Pushing Glass-Change of Season

Change of Season

James asked Deanna to join him at Haas' dinner. Throughout the entire evening, not a word was mentioned about work or even medicine. Irene Haas' husband, Tom, expertly prepared the main course of paella. He was the CEO of a local bank and relished opportunities to indulge his right brain. After dinner, he entertained the gathering with a selection of broadway show tunes performed upon their beautiful grand piano. Irene Haas prepared a chocolate souffle, which she quietly confided, was her family's secret recipe. Several bottles of wine flowed, connected by frequent bouts of laughter. Dozens of colorful candles scented the air with a thick sweetness. If this was an apology, James reluctantly accepted.

"Are you sure?" Deanna was puzzled as she looked across the car seat as they left the estate. The oncoming headlights cast a pulsing glow on her face.

"This is her way, Deanna."

Deanna nodded. "It was surreal, wasn't it? It's like we never met this woman."

"We haven't...until today."

"Let's see how long this will last." Deanna squeezed James' right hand. "Anyway, let's just enjoy the time we had. Tom's very talented, good voice too, don't you think?"

"Uh huh, they're so romantic. I thought he was flirting with her when he was singing."

"I liked it, reminded me of my parents. My dad used to serenade my mother with his guitar. He loved those Jobim songs." Deanna began humming the strains of Quiet Nights. The sweet notes carried over the sound of the oncoming traffic. She lifted her hands and cupped her chin. "I miss Brazil."

"When was the last time you were home?"

"Two years next month. My parents visited me last summer. That was nice, but I still miss the sounds and smells of home."

"Do you have any brothers or sisters?"

"No." Her voice trailed to a whisper. "My mother had a difficult delivery with me and needed a hysterectomy to stop the bleeding after she delivered. It broke their hearts because they really wanted another child."

"I'm sorry to hear that." James quickly went on. "My parents wanted a big family. I have three brothers and two sisters."

"I bet you're the oldest."

"How'd you know?"

"Aren't all doctors overachieving first borns?" Deanna grinned as she playfully pinched his arm.

James laughed. "Well, I'm a first born, that's for sure."

"Your father's a surgeon, right?"

James nodded. "An oncologic surgeon, he trained with Dr. Carter in New York."

"I heard that. So, he didn't want you to become a surgeon?"

"Oh he did, and I tried to be interested in what he was doing. I think my hands are okay but truthfully, when I saw what the pathologist did, nothing else mattered."

"So how did he take your decision?"

"You know, he was actually quite pleased. My dad doesn't say a lot but when I told him, he sat me down and gave me the only father to son talk I had with him."

"So he banished you to America?"

"I'm here, aren't I? No...he told me that the pathologist guides the surgeon's hand. He really respects pathologists."

"I heard that in the old days, surgeons would train in surgical pathology."

"In the Philippines, they still do." James shook his head. "Can you imagine how differently the other docs would treat us if they all had to rotate through surgical pathology?"

"Ooo!" Deanna flashed a wicked grin. "We'd have a lot of deflated egos. I think Dr. Elliot did some path training."

"He did, he told me he did. See? He actually likes pathologists."

"You make us sound like some leper. He's actually willing to be seen with us!"

"Deanna...strange people do go into pathology." James lightly brushed her cheek with his fingers.

"I agree." Deanna leaned across the car seat. "But don't be so hard on yourself, James."

James jabbed Deanna's side as laughter cascaded from both of them. It was close to 11PM when James dropped Deanna off at her apartment.

Sunday morning arrived and James soaked in the glory of the sunlight as it filtered through the barren trees outside of his apartment. The conversation about his family were a reminder that he had not written to his family in several weeks. He preferred speaking by phone but his parents preferred a hand-written letter. It showed more thought and would help him focus his thoughts, they insisted. As he wrote, his thoughts kept returning to the previous evening. He wanted to mention Deanna but knew he shouldn't. Above all, his father believed he was there to study. Plenty of time for women after you finish your training, he could hear his father's words. While this may have been true, James wrestled with his own feelings. I can't put off life. I won't, James thought. The grinding sound of tires against mud and salt drew his attention to the nearby parking lot. Winter in St. Louis crept in unnoticed amongst the shorter days of fall. Fall's shouts of colors and perfume were quieted by a white blanket and a clear blue sky. White, purity, softness; James was confident that a new season was beginning. A new and better season.

