Doctors at Play

By Samuel Weiss

Copyright © 2009 by Fred Moody and Herbert L. Fred

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If the principles of medicine are today unknown, or known to only a slight extent, this is
a direct result of the fact that they are no longer sought. Medicine, in short, has
succumbed to the twentieth-century habit of concentrating upon techniques rather than
upon the quest for understanding; of thinking that when phenomena have been described
they have been explained.

—Ian Stevenson

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Prologue

Dr. Ronald Stangler, Psychiatrist

So a dear friend of mine, Dennis Leonard, who’d been teaching medicine for

more than fifty years—a good part of it here at East Loop General Hospital—called me

one day and asked if he could see me “as a patient.” He’d been having disturbing

episodes of shortness of breath that he couldn’t explain, even after undergoing a battery

of tests and visiting a series of specialists. He finally decided to see a psychiatrist—he

didn’t know what else to do.

I told him to come see me right away.

He came in, said hi, sat down, and immediately started ranting about the

lamentable state of his medical school. (Dennis always was one to get right to the point.)

And not just his school, but medical schools across the country, it turned out, and even

then not just the schools but all of medicine, everywhere, at all levels. It just came

pouring out of him, horror story after horror story.

“Medical schools all over the country are graduating more and more physicians

who aren’t equipped to render good patient care! These graduates can’t take an adequate

medical history, can’t perform a reliable physical examination, can’t critically assess the

information they gather, can’t create a sound management plan, have little or no

reasoning power, and communicate poorly! The only thing they’re proficient at is

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ordering all kinds of tests and procedures. But even at that, they don’t know when to

order them or how to interpret the results! And all they know how to do is treat numbers,

rather than the patient to whom the numbers belong.”

He was just as unhappy about the faculty and administration at these schools.

“With all the shortcomings these trainees have, the powers that be don’t hesitate to

promote them, incompetencies and all, into public service. The basic qualities that used to

characterize our profession just don’t seem to matter anymore. Responsibility,

accountability, commitment, compassion, candor, discipline—they’re all lost arts. I don’t

understand it, I can’t accept, and the more I fight it, the more resistance I encounter from

above and below, and the more unpopular I become.”

It wasn’t hard to see what his problem was. He presented with all the classic

symptoms you’d expect—not of depression, though, as he’d suspected. It was grief, pure

and simple.

I let him go on for all of ten minutes before I stopped him. “Dennis,” I said.

“There’s nothing wrong with you—you’re just grieving. You’re grieving the death of

medicine.”

Thirty years of psychiatric practice and this was by far the shortest path to

diagnosis in my career.

I saw this sad light go on in his eyes, a combination of relief and

acknowledgement. We didn’t talk much longer after that—just caught up on things—

before he got up to leave.

And now? I don’t know…sometimes I feel like I’m as much to blame as anyone

for what happened after that.

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Chapter 1

Eric

I guess you could say that Dennis called me at exactly the right time. I was where

you always end up in journalism: burned out, self-disgusted, divorced. Fearful for the

future and increasingly disinterested in reaching it. Drunk half the time, filled with hung-

over self-loathing the rest.

In essence—a cliché! There was no getting around the fact that I had pretty much

turned into the worst thing writers can imagine becoming.

I was completely out of energy—there wasn’t a story idea on earth I could get up

for. After thirty years in this business, I had devolved from real reporting to writing

“essays” and personal “think pieces” without ever bothering to leave the office. The kind

of horrible stuff from burned-out journalists that used to make me puke.

But then when Dennis called me…I mean, the guy was a legend—eighty years

old, still working full time at his teaching hospital, a school he’d helped found some forty

years before, giving talks all over the place about the Decline of Medicine, arguably the

most quotable guy on the planet, brilliant, a guy who’d worked with some of the greatest

legends in medicine. I’d written about him quite a few times over the years, almost

always because of some award he’d gotten or milestone he’d reached. He was a

legitimate guru, with this huge following of younger doctors all over the world who’d

studied under him and who never stopped talking about how much he meant to them,

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how much they learned from him, how every day, years later, they still remembered

things he’d said to them when they were students.

I wasn’t sure at the time exactly why I’m the one he called, but I decided not to

look a gift horse in the mouth. I mean, it doesn’t get any better than what he was offering

me: complete unfettered access to everything going on in his hospital, behind the scenes.

Not for an article, or even a series of articles, but for a novel.

Once we started talking seriously about how to go about putting a novel together,

I talked to him about working the plot around some famous cases he’d worked on. I was

thinking in particular about this one early in his career that I’d written a newspaper story

about. It actually was how I met him, writing about that case. It was a weird medical-

detection event, basically, that ended up being a police matter—which is how the paper

got onto it.

What happened was, this guy kept showing up every few weeks at Dennis’s

hospital with the same weird array of problems: watery diarrhea, weakness, tingling in

his fingers and toes, brittle fingernails that were kind of reddish, hair loss, a metallic taste

in his mouth, and breath that smelled like garlic. His fingernails were really odd-looking,

with a white transverse band in the middle and this purple-red color at the base.

They would run every test they could think of on this guy, but nothing showed up.

And then after three days in the hospital, his symptoms would all disappear. So they’d

send him home and after a few days all his symptoms would return, he’d come back to

the hospital, and they’d go through the whole circus again.

So they finally called Dennis in and told him the whole story—this was after

they’d sent the guy home yet again—and Dennis didn’t ask them a single medical

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question. Instead, he asked about the patient’s personal life, and they told him that he was

an unemployed accountant who was divorced but living with a girlfriend.

And Dennis took all this in, then rendered a diagnosis on the spot: selenium

poisoning.

They waited for the guy to show up again, but he didn’t, so after about four

months Dennis had the hospital track him down and bring him in for a consult. The guy

showed up with no symptoms—he’d completely recovered. And all Dennis asked him

about was his personal life—the guy said that his girlfriend had left him. And that after

that, he got well, and was back at work.

That’s when they called the police. And Dennis was absolutely right: it turned out

that the girlfriend had fled the country, but the police discovered that back just before this

guy started getting sick all the time, she had bought a ton of gun blue at a gun shop. And

of course gun blue is a lubricant laced with selenium, and it was pretty obvious that she

was feeding it to this guy somehow.

The case made a legend out of Dennis—not just in the hospital, but among the

police and the guys working the story with me, too. And it was the first thing that popped

into my mind when Dennis floated this book idea to me. He had enough weird medical-

detective stories like that floating around in his past to make up a whole bookstore full of

novels.

It was funny how quickly our collaboration fell apart, though—at least the part

about co-writing a novel. We tried setting up this plot where a wise old doc is challenged

for power, hegemony, whatever, at his medical school by a bunch of young upstart

doctors who think he’s a has-been, hopelessly out of date, etc. etc. etc. While all he’s

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doing is trying to uphold traditional standards in medicine. But the whole project kind of

foundered because we could never set up any situations where the conflict was at all

compelling. Whenever I tried to get Dennis to think about how these younger docs could

match wits with him, he was helpless.

I remember sitting at dinner one night with him and his wife, talking about how

we were stuck. I turned to his wife and said, “The problem with Dennis is that he’s

incapable of imagining someone being as smart as he is.”

God, did she laugh. It was the biggest laugh I ever got out of that woman—I don’t

think she cared much for me. But Dennis—all he did was give me this long, searching

look. He didn’t say a word; didn’t so much as crack a smile, either.

Anyway, the upshot of all that was that we went to Plan B: a nonfiction tell-all

about all the real horror stories in modern-day medicine. It was kind of a heartbreaker for

me. Every journalist secretly wants to write a novel, and it really seemed to me that this

was a chance to write a great one that looked right into the guts of the health-care mess at

a time when it was on the minds of just about everybody in the country.

But we had a great opportunity to do the next-best thing, too, if we could pull off

writing this exposé. I mean, we had a perfect example in all the shenanigans going on in

medicine right there at East Loop General Hospital, where Dennis worked. We had a

perfect situation to riff off of there because the school was in trouble, and now had gotten

itself put on probation by the people who accredit medical schools, and nobody outside

the medical world knew anything about it. So obviously there was a great story just

sitting there waiting to be told, if someone could get inside the walls to tell it.

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 Who wouldn’t jump at that chance? Dennis had been telling me these stories for

years, but always off the record—he used to be terrified of damaging the medical

school’s reputation. “Now I don’t give a shit,” is what he said to me the first time we

talked about it. So it was a legitimately huge deal, his sudden change of heart, and such

an amazing opportunity that I decided not to bother examining or even thinking about his

motives. Given the way things were going for me, I felt like I was being given a second

chance at life when he called.

Joanne Leonard

Dennis is so darned stubborn. Once he gets his mind set on something, there’s

nothing you can do to change it. When he told me he’d called this Eric person and wanted

to cooperate with him on an exposé, I just shook my head. It wasn’t just that it was an

exposé –it was that it was an exposé of the place he’d devoted almost his entire career to!

What could he have been thinking?

After forty years of marriage, I knew better than to try to talk him out of

something once he’s made his decision. But then again, this was the wrong decision!

Anybody but him could see that!

His problem is also what’s the best thing about him: He just cannot compromise. I

love that about him, of course, but it’s also the thing about him that’s crazy-making. He’s

too much of a perfectionist! He always ends up at odds with the people who don’t do

things exactly his way, and his way is just too hard for regular people. Just nagging and

nagging and nagging at them, never leaving them alone. It’s why I don’t want him to

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retire: if I had him around all the time, he’d drive me crazy with all his ranting and raving

about how I should manage the house better. He’d just be in my hair all day long.

But getting involved with a writer. You simply cannot trust them to do what you

want! I just know that this Eric will end up wanting to make too much of a story out of

Dennis, and will take advantage of him, and Dennis is the one who’ll pay the price! Of all

the things to go and do! Especially at the end of what should be such a celebrated career!

All you have to do is look at what happened the last time he got involved with a

writer. Back in the 1970s, he helped this gentleman get a job as an orderly at the hospital,

kind of go undercover, and the guy wrote this big sensational book—called Hospital—

and then they made a movie out of it, with George C. Scott, of all people, playing Dennis.

It was ridiculous how they made him into this completely different person from what he

was: a drunk who was divorced, and who had this ridiculous affair with a much younger

woman. That wasn’t like him at all! And they had the nerve to give that character the

same first name and everything! It was so embarrassing, I can’t begin to tell you—I had

people asking me all the time if the woman in that movie was based on me and

everything, if that’s how Dennis and I met...the whole thing just made me sick.

Eric

So I started doing what I always do when I’m writing in depth about people:

plundering their lives, their pasts, their minds. Aside from the writing, it’s my favorite

part of these projects: just total voyeurism. Looking through everything I can find about

people—on the web, in libraries, everywhere. Talking to everybody. In Dennis’s case, it

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was pretty easy—he’s written hundreds of articles, and four books, and half the stuff in

the books is autobiographical, and it’s all insanely telling—both intentionally and

unintentionally.

And he’s a talking machine—every time I would ask him a question, he’d give

me an hour’s worth of stories by way of an answer. I remember thinking when I first

started in with him that this was going to be the easiest writing I ever did, because the

story did what stories never do: It practically told itself.

Book Jacket Copy from Dennis Leonard’s Pictures from the Bedside: 50 Years of

Diagnosis (2008)

Dennis Leonard, MD, MACP, is one of the nation’s best-known medical

educators and diagnosticians. He is the author of more than 400 publications, including

three books—each a collection of provocative essays—providing philosophical insights

into disease, the practice of medicine, the challenge of difficult diagnoses, the joys,

frustrations, and rewards of teaching, the pleasurable pain of learning, and the

exhilaration of true scholarship. He is the recipient of innumerable awards, including a

Citation from the President of the United States. The Dennis Leonard Medical Society,

Inc. founded in 2002 by Dr. Leonard’s former trainees, honors him for “a half century of

bedside teaching.” Dr. Leonard is an emeritus member of the American Osler Society and

has served on the editorial boards of numerous national medical journals.

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Doctor/Blogger, Fondly Remembering an Episode from His Residency, Long Gone

But Never Forgotten

Starting an IV on a head-injured patient early one morning, I heard loud voices in

the otherwise sepulchral neurosurgery ward where I was chief resident. I threaded the

needle into place, pulled the pre-cut tape off the sheets, secured the hub, and looked up. A

throng of white-coated internal medicine residents hove into view, trailing an animated

man scurrying toward our isolation ward.

The leader, identified by his shin-length white coat as an attending, stopped

suddenly and swung around, his hand in the air. He was nearly mobbed by the crowd

piling into one another to avoid hitting him. He snatched the chart off an adjacent bedside

table and held it high, gesturing and speaking rapidly and precisely. I had never seen an

attending in virtually any specialty in the wee hours of the morning at Central General, let

alone one with such a flair for the dramatic. So, knowing that this was probably my one

opportunity to view this phenomenon, I edged closer.

The attending turned to the resident who was in charge of the patient and asked,

“Well?” The resident began haltingly, obviously intimidated, reciting the mantra of a

fairly familiar history.

“This man was brought in stuporous by his family, or someone, placed on a

stretcher in the ER and abandoned.”

“OK,” the attending said, then asked, “What happened after that?”

The resident continued, “He was initially thought to be a drunk, because it was

payday Friday night, and he wouldn't respond to any questions. On painful stimulation,

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he moved his arms appropriately, his pupils were OK, vital signs normal except for a 105

degree rectal temp. And his neck was rigid.”

“Differential diagnosis?” asked the attending.

“Intracranial bleed or meningitis, Dr. Leonard.”

At last! I was about to meet the famous Dr. Dennis Leonard, intellectual, dynamic

teacher, leader, and motivator! I eased a little closer. Dr. Leonard led the resident through

the differential diagnosis: what kind of intracranial bleed? What form of meningitis? How

do you distinguish one from the other? Is it dangerous to do a spinal tap on an

unconscious patient with a stiff neck? Why? Why not?

When he had pumped that resident dry, he turned to another, then another, leading

them through the history, physical exam, the gamut of diagnostic tests, differential

diagnoses and how you would distinguish one from another—and the various forms of

treatment each would require. It was a classic lecture, performed at the bedside using the

Socratic method, delivered by a true master at 2 o'clock in the morning. I listened to the

dialogue, fascinated by Dr. Leonard’s intensity, his precision, and his bringing out the

best in his residents at Mach I speed.

I had never witnessed a more masterful performance, yet for him it was business

as usual and has continued to be business as usual throughout his entire magnificent

career.

I was sophisticated enough as a fourth-year resident to know that I was in the

presence of a giant. At Central General, we had other tigers as attendings, but seduced by

the income of private practice, they left the ranks of teachers to become practitioners.

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 Dennis Leonard, on the contrary, was to remain a full-time teacher for the next 40

years, and has amassed a 55-page abbreviated CV by exceeding the speed of sound as a

teacher and chronicler through his entire life. His questions to his students and residents

always focused on the patient. “What did your patient tell you?” “What did you find on

examination of your patient?” “What did you tell your patient?” “Did you touch your

patient?”

And the final salient question, “Did you do your best?”

Dennis Leonard has devoted his life as an academician to teaching students and

residents and caring for patients and he has been honored in many ways, so many that I

would not exaggerate by saying he has touched every academic base, and has been

honored in every conceivable way, teaching thousands of residents and students and

colleagues. His enthusiasm is legion, his ardor rivals that of Dr. Michael DeBakey, the

king of intensity, and we who have had the spiritual experience of being around Dr.

Leonard know him to be a doctor who has fought mediocrity, despised poor clinical

performance, and led by example throughout his career. Many of his students have

reached heights they never dreamed they could reach, trying to emulate his excellence.

I can't help but think about all the lives of doctors changed by Dennis Leonard’s

dramatic pleas to his residents and students to do their best always. Just floating on the

periphery of his charisma, I began driving myself harder, striving to excel rather than

being satisfied with just doing my job. If his example worked that well on me, an

onlooker rather than a participant, consider the salutary effect he has had on those sitting

at his feet for years.

