David wrote a short note in Marjorie's chart to make it official that he was assuming responsibility for her care; then he checked in on Nikki. She was already doing much better, even though the respiratory therapist had yet to arrive. Her improvement was probably due to hydration from her IV.
Finally, David headed over to the professional building to start seeing his patients. He was almost an hour late.
Susan was upset when David arrived. She had tried to juggle the patients' appointments and cancel those that she could, but there were still a number waiting. David calmed her as he slipped into his office to put on his white coat. She followed him like a hound, ticking off phone messages and consult requests.
With his white jacket half on, David abruptly stopped moving. Susan halted in mid-sentence, seeing David's face go pale.
"What's the matter?" Susan asked with alarm.
David didn't move or speak. He was staring at the wall behind his desk. To his tired, sleep-deprived eyes, the wall was covered with blood.
"Dr. Wilson!" Susan called. "What is it?"
David blinked and the disturbing image disappeared. Stepping over to the wall, he ran his hand over its smooth surface to reassure himself it had been a fleeting visual hallucination.
David sighed, marveling at how suggestible he'd become. He turned from the wall and apologized to Susan. "I think maybe I watched too many horror pictures when I was a kid," he said. "My imagination is working overtime."
"I think we better start seeing patients," Susan said.
"I agree."
Launching into work with gusto, David made up for lost time. By midmorning he was caught up. He took a brief time-out from seeing patients in order to return some of the phone calls. The first person he tried was Charles Kelley.
"I was wondering when you would call," Kelley said. His voice was unusually businesslike. "I have a visitor in my office. His name is Neal Harper. He's from CMV utilization in Burlington. I'm afraid there's something we have to go over with you."
"In the middle of my office hours?"
"This won't take long," Kelley said. "I'm afraid I must insist. Could you please come over?"
David slowly put the receiver down. Although he didn't know why, he felt immediately anxious, as if he were a teenager being asked to come to the principal's office.
After telling Susan where he was going, David left. As he arrived at the CMV offices, the receptionist told him to go right in.
Kelley got up from behind his desk, appearing tall and tan as usual. But his manner was different. He was serious, almost dour, a far cry from his usual ebullient self. He introduced Neal Harper, a thin, precise man with pale skin and a small amount of acne. To David he appeared the apotheosis of the bureaucrat who'd been forever locked in his office, filling out his forms.
They all sat down. Kelley picked up a pencil and played with it with both hands.
"The statistics are in for your first quarter," Kelley said in a somber tone. "And they are not good."
David looked back and forth between the two men, feeling increasingly anxious.
"Your productivity is not satisfactory," Kelley continued. "You are in the lowest percentile in the whole CMV organization according to the number of patient visits per hour. Obviously you are spending entirely too much time with each patient. To make matters worse, you are in the highest percentile in ordering laboratory tests per patient from the CMV lab. As far as ordering consults from outside the CMV community, you're completely off the graph."
"I didn't know these statistics were gathered," David said lamely.
"And that's not all," Kelley said. "Too many of your patients have been seen in the Bartlet Community Hospital emergency room rather than in your office."
"That's understandable," David said. "I'm fully booked out for two weeks plus. When someone calls with an obviously acute problem needing immediate attention, I send them to the ER."
"Wrong!" Kelley snapped. "You don't send patients to the ER. You see them in your office provided they're not about to croak."
"But such disruptions throw my schedule into a turmoil," David said. "If I take time out to deal with emergencies, I can't see my scheduled patients."
"Then so be it," Kelley said. "Or make the so-called emergency patients wait until you've seen the people with appointments. It's your call, but whatever you decide, don't use the ER."
"Then what's the ER for?" David asked.
"Don't try to be a wiseass with me, Dr. Wilson," Kelley said. "You know damn well what the ER is for. It's for life-and-death emergencies. And that reminds me. Don't suggest that your patients call an ambulance. CMV will not pay for an ambulance unless there is pre-approval and pre-approval is only granted in cases that are truly life-threatening."
"Some of my patients live alone," David said. "If they're ill…"
"Let's not make this more difficult than it need be," Kelley interrupted. "CMV doesn't operate a bus service. All this is pretty simple. Let me spell it out for you. You must seriously increase your productivity, you must lower your use of laboratory tests drastically, you must reduce, or better yet stop, using consults outside the CMV family, and you must keep your patients out of the ER. That's all there is to it. Understand?"
David stumbled out of the CMV office. He was flabbergasted. He'd never considered himself extravagant in the use of medical resources. He'd prided himself on always keeping the patient's needs to the fore. Kelley's tirade was unnerving to say the least.
Reaching his office suite, David limped inside. He caught sight of Kevin disappearing behind a closed door with a patient and remembered his prophecy about the utilization evaluation. Kevin had been right on target; it had been devastating. What also bothered David was that Kelley had not made a single reference to quality or patient approval.
"You'd better get hopping," Susan said the instant she saw him. "You're getting behind again."
Midmorning Angela ducked out of the lab and went to check on Nikki. She was pleased to find her doing as well as she was. The fact that she wasn't running a fever was particularly encouraging. There was also a definite subjective decrease in Nikki's congestion following a prolonged visit by the respiratory therapist. Angela used a nurse's stethoscope to listen to Nikki's chest. There were still sounds of excessive mucus, but not nearly as much as there had been that morning.
"When can I go home?" Nikki asked.
"You just got here," Angela said, giving Nikki's hair a tousle. "But if you continue to improve the way you've been going, I'm sure Dr. Pilsner won't want to keep you long."
Returning to the lab, Angela went to the microbiology section to check on Nikki's sputum swab; she wanted to make certain it had been plated. It was crucial to determine the mix of bacteria in Nikki's respiratory tract. The technician assured her it had been done.
Returning to her office, Angela hung up her white coat in preparation to read a series of hematology slides. Just before she sat down she noticed the connecting door between her office and Wadley's was ajar.
Angela went over to the door and peeked in. Wadley was sitting at a double-headed teaching microscope. He caught sight of her and waved for her to come over.
"This is something I want you to see," Wadley said.
Angela stepped over to the 'scope and sat opposite her mentor. Their knees almost touched beneath the table. She put her eyes to the eyepiece and peered in. Immediately she recognized the specimen as a sample of breast tissue.
"This is a tricky case," Wadley said. "The patient is only twenty-two years old. We have to make a diagnosis, and we have to be right. So take your time." To make his point, he reached under the table and grasped Angela's thigh just above the knee. "Don't be too impulsive about your impression. Look carefully at all the ducts."
Angela's trained eye began to scan the slide in an orderly fashion, but her concentration faltered. Wadley's hand had remained on her thigh. He continued talking, explaining what he thought were the key points for making the diagnosis. Angela had trouble listening. The weight of his hand made her feel acutely uncomfortable.