“Can I make a philosophical com–ment?” asked the gastroenterologist.

    He was tall and lean, in his early sixties.  The close-cropped beard streaked gray, the lower eyelids heavy and creased by decades of fitful sleep: they struck an impression more rabbinical than medical.  He even had that accent: the Bronx R’s vanishing from the ends of words, anguish in his brow as he squinted through a sentence’s conclusion, beleaguered by the spiritual burden of the thought to follow.

    “Right or wrong, most doctors when they are sued are dev-a-stat-ed,” he sermonized to his congregation, also called the Quality Improvement Committee. “They get raked over the coals and they are all alone.”

    His suit was dark blue, necktie folded into the inside pocket of his blazer.  Like many standing on the pulpit, you could hear in his words the exaggerated hyphens that mark their syllables in a dictionary. 

    “By the time they get to our com-mit-tee,” continued the stomach specialist, “they have been served with a subpoena.  They have met with a lawyer.  They have reviewed every aspect of the case, sometimes to great humiliation.  They have sat through a de-po-si-tion, often for hours, with hostile questions thrown at them from every angle.”

    His phrasing rang of skullcaps more than lab coats.  He paused after each sentence, long enough for those mournful eyes to pierce the souls of each committee member, sitting around our horseshoe configuration.

    “Then they get to meet with their attorney again and decide if they want to proceed with the case to trial, if they are lucky.  If they are lucky . . .”

    He let that fragment linger, really sink into the pews.  It was a crafty dual device of rhetoric: irony, of course, for no one facing a jury is all that lucky, and emphatic repetition.  I had no idea what clinical skill he possessed, but hanging on his words, their elusive moral weight dissipating with his R’s, I thought the gastroenterologist had missed his calling.

    “Finally, after the doctor has been walking around a wreck for six years, the case gets settled, with or with-out a jury.  And then we bring them before this com-mit-tee . . . and we torture them again.”

    He allowed the silence its space.  Two women, a radiologist and a surgeon, nodded in their seats.

    “Reuben, I agree with all your points.”

This time it was the Medical Director, an oncologist who served as the Quality Improvement chairman.  He was the same age as the gastroenterologist, but his September tan still held on to summer, his meticulous hair auburn and parted on the side.  The perfect knot on the tie, the creaseless pinstripe suit, the patience with which he sat at attention – it all belied the length of the day behind him.

“But given the hour, the Committee might be best served if we move on to a review of the case.”

    The gastroenterologist overruled.  “I have one more philosophical point to raise:  What is the purpose of the surcharge?”

    The chairman sighed.  “It is an alternative to the actuarial grid, Reuben.  The Committee has discussed this, the Board has approved it.  It is an opportunity to identify an egregious error, without imposing a premium increase on every doctor named in a case, no matter his role.”

    “Ev-ery-thing we have is punitive!” the gastroenterologist lashed back.  “Doctors can’t talk!  If you are sued, our lawyers will not let you discuss it.  That doctor has no support!”

    “Reuben,” the chairman interjected, “in the interest of time . . .”

The exhumed bones of the case lay sprawled on a folding table: photocopied chart notes and opinions of expert witnesses, all spilling out of a card stock maroon dossier with an elastic fastener.  The gastroenterologist held a sheet of paper up, disgustedly, before releasing it to a zig-zag float that missed the table and landed on the threadbare carpet.

“It’s not a good case.”

* * *

The physician had been identified on the agenda as “D.W.”  He was also a gastroenterologist, which is why Reuben was chosen to parse the record, and because they shared an office it slipped out that his name was Dan.

“An 81-year-old man came to him for chronic abdominal pain,” the gastroenterologist summarized.  “Generally, a gastro orders blood work and a CAT scan.  And once you get the CAT scan results, you’re dead.”

The scan demonstrated air in the bile ducts – a condition crystallized, poetically, as “pneumobilia”.  D.W. scheduled an ERCP.

“It should’ve been an MRCP,” the gastroenterologist commented.  

During the procedure, D.W. met resistance when he attempted to pass the endoscope through the duodenum, so opted for a dilating device.  On its margins, the gastroenterologist critiqued his own narrative.

“Dilating a stenotic duodenal bulb is extremely risky.”

In the post-procedure unit, D.W. spoke to the patient, but not to the patient’s son.

“The son was a dermatologist,” the gastroenterologist offered as context, “and the patient was an old man coming out of anesthesia.  Not wise.”

When the patient developed fever and dropped his blood pressure, he was admitted to the hospital for overnight observation.  When it dropped further, a repeat scan demonstrated a duodenal perforation.  The patient was transferred immediately to a tertiary care hospital, where he spent two months in an ICU before dying.

“Dan really hung himself,” the gastroenterologist concluded.

The walls of the boardroom were an institutional white, and with the yellow fluorescent ceiling lights they reflected a jaundiced pallor upon the Committee. A long silence was broken by the chairman.

“So, Reuben, do we ask Dan to come in and appear before the Committee?”

We all looked deferentially to Reuben.  Written across the seven other faces was the resonance of his earlier words:  Doctors are all alone.  Doctors have no support.  Everything we do for one another is punitive.

“Reuben,” repeated the chairman, “do we ask Dan to come in?”

“I have no problem with that,” said the rabbi.

Douglas Krohn is a Clinical Assistant Professor of Pediatrics at New York Medical College and a physician in practice outside New York City. His fiction and creative non-fiction have appeared in Intima, The Vincent Brothers Review, South 85 Journal and other publications.