It was Nomura who discovered the error. A pathologist covering a surgicenter in Ladue had performed a frozen section on an excisional biopsy of the left breast of a 34 year old woman. A previous needle biopsy performed by a radiologist a month earlier had been diagnosed by Nomura and James at ULS as DCIS. The surgeon and pathologist were both expecting to find DCIS. Instead, on the initial frozen section and on the permanent sections, only a fibroadenoma was present. After he examined the biopsy and found no evidence of DCIS, the pathologist contacted ULS and requested a recut and review of the original case. The ULS protocol was to recut the original case, make a photocopy of the original report, then request the pathologist to review the case before it is sent out. When Nomura reviewed the case, he was horrified to find the diagnosis did not match the slide. Nomura immediately cross checked the slide with the original tissue paraffin block, ruling out the possibility that the incorrect block was selected. When it matched, he knew he had a major problem.

Nomura met with Bryce Collins, the laboratory manager of ULS, who began an internal investigation. All breast biopsy cases from that day were retrieved with the accompanying reports. There were six needle biopsies from six different patients. Reviewing all of them in coordination with the reports revealed the error. There were two women, the patient, Paula Jackson, who underwent the excisional biopsy on her left breast in Ladue and a second patient, Marilyn Tarsus, who was given the identical diagnosis of DCIS on her right breast. When Nomura placed both surgical biopsy reports next to each other, the microscopic description and diagnosis were identical. Only the sites of the biopsies were different. But when he reviewed the slides, patient Jackson had a fibroadenoma while patient Tarsus had the DCIS. The case was over a month old and Nomura strained to remember that day. Did he somehow mix up the slides on the two cases? All ULS breast biopsy cases were presented to the pathologists in separate flats to prevent such an occurrence. Nomura compulsively double checked each case, assuring that the paperwork matched the slides; years of signing out dozens of identical appearing skin biopsies had conditioned him to perform this extra step. Could he have somehow misdiagnosed the case? Nomura reviewed the slides again. "Even a dog off the street could make these diagnoses," Nomura mumbled to himself.

No. As honest as he could be with himself, he knew all of these events could not have happened. When all logical choices were excluded, the only answers, however illogical, must remain. Nomura retraced the path for his dictated report. Each breast biopsy case was dictated on a casette tape which was then placed in a folder with the accompanying requisition sheet. The folder was placed in a tray in the transcriptionists' office and typed in the order in which it was received. Nomura scanned the two reports. AJ! The initials were at the bottom of both reports. Audrey Johnson had transcribed both reports.

Several scenarios played through Nomura's mind. Audrey could have mixed up the tapes, transcribing the wrong dictations for each case. It was possible, but unlikely since the other patient Tarsus would then have received the diagnosis of a fibroadenoma. Perhaps as she transcribed the Tarsus dictation of DCIS, she was distracted and when she continued, the paperwork for Jackson was inadvertantly substituted. If that did happen, she would have rewound the casette tape and re-transcribe the entire dictation. It sounded familiar. Nomura tried to recall when a similar event happened. Winter. It was during the winter when James was with him. There was a prostate cancer case that he dictated. The next day when he was signing the final report, both he and James noticed the microscopic description had been duplicated. Audrey was the transcriptionist and when he questioned her as to how such an error could occur, she flippantly replied, "I haven't a clue." Nomura had dismissed the incident as another example of her carelessness. Did he miss the signs of her frank negligence?

Nomura's dining table was covered with flow charts outlining the possibilities. All pointed to a transcription error. Could it be proven? He mentally reviewed her sloppy work which she regularly produced for all the pathologists. Every misspelled word, added phrase, or dropped punctuation convicted her. He managed only two hours of sleep that night as he pondered the possibilities.

The next morning, Nomura called James into his office at Memorial. The seriousness of Nomura's expression left a queasy sensation in James' gut. Nomura let out a barely audible sigh and then spoke.

"James, we may have a problem."

"Was it one of my cases?"

"You looked at it, yes, but let me explain." Nomura outlined the scenario. He succinctly summarized the leading possibilities in a new flow chart, decorated with several different colors. A red line in each chart led to AJ.

"I agree with you, Dr. Nomura. It looks like a transcription error. Either she transcribed the same case twice, or something happened in the computer system and it copied the entire paragraph for both patients. You remember that case she typed? You had dictated, 'No malignant cells present.' She transcribed it as 'Malignant cells present.' We almost missed it when you signed the final report."

Nomura nodded. "I remember. There's so many errors she made. I mentioned it to Bryce who gave me the usual ULS lip service. I should have dealt with her when I had the chance but I was just overwhelmed with the work and the attitude."

