Two weeks later, Mike left the chilled, filtered air of an operating room, lowered his surgical mask as he walked down the humid hall, and went into the dressing room. He took a white lab coat from the hook in his locker and retrieved his wallet and keys from the upper shelf. He pulled his lab coat on over his green scrubs and walked to the elevator.
Four minutes later he was on the twelfth floor. He opened the door to the administrative conference room.
Around the long, oval oak table in straight-backed wooden chairs sat the members of the hospital OR committee: nine surgeons, each representing a department; an OR coordinator; a secretary for minutes; an assistant dean; and the chair of anesthesia. He sat in the only empty chair, left vacant for him as the chair of the committee and chief of surgery. He never thought to apologize for his lateness; he was often late, but, as all the others knew, it wasn’t because he was lazy or slow. His time was never his own. No one in the room, friend or foe, blamed him. He nodded to the secretary, who started a tape recorder.
He followed the agenda: minutes approved, a vote on a new tech position, approval of a staged renovation of recovery room C, all thirteen items above five thousand dollars approved for purchase, financial stats since December reviewed. He could feel the unusual tension in the room. If he could delay consideration of Paul’s report on Clayton until the next meeting, he might fix Clayton’s problems and lessen the severity of the committee action. He was about to close the meeting.
Janet from orthopedics stood up demanding attention for new business. She was the first one to stand since the beginning of the meeting. He’d seen her memos about surgery for the obese. She was on a crusade against surgery for weight loss, and even though Clayton’s technical mistake was not directly related to obesity, it happened during a procedure for weight control and was exactly the ammunition she needed to load her gun for lethal shots against the surgeons. “You can sit down,” Mike said.
She ignored him. “Each of you has read my risk management memo. Each of you knows about this OR error of Otherson’s.” She paused. “A life-threatening complication of a gastric bypass! Bleeding out. Otherson should have his privileges rescinded.”
“A report has been filed,” Mike said. “It needs to come through channels.”
“We have responsibilities to make corrections now,” Janet said.
“The patient has no permanent damage,” a general surgeon said. “You just don’t like the operation.”
“It’s Otherson,” she said with a controlled voice. “Making advertising claims that can’t be true. Operating on anything that walks in the door. Threatening the life of a patient.”
“I don’t understand,” Oral Surgery said.
“You’re a fucking dentist,” Janet replied.
“I’m dual trained.” He shrugged his shoulders and looked around the table for support. No one responded.
“It’s the bypass surgery. They’re . . .” Janet stared at Mike. “. . . on television, and radio.”
“It’s common practice everywhere,” said another general surgeon.
“Make your point, Janet,” Mike said.
“There’s a national backlash against the procedure and now we’re advertising. It makes no sense. It’s become elective surgery and a patient in our hospital damn near died. Stop Otherson now!”
“Be reasonable,” said Thoracic.
“Don’t suggest I’m unreasonable because I’m the only one to bring to this committee what everyone knows. It’s not a good treatment. And it’s expensive. And it almost killed someone. And if I hadn’t brought it up, every one of you would have been happy to let it pass.”
“Not me,” said Oral Surgery.
“Please sit down, Janet . . .” Mike began.
“I don’t want to sit down!”
“I was there. The complication was laparoscopic, and had nothing to do with gastric bypass.”
“She wouldn’t have been on the table if she hadn’t signed a consent for bypass surgery. She expected weight loss. She almost lost her life.”
Janet’s point was valid, but her remedies were off the mark and too severe. He was losing tolerance. “If indications for bypass surgery are a problem, Janet, we’ll deal with that separately. The report is about a single complication. I’ve talked to Otherson. He’s agreed to more training with laparoscopy.”
“And he’ll stop operating?”
“He’s agreed to do open procedures until he’s finished with the training on laparoscopic surgery.”
Janet looked around the table. “That is not satisfactory. I move to revoke privileges to operate.”
“Second,” said ENT.
“Call the question,” Thoracic said.
Mike allowed for discussion. The room was silent. Janet had stirred up a mood of hostility among the surgeons that discouraged supporting her on any issue. He pressed on.
“All in favor,” he began. Two ayes. Seven nays.
“Motion is defeated.” Clayton was saved from any immediate surgical restrictions on operations for obesity. His technical improvement using laparoscopy would be his own responsibility through attending training from national experts.
Janet sat. “It still doesn’t address the advertising. He’s promising more than can be expected.”