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Dennis Leonard

Hell, I don’t even know where to begin when it comes to talking about what’s

wrong with this medical school. For one thing, it’s not just this school—it’s medical

education in general. The kind of rules they have now in this country, medical education

is all about the care of residents instead of patient care. Oh, every hospital administrator

speaks the same language—they all say, “Oh, yes, patient care is our first goal, the

patient always comes first,” but that’s never the case any more.

How on earth can you deliver good or even adequate patient care when you run a

hospital and medical school the way they run things here? The residents, first of all, get

little instruction—they’re just used as a source of cheap labor. They get limited

supervision from attendings. That’s one thing. Then there’s residents themselves, whose

priorities are driven in part by the way they’re exploited, and in part by the way that the

culture has changed. It’s just completely different today: striving for excellence is not

what people look for. Now, they strive for mediocrity. Mediocrity! Trainees just want the

most time off and the highest salary. Seriously! The two most asked questions by intern

applicants now are “What are the work hours?” and “What’s my salary?”

And people wonder why I keep saying that medicine is dying.

Everything’s breaking down. In the past, if I put a weak resident on notice, and

there was no improvement, the resident was fired! But now, for the last six or seven

years, I’ve been dealing with completely inadequate trainees from the standpoint of

knowledge and ambition. If I could, I would dismiss eighty percent of our housestaff. But

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I can’t! The school’s afraid to discipline people appropriately because residents sue if you

dismiss them.

Hell, lawsuits have so captured the medical profession that they’re afraid to pass

gas for fear of being sued.

Dr. Patrick Badger, Chairman of the Department of Medicine

I’m not going to try to hide the fact that we’re struggling here—struggling with

budget, struggling with the mandate to care for the most disadvantaged patients in the

county, struggling with some issues of quality and accreditation. We’re a hospital in

crisis, and it doesn’t help to have a senile old fart like Dennis running around telling

everybody who’ll listen about what a bad operation we’re running. And don’t even get

me started on his biases against technology. I don’t care how much of a legend he used to

be: With his attitudes now, he’s as responsible as anyone for the mess we’re in with the

ACGME—the Accreditation Council for Graduate Medical Education. He’s a dinosaur,

plain and simple.

What happened was, after they came through last time, the ACGME put us on

probation. We’ve been scrambling to get back in their good graces ever since. They gave

us a whole list of things they told us we need to get corrected, but I’m betting that the real

problem with them had to do with the group of residents who went to the Council on their

own, to complain about Dennis. The things they complained about are completely

reasonable, because a lot of what he does and says gives us a real black eye.

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 They had all these complaints, but the bottom line is that he’s demoralizing, and

his treatment of the residents here, along with his constant complaining that we’re giving

them a poor education, that we’re too easy on them, etc. etc. etc., has a terrible effect on

the quality of care and training we can deliver. And his insistence that we should be

teaching residents outmoded methods—taking a detailed history, doing a physical

examination, thinking things through instead of using sophisticated tests to get

diagnoses—he wants doctors to guess, basically, instead of get firm answers. Then he

grades residents down when they don’t spend countless hours studying all these old,

outmoded techniques they’ll never use in the real world. That’s what modern technology

is for, for God’s sake!

When I took this department chairmanship, I decided I was willing to put up with

him until he retired, but now it seems like he’ll never get around to that. Shit, he’s 80 and

still going strong! You can’t kill him! So it’s obvious that I have to do something about

him, and this accreditation mess gives me leave to act, basically, and force him out of

here.

José Pak, Third-Year Resident

I start bad here. Other residents rude and mean so I really sad. But they get better

and better when they know me better. But always, even now, attendings who teach us and

who we work with very rude and mean. Always. I never question attending—that like

questioning professor—but when I new here I see sometime attending do thing I think is

incorrect. Feel like I have to say something because patient in danger. But when I ask

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attending about it he yell at me and grade me down. Grade me down! So now I keep

mouth shut, only talk to Dr. Leonard. Other teachers here bad—that why Dr. Leonard not

like them. And why Victor leave.

Nancy Beardsley, Student Nurse

I feel so bad for Brandon. He works so hard—so incredibly hard—and never gets

the appreciation he deserves. Like when Victor left, Brandon felt like he would have been

in line to be chief resident if it weren’t for Dr. Leonard disliking him so much. I’m doing

my residency, too, in nursing, so I see it all, and I can tell all Brandon’s troubles are

because of Dr. Leonard, who Brandon says is trying to get him flunked out. Dr. Leonard

never cuts him any slack—ever. It’s like he’s practically stalking him, looking for things

he can use against him. And he makes it clear without actually saying it directly that if

medical schools were the way they used to be, Brandon would be kicked out.

I keep telling Brandon not to give up. He just has to keep believing in himself and

working hard like he does and he’ll get through the Dr. Leonard phase of his residency

and go on to finish here and start his career. He gets so down on himself sometimes, and

so mad! But I just know that someday he’ll be able to look back at this time of his life

and just laugh at how wrong Dr. Leonard was about him.

Eric

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 So one of the things Dennis and I started doing was meeting one night a week, at

this place called Café Luk, which was basically the only place Dennis will go for dinner.

He’s been going there for years, and the owner always has his same table set up for him,

and Dennis always sits in the same chair. I still remember the first time I showed up

there: Dennis wasn’t there yet, and when I told the waiter I was there to have dinner with

“Dr. Leonard,” he led me over to his table in the corner, then panicked when I started to

sit in Dennis’s chair.

We’d both order the same thing every time: two orders of ribs each. And Dennis

would bring his own beer—XX Light—that he brings in this little canvas bag that he

carries everywhere he goes.

So on this one night, I was all excited because I’d done one of my Google

searches on his name—it was part of my routine on this project, I’d do that search every

couple of weeks or so—and I came across a YouTube video that some residents had done

as a tribute to him a few years ago.

So we sat down, and I said right away, “Dennis! You didn’t tell me! You’re a star

on YouTube!”

“What the hell are you talking about?” He had no idea what this thing was, this

video. But I thought it was interesting that he knew what YouTube was, even though he

never uses a computer.

“Let me see if I can pull it up on my iPhone,” I’d just gotten one a few days

before, and hadn’t tried its YouTube application. And it turned out that I could find the

video, easily, so I started it playing and handed the phone to him. He was enthralled—he

just sat there staring at it, enraptured, for the ten minutes or so that it ran.

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 About two weeks later, we had dinner again, and his wife came along. I’d gotten

to know her a little by then even though she never had much to say about Dennis, no

matter how much I asked.

They came in separate cars, and she got to the restaurant before he did. Man, she

jumped all over me: “Why the hell did you have to show him your iPhone? Now he’s

insisting that I get him one! It took me months to teach him how to answer the cell phone

he has! I can’t go through that again! Don’t ever show him any of your gadgets again!

Ever!”

Dennis Leonard on YouTube

I’m amongst the last of a breed of physicians who were trained to take a good

history, do a good physical examination, and then say to themselves, “OK, now from the

history and the physical, these are the findings. Now what are the possibilities? What

should I do?”

I will not sell my integrity, I will not lower my standards, and I will not sacrifice

my principles, no matter what the pressures are. And there are a helluva lot of pressures,

I’ll tell you that.

I’ve been teaching medicine for over fifty years. I graduated medical school in

1954 and I’ve been here in this city ever since 1961. I’ve been a professor of medicine

working here at East Loop since 1988.

Still going strong, I hope.

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 The very first patient I had as an intern, the very first one, I introduced myself to

him and shook his hand, and five days later he was dead. And I was shocked, and

saddened, and I cried. That was the first time I cried over the death of one of my patients,

but I have cried more than once. Because when you get involved…you know, I teach this,

I never did it when I was young because nobody ever asked me to do it, and I just wasn’t

mature enough myself to do it, but if you’re really concerned about the welfare of your

patient, and that patient dies, one of the most compassionate things you can do is go to

his funeral.

I’ve spent over fifty years honing my diagnostic skills. I don’t know too much

about therapy, because I often say, “Anybody can treat, but not anybody can diagnose.”

You’ve got to be able to diagnose something properly before you treat it. Use your eyes!

Look at the patient! What does he look like, or what does she look like? What do you

see? And if you teach yourself to look at your patient, you will see a lot more than what

you thought you were looking at. We see what we look for, not what we look at. And

your ears, your ears are very important, not only to listen to your patient, but also to listen

for heart murmurs, or murmurs in other parts of the body that can help you understand

what’s going on. Using your hands to feel, examine the abdomen, feel the testicle, feel the

breast, and you develop a sensory…you know what feels normal and what feels

abnormal. Hearing…tasting…you know, in the olden days, they would make a diagnosis

of sugar in the urine by tasting the patient’s urine! I don’t recommend that, but using

your nose, for example, your sense of smell…the old doctors…I’ve done this, not for

typhoid fever, but the old doctors—old when I was young—could walk onto a hospital

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ward and smell, and say, “You’ve got a patient with typhoid fever on this floor, don’t

you?” They could tell by the odor of the patient.

So those are examples of using your eyes, your ears, your nose, and your hands.

But most of all, use your head! You have to blend what you’ve got up here with common

sense. And common sense is uncommon. Period.

You’ve got to be individualistic. You’ve got to ask yourself and others questions.

And you shouldn’t accept everything you hear in medical school as being the gospel.

Science owes its success to doubting all things. An example of that is Ignaz

Semmelweis, who’s the one responsible for really proving that simply washing your

hands with soap and water can prevent infection. When he introduced this concept in the

mid-1800s, he was considered insane and placed in an insane asylum, where he passed

away. And yet we now consider him a hero.

Perhaps the most rewarding aspect of being a teacher is to see your students grow.

That’s why you’re around—to promote learning. Teachers don’t teach—they promote or

stimulate learning. The most important role in the education of a person belongs to the

person. And my joy comes in finding the relatively few students who show a passion for

learning. Who enjoy learning. Who don’t mind working hard, which is essential to

learning. So those few who might see this tape, who feel that they have to struggle to get

what they want, that’s good—because that’s the way you remember. As Dr. William

Beam, one of the giants of internal medicine, who’s now passed on, said, “There’s no

magic capsule, there’s no vitamin, that you can take to become excellent. The only secret

to becoming excellent is hard work.”

22
Osmun Gienger, Fourth-Year Resident

You can’t even begin to imagine what it’s like to get through medical school and

into a residency. You kill yourself for years, you have no life, you borrow and borrow

and borrow…and then you end up in a place with this old asshole lording it over you and

acting like his only goal in life is to get you to flunk out and give up on your life’s dream

of being a doc.

Seriously—I never have any kind of encounter with Dr. Leonard that doesn’t

include him saying or doing something to make sure I remember that he wants to kick me

out of the hospital for good. All you ever hear from him is that medical students and

residents and even attending physicians “these days” are inferior to the ones from his

era—about a hundred years ago or whatever. He just fixes that evil eye of his on you and

scares the shit out of you.

It’s not just me, either—a whole bunch of us feel that way about him, even though

most people would never admit it out loud.

Benjamin Hudson, Fourth-Year Resident

Okay, here’s the deal with Dr. Leonard: His whole thing is preparing us for a

career no one in medicine has anymore. We don’t “diagnose” like they did when he was

young. That work is done for us by technology, and done better. No one goes to medical

school anymore to learn how to diagnose patients without using the sophisticated testing

23
protocols available to us now. It’s a waste! Plus, it doesn’t pay shit, being a “general

internist.”

Like with me: If I wanted to be the kind of general diagnostics guy like Leonard

wants us all to be, I’d come out of my residency owing $400,000 or so and get a job

paying like $100,000. Instead, I specialize in Gastroenterology, and guess what? I’ll be

coming out of here with a $700,000 a year job waiting for me, and an employer who’s

already paid off my loans. It’s just the economics of medicine now: I can do seven

procedures a day where I run a scope down someone’s nose into their stomach, take a

look at what’s wrong, prescribe something, and charge them $600. Do that seven times a

day, five days a week…see what I mean? Everybody wins. Except for the outmoded old

bastard who thinks real medicine is spending hours talking to patients, touching them all

over the place with your hands, listening through a stethoscope, taking a whole hour to

make a measly hundred bucks for your office.

All we’re doing is following the money. I signed up here to learn medicine, not

sainthood.

24
Chapter 2

José

I walking down hall on fourth floor and see Dr. Leonard talking to Osmun and

Brandon and some others. He seem angry. I not sure what wrong, what they do, but

something that happened make him want to talk to them about “arrogance.” He telling

them patients think doctors know everything, and that it dangerous when doctors start to

believe same thing about themselves. Then he say problem worse when we not know

something—when we “ignorant.” He say we “cover up” by acting like we know

everything. Then he say, “There nothing special about doctors. We not smarter than

everybody else. We not gods. We just regular people who happen to go to school a little

longer than everybody else.” Then he say something that confuse me: “When people

come out of medical school,” he say, “they should have to take antideiotics.”

Osmun and Brandon not happy. But I always listen when Dr. Leonard talk,

because he very wise. I want to know everything he can teach me. But this time I not

know what he mean and I afraid to ask. So I spend hours on computer, researching, trying

to find what is “antideiotic.” I try every spelling I can think of. Even go to library. Finally

in morning I tell Osmun, and he laugh so hard. So hard. Then he tell everybody, and

everybody think I so funny.

English language so hard to understand. No rules! And words can be bent and

twisted all different ways, to mean different things, even make new words. Impossible!

25
People say medical school must be hardest thing in world, but they wrong: English much

harder.

Eric

At first, I was surprised that Dennis offered me this opportunity like he did, to get

this inside look at everything. He’s been hounded by reporters and writers for his whole

career, and he’s never wanted to have anything to do with the press. But I think he saw

this exercise as a kind of swan song for him, a mournful kind of goodbye not only to the

place he’d be leaving in a few years (even if they had to carry him out feet first), but to

medicine the way it used to be.

He filled me in pretty quickly on the underlying problems at East Loop. Some

problems it shares with medicine all over the country—problems with the medical-school

faculty, problems with declining student quality, that kind of thing—but most of the stuff

he talked about seemed unique to the hospital itself. Like how it’s at the bottom of

everybody’s funding priority.

Or, to put it the way he put it: “We suck hind tit, so to speak.”

Some of the problems are the kind of problems every county hospital faces,

mostly because they can’t turn patients away who can’t pay. They have to take

everybody, no matter what, which means that they get all the people the other hospitals

refuse to take.

It also means the place is completely overwhelmed. It’s not that big of a hospital,

to look at it from the outside, but man, does it ever get the visitors: forty-three people a

26
day are admitted, on average—almost 16,000 a year. Dennis told me that 259 patients

died in the hospital last year. They get 253 outpatients a day coming to the hospital

clinics—that’s almost 100,000 a year. Throw in another 40,000 emergency room

visits…well, you get the picture. The need at this place is basically infinite.

But East Loop has a whole host of other problems that mostly have to do with

local politics and the way the South provides health care to the indigent. There’s two

county hospitals here—East Loop and Central General—but Central General is located in

the medical center near downtown, which is where all the glitzy hospitals and clinics are,

and East Loop is fifteen miles outside of town. There are 100,000 employees in the

medical center—it’s the largest medical center in the world, and obviously where most of

the action is for doctors and residents. So when the hospitals compete for residents,

Central General has a huge advantage because of where it is. Nobody wants to be out in

the sticks, at East Loop.

Central General also has all kinds of prestige because it’s allied with the Baines

College of Medicine, one of the most prominent schools around here. East Loop is allied

with a state university, which has hospitals all over the state, including one in the medical

center that gets the lion’s share of its local resources and attention. Moreover, faculty

prefer to teach there, most of the residents would rather be there, and money from donors

to the hospitals—the hospital in the medical center gets the lion’s share of that, too.