The arrogance was still fresh in James' mind, but fear now gripped him. "Do you think the patient will sue?"

"Who can tell? Any patient can sue anyone at anytime for any cause, nothing prevents them from doing it. The question is whether it will go to trial or whether we can get it dismissed or settle out of court. You never want to go to trial if you can avoid it."

James swallowed. "Have you ever been involved in a lawsuit?"

"Thankfully no. I have appeared as an expert witness several times but I have never been the defendant. We'll see. Sometimes these things just drag on and everything is forgotten. Maybe the patient is happy that she doesn't have a diagnosis of cancer. I've seen that happen before. Pathologist makes a diagnosis of breast cancer on a needle biopsy. The surgeon does a lumpectomy and finds that it was an atypical sclerosing lesion, but no cancer. The patient is ecstatic. I've seen it go the other too, however. We'll have to wait and see.

The answer arrived one month later via a certified letter.

Goldstein and Stewart, LLP.
for Paula Jackson

Re: Paula Jackson vs. Ladue Surgicenter; United Laboratory Services; Masao Nomura, M.D.; James Deetan, M.D.

Nomura and James met with the department chairman Morelli who contacted the malpractice carrier for the hospital. Within an hour, the lawyer, Jerome Moynihan, had called Nomura. James sat in the office and listened to the conversation by speaker phone. After 45 minutes, Moynihan appeared satisfied with the sequence of events Nomura outlined.

"I see. It sounds pretty straightforward. We'll need depositions from Audrey, Bryce, and Dr. Deetan. If you could send me a copy of those flow charts and give me a summary of the events, that would be helpful."

"No problem."

"I'll be in contact with the plaintiff's attorneys. I don't know them so it may mean they're young, which is a plus for us."

"Ok. What time frame are we looking at?"

"If we can arrange the depos, things can move along. I'm going to call an expert on computer transcription systems as well, have him review the case and the ULS computer system." Moynihan's voice softened. "Dr. Nomura...Dr. Deetan...I know you must feel like the entire world is collapsing on both of you right now. I've been doing this for over 30 years. Believe me, it never gets any easier. Just work with me and it will be fine. Transcription errors are very common. We deal with them all the time in all medical specialties."

"Thanks for the reassurance. James do you have any questions?"

"No sir. Thanks Mr. Moynihan."

"Great, we'll be in touch."

Nomura looked over to James and nodded. "It will be okay, James. I don't think you'll be involved, since you're a resident in training."

"You think so?"

"Yes. They want to go after the deep pockets. ULS has the deepest. They're used to being sued."

"Really?"

"There was a very well-publicized case a few years ago where ULS was found guilty for overbilling Medicare patients for liver function studies. Huge settlement, something like $200 million."

James shook his head. "Very deep pockets."

The initial meeting with Moynihan outlined a plan for intended cooperation with ULS attorneys. It presented a unified front to the plaintiff's attorney. As a courtesy, the attorney for Ladue Surgicenter was also invited though all parties agreed that Ladue should be dismissed. As Nomura predicted, James, was dismissed as a defendant, but would be asked to give a deposition. Moynihan was upbeat after the meeting.

"I've been going through my notes and your flow charts. I think this is a straightforward case and the burden of blame should be shifted to ULS and the transcriptionist. We'll see what happens during discovery."

"Discovery?"

"Exactly as it sounds, Dr. Deetan. Both parties will investigate all of the facts to see if there are any points that have been missed. All information that is discovered will be made available to each side."

"I see. Does discovery ever lead to a radical change in the case?"

"Yes, sometimes. This is the heart of the case. We need to line up our experts just as the plaintiff's are lining up theirs.

Moynihan stood to leave. "Didn't think you'd go to medical school to have this happen, eh?"

"No sir."

"Get used to it. It's probably a good thing you are experiencing this so early in your career. Makes you aware that it's a cruel world out there."

"Dr. Deetan is holding up very well, " Nomura jumped in. "He is an excellent physician."

Moynihan looked at both of them and registered a half-smile. "I'm sure he is. Be talking to you soon."

Through Nomura's window, both saw the snow begin to fall again, coating the sill with a thin layer of flakes. It barely covered the dirt and pigeon dung that had built up.

"It will be cold tonight. You better leave early if you want to beat this storm."

James searched the sky until he recognized the gathering storm clouds.

"I may not make it, but I'll survive."

James turned to leave. "Thanks for your support, Dr. Nomura."

Nomura smiled. "We need to support each other. After all, we're on the same side."