She wouldn’t let go. It was her need for confrontation – against everything, not just Clayton or surgeons. “We’ve voted,” Mike said. “That’s an issue for the next meeting.”
“Morbid obesity is a nationwide problem and growing,” Oral Surgery said immediately, to prevent a motion to adjourn. “We have to deal with it!”
“What do you know about it?” a general surgeon snapped. “Fucking dentist,” he mumbled, but all heard.
Janet grinned and nodded. “He knows what I know . . . and that’s a hell of a lot!”
“I’m on the ethics committee,” Ophthalmology said. “There’s concern. He’s operating with a very low threshold for indications.”
“Don’t be trivial,” the general surgeon said.
“Morbid obesity is hardly trivial,” Ophthalmology countered.
“That’s why we operate, you idiot,” the general surgeon said.
“A lot of well-founded suspicions of preventable complications caused by bariatric surgery are simmering in every clinic in this hospital.”
“It’s reasonable to find facts,” Mike said. “We’ll check the results. It will be a top agenda item as soon as possible.”
“That’s not enough,” said Oral Surgery. “I move Otherson at least be censured for bariatrics. That would give the hospital some legal protection.”
“It’s insulting,” Thoracic said.
“It’s only a slap on the wrist,” Janet said.
“Second,” Ophthalmology said. “It’ll tell him we’re watching. And that we expect him to curb obese surgery in addition to retraining.”
“Is that what you want to do? A formal censure?” Mike asked the committee.
On vote, only two of the general surgeons and Thoracic disagreed.
As the meeting adjourned, Mike whispered to the coordinator to have Otherson’s obese stats on his desk tomorrow afternoon.
He went to his office and called Clayton directly. “You were censured.”
“What the fuck does that mean?”
“You’ll be informed in writing that the committee does not approve of your low threshold for recommending bariatric surgery. But if you tighten your indications, you can operate.”
“Without restrictions on other surgeries?”
“Only restrictions on use of the laparoscope. They agree with the additional training in laps. Just reevaluate your indications for obese surgery.”
“You should have done more,” Clayton said.
“You should have stepped down,” Mike said and hung up.
The next afternoon Mike received the coordinator in his office. She laid a report on his desk.
“Sit down,” he said. He studied the report.
As part of the general surgery service, gastric bypass surgery was expanding rapidly. Obese was a financial success.
The bulk of the report was devoted to outcomes. Department bariatric mortality was higher than the published national average by almost two percent, significant at the .01 level. Clayton would argue the cases done were often the most difficult, and that a case mix weighted with seriously ill patients would always increase the mortality. But it was clear, too, that the body mass index threshold had been lowered so that the concept of morbid obesity had changed. In essence, skinnier people were now being offered the operation based on lowered admission criteria.
“Where is patient satisfaction?” Mike asked the coordinator.
“There’s not much,” she said. “I put what I could find in the appendix.”
“Any significant findings?”
“Hard to quantitate the quality-of-life stuff. But look at the summary page. The research protocols for studying psychological adjustment don’t meet the standards of other institutions, and the results we have are below standards.”
“It doesn’t look good,” he said mostly to himself.
“One third had no effective weight loss. Those who did lose weight had a recurrence rate of more than fifty percent. One hundred percent are on lifetime vitamins and supplements.”
“We’re being accused of operating for cash and lowering the indications,” he said. “What do you think?”
“I wouldn’t have the operation,” she said. “Even if I dove into a swimming pool and emptied all the water out.”
“Sit on these stats until the meeting.”
“I’m not a crusader,” she said. “Whistleblowers are the first ones pushed out a top-story window.”
“But you don’t like what you see?”
“I’m ashamed. It’s got nothing to do with the profession of healing.”
Within minutes Mike was in the office of Hammond McLaughlin, the chair of the department of surgery, who was a head shorter than he even when they were sitting. McLaughlin had a new red scaly patch on his head near the front. It needed treatment.
McLaughlin took out a comb and gave his bald dome a self-conscious left-to-right comb-over.
“Make it snappy, Mike. I’ve got an interview waiting.”
Mike laid the report on McLaughlin’s desk. “You need to give this some thought, Hammond.”
“Clayton warned me. Said you might be coming by.”
“We’ve slipped,” Mike said. “We’re doing borderline cases. Some unnecessary.”
“Speak straight, Mike. It’s not ‘we.’ It’s Clayton you’re after.”