There’s like eleven state university hospitals all together, and East Loop is at the bottom

of that heap. It’s this dumping ground for the indigent and for illegal aliens, it’s out in the

middle of nowhere, and nobody wants to work there. It’s so bad that a lot of the time the

residents are supervised by trainees rather than full-fledged doctors because the faculty,

27
who also see private paying patients, would rather spend their time making money that

way than driving all the way out to East Loop to supervise residents for free.

Dennis gets really worked up when he talks about this stuff. Some of it he blames

on national problems—he says the whole health-care system is a mess—but a lot of it he

blames on the hospital and medical school leadership. That’s what he keeps saying to me:

“There is no place in America that provides such an opportunity to see amazing patients,

material the Mayo clinic rarely sees, and one of the best libraries, too…we should be on a

par with anybody, but we’re not. And I have to attribute it to lack of leadership.”

In case you were wondering why the administration here is so fed up with him.

Dennis Leonard

Here’s a perfect example of what I’m talking about when I talk about the decline

in medical education: When I was in training, you were on every day and every other

night for an entire year. But in 2003, the Accreditation Council for Graduate Medical

Education, which covers all post-graduate training of doctors, came down with strict rules

about how long a post-grad in training can work. The rule calls for no more than eighty

hours of work per week, and the resident must have one day per week completely off, and

when they’re on call for twenty-four hours they must leave the hospital by one the next

afternoon. Shit, that rule has made medicine a screwed-up mess that’s a major problem

for educators and the educated. The interns and residents never learn what we call the

natural history of a disease! For example, if you develop pneumonia and are admitted to

East Loop, in your sickest hours when it’s most important for the doctor to learn how to

28
deal with the patient, he’s not there! He has to leave because of a ridiculous and firm rule

that has impacted the medical education of physicians all over the country. So now we’re

graduating too many physicians who don’t know their asses from a hole in the ground.

Joanne

I learned to live with Dennis’s drive before we were even married. With him, you

either adapt to life in the twenty-four-hour fast lane or you get the hell off the highway.

It’s not like I didn’t know what I was getting into. I was a nurse before I retired,

my first marriage was to a doctor, and I was divorced when I met Dennis, who was

divorced from his first wife. It happens a lot in medicine, divorce. Between us, we had

seven kids. I knew that doctors are workaholics; I can handle that—even a workaholic

like Dennis. He works eighteen hours a day six days a week, and ten or so hours on

Sundays, and doesn’t come home until nearly midnight almost every night. He eats his

only meal of the day when he gets home—either then or if he goes out in the evening for

a meal having something to do with his job—then he goes to bed and is up by five and

out of the house by six. We talk on the phone a few times a day, and have dinner together

every few days.

People are always asking me, “Don’t you want him to retire?” And I always say,

“No! Because then he’d be in my hair all the time!” I got a taste of that years ago, when

he got hit by a car when he was out running, and had to convalesce at home for a couple

months. He drove me absolutely crazy with his complaints about how I manage the

29
house! I swore that I wouldn’t let him move home when he retired—I told him that he

could just stay in his other home, that office of his, where he does all his writing.

I remember when we first started dating. He was completely into his

ultramarathoning in those days—this was more than forty years ago—and on the nights

we planned to have dinner, he’d call me from work and say he was on his way. Then he’d

run the twenty miles from his office to my apartment, take a shower, have dinner with me

and the kids, and then we’d drive him back to his office.

The kids loved it. They were always so excited when he called, because they

knew exactly how long it took him to run to the house—two hours and fifteen minutes,

almost exactly that every time. They would watch the clock, and then when there were

just a few minutes to go, they’d all go kneel on the davenport in front of the living room

window and watch for him. It was adorable.

Dennis Leonard, American Journal of Sports Medicine, 1981; 9:258-61

In April 1966, I began a long-distance running program. By the end of 1969, I had

logged almost 10,000 miles. During the next ten years, I ran an additional 58,118 miles,

including 30 marathons, one 50-mile race, and two 100-mile races.

I prepared for both of my 100-mile runs in much the same way. In the eleven

months before the first race (May 1979) and the eight months before the second

(February 1980), I averaged 20 miles per day at a pace of 8 to 10 minutes per mile. As

the races neared, I did many 30-mile runs and one 40-mile run, tapering my mileage only

in the final six days.

30
 I craved and ate large amounts of meat, especially beef, with bran, fruit, and nuts

for dessert. I also took one multivitamin tablet, 3 to 4 gm of vitamin C, and 4,000 IU of

vitamin E daily, because that combination and dosage of vitamins seemed to keep me

virtually free of muscle stiffness and soreness. Forty-eight hours before each race, I

stopped eating all roughage. I also loaded up on animal protein and fat, because these

foods seemed to boost my endurance.

The first run, the Primo 100-Mile Race, took place in Honolulu under miserably

hot, humid conditions. Because I had tendinitis in my right knee, I took two aspirin

tablets every four hours for a week before and throughout the run. That was a serious

mistake, because the aspirin increased my sweating, urinary output, and body temperature

while inhibiting my thirst. As a consequence, I felt sick all during the race and suffered

severe heat exhaustion at ninety-two miles. After being covered with cold, wet towels for

fifteen minutes, I was able to continue and finished the race in twenty-two hours, twenty-

one minutes, thirty-nine seconds. My total fluid intake, despite prodigious fluid losses,

was six quarts—only one-fourth of what I planned to drink.

In my second 100-mile run, freezing, windy conditions prevailed. Because I did

not take any aspirin, and because of the weather, I lost much less fluid than in Honolulu.

During the first forty miles, I drank two quarts of sugared tea. In the final sixty miles, I

consumed one quart of water, two large packages of cookies, and 2.5 quarts of ice cream.

In spite of the numbing cold, the run was surprisingly easy. I experienced none of the

difficulties I had in Honolulu, and I finished in nineteen hours, ten minutes, nineteen

seconds.

31
 Recovery from the two runs differed. After the first one, I did not run for six days,

and it took me a month to work up to my prerace mileage. After the second one, however,

I resumed training the next day and, within a week, was running my usual 20 miles per

day.

For one week after the first race, my lower legs and ankles were edematous. After

the second race, similar swelling appeared, but it was milder and only lasted three days.

Such swelling had not occurred previously. I had essentially no soreness after either run.

Eric

Sometimes these conversations with Dennis take such a weird turn that afterwards

you’re asking yourself if it really happened. Did he really say that? Like when I asked

him the other day about his first marriage, why it ended. “Well, my wife was the kind of

woman who liked to have a husband who would be home in the evenings and have dinner

with his family and talk to her and help out around the house, basically be there a lot,” he

said. He made it sound like she was kind of unusual in that respect. “And I just wasn’t

that kind of husband. I was working all the time, and seldom came home until very late at

night, and when I was home I was writing and working on other things instead of talking

to her. That’s just the way I was.”

By the time we had this conversation, I’d gotten to know Dennis pretty well, and

was amazed by the way he lived. It’s not a life that you could ever share with anyone—

it’s like being a hermit, basically. The only people you see are people you’re either

working with or working on.

32
 He just kind of sat there for a minute or two after telling me all that stuff, almost

like he was thinking about that whole first-marriage fiasco for the first time, like it never

really occurred to him that he was hard to live with—or, I guess in his case, live without.

Then he said, without apparent irony, “She just got tired of the lifestyle.”

2003 Press Release

Leonard has more first-hand running knowledge than almost anyone alive. He

became a distance runner in “April 1966,” and since that time has covered some 206,000

miles of running and treadmill walking, according to the log which he’s kept from the

beginning.

Brandon Dameron, Fourth-Year Resident

Here’s an amazing story that says it all about what it’s like here. Normal people

get to a doctor as soon as they realize something’s even a little bit wrong. But the people

who come here seem to always wait until it’s almost too late.

We had a woman come in here who had been suffering a cough and chest pain for

four months. Her English was pretty bad, so it was hard to get her story straight, but she

seemed to be telling us that she first started having problems about six months before she

got her cough, after she took quinine to induce an abortion. She came down with uterine

bleeding, abdominal cramps, and fever after that, and the docs at a different hospital

found a piece of partially expelled placenta that they took out with forceps.

33
 She said her symptoms went away after that, but she got the fever and cramps

again about two weeks later. This time, she had a cervical discharge and a tender right

adnexal mass, but it more or less went away after ten days of antibiotics.

But then a couple months after that she started having this dry cough and pain on

the left side of her chest. It would come and go, and she finally went and got a chest X-

ray that showed fluid leaking into the lower part of her left lung. Her cough kept getting

worse, her chest pain got worse, the tips of her fingers and toes gradually enlarged, she

started coughing up really bad-tasting yellow sputum, and she started getting short of

breath and having night sweats.

By the time she came to us, she looked like hell. Her fingers and toes were

clubbed, she had a bad fever, and rales at the base of her left lung. But we couldn’t find

any bacterial cause for any of this, and penicillin didn’t do any good either. We drained

the lung but it just filled up again.

So we had to go in there surgically. Even Leonard couldn’t believe what we

found: a foot-long silk catheter embedded in the lingula and extending into the upper left

lobe of her lung. It reached down through the lower left lobe and all the way through the

diaphragm.

It turned out the woman had had an illegal abortion and was afraid to tell anyone

about it. José was the one who got her to talk—he has everybody confused, because he’s

a Korean with a Spanish name that he took I guess when he was training in Argentina or

something, I don’t know. She must have totally freaked out when this Asian doc started

speaking to her in fluent Spanish, because she just broke down and started crying and

opened up to him like she’d never done before when he asked her if she knew how that

34
thing got in there. She just spilled the whole story. She’d been afraid to say anything

before because she thought she’d be arrested or deported or something for having an

illegal abortion.

Leonard—who is always braying at us about how much he’s seen—said this was

a first even for him. He said he’d never have imagined that a catheter could make its way

out of the uterus and spend five months going through the abdominal cavity, piercing the

diaphragm, and getting into the lung. He told us there were two important lessons here:

anything can happen in medicine; and patients sometimes lie. I’m pretty sure we

wouldn’t have figured this one out even if she’d told us the truth, though.

But I’m betting Leonard thinks we should have anyway. He’s always bitching at

us when we can’t figure out impossible problems.

Dennis Leonard

Our biggest problem, as far as I’m concerned, is our attending physicians, who are

supposed to supervise the residents and interns in the care of patients. The attending are

all over the place in terms of their ability, knowledge, and so on. Most of ours are

inexperienced, because we can’t compete salarywise with the private sector, and most

people who want to stay in academic medicine want to stay in the medical center, where

all the glitzy buildings are, basically.

So each patient admitted to East Loop is theoretically seen daily by the attending

physician as long as the patient is in the hospital. In years past, the attending’s prime

responsibility was to supervise patient care and teach the students, interns, and residents.

35
Nowadays, the attending’s prime responsibility is to bill as much as the system will

allow. In fact, the department leaders pay constant attention to how much each attending

bills, and show almost no interest in how well and effectively each attending teaches or

manages the patients’ illnesses.

Even worse is the fact that some attendings literally commit fraud in the way they

bill. They don’t always see and examine each patient daily, and sometimes they don’t

actually see the patient at all because they make rounds by telephone, if you can believe

that. And if they do show up, they may only see the patient from the door—they just ask

the resident how the patient is doing, then pretend that their “diagnosis” is based on their

own examination.

And the fraud doesn’t stop there. The amount billed depends on the patient’s level

of sickness—the sicker the patient, the higher the bill. So some attendings rate the illness

as severe when it actually is mild.

The same billing procedures apply to the outpatient clinics—except on a smaller

scale. It’s the same story all over the hospital: the more one bills for, the more likely it is

for the attending to receive a salary bonus.

It’s like it is everywhere, basically: If a private doctor in the real world orders

$25,000 in tests, that looks good because he’s brought a lot into the office.

But in the long run it backfires, because it raises insurance premiums.

Here, without the extra billing, we’d be a lot worse off than the worse off we

already are. This is the only way to compensate for the loss of what at one time was an

adequate amount of grant money supporting medical education. Now, medical education

is like medicine in general—it’s a business, not a profession anymore.

36
 In fairness to our attendings, most of them are totally honest—they try their best

to be good teachers. But we need more than that. We need teachers who truly

comprehend the value of a good medical history, the rewards of a pertinent physical

examination, the power of knowing how to think, and the importance of accountability.

We need teachers who use the stethoscope first, not an echocardiogram, to detect valvular

heart disease, and who first use the ophthalmoscope, not magnetic resonance imaging, to

detect intracranial hypertension. We should be teaching how to use your eyes instead of a

blood gas apparatus to detect cyanosis, or your hands instead of computed tomography to

detect splenomegaly. It used to be that teachers always used their brains and their

hearts—not a horde of consultants, like they do now—to manage their patients.

I wish we could bring back the kind of teacher who didn’t order expensive, state-

of-the-art studies when cheaper conventional tests could supply the same information,

who didn’t administer a whole slew of medications in an effort to alleviate every possible

ill, and who understood that doing nothing is at times doing a lot.

We need to go back to teaching humility! We need teachers who realize that many

patients get well despite what we do, not because of what we do.

We need teachers with commitment, compassion, candor, and common sense;

teachers who understand and believe that medicine is a calling, not a business; teachers

who can look at, listen to, and talk with patients; teachers who will work as long and as

hard as it takes to ensure patients’ welfare; and teachers who always put patients first. I

know people get tired of hearing me rant and rave about these matters, but when I see

how bad things have gotten—and they’re only getting worse—I just can’t help myself.

37
Eric

So I would meet with Dennis both at the hospital and at his office, in addition to

our Café Luk meetings. He has this apartment that he’s rented for the last thirty years or

so, in this complex that’s mostly occupied by medical students and residents. It’s a two-

bedroom place that he turned into a writer’s office. I think he rented a ground-floor place

so he wouldn’t have to go up and down stairs, which is really hard for him now.

I’ll never forget the first time I went out there. You walk in, and the first room to

the left—one of the “bedrooms”—is full of floor-to-ceiling shelves. There’s barely

enough room in there to stand between the rows of shelves, which are packed with

medical reprints. Dennis told me it was the largest collection of medical reprints in the

world—something like three million articles. All of them are labeled and sorted by

subject, and he has a card catalog out in the next room—there’s a secretary who comes in

two days a week to do all this cataloging along with his typing and anything else he needs

done.

The other bedroom has his writing desk in it, which is where he spends most of

his time. It’s covered with sticky notes with all kinds of little aphorisms and citations and

stuff he wants to remember, but the middle of it, right in front of the chair, is always

clean, just this single notebook sitting on it. He doesn’t work at a typewriter or computer

or anything—just writes in longhand and turns it over to his secretary.

The kitchen/living room has more books and articles, a set of weights, a table and chair

where he sits and works sometimes, a desk for his secretary, the card catalog, and a big

treadmill that he still uses every day. It’s pretty cluttered—there’s not a lot of room to

38
walk around in there. There’s a table with a TV set on it, so he can watch stuff while he

works out—which he still does every day, incredibly enough. He gets up on that treadmill

and leans on the handles and just cranks away, faithfully logging his miles. He’s up to

238,000 miles over the time since he first started keeping track.

Dr. David Cowan, Accreditation Consultant

The school brought me in to consult after it was put on probation by the ACGME,

and after they took steps here to clean up the problems they were cited for. The general

sense here now—and from what I’ve seen so far, I have to agree—is that the big

outstanding issue, the one thing they haven’t really dealt with yet, is this old doc here

named Dr. Leonard, who is one of those old-school gentlemen who just can’t tolerate the

kind of changes medicine is dealing with these days. The modernization of equipment

and practices and ethics and everything. He’s not all that unique among docs of his

generation—he’s just unique in that he’s still working, and still apparently has a lot of

influence, if not over the administration here then certainly over the day-to-day lives and

morale of the residents. I’ve got my eye on him mostly—the bulk of their other problems

are pretty much cleared up.

Brandon

I could tell as soon as he came shuffling in for Morning Report that he was out to

get me. For one thing, only half of us were there because the other half weren’t allowed

39
to attend. They’d been “late”—one whole minute late!—“without an excuse” the day

before, so Dr. Leonard threw them out and won’t let them back in for the rest of their

rotation. It’s like the guy is hard-ass just for the sake of being hard-ass.

