner, I read to her, and we said our evening prayers. When Mark and Alyssa arrived, I turned Rachel over to them and headed to bed.

September 16, 1988, McKinley, Ohio

The week was routine, including a round of golf on Thursday, though I wasn't improving very much with just one round a week and no practice. After lunch on Friday, Clarissa and I headed to the main auditorium for the M & M Conference, which would review the case of a patient who had nearly died in Internal Medicine because he had been administered the wrong medication on orders of a PGY1 who was at the end of a thirty-six-hour shift.

"You know this could easily be us next year," I said to Clarissa.

"Oh, I know," she agreed. "And only a written warning because it's only his third month."

"What I don't understand," I said, "is why the nurse didn't catch it, and why he didn't check with an Attending."

"Both drugs were on the Medicine 'standing orders' list, so he didn't need a sign-off."

"And you can count on the Attendings not agreeing to change that procedure," I replied. "Heaven forbid they get woken up in the middle of the night!"

"You're going to change that, aren't you?"

"First, I will not hesitate to wake up an Attending if I'm at all unsure; second, when the day eventually comes, I'll tell my Residents to wake me up. No patient's life is worth an extra few minutes of sleep, and Attendings are supposed to be teachers."

"The system is really fucked up, isn't it?"

"It is. The thing is, despite that, it turns out excellent physicians. I think we can do better."

"What would you say to the family?" Clarissa asked.

"If it were up to me? The unvarnished truth. The thing is, it's not up to me, it's up to the Hospital Administrators and legal counsel."

"So you'd just say 'Sorry, we screwed up'?"

"Not in those terms, but I think it's incumbent on the profession to maintain the trust of the public, and only truth can do that in the long run. And, if we had to admit medical error directly, I think it would force improvements that take far too long for the profession to embrace."

"And the idea of a slow, methodical process?"

"Is important, but that has to be balanced with everything else. It's always a tricky balance, and I'm not saying I don't understand why things are the way they are, just that I don't agree we're doing the best we can to serve our community if we don't recognize error and take proper actions to fix it. Of course, that would require malpractice reform, as the insurance company basically dictates the rules."

"What would you do?"

"In exchange for complete transparency, strict liability limits, and a medical review board that evaluated errors for negligence."

"As you want done with the psychiatrist who harmed Angie."

"Exactly. Honest error is one thing, and M & M conferences are sufficient for that, but we should refer cases of potential negligence to an independent review board that consisted of doctors, nurses, and medical ethicists."

"And you think that's possible?"

"No, but a guy can dream, right?"

"Ever the idealist."

"We strive for perfection our entire life, and when we miss the mark, we try again, and again, and again."

"The Orthodox view on sin."

"Exactly. It applies to just about every aspect of life — aim for perfection; if you don't achieve it, figure out how to improve, then try again. It's a lifelong process."

We took our seats and waited for the rest of the medical staff to assemble, though not everyone would attend. Some doctors and medical students did so by choice, others because they had to cover their services. The conferences started exactly on time, out of respect for the presenting doctor's time, and the current conference conformed to the norm. Doctor Baker, Chief of Internal Medicine, stepped up to the lectern.

"One of the major causes of medication errors is distraction. A study has shown that nearly 75% of medication errors have been attributed to this cause. Physicians have many duties in a hospital, and the combination of those duties can distract us."

"He wasn't distracted, it was lack of sleep!," Clarissa whispered.

Doctor Baker continued with his discussion of medical errors, and to me, it was obvious he had completely missed the point, most likely intentionally. He was, in effect, covering for his Resident, quite the change from his initial attitude when he'd first come to Moore Memorial. Or, perhaps, it was only because the error had occurred on his service. I could only hope that someone called him on it, but I didn't expect that to happen, because the system couldn't be changed unilaterally by Moore Memorial.

"Whitewash," I said when we left the auditorium forty minutes later.

"What did you expect?" Clarissa asked. "You know they can't do anything about Resident hours."

"I know." I sighed. "Even that case in New York that was reported in NEJM back in March hasn't changed anything."

"Rumor has it that the Medical Review Board n New York is going to clear the Residents."

"Of course they will," I replied. "It's not the Resident's fault that they had to work those shifts, so blaming them makes no sense. From what I could tell from reading the article, it wasn't negligence, it was the system. Do you think the medical community as a whole is going to acknowledge that the system killed that poor girl?"

"No, I don't," Clarissa said. "Unfortunately. Maybe New York will change their law."

"And if the other states don't follow, then Residents in New York will have fewer training hours, and that can disadvantage them for Attending roles, or means they have longer Residencies."

"Couldn't they write a law that required New York hospitals to honor those Residencies?"

"I have no idea," I replied. "That's a question for Melody Coates or Jos."

"Have you spoken to Melody?"

"Not since Elizaveta's funeral. She's working for a law firm in Cleveland, or at least she was a year ago."

"Are you and Kris joining the gang tonight?"

"Yes. Peter mentioned that the guys want to see Eight Men Out, about the 'Black Sox' scandal when the Chicago White Sox threw the World Series to the Cincinnati Reds.

"I'm not sure everyone will want to see that. What about you?"

"I do, though I don't know about Kris, given I suspect she's never been to a baseball game in her life!"

"I guess we'll see what she says at dinner," Clarissa observed.

"Are you going to the lecture?" I asked.

"I'm not particularly interested in hearing a pharmaceutical rep discuss their latest so-called wonder drug. If they sent a scientist or doctor instead of a marketing rep, then I might go."

"I don't know," I chuckled, "According to Doctor Taylor, the pharmaceutical reps are almost always smoking hot women!"

"Because they know male doctors are pigs!" Clarissa replied. "So they play to their audience!"

