They moved to the long table, some of the senior staff members going automatically to the front rectangle of chairs, the others dropping into the row behind. Lucy herself was in front. O’Donnell was at the head of the table, Pearson and his papers on the left. While the others were settling down she saw Pearson take another bite from his sandwich. He made no effort to be surreptitious about it.
Lower down the table she noticed Charlie Dornberger, one of Three Counties’ obstetricians. He was going through the careful process of filling his pipe. Whenever Lucy saw Dr. Dornberger he seemed to be either filling, cleaning, or lighting a pipe; he seldom seemed to smoke it. Next to Dornberger was Gil Bartlett and, opposite, Ding Dong Bell from Radiology and John McEwan. McEwan must be interested in a case today; the ear, nose, and throat specialist did not normally attend surgical-mortality meetings.
“Good afternoon, gentlemen.” As O’Donnell looked down the table the remaining conversations died. He glanced at his notes. “First case. Samuel Lobitz, white male, age fifty-three. Dr. Bartlett.”
Gil Bartlett, impeccably dressed as ever, opened a ring notebook. Instinctively Lucy watched the trim beard, waiting for it to move. Almost at once it began bobbing up and down. Bartlett began quietly, “The patient was referred to me on May 12.”
“A little louder, Gil.” The request came from down the table.
Bartlett raised his voice. “I’ll try. But maybe you’d better see McEwan afterward.” A laugh ran round the group in which the e.n.t. man joined.
Lucy envied those who could be at ease in this meeting. She never was, particularly when a case of her own was being discussed. It was an ordeal for anyone to describe their diagnosis and treatment of a patient who had died, then have others give their opinion, and finally the pathologist report his findings from the autopsy. And Joe Pearson never spared anyone.
There were honest mistakes that anybody in medicine could make—even, sometimes, mistakes which cost patients their lives. Few physicians could escape errors like this in the course of their careers. The important thing was to learn from them and not to make the same mistake again. That was why mortality conferences were held—so that everyone who attended could learn at the same time.
Occasionally the mistakes were not excusable, and you could always sense when something like that came up at a monthly meeting. There was an uncomfortable silence and an avoidance of eyes. There was seldom open criticism; for one thing, it was unnecessary, and for another, you never knew when you yourself might be subject to it.
Lucy recalled one incident which had concerned a distinguished surgeon at another hospital where she had been on staff. The surgeon was operating for suspected cancer in the intestinal tract. When he reached the affected area he had decided the cancer was inoperable and, instead of attempting to remove it, had looped the intestine to bypass it. Three days later the patient had died and was autopsied. The autopsy showed there had, in fact, been no cancer at all. What had really happened was that the patient’s appendix had ruptured and had formed an abscess. The surgeon had failed to recognize this and thereby condemned the man to death. Lucy remembered the horrified hush in which the pathologist’s report had been received.
In an instance like this, of course, nothing ever came out publicly. It was a moment for the ranks of medicine to close. But in a good hospital it was not the end. At Three Counties nowadays O’Donnell would always talk privately with an offender and, if it were a bad case, the individual concerned would be watched closely for a while afterward. Lucy had never had to face one of these sessions herself, but she had heard the chief of surgery could be extremely rough behind closed doors.
Gil Bartlett was continuing. “The case was referred to me by Dr. Cymbalist.” Lucy knew that Cymbalist was a general practitioner, though not on Three Counties’ staff. She herself had had cases referred from him.
“I was called at my home,” Bartlett said, “and Dr. Cymbalist told me he suspected a perforated ulcer. The symptoms he described tallied with this diagnosis. By then the patient was on the way to the hospital by ambulance. I called the surgical resident on duty and notified him the case would be coming in.”
Bartlett looked over his notes. “I saw the patient myself approximately half an hour later. He had severe upper abdominal pain and was in shock. Blood pressure was seventy over forty. He was ashen gray and in a cold sweat. I ordered a transfusion to combat shock and also morphine. Physically the abdomen was rigid, and there was rebound tenderness.”
Bill Rufus asked, “Did you have a chest film made?”
“No. It seemed to me the patient was too sick to go to X-ray. I agreed with the original diagnosis of a perforated ulcer and decided to operate immediately.”
“No doubts at all, eh, Doctor?” This time the interjection was Pearson’s. Previously the pathologist had been looking down at his papers. Now he turned directly to face Bartlett.
For a moment Bartlett hesitated and Lucy thought: Something is wrong; the diagnosis was in error and Joe Pearson is waiting to spring the trap. Then she remembered that whatever Pearson knew Bartlett knew also by this time, so it would be no surprise to him. In any case Bartlett had probably attended the autopsy. Most conscientious surgeons did when a patient died. But after the momentary pause the younger man went on urbanely.