And then of course he gave me The Look. He always gives me that look of

disdain when he sits down and picks up the note cards we leave on the table for him. I

can tell what he’s thinking, too: “If they’d expel people like they used to, you’d be gone.”

That’s all he ever talks about: How the best part of the good old days was that residents

were let go, with no chance of appeal, if they weren’t “up to snuff.”

Naturally, the first note card he picked up was one of mine. And naturally,

everything I did was wrong.

“Why’d he come in?” he asked me.

“He was sent in from jail. They sent him here because he had a ‘productive

cough.’”

“Is the sputum thick or thin?”

“Thin, sir.” I hate it when I do that, but I can’t help it—I just fall into this fear-

driven habit of calling him “sir.” It’s just because he has this old-fashioned thing about

respect—he makes us all feel like we have to call him that.

“Do you know why he’s in jail?”

“No, sir.”

See, this is the other thing—he wants us to waste all this time asking questions

that have nothing to do with illness or symptoms. Like we have time to sit there talking to

these guys that nobody else cares about anyway.

“Why do you think he’s got pneumocystis carinii pneumonia?”

40
 “Sir, because he was coughing up thin sputum, sir.”

And of course then he got really pissed off. He just totally sneered at me and said,

“Thin sputum ordinarily isn’t a sign of pneumonia—thick is!” You would have thought

I’d tried to burn a flag or something.

Then I started floundering—he just makes me feel so fucking stupid—and I

brought up the X-ray, which looked atypical to me, and he jumped all over me for that,

too. “What’s quote, atypical, unquote, about this X-ray?”

I was too nervous by then to tell him what I thought, and then he went off on me

again with something completely pointless: “You can’t just treat the x-ray—you have to

treat the patient.”

Like I don’t get that.

By then I was completely flustered and I must not have heard what he said—I was

so damned tired!—because the next thing is, he’s blurting out at me, “What was my

question? What was my question?”

And I had to tell him I didn’t know, and then we got on with more of this stupid

back-and-forth, and finally he just came right out and hammered me: “You don’t have

any basis for saying he’s immuno-impaired, based on what you’re telling me. And he

damn well doesn’t need a bronchoscopy”—which is what I wanted to give him. “What

does he need?”

I just sat there—I couldn’t think of an answer. This is what he does to you—he

makes you afraid to say anything.

Then he said, “He needs a doctor! Do you know where he might find one?”

41
 I don’t know why he can’t just tell us what we need to know instead of putting us

through this stupid “Socratic method” bullshit that he’s always braying about. It’s always

Socratic method, Socratic method, Socratic method, with him. He acts like it’s the Great

Secret to medical education. I heard him joking about it once to this other doctor here

who thinks Dr. Leonard is God’s gift to medicine. And of course the joke amounted to

the usual expression of contempt for us residents. “I use the Socratic method when I

teach,” he said “because if I give them the answer, it’ll come out in their next bowel

movement. If they have to work for it, they’ll remember it.”

Then the other doctor mumbled something I couldn’t hear, and then Dr. Leonard

said, “It’s something I picked up from Abner Socrates, from East Texas.” Then they both

laughed, like it was the funniest thing they’d ever heard.

The guy is such an asshole.

Eric

So Dennis and I got into a pretty good routine. I would go out to East Loop at

eight or so in the morning on the days I could get away, and he’d already be there. I’d

pretty much just follow him around or sit with him in his office talking, then when he

went over to his other office late in the afternoon—he’d stay there until nearly midnight,

reading and writing—he’d give me an hour or so with him before I took off for the day.

The guy is eighty years old, and I’d leave him there working for another seven hours after

a more or less normal workday that left me exhausted. I’d go back home and sit there

thinking and drinking and trying to write.

42
 I almost immediately got way too invested in this project. It was like the only

thing I was counting on to pull me up out of the pit my life had sunk into. With my wife

gone, our kids gone with her, my job a depressing bore, this was more or less all I had

going for me. I would sit there in the evenings thinking about how Dennis was still

working, how envious I was at his energy and powers of concentration, at his passion for

his work, and how if I could just write as good a book as he was giving me with all this

access and everything, I’d finally have done something I could really be proud of.

Then I’d sit there thinking about how it’d be so weird to feel like my life—or at

least my career—had amounted to something.

Dennis Leonard

This isn’t the only thing that soured me on Osmun, but it’s the thing that

convinced me beyond all reasonable doubt that he is not fit to be a doctor. We had a

patient admitted who was having coordination problems and who said he’d blacked out

and fallen. I watched Osmun take a history and do a physical examination, and it’s not

like he doesn’t know how to conduct himself properly—he’s capable of being competent.

I watched him carefully take the blood pressure in each arm. But when he presented his

findings later he didn’t tell me the blood pressures. Those were key findings because in

this case I knew they were wildly different—a strong clue suggesting restricted blood

flow to one side of the brain. That’s one reason for taking the blood pressure in both

arms. I even asked him about it—“I saw you the take blood pressure in both arms,” I said,

43
“what did you find?” “Normal,” he said, “120/80 on both sides.” And he went on to give

an incorrect diagnosis—one consistent with what he said were his findings.

I went to the department chair and said that Osmun ought to be fired—even

though he’s basically competent—because he had lied. In my day, if a trainee lied,

dismissal wouldn’t even have been debatable. But the chair told me to forget about it, as

Osmun was sure to sue, and I guess I knew better than to fight him.

So I backed down. I’m ashamed to say that. But at the same time, I felt like the

deck was stacked against me. That’s one of the biggest ways medical education has

changed: Residents can sue you now for failing them, and schools are so afraid of being

sued that there’s basically nothing you can do about it if you have a bad resident.

All that’s left for me to do now is keep an eagle eye on people like Osmun, in the

hopes that I can keep exposing their weaknesses in a way that will prevent them from

ending up in a position where they can do real harm to people. Which they will if they go

on to practice medicine. I can guarantee you that.

Nancy

Brandon says that he’ll be able to think about our life together after he’s finished

here. That we’ll be together someday, like a real couple, instead of hardly ever seeing

each other and not having a true life together because of his residency and how

demanding it is. All because of Dr. Leonard.

Dr. Leonard is so mean to him! Like last Christmas Eve, all the other residents

except for Dr. Leonard’s got off early. Dr. Leonard made his residents stay here at the

44
hospital with him all night long, through their whole shifts, all the way to one o’clock

Christmas afternoon. It was just so mean!

And then in the middle of the night Brandon called me and begged me to drive

down here—I was off, our rotations are always different, it seems like—and let him come

out to the car for a few minutes so we could make love on Christmas Eve. It was so

funny, how desperate he sounded! Kind of flattering, too. So I did…I can’t believe I

really did it, but I drove down here and he came out and we got in the back seat and—he

didn’t have much time, obviously—we just started doing it.

And then I just got this really funny feeling, and I looked up, and there in the

window was Dr. Leonard’s face, just looking in at us! And then before I could even react,

he disappeared. Brandon didn’t see him, so I didn’t say anything because I knew he’d

totally freak out.

But I know Dr. Leonard knew it was Brandon…even though he never said

anything to him about it, ever. It was just so creepy that he knew! He always seems to

know everything about Brandon!

Eric

These conversations every day with Dennis were pretty funny, the pattern they

fell into, which was mostly him ranting about how much medical education sucks. He

even used that actual word—”sucks”—which I thought was hilarious for a guy his age.

I still remember how he said it, too, the first time: “Medical education today

sucks, period. We’re producing lab technicians, not physicians…it’s pathetic.”

45
 “Pathetic” was his word for just about everything. Certain fellow faculty members

were “pathetic”; he had a lot of “pathetic” students; the system was “pathetic”; his salary

was “pathetic.” Because he refused to do any billable work—”I’m here to teach,” is what

he always said—he couldn’t augment his salary the way these other guys did, by looking

at a resident’s report, signing off on it, and making it look like they’d spent a lot of time

examining the patient.

Dennis wasn’t all that happy about a good number of the attendings. He had this

one resident he liked, he told me one day, “who when he first came here, he saw

attendings doing things he thought were incorrect, and he asked about it, and he was

graded down for questioning their decisions. He told me, ‘From that point forward I kept

my mouth shut.’ I thought that was a sad revelation, and verification of my impression of

some attendings. They are limited in knowledge, arrogant, defensive…it creates nothing

but a sad environment for our education.”

It seemed like every conversation we had always went back to that same thing:

how the only thing doctors were trained to do now was order lab tests, CAT scans, all

kinds of other technological stuff—boy, did he ever hate high-tech medical trends. He

felt like you should ask patients hundreds of questions, and put your hands all over them.

Examine them. That was what he was always ranting about: how much he hated what he

called “high tech” medicine, and how much better his old-fashioned medicine—which he

called “high touch” medicine—was. And I’ll tell you—the more he talked, the more he

made a believer out of me.

But he often felt, for all his passion, like there was no hope. “The powers that be

are part of this good ‘ol boys network,” he said once, “and through passive aggression,

46
they try to make life difficult for me, and they sequester me from the students and

residents, they know it makes me unhappy, they’re trying to force me to resign. But they

can’t fire me because my record is impeccable.” I could never tell whether he was really

hoping to turn things back or was just willfully setting himself up for some kind of grand,

grotesque, Quixote-esque tragedy. “I’m kind of like Ron Paul trying to win the

Presidency, basically,” he told me one day.

It’s pretty much impossible to describe how sad he sounded right then—

incredibly, surprisingly sad. Usually he just sounds like he’s pissed off.

Benjamin

I worked my ass off to get where I am, and if I ever get out of here I have a huge

payoff waiting for me—a job lined up, my loans paid off, and a sweet salary for just

concentrating on the same procedure every day. Ninety-nine percent of what I have to do

here is completely irrelevant to what I’ll be doing in the real world. And 200 percent of

every fucking thing Leonard tries to make me do is irrelevant to that. I try to tune the guy

out, but every time you come up even a little bit short of what he wants he’s all over you.

And even though everybody knows he’s an anachronism, you still feel like he has some

power here, and can really screw things up for you. I’ve been working for almost eight

years on getting to that private practice where I’ll be set for life the minute I walk out of

here, and here he is trying to screw things up for me. That’s why Brandon and Osmun

and me feel like we have to lean on this consultant—Leonard wants to ruin everything for

us just because we’re late to one of his conferences or we don’t like being held

47
accountable for stuff that isn’t necessarily our fault, or we can’t spot some weird disease

we’ll never see again in some loser homeless guy who’s not like anybody we’ll ever see

in our practices. I just need to concentrate on my specialty—all the extraneous crap he

wants us to learn…that’s from a bygone day, to say the least.

I’m not letting him screw things up for me, and neither are Brandon and Osmun.

He can abuse us all he wants, but that’s as far as we’re willing to let him go.

48
Chapter 3

Evening Lecture Delivered by Dennis Leonard

Health care in America today leaves much to be desired. Among its glaring

deficiencies are fragmented and impersonal delivery of service, high costs, and adverse

events. Moreover, physicians now march to bureaucratic drummers, have little or no

autonomy, suffer diminishing prestige, and exhibit sagging professionalism. To make

matters worse, many recent medical graduates lack the clinical skills necessary for good

patient care….

(Dr. Badger

Oh gosh—I wonder where he’s going with this? As if you can’t always tell with

him. I can’t stand the amount of attention he can attract, either—especially when he’s

ranting about the education we provide. Case in point: I’m pretty sure at least one person

sitting here in the audience is a media person.

I swear to God, he’s going to kill me with this stuff. He never lets up! He’s all but

gotten the school shut down with this schtick. I’m so sick of it, I can’t begin to tell you.)

49
 …A further element in this medical mess is dishonesty—an embarrassment that

pervades our profession and undermines its core values of truth, integrity, philanthropy,

and altruism….

(Dr. Badger

“Philanthropy”? “Altruism”? Please!)

…Without question, dishonesty comes in all shades, and at times it can be a matter of

interpretation. That said, dishonesty (as defined here) encompasses any form of

professional or academic misconduct, including fraud, deceit, cheating, lying, shirking

responsibility, abuse of authority, conflicts of interest, plagiarism, alteration of medical

records, forgery, false representation, and knowingly assisting another person in

dishonest acts.

Long before attending medical school, some students exhibit unethical academic

behavior. Cheating, for example, is prevalent in grade schools and colleges and is

independent of religious or moral attitudes or of the desire to study medicine. And there

is no evidence that unethical academic behavior of any type is diminishing at the

premedical level.

Given the high-powered, competitive environment of medical school, some

students will do anything to get ahead, or simply to survive. As a result, cheating

abounds. Studies indicate that between 27 percent and 58 percent of students cheat at

least once in medical school, that those who cheat are likely to be dishonest when

50
providing patient care during their clerkships, and that the number of students who cheat

increases from the freshman to the senior year.

The time-honored methods of cheating include copying from another student or

from a “crib-sheet” during a test, having someone else write a paper or complete a

homework assignment, plagiarizing, signing an attendance sheet for a classmate, faking

the result of a laboratory experiment, and falsifying information from the medical history

or physical examination….

(Osmun

God, this mantra of his…he’s as tiresome in public as he is in school. Yelling at

us all the time …it drives you crazy, listening to him. It’s not just that he’s unreasonable,

wanting us to be superhuman—it’s that he’s unrealistic. Does he really think the real

world can operate the way he thinks it should? He always acts like in his generation it

did…like everybody his age was a paragon of virtue in medical school! Don’t think so!)

…Nowadays, technology has taken cheating to a much higher level.

Cyberplagiarism, for example, is a new term that refers to obtaining information from the

World Wide Web without proper citation. The “Key Katcher” is a small gadget that

records keystrokes on a personal computer and can be used to obtain an instructor’s

computer password to access his or her files. Personal Digital Assistants (PDAs) store

notes for quizzes; cellular telephones enable text messaging, the performance of

calculations, and access to the Internet for answers to questions; and camera telephones

51
can photograph notes for use during tests—or can photograph test questions for later use

by other students….

(Brandon

Spoken like a true technophobe—he can’t use a computer, therefore nobody else

should, ever. That’s not a moral objection he’s voicing; he just flat-out hates computers.

And we’re supposed to follow a leader like that? Seriously: How can a guy like this still

be wielding so much power in a medical school?)

…Another major form of dishonesty occurs in the final year of medical school,

when students face the ordeal of applying for fiercely competitive residency positions. To

have the best chance of obtaining the training program they want, many students pad the

application package with as much supporting evidence as they can muster. “Honesty is

never an issue—emphasis is on avoiding failure and achieving success,” they say. These

students argue that being completely honest would hurt their chances.

In a powerful, award-winning essay on the resident-selection process, Tara Young

says, “It is disconcerting that medical students openly resort to the use of deception,

dishonesty, and outright lies in the resident-application process…. There is something

morally reprehensible about a process in which inherent dishonesty is needed in order to

succeed…. Everyone involved in resident selection must begin to acknowledge and

realize the potential implications of the institutionalized dishonesty that has become an

integral part of the selection process.”

52
 From personal observations during 50 years as a full-time medical educator…

(Benjamin

About 49 years too long, if you ask me.)

…including 19 years as program director of a transitional internship, I wholeheartedly

endorse Young’s sentiments. I, too, firmly believe that there is no place in medicine for

cheaters or liars. In today’s permissive culture, however, automatic expulsion of such

miscreants—the rule when I was in training—no longer occurs, and most of these guilty

students (and house officers) ultimately enter private practice or remain in academic

medicine. Not surprisingly, this unprofessional behavior in medical school correlates

strongly with subsequent disciplinary action by state medical boards.

Sadly, students aren’t the only ones in medical school who are guilty of

misconduct. At times, they are the recipients of misbehavior. A pilot survey of a third-

year medical school class explored students’ perceptions of mistreatment and

professional misconduct during medical school training. Of the 75 students who

responded, most reported having been humiliated or belittled at one time or the other by

house staff, nurses, or clinical faculty….