"Last I checked, you liked girls!" I chuckled.

"And you think I'd prescribe a drug because some hot chick marketed it to me?"

"No, of course not. Neither would I. They publish transcripts of the presentations, so I'll just get a copy and see if they say anything worthwhile. The drug info sheet will have the key points, including interactions and adverse reactions, because the FDA requires it. The rest is just marketing fluff."

"Are you taking off, then?"

"Yes. I'll get Rachel and take her to her grandparents' house, and I'll spend some time with Viktor."

"See you!"

We hugged, and I headed to daycare to retrieve my daughter before heading to Viktor's house, where she was quickly taken into custody by Yulia. Viktor and I went into his study, and he poured coffee for both of us from a freshly brewed pot.

"Yulia is concerned about your upcoming marriage," Viktor said.

"Reässure her that I have no intention of changing Rachel's routine. Obviously, we'll have to sort out holidays with my parents, Kris' parents, my grandparents, and you and Yulia. When Kris and I have kids, it'll complicate things a bit, but we'll figure it out. Rachel needs a good relationship with all her grandparents, which will include Kris' parents, because I'm going to have Kris formally adopt Rachel."

"In case something happens to you?"

"Yes. If Elizaveta's repose taught me anything, it's that none of us can count on the future, and we need to prepare for all eventualities."

"That's for sure. Do you have a will?"

"I do. Mr. Winston, the lawyer for whom my mom works, created one, and it's been updated. It'll be updated again once Kris and I marry."

"May I ask who Rachel's guardians would be?"

"Elias and Serafima," I replied. "With you as trustee for the assets I'd leave to her. I saw no reason to change that. My grandfather is executor. I can't imagine the two of you not being able to resolve any differences of opinion."

"You Borodins are a stubborn lot!" Viktor said with a sly smile. "You've said so yourself!"

"And from personal experience, I can say the same thing about you Kozlovs!"

Viktor laughed and nodded, "My daughter was very determined to get her way!"

"We Russians as a group tend to be stubborn," I observed.

"Which is why we are all successful," Viktor replied. "We do not give up so easily and do not take setbacks as anything other than a challenge to overcome."

"Which," I replied, "is a direct result of our Orthodox worldview."

"I agree. How are things going at the hospital?"

"Things are going well, though I'm looking forward to graduating, so I can actually do more procedures. I'm curious, but were you aware of the topic of the Morbidity and Mortality conference today?"

"The patient who nearly died from being given the incorrect drug?"

"Yes."

"I'm aware. The board reviewed the case with the hospital legal counsel."

"Were you aware that Doctor Baker was going to pass it off as a distracted PGY1 rather than a doctor who was at the end of a thirty-six-hour shift? And that the parallels with the case in New York are fairly strong, minus our patient not dying."

"I was aware," Viktor said. "But I really can't discuss this with you."

I frowned, "Well, someday, and not too far in the future, we'll have a repeat of the New York case unless something changes."

Viktor nodded, "I hear you, Mike, but I truly cannot discuss it."

That didn't surprise me, given what I'd heard from doctors about the limits imposed by the hospital's insurance carrier and the county government when there was a significant risk of a lawsuit.

"How are things going with the transition with Geno?" I asked, changing the subject.

"I'm down to working about two hours a day, and he's taken the brunt of the work. It takes time to transition relationships, which are so important in business."

"What do you plan to do once the transition is complete?"

"Yulia and I will probably go on a month-long cruise in the Mediterranean. Then we'll be around to spoil our grandchildren!"

"The time-honored role of every grandparent and great-grandparent!" I said with a smile.

I finished my coffee, declined a refill, and let Viktor know I needed to get home to shower before Kris arrived. I said 'goodbye' to Rachel, then left the Kozlovs' house and headed home. When I arrived, I showered, then dressed, finishing just before the doorbell rang, announcing Kris' arrival. I opened the door, and we greeted each other with a light hug, as was our practice.

"Anything interesting happen since last night?" Kris asked.

"You being here!" I replied.

Kris laughed, "OK, besides that!"

"Not really. Just a routine surgery this morning and then our usual Friday afternoon conference, though I skipped the marketing presentation by the pharmaceutical company representative."

"Is it true that doctors can receive payments for prescribing certain drugs?"

"It's usually in the form of trips or other non-cash premiums," I replied. "I find it completely unethical, and I'd never do it."

"Such a thing would not be possible in France, as the social insurance fund is responsible for negotiating prices and approvals."

"Just different people to bribe," I replied with a sly smile.

"Except it does not happen!" Kris protested. "The government watches over the social insurance system very carefully and establishes rules for negotiations and care provision."

"Right," I replied, "because politicians are not susceptible to bribes! And you yourself said that physicians are often in private practice and that there are privately run hospitals."

"Yes, of course, but there is no way for them to avoid the regulations or the supervision."

"And there is no corruption of any kind in France?" I asked.

"Well, the National Front is quite corrupt!" Kris said with a silly smile.

"I'm going to guess that's the right-wing party?"

"Yes, of course!"

"And the Socialists are as pure as new-fallen snow?" I asked.

Kris laughed, "I think we both know better, but the system is nowhere near as corrupt as yours!"

"Well, one thing you can be absolutely sure of is that I will never take a bribe or any kind of gift in exchange for preferring a certain prescription drug over another, nor would I ever order any procedure that generated revenue in exchange for personal gain. Anyway, shall we go?"

"Yes, of course!"

We left the house, got into my car, and headed for the Chinese restaurant to meet with our friends. We had a nice meal, and I explained the premise of the movie to Kris, and gave her a brief background on the scandal, which everyone else in the group knew, at least in a broad outline.