“One always has doubts in these emergency cases, Dr. Pearson. But I decided all the symptoms justified immediate exploratory surgery.” Bartlett paused. “However, there was no perforated ulcer present, and the patient was returned to the ward. I called Dr. Toynbee for consultation, but before he could arrive the patient died.”
Gil Bartlett closed his ring binder and surveyed the table. So the diagnosis had been wrong, and despite Bartlett’s outwardly calm appearance Lucy knew that inside he was probably suffering the torments of self-criticism. On the basis of the symptoms, though, it could certainly be argued that he was justified in operating.
Now O’Donnell was calling on Joe Pearson. He inquired politely, “Would you give us the autopsy findings, please?” Lucy reflected that the head of surgery undoubtedly knew what was coming. Automatically the heads of departments saw autopsy reports affecting their own staff.
Pearson shuffled his papers, then selected one. His gaze shot around the table. “As Dr. Bartlett told you, there was no perforated ulcer. In fact, the abdomen was entirely normal.” He paused, as if for dramatic effect, then went on. “What was present, in the chest, was early development of pneumonia. No doubt there was severe pleuritic pain coming from that.”
So that was it. Lucy ran her mind over what had been said before. It was true—externally the two sets of symptoms would be identical.
O’Donnell was asking, “Is there any discussion?”
There was an uneasy pause. A mistake had been made, and yet it was not a wanton mistake. Most of those in the room were uncomfortably aware the same thing might have happened to themselves. It was Bill Rufus who spoke out. “With the symptoms described, I would say exploratory surgery was justified.”
Pearson was waiting for this. He started ruminatively. “Well, I don’t know.” Then almost casually, like tossing a grenade without warning: “We’re all aware that Dr. Bartlett rarely sees beyond the abdomen.” Then in the stunned silence he asked Bartlett directly, “Did you examine the chest at all?”
The remark and the question were outrageous. Even if Bartlett were to be reprimanded, it should come from O’Donnell, not Pearson, and be done in private. It was not as if Bartlett had a reputation for carelessness. Those who had worked with him knew that he was thorough and, if anything, inclined to be ultra-cautious. In this instance, obviously, he had been faced with the need to make a fast decision.
Bartlett was on his feet, his chair flung back, his face flaming red. “Of course I examined the chest!” He barked out the words, the beard moving rapidly. “I already said the patient was in no condition to have a chest film, and even if he had—”
“Gentlemen! Gentlemen!” It was O’Donnell, but Bartlett refused to be stopped.
“It’s very easy to have hindsight, as Dr. Pearson loses no chance to remind us.”
From across the table Charlie Dornberger motioned with his pipe. “I don’t think Dr. Pearson intended—”
Angrily Bartlett cut him off. “Of course you don’t think so. You’re a friend of his. And he doesn’t have a vendetta with obstetricians.”
“Really! I will not permit this.” O’Donnell was standing himself now, banging with his gavel. His shoulders were squared, his athlete’s bulk towering over the table. Lucy thought: He’s all man, every inch. “Dr. Bartlett, will you be kind enough to sit down?” He waited, still standing, as Bartlett resumed his seat.
O’Donnell’s outward annoyance was matched with an inward seething. Joe Pearson had no right to throw a meeting into a shambles like this. Now, instead of pursuing the discussion quietly and objectively, O’Donnell knew he had no choice but to close it. It was costing him a lot of effort not to sound off at Joe Pearson right here and now. But if he did he knew it would make the situation worse.
O’Donnell had not shared the opinion of Bill Rufus that Gil Bartlett was blameless in the matter of his patient’s death. O’Donnell was inclined to be more critical. The key factor in the case was the absence of a chest X-ray. If Bartlett had ordered an upright chest film at the time of admission, he could have looked for indications of gas across the top of the liver and under the diaphragm. This was a clear signpost to any perforated ulcer; therefore the absence of it would certainly have set Bartlett thinking. Also, the X-ray might have shown some clouding at the base of the lung, which would have indicated the pneumonia which Joe Pearson had found later at the autopsy. One or another of these factors might easily have caused Bartlett to change his diagnosis and improved the patient’s chances of survival.
Of course, O’Donnell reflected, Bartlett had claimed the patient was too sick for an X-ray to be taken. But if the man had been as sick as that should Bartlett have undertaken surgery anyway? O’Donnell’s opinion was that he should not.
O’Donnell knew that when an ulcer perforated surgery should normally be begun within twenty-four hours. After that time the death rate was higher with surgery than without. This was because the first twenty-four hours were the hardest; after that, if a patient had survived that long, the body’s own defenses would be at work sealing up the perforations. From the symptoms Bartlett had described it seemed likely that the patient was close to the twenty-four-hour limit or perhaps past it. In that case O’Donnell himself would have worked to improve the man’s condition without surgery and with the intention of making a more definitive diagnosis later. On the other hand, O’Donnell was aware that in medicine it was easy to have hindsight, but it was quite another matter to do an emergency on-the-spot diagnosis with a patient’s life at stake.