(Dr. Cowan

53
 I’m really glad I came to this. It gives me a unique—and unexpected—chance to

evaluate the complaints of the residents about Dr. Leonard. When the school hired me to

come in and evaluate everything before the ACGME comes back, they told me they’d

taken care of all the accreditors’ concerns from the last audit except for the “Dr. Leonard

problem,” as they put it.

I have to say that they have indeed done a reasonable job of cleaning up the stuff

that got the medical school on probation in the first place. And Badger might be right,

after all, about how if it weren’t for this Leonard business, they’d be free and clear.

After coming down here to listen to him, I can see why they’re worried about the

death penalty, too. I haven’t heard this rigid or old-fashioned a litany since way way back

in the day, when I was in med school. This man is a throwback’s throwback! And I have

to laugh at the irony of him of all people complaining about residents being mistreated.

From what I understand, he wants to all but kill them before he’ll let them out of school.

Knowing what I know about him, I can just imagine what he said when he read the stuff

in the probation report about how the school was providing inadequate sleeping quarters

for the on-call residents. I can almost hear him: “This is the kind of crap they always put

in these reports nowadays!”)

…Twelve students allegedly were physically harmed, six by house staff and six

by clinical faculty. Varying types and degrees of sexual and racial harassment from

classmates, house staff, and clinical faculty were common as well. Forty percent of the

students had observed house staff covering up mistreatment of patients, while 20 percent

54
of the students had witnessed clinical faculty doing the same thing. A small percentage of

the students had seen house staff and clinical faculty falsify information.

Dishonesty also creeps into letters of recommendation. Medical students and

house officers obviously seek such letters only from faculty members who are likely to be

supportive. The letters, in turn, typically are supportive—but often to a ridiculous extent.

They oversell the positive and ignore or cover up the negative. With few exceptions the

candidate is “enthusiastic and above average,” or “gets along well with everyone,” or

“will be a fine physician.” No one’s work seems to be below average or cause for

concern. In the rare event that drawbacks are mentioned, excuses for them are almost

always given—”pressing family issues,” “heavy workload,” etc….

(Osmun

So what am I supposed to do? Ask docs for negative recommendations?

You can bet Leonard would be happy to give me one—he hasn’t had a kind word

for any of his residents ever, as far as I know. He even tried to get Brandon to sign off on

an evaluation once where Leonard said he was “dangerously incompetent”! Think about

that…he told him that right to his face, then he put it in writing and tried to get Brandon

to sign it! It’s a good thing they make the docs here tell the residents to their face what

they’re saying about them in their evaluations…otherwise, Brandon would’ve been out of

here and not even known why.

My thing was bad enough—he said I was “the best of a bad lot.” But at least I

didn’t get thrown to the bottom of the barrel like Brandon did. And the people I had to

55
show that to already know that Leonard’s a worthless old fart, so there was basically no

harm done.

Still…if it weren’t for him, I’d be in a lot better place than I’m in now.)

…Grades in medical school, regardless of the format used (numerical, letter, class

standing, or pass/fail), commonly reflect a vote for the student’s charisma rather than a

rating of academic accomplishments. Accordingly, few students ever fail, and almost all,

somehow, end up “very good” or “exceptional.”…

(Benjamin

He even shits all over the good stuff you do: I came in here with perfect grades

from all through school and med school, and he kicked off my residency by telling me

they don’t mean a thing to him—that he thinks they’re bullshit, basically, because “you

have no idea what it takes to be a good doctor,” in his exact bullshit words.)

…Complicating the issue of grades is the “fear of recrimination syndrome”—

students, for good cause, are afraid to challenge their instructors, even when they know

them to be wrong. In the previously cited pilot survey regarding medical student abuse,

29 percent of the students reported that clinical faculty had threatened them unjustifiably

with a bad grade. And five students claimed that clinical faculty had threatened to ruin

their careers….

56
(Osmun

Right. And all he ever wants to do is kick us out for good.)

…Dishonesty in the postgraduate setting appears in numerous, but often subtle,

guises. Sycophancy, better known as “brown-nosing” or “apple-polishing,” is the norm. It

surfaces daily, especially during teaching rounds, when the teacher and house officer say

and do what each presumes the other wants, rather than what the house officer needs and

the patient deserves. The participants leave these sessions with their egos and

misconceptions intact.

One-upmanship usually consists of a teacher or house officer intentionally

spewing forth information that no one can verify. “A British researcher described that

phenomenon about 30 years ago in one of the basic science journals, but I can’t

remember which one.” Or, “Yes, it’s rare, but I’ve seen it on numerous occasions.”

False reporting of physical findings is almost standard. Pick up any inpatient

record, especially on the medical service, and turn to the section on physical examination.

There, under “Eyes,” you will typically find PERRLA (pupils equal, round, and react to

light and accommodation). When I see that particular abbreviation, I always ask the

house officer, “Did you actually check the pupils for accommodation?” The answer

usually is “No.” Another example appears under “Neurological,” where “cranial nerves

intact” is common. In most of these cases, however, cranial nerves I, II, and VIII have not

been tested….

57
(Benjamin

Give me a fucking break. Like we’re supposed to go through all those gratuitous

examination procedures with every patient we admit. Why the fuck should I look at a

patient’s pupils when he’s in there for some fucking gastric problem? The pupil answer’s

the same every fucking time, so why bother?

It’s just like him to be such a stickler—the guy’s a total tight-ass. I mean, why

should a gastroenterologist have to bother learning about neurology symptoms?)

…Why, then, do so many house officers (and practicing physicians) record these

false physical findings? It’s because, as medical students, they observed house staff, and

even some senior staff, doing precisely the same thing. And with herd mentality prevalent

in medical school, students mindlessly embrace this habit and never let it go. Despite its

seemingly innocuous nature, this practice is dishonest and potentially harmful to the

patient.

Ward games take place daily. For example, some house officers never answer

their beepers. “The battery was dead,” they say. Other house officers habitually miss or

come late to conferences. For their excuse, they invariably offer the fail-safe answer: “I

was taking care of a patient.” When the attending asks for the result of a test that has not

been ordered, “It’s not back yet,” the house officers characteristically reply. But as soon

as the attending leaves, they order the test “stat” so that the result will be available when

the attending returns.

58
 Copycatting occurs frequently. On careful review of inpatient records, I find

numerous cases in which the admission write-ups and progress notes by the student,

intern, and resident are almost identical. When questioned about it, the participants admit

to copying each other’s work. “Too much to do and too little time to do it in,” they say.

Copycatting may serve them, but it never serves the patient….

(Nancy

Boy, Brandon’s not going to like that part.)

…Dishonesty in medical practice takes many forms, virtually all of which stem

from the same cause—serving one’s self before serving one’s patients. The

manifestations can be difficult to spot when they apparently conform to the standard of

medical care in the community. A prime example is shirking responsibility (that is,

failure to take charge). In such cases, the attending physician—faced with a busy

schedule and fearful of being sued for missing something—orders myriad tests and

prescribes a multitude of drugs, hoping thereby to detect and alleviate every conceivable

ill. If the patient’s condition fails to improve or a test result is abnormal, the attending

physician defers to an army of consultants who march in and take over, each managing a

part of the body but no one managing the whole.

A cascade of ill-advised activities ensues—more consultations, inappropriate

testing, over-prescribing of medications, uncalled-for procedures, needlessly prolonged

hospitalizations and unnecessary office visits. This process continues until a definitive

59
diagnosis surfaces, the patient’s complaints subside, the patient or the patient’s family

intervenes, or the patient dies. Meanwhile, the attending physician simply watches the

medical merry-go-round.

Consultants in these cases are ideally positioned to halt the ride but hop on board

instead, typically with gimmick in hand. And even when they know that their gimmick is

not indicated, they still use it, because “It’s what the referring physician wanted,” or “It’s

important for research,” or “It’s the only way to know for sure.” Too often, however, it

isn’t what the patient needs or deserves….

(Dr. Badger

It’s called “change,” Dennis! For God’s sake…why would you turn your back on

all these marvelous technological tools we have now for diagnosis? Do you take your car

to a mechanic who trusts his ears and eyes rather than the computer-diagnostic equipment

shops have now?

I know people like this guy, but it’s dangerous to mistake romantic notions and

nostalgia for good scientific judgment.)

…Other acts of dishonesty include fraudulent or inappropriate billing;

expurgating or manipulating medical records to conceal complications, pass peer review,

or prevent lawsuits; hospitalizing patients solely for better reimbursement; serving as

expert witnesses when not qualified to do so; falsifying curricula vitae; and keeping quiet

when suspecting or knowing that a colleague is emotionally disturbed, outright

60
incompetent, guilty of sexual misconduct, a liar, a cheater, or an abuser of alcohol or

drugs.

Money and prestige seduce some practitioners (and academicians), which allows

conflicts of interest to take root. And the soil in clinical practice is particularly fertile for

such conflicts. Consider, for example, physicians who own and operate specialty

hospitals or have their own high-tech diagnostic or therapeutic machinery. Critics argue

that these physicians have strong incentives to refer patients to their own facilities.

Next, consider the many physicians who go around the country promoting

specific drugs or biomedical devices manufactured by the companies that sponsor the

trips; physicians who join drug company advisory boards or help create industry-

supported clinical trials; physicians who affix their names to articles drafted by industry-

hired ghostwriters; and physicians who accept substantial company-sponsored gifts or all-

expense-paid trips. These and other kinds of inappropriate, unprofessional, or

questionable physician interactions with big business are discussed in depth and in

riveting fashion elsewhere….

(Benjamin

This is what I hate about him—and not just him, but all these old fuckers who

complain about everything so much. They cash in for their whole careers, and now that

they’re on the downside, on the way to retirement, and nobody’s interested in them

anymore, suddenly they want to clean up medicine and take away all these opportunities

61
for those who come after them to make extra money. They get this sudden attack of

ethics when the gravy train isn’t available to them any more.

Not that he’d ever admit that that’s what’s going on with him. Oh, no…he’s

Perfection Itself, and always has been.)

…The pharmaceutical industry’s effort to alter physicians’ behavior has largely

succeeded, and the process usurps the physician’s independence while increasing the

retail price of the product. From 1997 to 2005 in Minnesota alone, drug makers paid at

least $57 million to doctors, nurses, and other health care workers. Another $40 million

went to clinics, research centers, and other organizations. More than 20 percent of the

state’s licensed physicians received money. In fact, one physician received more than

$798,000, while another took in $710,000….

(Brandon

Somebody’s jealous!)

…More insidious than its overt efforts is the pharmaceutical industry’s subsidy of

continuing medical education, including professional publications, notably journal

supplements. In 2005, the tab for such subsidies in the United States exceeded $1.1

billion. From the industry’s perspective, it is money well spent, because most practicing

physicians must accrue a certain number of accredited CME hours to maintain their

62
licensure. By sponsoring CME activities, the company creates an ideal marketplace for its

products.

Dishonesty in medical research boils down to two basic kinds of participants:

ambitious investigators whose quest for fame and glory overshadows whatever integrity

they might have; and financially motivated drug companies that spare nothing in their

attempts to capture a dominant share of the pharmaceutical market….

(Dr. Badger

I knew he was going to go off on this tangent—it’s one of those hobbyhorses he’s

always on. Everybody agrees with him that there are some problems in this area, but he

has to be realistic—we live in a different world from the one he came up in. These

companies drive almost all of the innovation in this country now, and medicine owes

more to the funding they provide to labs and research than it does to universities working

on their own the way they used to. Schools no longer get the kind of grant funding for

research that they used to get from their parent institutions. We have to fund ourselves,

and the pharmaceutical companies are just filling a void, quite frankly.

There are just some ways where medical schools have to learn to change with the

times. Nobody likes it, but there you go! He doesn’t do anybody any good by trying to

paint this in as bad a light as he can.)

…Misconduct by ambitious investigators has been a recurring problem for the

American scientific community since the early 1960s. One of the most widely publicized

63
examples of such misconduct occurred in the early 1980s and involved a brilliant young

clinical investigator at Harvard who fabricated an extraordinary series of published

findings. His deceit extended from his days as a college student through his medical

residency and two different fellowships. As a postscript to the story, a researcher close to

the scene said, “The man could have faked his way through a lifetime of research and

have been greatly honored. We all know scientists like that.”

The deceitful research and business practices of financially motivated drug

companies are the targets of a widely acclaimed book, Hooked. Viewed as a scorching

indictment, the book leaves little need for further comment on the subject; accordingly, I

will cite only a few additional reports.

In an effort to determine the safety of calcium-channel antagonists in the

treatment of cardiovascular disorders, Stelfox and his group examined 70 articles—30 of

which they classified as supportive, 17 neutral, and 23 critical. They found that authors

who supported the use of calcium-channel antagonists were significantly more likely than

the neutral or critical authors to have financial arrangements with manufacturers of

calcium-channel antagonists (95 percent, vs. 60 percent and 30 percent, respectively).

Bekelman and associates searched MEDLINE from 1980 to 2002 for all English-

language studies containing original, quantitative data on financial relationships among

industry, scientific investigators, and academic institutions. In their systematic review,

they found strong and consistent evidence that industry-sponsored research tends to draw

pro-industry conclusions.

Heres and colleagues reviewed results of 42 head-to-head studies that were

funded by pharmaceutical companies and that targeted second-generation anti-psychotic

64
agents. In 90 percent of these studies, they found that the overall outcome favored the

sponsor’s drug. Their review also found that only studies with significant findings tend to

be published, an observation that led Melander and co-workers to coin the phrase

“evidence b(i)ased medicine.”…

(Osmun

He’s so fucking clever, isn’t he? Him and his fucking puns...he’s so proud of

those things, always driving us up the wall with them. He’s too damned smart for his own

good—which one of these days people are going to figure out how bad that is for the rest

of us, that ridiculous self-regard he has.)

…A very recent report by Turner and fellow investigators reinforces the

impression that we are under assault by evidence-b(i)ased medicine. These workers

obtained 74 reviews from the Food and Drug Administration for studies of twelve

antidepressant agents that involved 12,564 patients. Fifty-one percent of these FDA

reviews had a positive result. The authors then conducted a search to determine which of

the 74 studies had been reported in the medical literature. They found that 51 of the

original 74 studies had been published, but that 94 percent of those 51 had appeared as

positive reports. The authors also compared the effect size derived from the entire FDA

data set with the effect size in the published articles. Separate meta-analyses of the FDA

and journal data sets showed an overall increase in effect size in the published articles of

32 percent, with a range of 11 percent to 69 percent for individual drugs. It was not

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determined whether the bias toward publication of positive results occurred because

authors and sponsors did not submit certain manuscripts or because the journal editors

and reviewers rejected those manuscripts—or both. Whatever the reasons, the widespread

and potentially harmful effects of such selective reporting are undeniable….

(Benjamin

This is just lying with statistics, is all it is.)

…From the aforementioned studies and more, one thing is clear: bias in drug

trials is common and overwhelmingly favors the sponsor’s product.

Fabricating or manipulating data is the most egregious form of dishonesty in the

medical literature. In most cases, however, its detection is virtually impossible. Editors

can do little more than trust the integrity of their contributors and the astuteness of their

reviewers, but that approach falls short. Consequently, the prevalence and extent of

fabricated or manipulated data in the medical literature remain problematic. So caveat

lector—let the reader beware!...

(Joanne

Well, apparently the conceit here is that all these people came down here to sit at

this talk and think about all the reasons they hate Dennis. While Dennis goes on and on

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like he always does about what’s wrong with all of them. It’s a silly and clumsy device, if

you ask me.

I really don’t like the idea of Dennis talking to this writer! I told him he could end

up destroying everything he’s worked for for his whole life, and that he’d end up not

being able to control what this writer did! But of course he didn’t get where he is by not

being stubborn. Now he’s telling all his secrets to this young man he doesn’t even know,

really. It’s not going to end well! Why does he think this man has his best interests at

heart? All he wants is a good story—or an award. That’s all writers ever think about, is

awards. And he’s not going to let Dennis’s welfare get in the way of that!)