“He does more than ninety percent of the surgeries.”
McLaughlin pushed back from his desk. “You’re accusing Clayton?”
“Not accusing. We need tighter indications for all surgeons.”
McLaughlin turned serious. “Jesus, Mike. He’s a good man. We went to school together. I was in his wedding . . . did you know that? I flew in from Philadelphia. Stayed at his mother’s place – like some fucking castle for a queen. Filthy rich.”
“It’s not just Clayton,” Mike said, exasperated. “There are others starting up. We need department-wide rules. I’ve reviewed his bariatric cases – his indications are loose. On his volume alone, the bad outcomes add up fast.”
“Don’t make this personal, Mike. This ‘we all need tighter indications’ is a lot of crap. This is about Clayton making a mistake. We all accept he made a mistake.”
“It’s not personal!” Mike said. “And he makes mistakes on his bariatric cases.” McLaughlin assumed everyone acted in his own interest. “He was my mentor,” Mike added. “This is not easy for me.”
“Then back off. Clayton is the number one surgeon in gross billings and collections. He damn near supports this department. All the start-up guys’ salaries depend on him. And all those no-pay surgeries you like to do. Those trauma cases from out of state? Not possible without support from faculty like Clayton!”
“It can’t be money, Hammond. That’s not what we’re about.”
“Don’t be an idiot. It’s all about money. The state keeps cutting back. Medicare and Medicaid deny and won’t pay a reasonable percentage. Money keeps us afloat. That’s life. Guys like Clayton save guys like you; it’s like some shitty socialistic mandate.”
Mike took a straight-back chair and dragged it near the desk to sit in front of McLaughlin. “Listen carefully,” Mike said. “A majority of the OR committee is very concerned over this bariatric issue. And the technical failure, too. Orthopedics will turn this into a battle against surgery that will up their power in the OR. And they’ve got a silver-bullet issue here. Believe me, this is not the time to dodge and weave.”
McLaughlin frowned. “Clayton doesn’t deserve this,” he said and picked up the report, tilting his head to focus his reading glasses. He scanned it just enough to shiver with a shard of fear over the potential damage it contained.
Mike stared. Hammond played favorites. His best skill was politics. He avoided conflicts and rarely made decisions unless pressed. But most disturbing, he resented the good surgeons, resented what they could do, what he would never achieve in the OR. He had built his shaky power base in administration to find some value in his career.
“Can this report be trusted?” McLaughlin asked.
Mike tensed. “Nothing is faked. I’m chair of the OR committee. I don’t make up bad outcomes.”
McLaughlin tilted back in his chair. He wasn’t finished talking. “We can’t restrict our faculty,” he said thoughtfully. “We hire a guy like Clayton, he comes to do his thing. He’s honest, trying to do the best he can. Volume is important. He ought to have the right to choose his cases.”
Mike leaned forward. “Clayton’s advertising. Orthopedics is right to be upset. The marketers fake pre-op shots using actors with pillows stuffed in their clothes, then cut to fake post-ops with the same guy strutting fatless on a beach in a Speedo. That’s not helping the sick, that’s looking for people who will agree to a risky operation.”
“That’s unfair . . .”
“Fair is exactly how most of the OR committee sees it. They might let Clayton operate after a lap bleed-out, but they didn’t like that it was obese elective surgery.”
Mike made an effort to keep his voice normal. He took the report from McLaughlin and stood.
“This was gathered by the committee coordinator. It will be committee information. Unless you take action, the committee will take action. It will be common knowledge. The world will come down on us.”
“Calm down.” McLaughlin paused. “Look. I see your point.”
“I need action. Not understanding.”
“I’ll call a task force. That’s the way to handle it. That way all sides can be heard.”
“This is not a sporting event, Hammond. The department needs to publish strict indications.”
McLaughlin looked up at him. “A task force is action. No one could fault that.”
“We’re trying to improve patient care, not escape fault.”
“Patient care issues need a measured, non-emotional approach.” Hammond wrote names on a pad. “Use these names. They’re our friends; you choose more if you need to.”
“The task force will have more clout if the names come directly from you,” Mike said.
“You’re the one with a carrot up your ass.”
As Mike walked out, he gave a full list of names to McLaughlin’s administrative assistant to make the arrangements for the first task force meeting. He had little respect for McLaughlin’s delaying tactics. It could take months to work this out, for better or for worse.