All of this the chief of surgery would have had brought out, in the ordinary way, quietly and objectively, at the mortality conference. Indeed, he would probably have led Gil Bartlett to make some of the points himself; Bartlett was honest and not afraid of self-examination. The point of the discussion would have been evident to everyone. There would have been no need for emphasis or recriminations. Bartlett would not have enjoyed the experience, of course, but at the same time he would not have been humiliated. More important still, O’Donnell’s purpose would have been served and a practical lesson in differential diagnosis impressed on all the surgical staff.
Now none of this could happen. If, at this stage, O’Donnell raised the points he had had in mind, he would appear to be supporting Pearson and further condemning Bartlett. For the sake of Bartlett’s own morale this must not happen. He would talk to Bartlett in private, of course, but the chance of a useful, open discussion was lost. Confound Joe Pearson!
Now the uproar had quieted. O’Donnell’s banging of the gavel—a rare occurrence—had had effect. Bartlett had sat down, his face still angry red. Pearson was turning over some papers, apparently absorbed.
“Gentlemen.” O’Donnell paused. He knew what had to be said; it must be quick and to the point. “I think I need hardly say this is not an incident any of us would wish to see repeated. A mortality conference is for learning, not for personalities or heated argument. Dr. Pearson, Dr. Bartlett, I trust I make myself clear.” O’Donnell glanced at both, then, without waiting for acknowledgment, announced, “We’ll take the next case, please.”
There were four more cases down for discussion, but none of these was out of the ordinary and the talk went ahead quietly. It was just as well, Lucy reflected; controversy Eke that was no help to staff morale. There were times when it required courage to make an emergency diagnosis; even so, if you were unfortunate and guilty of error, you expected to be called to account. But personal abuse was another matter; no surgeon, unless grossly careless and incompetent, should have to take that.
Lucy wondered, not for the first time, how much of Joe Pearson’s censure at times like this was founded on personal feelings. Today, with Gil Bartlett, Pearson had been rougher than she remembered his ever being at any mortality meeting. And yet this was not a flagrant case, nor was Bartlett prone to mistakes. He had done some fine work at Three Counties, notably on types of cancer which not long before were considered inoperable.
Pearson knew this, too, of course, so why his antagonism? Was it because Gil Bartlett represented something in medicine which Pearson envied and had never attained? She glanced down the table at Bartlett. His face was set; he was still smarting. But normally he was relaxed, amiable, friendly—all the things a successful man in his early forties could afford to be. Along with his wife, Gil Bartlett was a prominent figure in Burlington society. Lucy had seen him at ease at cocktail parties and in wealthy patients’ homes. His practice was successful. Lucy guessed his annual income from it would be in the region of fifty thousand dollars.
Was this what griped Joe Pearson?—Joe Pearson who could never compete with the glamor of surgery, whose work was essential but undramatic, who had chosen a branch of medicine seldom in the public eye. Lucy herself had heard people ask: What does a pathologist do? No one ever said: What does a surgeon do? She knew there were some who thought of pathologists as a breed of hospital technician, failing to realize that a pathologist had to be first a physician with a medical degree, then spend years of extra training to become a highly qualified specialist.
Money sometimes was a sore point too. On Three Counties’ staff Gil Bartlett ranked as an attending physician, receiving no payment from the hospital, only from his patients. Lucy herself, and all the other attending physicians, were on staff on the same basis. But, in contrast, Joe Pearson was an employee of the hospital, receiving a salary of twenty-five thousand dollars a year, roughly half of what a successful surgeon—many years his junior—could earn. Lucy had once read a cynical summation of the difference between surgeons and pathologists: “A surgeon gets $500 for taking out a tumor. A pathologist gets five dollars for examining it, making a diagnosis, recommending further treatment, and predicting the patient’s future.”
Lucy herself had fared well in her relationship with Joe Pearson. For some reason she was not sure of, he had seemed to like her, and there were moments she found herself responding and liking him also. Sometimes this could prove a help when she needed to talk with him about a diagnosis.
Now the discussion was ending, O’Donnell winding things up. Lucy brought her attention back into focus. She had let it wander during the last case; that was not good—she would have to watch herself. The others were rising from their seats. Joe Pearson had collected his papers and was shambling out. But on the way O’Donnell stopped him; she saw the chief of surgery steer the old man away from the others.
“Let’s go in here a minute, Joe.” O’Donnell opened the door to a small office. It adjoined the board room and was sometimes used for committee meetings. Now it was empty. Pearson followed the chief of surgery in.