…Recently, two reports of more flagrant disregard for ethics surfaced in the New

York Times. In one, a prominent diabetes expert at the University of Texas Health

Science Center in San Antonio agreed to review a confidential drug study for The New

England Journal of Medicine. He then faxed the study to GlaxoSmithKline, tipping the

company to the imminent publication of safety questions regarding its diabetes drug

Avandia. According to the journal Nature, the expert said, “Why I sent it is a mystery. I

don’t really understand it. I wasn’t feeling well. It was bad judgment.” Disclosing the

contents of a pending article violates not only The New England Journal’s rules for peer

review, but breaches professional ethics in science and medicine. Furthermore, there is a

potential conflict of interest in this case: The expert acknowledged having received

$75,000 in consulting and speaking fees from GlaxoSmithKline since 1999.

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 The second case involved a physician from Columbia University, who had peer-

reviewed a study of cardiac stents for The New England Journal of Medicine. Before the

study was published, the reviewer commented on its results at a medical conference. In

response, the journal barred the physician from reviewing its articles for five years and

prohibited him from submitting commentary for publication in the journal during that

period.

Of the many types of dishonesty in the medical literature, plagiarism is the most

common and the only one easily detected and uniformly condemned. The rest are much

harder to prove, and, even when discovered, are frequently condoned. For example,

authors may digitally manipulate the color or content of original images, deliberately

discard data that do not fit the model, design studies that yield only desired results, or rig

references—that is, cite evidence that supports their view and ignore evidence that

opposes their view. They may also steal from themselves—autoplagiarism…

(Joanne

Hello! And this is…what, exactly?)

…and submit the same material, rearranged as new articles, to several different journals.

And they may allow their names to be listed as authors when they have made no real

contribution to the work published. Conversely, it is common practice to omit from

authorship the names of people who made substantive (if peripheral) contributions:

internists or surgeons, for example, may not credit radiologists and pathologists whose

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imaging and histopathologic studies contributed significantly to the resolution of a

particular medical or surgical problem….

(Dr. Cowan

There really should be an upper-age limit for doctors. Medicine is probably one of

the fastest-changing arenas in the world, but the people who thrive in it are hard-headed,

stubborn, Type A personalities who got where they are by virtue not only of their

brilliance but by being rigid, determined, proud. They believe they were tempered in a

forge, as it were, and as time goes on and the world around them changes, that world they

came up in—that forge—becomes ever-more “perfect” in their eyes. There’s no nostalgia

like a Type A’s nostalgia. And of course the older they get the worse the disconnect gets:

the longer a doctor hangs on, the more the world changes and the more his attitude

hardens.

The hardest thing with doctors like this is that there’s no way to ease them into

retirement or even partial retirement. They’ve never eased into or out of anything in their

whole lives. For them, it’s all or nothing—they work eighteen hours a day, even more

sometimes, going full on the whole time, and they feel dead if they try doing anything

less. So when it comes time for them to step back, they just can’t do it. And you can’t

force them out of their jobs, because they tend to be really good. You can’t find cause to

fire them. It’s just that these other problems—them clinging to productive life long past

the time they should let go—distorts everything and everybody around them. It’s this

vague kind of subjective thing that is very hard to invoke if they contest their firing. I see

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this all the time now at the med schools that call me in for consultation. There’s usually at

least one of these guys everywhere I go. You have to either kill them off or come up with

some ingenious way to force them out.)

…Another source of dishonesty involves the peer reviewers of medical

manuscripts. When these individuals have a vested interest in a particular matter, they

may approve or reject an article simply because it favors or contradicts their own

interests. Their decisions may also be swayed, one way or the other, by their knowledge

of who wrote the article. And in some cases, they may use ideas pilfered from articles

that they have rejected.

In recent years, ghost authorship—also referred to as ghostwriting—has come

under special scrutiny. Many articles appearing in scientific journals under the bylines of

prominent physician-scientists are, in fact, written by professional medical writers who

are paid by drug companies or, in some cases, by the journal itself. The consequences can

be devastating, because doctors worldwide use information from these apparently

objective articles to guide the care of their patients. In truth, however, the articles are

merely part of a marketing ploy to promote a product or add prestige to a journal….

(Osmun

What he doesn’t understand is how different everything is now than when he was

in medical school. When I finish, I’ll owe hundreds of thousands of dollars, and will have

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sacrificed everything to get through my education and training. And medicine doesn’t

pay as well as it did when Dr. Leonard was young. You have to look for ways to

supplement your income and cover the kinds of huge expenses doctors have these days.

Malpractice insurance. Technology. Taxes. Just the cost of doing business plus the cost of

becoming a doctor completely changes the kinds of “moral options” you have when

you’re dealing with all these companies and people and practices that make being like Dr.

Leonard impossible now. Yet even though everybody knows how out of touch he is, how

much of a crank he is, he still has all this influence. He can really make it hard for you

here—really, really hard.)

…Finally, even some editors misbehave, at times outrageously: We’ve all heard

the story of Sir Cyril Burt, who stars in a classic case of editorial misconduct. His

important—and much disputed—work on intelligence was important in designing

education systems. He founded a journal called the British Journal of Statistical

Psychology and was its editor. He published 63 of his own articles and often altered the

work of others without permission, sometimes adding favorable references to his own

work. Once he published a letter he wrote himself under a pseudonym and a response he

also wrote himself under another pseudonym in order to attack a colleague.

What causes dishonesty at every level of our profession? In considering the

answer, I find two factors working in synergy. The first is the background of intense

competition. We compete to get into medical school and compete to stay there. We

compete for internship and residency positions. And we ultimately compete for patients,

research grants, or whatever. The other factor is human frailty—particularly ignorance,

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greed, the fear of being found wrong, and the need for aggrandizement. Patients often

foster our frailties by conferring god-like qualities on us. We, in turn, accommodate that

perception in order to protect the image for them, as well as for our colleagues and

ourselves.

Is there a cure? I think not, human nature being what it is. But I do think that we

can reduce the level of dishonesty in medicine and the adverse effects of such misconduct

in our profession. First, we must acknowledge that dishonesty exists. Second, we must

create and implement strategies to combat it. Third, we must have the courage and means

to administer swift, appropriate punishment. In that light, I favor expulsion of any

medical student or house officer caught cheating or flagrantly lying. I favor media

exposure of researchers who manipulate or fabricate data. And I favor notifying state

medical boards of practitioners who are clearly incompetent or who act unprofessionally.

Like it or not, that’s what the public expects of us, and well it should. No measures will

work, however, unless we serve as role models of integrity and honesty for each other.

Eric

This was my first shot at getting a look at all the so-called “major players” in the

effort to get rid of Dennis. It’s interesting that they all opted to come to this lecture, given

how they feel about him. And now they’re all milling around up there, congratulating

him, pretending to be interested.

Dennis has a big poster on his wall with pictures of all the residents, so it’s easy to

pick out Brandon, Osmun, Benjamin, and that student nurse, Nancy—Brandon’s

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girlfriend. Dennis calls those three guys The Unholy Trinity. Brandon’s hilariously

handsome, a real stereotype. People call him McDreamy as a joke, but also because the

guy is television-handsome, right off the set of Grey’s Anatomy. He and his cheap cutie

of a girlfriend—teased-out blonde hair, aggressively perky little butt, big pouty lips and

great big baby-blue eyes, a ton of eyeliner—they’re the only ones standing back from the

crowd around Dennis. Osmun and Benjamin are up there with everybody else,

congratulating or pretending to congratulate him. Those two guys look like somebody out

of central casting, too: Osmun with this wavy black hair, shoulder-length, combed

straight back so that he has this kind of middle-part pompadour thing going; and

Benjamin, with his Omar Sharif moustache, cleft chin, and these deep dark eyes that look

like precious stones. Onyx. It’s weird how all three of those guys look like they went to

Handsome School.

Brandon

That speech tells you everything about why I hate studying under Dr. Leonard:

The self-righteousness, the rigidity, the complete refusal to cut anybody any slack, the

way he’s completely out of touch with the real world. In the real world, you have to be

able to compromise! You can’t be some pure, untouchable Hippocrates anymore! We

have to deal with insurance companies, drug companies, HMO bullshit, lawyers,

bureaucracies—it’s not like we’re out there in some clean, clear-cut world, dealing just

with patients in some kind of purely medical, context-free environment! And it’s not like

we’re not overworked in our residencies, either. The kind of medical care he’s talking

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about, the kind of approach he’s talking about, is something out of another century. It

pisses me off the way he gets to run around our hospital treating us like shit, and nobody

ever does anything to rein him in because he’s such a “legend.” When what he really is is

a has-been who hasn’t changed with the times.

I mean, come on—automatic expulsion for short-cutting on a physical exam?

When you can tell at a glance that you don’t need to do all that crap? Name me a single

resident who hasn’t skipped some completely unnecessary step in an exam…does he just

want to expel every single student he has? For “lying”? It’s not like the lie—if you want

to call it that—hurts anybody or anything.

But that’s what it’s like with him—just sweating the small stuff all the time. He’s

a walking anachronism…and I use the term “walking” generously.

The good news is that we got that consultant to come down here to listen to this

shit. Now he can’t help but know what we’re talking about.

And now look how they’re milling around him, sucking up to him after this talk

that was nothing more than a we-were-holier-then-than-thou-art-now rant by an oldtimer.

Just coming all the way down here on my one night off from the hospital was a total

suck-up move.

The funniest thing is that Benjamin and Osmun are up there—and they’re the

ones who went with me to the consultant. And man, did we give him an earful.

Not to brag or anything, but we had a lot to do with the school being put on

probation, too. Mistreatment of residents was one of the big things on their list of things

to be corrected. Especially the shitty sleeping quarters we have to use when we’re on call.

Now all we have to do is work the correction process right, and Dr. Leonard’ll be fired.

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So far, everything’s gone perfect. And now that we have the consultant here—especially

here here—going over everything to see if we’ve addressed the accreditors’ concerns,

we’ve almost got the last nail in the bastard’s coffin. The school’ll have to fire him after

the consultant files his report—it’s all set up for him to say that the last remaining

obstacle to getting off probation is firing Dr. Leonard.

It sounds mean, but it’s totally reasonable—he’s so anti-progress, anti-technology,

anti-reality, that he’s holding the whole school back. Show me another doc in the whole

school—in the whole profession, for Christ’s sake—who doesn’t have a computer in his

office.

No shit—he refuses to use computers. Because he says technology’s ruining

medicine. You half expect him to try to apply leeches to people, I swear to God.

Eric

I’m telling you, the guy is just insanely inspiring. I can’t really put my finger on

it—part of it is the old-fashioned, uncompromising morality, I guess, when it comes to

medicine and patient care. There’s no ambiguity with Dennis: He draws a definite line

between good and evil, acceptable and unacceptable, and never deviates from his

principles—ever. People just aren’t like that any more, anywhere. That moral

simplicity—it’s like sanctity, really—just draws you to him. It’s a powerful charisma he

has in spite of himself—when he starts talking to you, you feel like you’re being drawn

more by some supernatural force than by a person.

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 I think too that he is onto something that everybody out there suspects is wrong

with medicine: That it’s lost its bearings, its values. Absolutely everybody I know will

say they remember when doctors were better, and medical care was better and cheaper

and safer and more reassuring. Dennis makes us all feel like our unease is appropriate,

basically. And that there are still some people on the inside who care. He gives you hope

that we can actually turn off the corruption and make things more like they used to be.

Plus part of what makes him so compelling is just the way he looks—absolutely

transcendent: You see him standing up there at that lectern, all bent over from

osteoarthritis or whatever it is he has, tremendously old, barely able to walk on his own,

shuffling along the way he does with that cane of his. And yet there is all this strength

and power in his voice. And he has all this determined energy! Like he just won’t give in

to what age is doing to his body. He’s insanely alert, insanely hard-working—way more

than I am, at half his age—and that look on his face, that beatific anger, that bristly

wisdom! It makes him look like a pissed-off Yoda.

Seriously—he’s that compelling.

And he still works seventeen, eighteen hours a day, seven days a week. He told

me the other day that he was “starting to slow down,” and that in a couple years he was

going to start thinking about retiring. I told him I hoped like hell I’d be saying that to

myself when I was his age: That I was just starting to think about retiring. And he said,

“You should just hope to make it to eighty.”

José

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 Funny to hear Dr. Leonard talk like that about “honesty.” He call me in yesterday

and tell me about patient coming to hospital next morning—today, early. He tell me very

sad story about this man. Patient come here from Mongolia. He philosopher at university

there, and get fellowship at university here for one year. But when university person pick

him up at airport, she see he very sick. She not know what to do, and friend give her

name of Dr. Leonard. Patient have bad insurance—only pay $10,000 no matter what he

need—and in America that almost no money.

That hardest thing to understand about American system. In Korea, everybody get

what they need for medical care. Here, it confusing. It seem like nobody get what they

need unless they very rich. Rules so confusing and so different for everybody that I not

understand how anybody get well. Our hospital place where people come who can’t pay,

but then we always in trouble because nobody pay us. It make no sense when country so

rich like America.

Anyway, Dr. Leonard say Mongolian “very sick man.” He have old student of his

now in private practice examine him. Mongolian have bad abdominal pain, malnutrition,

dehydration, salmonella enteritis, and masses in small bowel. It very serious. Dr. Leonard

tell university person to bring Mongolian to emergency room at 9 am, and ask for me. I

admit him for examination and biopsy, and fill out paperwork using results from exam he

already have.

This tell me Dr. Leonard very good man. He know when it bad to be “honest.” He

go outside rules to save sick man. Hospital spend huge money on Mongolian’s care, but

get money from no one. There nobody out there we can make pay. But Dr. Leonard not

care. He care only about sick man.

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Chapter 4

Brandon

Another fucking fiasco with The Bastard this morning. I would kill to get out of

having to go to his damned Morning Report. I haven’t been to one yet where he hasn’t

singled me out for abuse. Seriously—not one!

This time he made us each bring a patient chart for him to go over. And guess

which one he zeroed in on to scream about? He was upset—he claimed—because mine

was full of too many abbreviations. It turned out that abbreviations are yet another of his

obsessions. He lit into me about how they were rampant in medicine and that they “are

one of the leading causes” of medical errors. Then he went into yet another story from his

glory days…every single thing we ever do in this place turns into an excuse for him to go

on and on with these stories from when he was young. This one—he claims—was about a

Death by Abbreviation during his residency, where he said this patient died because her

doctor was too lazy to write out what he wanted instead of using a bunch of

abbreviations. The doc wrote “IVP” on this woman’s chart because he wanted an

intravenous pyelogram done, so he could see what might be wrong with her kidney

function. But the nurse—supposedly—thought IVP meant “intravenous push,” which it’s

true it also does, except any nurse with half a brain can figure out what it means from

context, and Leonard said she gave the patient a shot of potassium intravenously that

78
stopped that patient’s heart. The only reason they knew what happened is that the nurse

told the truth about what she’d done. Potassium doesn’t leave any traces, so it’s possible

they never would have figured it out if she hadn’t come clean.

Interesting, I guess, if it’s even true. But that doesn’t mean I deserved the

screaming fit I got. It’s not like I’m the only resident in this place that doesn’t write

everything out. And it’s not like a practical possibility to write every fucking thing out all

the time, either. None of us does—and he knows it, too. It’s just that I’m his personal

whipping boy.

Dr. Badger

I’ve had endless interviews with Dr. Cowan throughout his evaluation, and I think

we’re in pretty good shape as far as he’s concerned. It’s vital to bring consultants in like

this when you’re on probation—you do this kind of mock accreditation review, go over

everything, like it’s a dry run for the real thing, and when the real accreditors come back

in here to re-evaluate, we’re ready for them.

