The Final Diagnosis

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.

O’Donnell was elaborately casual. “Joe, I think you should quit riding people at these meetings.”

“Why?” Pearson was direct.

All right, O’Donnell thought, if that’s the way you want it. Aloud he said, “Because it gets us nowhere.” He allowed his voice to take on an edge. Ordinarily in dealing with the old man he deferred a little to the gap of years between them. But this was a moment to exercise his own authority. Although, as chief of surgery, O’Donnell had no direct control of Pearson’s activities, he did have certain prerogatives when the work of Pathology cut across his own division.

“I pointed out a wrong diagnosis—that’s all.” Pearson was aggressive himself now. “Do you suggest we keep quiet about such things?”

“You know better than to ask that.” O’Donnell slammed out the answer, this time not bothering at all to keep the ice from his voice. He saw Pearson hesitate and suspected the old man knew he had gone too far.

Grumblingly he conceded, “I didn’t mean that; not that way.”

Despite himself Kent O’Donnell smiled. Apologizing did not come easily to Joe Pearson. It must have cost him quite a lot to say that. Now O’Donnell went on more reasonably, “I think there are better ways to do it, Joe. If you don’t mind, at these meetings I’d like you to give us the autopsy findings, then I’ll lead the discussion afterward. I think we can do it without getting tempers frayed.”

“I don’t see why anybody has to get in a temper.” Pearson was still grumbling, but O’Donnell sensed he was backing down.

“All the same, Joe, I’d like to do it my way.” I don’t want to ram it down his throat, O’Donnell thought, but this is the time to make things clear.

Pearson shrugged. “If that’s the way you want it.”

“Thanks, Joe.” O’Donnell knew he had won; it had been easier than he had expected. Maybe this would be a good time to raise the other thing. “Joe,” he said, “while we’re here, there’s something else.”

“I’ve got a lot to do. Couldn’t it wait?” As Pearson spoke, O’Donnell could almost read his mind. The pathologist was making it clear that though he had conceded one point he had not abandoned his independence.

“I don’t think it can. It’s about surgical reports.”

“What about them?” The reaction was aggressively defensive.

O’Donnell went on smoothly. “I’ve had complaints. Some of the reports have been a long time coming through Pathology.”

“Rufus, I suppose.” Pearson was openly bitter now. You could almost hear him saying: Another surgeon causing trouble.

O’Donnell determined not to be provoked. He said quietly, “Bill Rufus was one. But there have been others. You know that, Joe.”

For a moment Pearson made no answer, and O’Donnell reflected that in a way he felt sorry for the old man. The years were slipping by. Pearson was sixty-six now; at best he had another five or six years of active work ahead of him. Some people reconciled themselves to change like that, to younger men moving into prominence and taking over leadership. Pearson had not, though, and he made his resentment plain. O’Donnell wondered what was back of his attitude. Did he feel himself slipping, unable to keep up with new developments in medicine? If so, he would not be the first. And yet Joe Pearson, for all his disagreeable ways, had a lot to commend him. That was one of the reasons why O’Donnell trod circumspectly now.

“Yes, I know.” Pearson’s reply held a tone of resignation. He had accepted the fact though. That was typical of him, O’Donnell thought. Right from the beginning at Three Counties he had liked Pearson’s directness and at times had made use of it in raising surgical standards.

O’Donnell remembered that one of the problems he had faced in his early months at the hospital had been the elimination of needless surgery. Under this heading had come an unnatural number of hysterectomies, and in too many cases healthy, normal uteri were being removed by a few staff surgeons. These were men who found surgery a convenient and profitable remedy for any female pain, even those which might have responded to internal medication. In such instances euphemisms in diagnosis like “chronic myometritis” or “fibrosis of uterus” were resorted to as a smoke screen to cover up the pathology report on the removed tissue. O’Donnell remembered telling Pearson: “When we’re reporting on tissue we’ll call a spade a spade and a healthy uterus a healthy uterus.” Pearson had grinned and co-operated fully. As a result most of the unnecessary surgery had stopped. Surgeons found it embarrassing to have tissue they had removed from patients listed for all their colleagues to see as normal and uninfected.