I’m sure he’ll tell us we’re ready to get our accreditation back. Of course, I can’t

even think about the alternative—if we aren’t reinstated, it’s all over. We can’t keep

operating as a department of medicine if the accreditors rule against us again.

The only thing we haven’t addressed from the original list of particulars is the Dr.

Leonard problem. But I have a plan for that—I just need to make it clear to Cowan that

we have that handled. He’ll have to help us out a little, but there’s little question but that

he’ll be glad to. After what the residents have told him, after what I’ve told him, after

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what a lot of other docs here have told him, and after he’s seen Leonard in action at that

talk, the jury’s all but in on him now.

Eric

I was a little shocked when I got all set up out here and then Dennis all of a

sudden tells me they’re trying to fire him. I mean, I don’t know that I’d have wanted to

get into this project if I knew what was going on with him and the administration here. It

calls into question his motives, for one thing. And for another: I mean, if he’s not here

anymore, I’m not either—the hospital sure as hell isn’t going to let me stay out here

rooting through their dirty laundry like this, unless the dirty laundry is Dennis. And in

any case, I’m pretty sure he hasn’t really leveled with anybody about me—I never seem

to see anybody important around here when I’m with him, and he never introduces me to

anybody.

José

Last week so stressful but this week going OK. But everyday I exhausted and

need more time to sleep. But also like Dr. Leonard say, “Being tired part of being

doctor.” So I not complain like the others.

Dr. Leonard my hero. He teach like Koreans teach—very hard. Demanding. And

he understand why so different here from Korea and from Argentina, where I train before

I come here. And so funny about my name—José. Every time anyone call me that—I

80
took name when I in Buenos Aires—he get funny look on his face. But once he tell me he

like my name because it unforgettable. He say he can’t keep other foreign students’

names right, and almost all of us foreign here now.

I only resident here who volunteer to be study under Dr. Leonard. They let me

follow him around for whole month—best month of my life as student. I laughing by

myself when Brandon and some others were telling me I crazy. They all try to stay away

from Dr. Leonard. They afraid of him. But I want to be best. And he teach like Korean

doctors: teach to ask questions, examine patient, pay attention to patient, and not tests and

x-rays and scans. He like old doctor—like shaman, even. When this month over, I have to

study with different doc, but I try everything to come back to Dr. Leonard. I can’t

forbear!

I like how he make you think about everything. I hope so much to be good

doctor—that why I try to work under him. If I fail—I so frustrate.

We had morning report yesterday—I work computer and other residents report.

He very hard on them—especially Brandon. Everything Brandon say seem to make Dr.

Leonard mad. Poor Brandon—Dr. Leonard always mad at him. Everything Brandon say

wrong. Everything!

Dr. Leonard

So this Korean resident—he’s a Korean who trained in Argentina, and he calls

himself “José,” which is a whole other thing that keeps me confused half the time: We

have all these foreign residents here who have all these long names that sound alike and

81
are spelled alike—it’s difficult for me. And then there’s this guy: a Korean with a

Hispanic name. Half the time I’m confused about him and half the time he’s the only one

whose name I can remember because he’s so unusual.

He’s very good, even though he has a language problem. I don’t know much

about him, except that he takes every opportunity he can to come to anything I’m doing.

And he asks penetrating questions of me—very intelligent questions. And he’s very

perceptive of things I say, and he forces me to qualify or amplify what the hell I’m

talking about. And he’s very nice, never objectionable. He’s around me because he wants

to be. And he is very, very good—but he’s very unusual. We have a lot of people who

come from Argentina or Korea who can’t even speak the language. But he’s worked

really hard at that, too—he really is an unusual character. He actually asked to do a

rotation with me. All the others, they either refuse outright or at least try to avoid me.

Here’s another important point: When students come from Korea, India, Pakistan,

the societal way of doing things is such that the professor is always right. And whatever

the professor says, you better pay attention. But at the same time, they don’t have the

technology that’s available here. So by definition and by necessity, they learn how to be a

good doctor. Where they come from, they have to learn how to talk with patients,

examine patients, organize their thoughts.

So they come over here well trained, much better than the average American

student, but they come into our system and unwittingly become victims of our system, in

which all the techniques and attitudes that they learned in their country are not

emphasized here. Here, what’s emphasized is the use of technology. So over a period of a

year or two, they become brainwashed and don’t realize it until they come in contact with

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me. And then they realize that I’m emphasizing what their doctors in their home country

emphasized. They come to me and say, “Look Dr. Leonard, when I came over here, I was

pretty confident, but now I realize that all I’ve been doing is ordering tests, and I’ve lost

all my diagnostic skills.”

That’s the way it is here—our American training system is bad, and we turn the

good foreign students into American students. And it’s not just us—this is the way it is

all over the country now. But my attitude is that we don’t have the right to kill patients

just because they’re being killed everywhere else. Whatever’s bad with us can and should

be corrected.

Eric

I’ve been trying—hard—to figure out how to quantify Dennis’ charisma. He

walks down the hall and all the orderlies and nurses call out his name—it’s “Good

morning, Dr. Leonard!” everywhere he goes. And he always growls in response—another

weirdly charming thing about him. They clearly regard it as a sign of his affection for

them, because they always smile at that growl of his.

He has this twinkle in his eye when he’s amused, which is a great deal of the time,

way more than you’d think, and he talks about everything with this incongruous passion

and energy that’s all the more noticeable at his age and condition, when you’d expect

from his appearance that he’d barely be able to move, let alone work like he does. You

see him struggle to do the simplest things—put on a jacket, get in or out of a car—and

you expect him to be sluggish, half-awake, the way the elderly normally are. But then he

83
starts talking, his eyes light up, he’s alert and passionate and marked with this

tremendous drive. It’s incongruous, to say the least: He’s a young firebrand trapped in the

body of an octogenarian.

People can never figure out with him whether to be condescending and indulgent,

the way you are with old people, or just awestruck and worshipful. He makes you feel

weirdly emotional in ways you can’t understand—people who meet him for the first time

are completely unprepared for their reaction to him.

Dennis told me once that people who see him shuffling along with his cane often

rush to help him. At which point, he said, “I just want to tell them to go to Hell.”

Like this guy José’s wife—I happened to be standing there when he introduced

her to Dennis for the first time. She just kept staring at him while he was chatting with

them, and when Dennis turned around to go back into his office, I saw her turn to José all

wide-eyed and say, “Oh my God…can we keep him?” Like he was a pet or something.

But at the same time, you could hear this reverence in her voice; she basically couldn’t

get a handle on her own reaction to him, which was hilarious.

Osmun

I know Brandon thinks Dr. Leonard is out to get him and only him, but it’s just as

bad for me—maybe even worse. I get set up all the time with cases I just know he knows

I can’t handle, and he steers me toward them just because he wants to beat me over the

head when I fuck up.

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 The worst reaming of all was the one I got last month, at Morning Report, over

this case that was so weird I don’t see how anybody could have figured it out. Even Dr.

Leonard got lucky, if you ask me, even though he’d never admit it.

Anyway, this guy came into the ER with chest pain, and I had him put in the

coronary care unit because you can’t take chances with symptoms like that. I had them

look for heart problems, and they did a bunch of tests and couldn’t find anything, so I had

to bring all this to Morning Report even though I knew it was going to get me in trouble.

Nothing sets Leonard off like a battery of inconclusive tests.

Of course he starts in with all these questions I didn’t have answers for, and he

ended up doing something I’ve never seen him do with any other resident here: He went

down afterward and did his own exam on the guy.

He made me watch the whole thing, too, which of course took forever. The first

thing he did was try to get the guy to tell him exactly where the pain was—in what part of

the chest—and it turned out to be kind of just under the chest, technically, rather than

where the heart is. And he goes on and on and on and on, like there weren’t any other

patients in the whole fucking hospital, and at the end of all that and after looking at his

blood work, he said that it turned out that all the guy had was lead poisoning—one of

those things you never see any more. Which of course Leonard just used the whole

fucking mess as an excuse to beat up on me in front of all the other residents. It was like

the whole thing from beginning to end was just a trap. And then as if that wasn’t bad

enough, he made me follow him around while he tried to figure out how the guy got what

he got.

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Dr. Leonard

A good doctor is like a good detective. Your endeavor is to capture the culprit. In

medicine, the culprit is the disease process. You don’t leave any stone unturned. You take

up every lead you can get, until you find the criminal, get the diagnosis.

I can tell you case after case in which just history and a physical exam and a little

knowledge would have prevented a lot of things. This one, for example, was simply a

matter of deduction!

This guy came in, and because he had what was interpreted by Osmun as chest

pain—but really it was high in the abdomen, just below the chest, the abdominal type of

pains that you get with lead poisoning—he was put in the coronary care unit, unnecessary

testing on his heart, intensive care, all unnecessary, because what he had was not life-

threatening, totally outside of the heart, diagnosed by looking at his peripheral blood

smear.

So when he was found to have had lead poisoning, obviously he was exposed to

lead. So you look at everybody in his house and find out if they were exposed. Well, his

wife had the same findings, but his son did not. So then the question was, what do the

husband and wife do that the son doesn’t do, at home? It became apparent that the

husband and wife had cocktails before dinner, but the son didn’t. So we had to find out

what they put their drinks in. It turns out that they always put them in glasses that were

painted with lead paint, and washing the glasses caused the paint to dissolve slowly,

allowing the lead to get into their drinks. We were able to prove that by having the

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glasses analyzed by a chemist, who said the lead content in the paint on these glasses was

very high.

That was a very nice story of detective work. And that’s how I approach all

patients. They’ve got a culprit in there somewhere and I’ve got to find that little bastard.

And the harder the case, the more challenging it is and the more fun it is.

Dr. Badger

It’s just been one thing after another here. There’s the accreditation mess, which

makes getting decent students even harder than it already was, but even that’s not the half

of it: the larger problem is that for years, we’ve been fighting a decline in the kind of

students we can attract.

This match system makes things really tough for us. Students applying for

residencies and internships apply to a whole bunch of places, and rank them in order of

preference, and we do the same with the students we agree to interview. Then the system

matches them.

Our problem is that the students we rank highest never rank us anywhere near as

high, so we never get the top students anymore. Even worse, our own students opt to go

elsewhere for their residencies. That’s a really bad sign, when you can’t attract your own

top students, and I think the biggest problem there is Dr. Leonard, who either scares

students off or makes them hate this place because they can’t get far enough away from

him.

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 In any event, we end up with a large number of piss-poor residents, and many of

them are foreigners. Not that there’s anything wrong with that—it’s just that it kind of

shows that only the desperate will come here, the ones who will go anywhere that gives

them a foot in the door to America.

And then we had this accreditation thing, and then the biggest disaster of all: One

of our chief residents up and quit, transferred to another school, supposedly because he

was disgusted with the educational side of our program. I’ve never even heard of that

happening anywhere before—it was a huge publicity hit for us, and you can see its effects

already in the big dropoff in applications we have this year. It could take years for us to

recover from that nightmare—word about things like that gets around pretty fast.

I sat here for days trying to figure out how to spin that…I actually think I

managed that pretty well, given what a disaster it was.

Nancy

When Victor left, it was a really, really big deal—everybody was shocked.

Morale was already bad here, but to have a chief resident actually just up and leave in the

middle of everything, especially when he was such a star, left us all feeling kind of

hopeless. The only one who wasn’t upset was Brandon—whenever we talked about it, he

would just say it wasn’t that big a deal. But for the rest of us, it seemed like such a sign of

how bad things were here. I’ve never, ever heard of a chief resident leaving a program,

and nobody I know had ever heard of it, either.

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 But what made it even creepier was what happened a few days afterwards, when I

was talking to Dr. Badger about something else and he just kind of brought Victor’s

departure up without me even saying anything about it. He said something like, “It’s

really too bad he was having so many problems,” and when I asked him what he meant—

I thought he was going to say he was having some kind of problem with the program or

something—he said that Victor showed signs of having a brain tumor, that he had all

these other symptoms none of us knew about, and Dr. Badger thought the tumor was

affecting his judgment, which is why he left. He didn’t say so directly, but he kind of

made it seem like Victor had talked to him about it.

I didn’t tell anybody about what he said, except for Dr. Leonard, because for

some reason he figured out to ask me. It’s so strange how he seems to know everything,

somehow! Oh, he got so mad! I could tell that he thought Dr. Badger was trying to spread

a lie about Victor, to cover up why he really left.

But I know Dr. Badger told other people, because I heard other residents and

nurses talking about it. When you think about it, it was really upsetting that he did that,

because I knew Victor pretty well, and he never showed any signs that he had any health

problems of any kind, as far as I could tell. It kind of makes you wonder how far the

administration here will go to protect its reputation.

Eric

So there’s always this point when you’re working a big story where you have to

start cultivating relationships with the “bad guys.” It’s always tricky, because you have to

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come across to them as someone who thinks they’re the good guys, basically, or at least

as someone who’s trying to be fair and keep an open mind. Even when secretly you know

what the real story is.

And it was particularly tricky in this case because I’m pretty sure Dennis didn’t

really…I mean, there was this kind of unspoken agreement between us that he’d be more

or less controlling where I went, who I talked to, what the story was, and all that. It

wasn’t like anything we actually talked about or that I agreed to, but I did kind of let him

believe that’s the way we’d operate, I guess is the best way to put it. That we were

collaborating on this storytelling exercise together, rather than that he was just one of my

many sources from all sides. You let people believe what they need to believe, basically,

so you can do a better job.

Dennis Leonard

Now I had no quarrel with the accreditation board when they put us on probation.

None at all. Except for all the crap they threw in there about how the residents have to

have adequate sleeping quarters when they’re on call, how we have to limit their hours to

the point where we can hardly give them any meaningful training at all. It’s crap like that

that’s destroying medical education. No one is served by this—not the doctors we turn

out, not the patients, not anyone.

Osmun

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 It seems to me that every one of us has his straw-that-broke-the-camel’s-back

moment with Dr. Leonard. For Brandon and me, it’s a little harder to pick a single one,

because he never stops picking on us. I can tell you the time he made me the maddest,

though—it was at Morning Report about a month ago, when I came in with a sandwich

after having been up all night and not having had time to get even a bite to eat for like

twelve hours. I came running in—if you’re late, he throws you out—with this tiny little

sandwich and a bottle of water, and he gave me that look you get when you’re on his shit-

list again, and he yelled at me in front of everybody to get the hell out of his conference

with “that food.” He just loves to humiliate you. I’m walking out, furious, and I hear him

yelling, “As I have already said—at my conferences, we feed our brains, not our

stomachs!”

It’s how he digs at you constantly, makes you behave completely different than

you have to with all the other faculty, like he’s someone special and you better know it.

You can’t go near him without thinking over every little thing you do. If you ask me, he’s

the one who should have to take the fucking “antideiotic.”

José

Everybody say Dr. Leonard mean. Too hard. No fair. But informations about him

wrong. I see how he real good doc. Real good teacher. He know everything—he not rude

and mean like people say.

I feel like something connect between him and me cause he understand how you

have to make for impossible decisions.

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 Like when I have patient with chronic lung disease who develop heart attack.

Lung disease mean no morphine because morphine suppress respiratory apparatus. But

big heart attack mean must give morphine or patient die. I so frustrate—I have to make

decision right now, so I give man morphine. And he die.

I go to Dr. Leonard instead of head resident cause I feel too bad. I wait for Dr.

Leonard yell at me. I even think he expel me.

But he very kind. “You did best you could” is what he say. “Sometimes doctor

have impossible choice to make.”

So he not unfair, not mean like people say. He understand.

Eric

You never know when you show up out here which Dennis you’re going to

encounter. There’s the hard-working Energizer Bunny Dennis, scooting around the halls

all day long, going at it harder than anyone else out here; there’s the pissed-off Dennis,

who starts snarling at me as soon as I show up about how incompetent everybody around

him is, how so many of his fellow faculty are a joke, how the residents are helpless and

dangerous; there’s the depressed Dennis; and there’s the Dennis I saw this morning—

practically devastated.

For something like thirty years, he started in telling me, he has been in charge of

this monthly teaching conference for the house staff. He and a staff radiologist would

discuss the differential diagnosis of about six to ten interesting cases. Dennis would

supervise the clinical aspects and the radiologist would lead the radiologic discussions. It

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was obviously one of Dennis’ favorite things to do at the hospital—I mean, diagnosis is

his thing the way break-ins were Willie Sutton’s thing. He practically lived for these

sessions—I’d been to the one the month before, and he was just alive with excitement,

leading his audience with question after question, just engaged as Hell. And his residents

weren’t afraid to talk, either—they really got into the whole find-the-answer thing with

him.

Anyway, he practically threw this piece of paper at me, which turned out to be the

announcement for the next conference, and it said that they have a new way of doing it

now: they’re combining pathology and radiology into a single presentation, a single case,

and having the chief resident run the show. Dennis isn’t even supposed to be there

anymore.

God, he was depressed. “I called the chief resident, who’s in charge of setting

these things up, and he acted all surprised that I hadn’t been told about this,” he said. “He

said this is the way the chief resident started doing it at the medical center hospital, and

they thought they’d try it here, too. It’s bullshit—this is what they do, they try to make it

more and more miserable for you so that you’ll quit. And of course the real reason they

want me out of there is that they don’t want to have to do the work I put them through in

working up the cases properly for presentation.”

He just sat there for a while longer not saying anything—very unusual for Dennis,

who’s always such a talking machine. “They just keep digging at you and digging at

you,” he said. “They want you to finally get fed up and quit because they want you the

hell out of here but they can’t come up with cause to fire you.”

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 More silence, more brooding. “Shit, I was running these things back before that

damned chief resident was even born.” Then he kind of waved me away the way he

does—one sudden sweep of his hand, like he was shooing me out of the room.

Brandon

Basically, this is a place where losers come—people who can’t go to a better

hospital, or who don’t have a doctor, and who sure as hell never have medical insurance.

They always wait until it’s almost too late to see a doctor—they are really sick by the

time they come to us. It’s not like the real world, where someone goes to the doctor as

soon as they have some mild symptom; here, they come in after they’ve had something

for weeks or months, and it’s finally gotten to the point where it’s about to kill them.

The point is, by the time people come here they have advanced cancers and

diseases that better-off people catch early. Shit, we even had a leper in here a month

ago—how many places can say that?

This is why I get so pissed off at Dr. Leonard: He wants us to take up all this

fucking time asking people countless questions when the more efficient thing is to get

their tests ordered and done—it’s a way faster way to find out what’s wrong, and way

better, way less subjective. Everybody on earth knows that except him. Everybody.

Now that doesn’t mean that every single time you order a scan or test or

something that it’s going to come back positive for some advanced cancer. But you save

a lot of time, you cover your ass, and you see a lot more patients if you just move them

through that way instead of wasting all this time trying to talk them out of feeling sick.

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 Anyway…the reason I’m so hung up on this is because of what happened the

other day at Morning Report.

I had this guy come into the emergency room the day before with abdominal pain.

So I ordered a CAT scan, to rule out cancer. And it came back looking like he had some

kind of nebulous mass that you couldn’t tell what it was. But it looked like it could be

something serious—a big tumor, which isn’t all that uncommon around here. So I

ordered some more tests and had him admitted. Given the normal kind of patient we have

in here, it was reasonable to assume he was seriously ill.

So then, after he was settled in his room and everything, another resident did a

routine workup, physical, which included a rectal exam, and a little while after that the

guy took a crap, and then he felt better, his pain was gone, and he wanted to go home.

But I didn’t want to release him because of that CAT scan, and I brought his case to Dr.

Leonard the next day, at Morning Report.

And sure enough, right in front of everybody, he went bananas. If anybody but me

had brought that case to him, he’d have been far nicer. But with me, he went on and on

with his withering questions and comments until he was basically holding me up as a

shining example of the Death of Medicine. “Did you question him at all?” he asked me. I

tried to explain that I was really busy, that patients were stacked up there, but he wouldn’t

have any of that. “You should have asked him, ‘What kind of pain? When did it come

on? Is it constant or intermittent? Does it have anything to do with your bowel

movements? What time of day does it come on?’ The more information you get, the more

you can correlate it with disease processes. Once you get an idea of what you’re dealing

with, then you examine the patient! That’s the standard, time-honored approach! There’s

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no need to order all these tests! That was a $1500 procedure you ordered, which caused

him a significant amount of unnecessary irradiation, I might add, plus you admitted him,

which costs considerably, both in money and time, and for what? For a guy with

constipation! I mean…do any of you have any idea how much money we waste every

year on unnecessary CAT scans? Do any of you?”

Obviously, nobody was going to say anything. We all just sat there, scared

shitless. And finally he shouted, “Five million dollars! Every year! Think about that!

Think about it the next time you start to order one without bothering to do any real

medical work!”

He pretended like he was talking to everybody, but with him it’s always me. The

guy is doing everything he can to get me canned.

I still think I did the right thing—took the right precautions. You have to rule

things out, and you have to take as much human error out of the equation as you can.

That’s why we have all this technology—that should be obvious even to that fucking

Leonard.

Dr. Leonard

Like Brandon, who’s much more the typical kind of resident we get nowadays.

He cuts corners, doesn’t do his paperwork properly, never does a proper physical

examination, and when I try to help him, try to make him better, try to show him where

he’s wrong, he gets defensive. When a resident who is clearly wrong tries to defend what

he did—that’s inexcusable. I would never let him continue if I could do things around

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here the way I want to—the way they should be done. When I was in training, someone

like him would have been expelled on the spot before he could even get started. But these

days, all most people aspire to is mediocrity.

It’s not that he’s ever done anything egregiously wrong per se. It’s the fact that

he’s totally in a different world. He does not grasp what medicine really is. He…it’s like

me going to Turkey and trying to figure out how the Turkish parliament works. I can’t

speak the language, I have no idea what the culture’s like, but there I am trying to be a

senator in the Turkish parliament or something. He’s just simply out of his element, and

yet he’s leading a team of interns and students—he’s their role model!

The hard thing is, I can’t go in and point out any kind of smoking gun with him.

It’s just that I know he’s not cut out to be a doctor! And I know that other people

recognize it, but instead of getting rid of him in a polite, fair, humane way, they’re going

to wait for some disaster to strike. He hasn’t killed anyone yet, but he damned sure will if

we let him out! He’s in the wrong profession! He doesn’t understand!

He’s the kind of person here who’s particularly difficult to get rid of, which

makes him even more dangerous. He’s not like a drug abuser or sexual harasser—they’re

easier to get rid of because things like that can be documented. But this other stuff is

much harder. A guy like him who honestly does not see himself as anything other than a

good doctor, when in fact he’s a walking disaster, a menace. We’ll end up graduating him

and he’ll go out and eventually will kill someone.

Dr. Cowan

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 So the more time I spent going over things here, dealing with the accreditors’

concerns, the more people kept bringing up old Dr. Leonard to me. I had a group of

residents come and talk to me, telling me all about how arbitrary he is, how hard he

drives them, how he’s always trying to make their lives harder, and how he never tires of

telling them how they never would have survived in the kind of medical school he went

through. I even had some of the hospital administration, including the head of the medical

school, come to me to talk about how he keeps dragging their program back into the last

century. It was obvious that they wanted—needed—me to cite him as the leading cause

of their accreditation problem.

He’s an easy target, because everybody understands the situation. It’s the problem

you have with these old legends: You can’t find anything to fault in their job

performance, per se, but at the same time they won’t let a school advance with the times.

It can be a terrible problem—it’s particularly acute in medicine, where people have such

drive. But if someone like me comes in, someone from outside, to say what needs to be

said, then you can ease the person out. It’s the way it has to be done sometimes.

Eric

I keep having these episodes where I wonder what I got myself into. Like when I

went out one night a couple weeks ago with Billy Joe and a couple other guys I used to

work with, and they were asking me what I was up to, and I told them about Dennis.

Billy Joe just laughed his ass off, right when I was expecting him to be amazed by

Dennis. “These old docs!” he was shouting. “They all think medicine’s dead! They’re all

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fucking insane!” He made it sound like Dennis was just one of hundreds of these old

cranks running around being unintentionally funny.

Of course it made me freak out, worry that I’ve invested way too much in this

project—which actually has kind of turned into my reason for being.

I have these days where I look at Dennis and wonder if maybe the other people

are right: that the days of uncompromising principle in medicine—if they ever were

really what Dennis thinks they were—are gone. That we really do just live in a different

age now, one that’s all gray areas. Where you look beyond a given “offense” or lapse to

see if there might be an explanation other than lack of ability or moral fiber. You give

people second chances. You do the best you can with the kinds of people you have to

work with. I mean, really, what if Dennis had his way? This school might never graduate

anybody.

And then of course I keep finding myself thinking about his age.

But then he’ll say something or I’ll watch how carefully he guides residents

through one of his sessions—question after question after question—and I’ll see how

engaged many of them are, how alive, how hard they work when he works on them, and

I’ll just get all caught up again in making people understand how remarkable he is. The

hold he has over receptive people, that amazing charisma …he just makes you want to

believe that things not only can be better, but can be as good as he thinks they should be.

And you can see that he has that power that only a few people have, where he makes

people awfully anxious to please him.

And there’s no question about his medical abilities, which seem to be recognized,

known, all over the country. Last week, they flew in some woman from Michigan who

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had a condition no one could diagnose. Someone who knew about Dennis had called him

about this case, and he’d ventured a diagnosis over the phone. She’d had this huge hard

stomach, all distended, for months, then a few days ago this yellowish jelly started oozing

out of her navel. Dennis said he suspected she had something called pseudomyxoma

something-or-other.

When the woman got here and got checked in, Dennis was there immediately. It

was the first time I got to watch him actually do an exam—I was crowded in there with a

bunch of residents. He took an incredible amount of time chatting with her, looking her

over everywhere, palpating her…and he must have asked her a thousand questions. At

one point, he was just sitting beside her on the bed, holding her hand, asking her

questions in this surprisingly gentle voice—normally all I ever hear from him is a

drawling growl—and she had the most peaceful, grateful expression on her face. After

coming in looking grim, pained, despairing. She actually thanked him when he left.

Dennis has this quiet, deep chuckle when he’s satisfied with himself. “Heh…I

was right,” he said when we were safely out the room. “You don’t see but one or two

cases of that in the whole country in a year. I’ve never actually seen a patient in person

with that before.”

Dr. Badger

So here’s where we stood with the accreditors after they did their evaluation and

put us on probation. We cleaned up our act as far as all the stuff on their list and brought

in Cowan, the consultant, to evaluate what we’d done. Of course Dennis was the only

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outstanding matter. The residents had their turn with Cowan, then I made my case, which

was basically that we were saddled with this old doctor who was casting a terrible pall

over the program. His reputation as an unreasonable, capricious old man who wouldn’t

embrace the current way of doing things—who wouldn’t even embrace advances in

medical technology—was driving the best students away from us and making it all but

impossible for the ones we have here to get anything done. They’re always afraid he’s

going to come down on them unreasonably. Everybody tries to avoid him, but he’s the

one physician who’s here all the time, so it’s all but impossible. He singlehandedly

creates this atmosphere of fear and recrimination that keeps people from doing their best

work. I let Cowan know that if we got the kind of report I expected from him, we’d be

able to remove Dennis and get our program on a more stable footing, bring it up to date.

So I was pretty sure when he gave us his full evaluation, with its list of things we needed

to do to get back in the accreditors’ good graces, the number one thing on the list would

be moving Dennis into retirement and replacing him with good, modern, technologically

savvy teachers.

Dennis Leonard

Medical school is a “three-legged stool”: patient care, education, research.

Medical schools won’t admit it, but their first interest is research, their second is patient

care. Education always comes third.

You have to be careful about what you say around here. It’s like the Mafia or

something: If you say something out of the network, you get eliminated. People know

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that I don’t respect the department—I try to make it obvious, tactfully, to the residents.

I’m confident that the powers that be are part of this good ol’ boys network, and through

passive aggression, they try to make life difficult for me, and they sequester me from the

students and residents, they know it makes me unhappy, they’re trying to force me to

resign. They can’t fire me because my record is impeccable.

Like this latest bullshit move: they made Morning Report with me “optional”

instead of mandatory. An absolute deliberate insult and yet another way to cut away at

my standing here. It used to be that even the students who hated me the most couldn’t

avoid me—they had to take their punishment on a regular basis. Now, anybody who

wants to stay away from me can. I’m sure they’re hoping I end up with nobody at all—

shit, the last Morning Report, the day after they made that announcement, only three

residents showed up. Normally, you have eight, unless I had to kick a bunch of them out

for one reason or another.

I’ll tell you this, though—we had a hell of a time, me and those three. A hell of a

good time. And now when the optional program is completely in place…well, I guess

we’ll just have to see who shows up. I’m not going anywhere in the meantime, I’ll tell

you that.

Letter

Dear Eric,

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 In looking through my files, I came across the complaints made against me by a

few of the residents when our department of medicine was placed on probation. In

essence, there are four complaints:

1. I use profanity when teaching (in fact, I do!).

2. I enjoy depriving residents of sleep. This of course is ridiculous, but was the

residents’ way of emphasizing that they were too tired to prepare cases for

presentation to me. In regard to this issue, I have NO sympathy for residents

who are fatigued from duty. Being tired is part of being a doctor!!

3. I won’t allow food and drink to be consumed during my teaching conferences.

Also true!

4. I won’t allow other faculty to attend my Morning Report sessions or my

teaching (bedside) rounds. The fact is, the faculty has been invited verbally

and in writing by the department chairman on more than one occasion, but

few faculty ever attend my conferences. I believe they never attend because

they aren’t interested, don’t care, or they (like many of the students and house

officers) are (feel) intimidated by me.

Sheriff’s Officer Chris Richards

I know what people here at East Loop think of us—it’s not like they try to hide it

or anything. The way they look at you, the things they say…they don’t give a shit about

how we feel. They talk about us right in front of us like we’re not even here.

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 It’s not like I chose this duty—that asshole supervisor of mine is just pissed off at

me.

The county has this policy which I know looks stupid from the civilian standpoint

of having a sheriff’s officer sit outside the hospital room of every single inmate who gets

put in the hospital. So you look around here, and there’s deputies sitting outside…I don’t

know…maybe twenty of the rooms at any given time? Around the clock, so there’s three

shifts of us. It looks stupid as hell, and yes it’s a complete waste of time for somebody

like me who could be out doing real police work and who’s good at it but whose boss is

an asshole, to be sitting outside the room all day long, every day, of someone who’s

basically in a coma. My guy right now really is in a coma, for Chrissakes, and is hooked

up to all these tubes and wires, and even has both legs shackled to his bed. He couldn’t

get out of here if a bunch of guys tried to carry him, let alone on his own. But the policy

is still that I have to sit here acting like The Thin Blue Line…the last defense for

civilization against this “menace.”

Anyways, this is like my second week pulling this bullshit duty. I think my guy is

just here to die…it’s hard to tell, partly because the damned medical people never talk to

us. It’s like they’re either embarrassed for us or mad at us for wasting so much taxpayer

money.

It’s stupid on their part—they should think of us as a resource. It’s true that a lot

of the guys who pull this duty are horseshit, just putting in their time—especially the ones

who bring portable TVs—but I’m not. I still work hard at my job—I’m not phoning it in

like a lot of the guys at the county. And it’s not like I don’t see weird stuff going on

around here that people maybe should know about. I have what you might call a “trained

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professional eye”—I know how to “observe.” I could tell the docs here a few important

things about the residents and nurses running around here doing their things, that’s for

sure. Stuff that happens when they’re not around.

What I’m saying is, I can still do detective work even though I’m stuck here on

this assignment. But the people here just think we’re this perfect example of stupidity and

waste. “Good enough for government work” types. Which some of us are, I know…like

Herb, who’s been pulling this duty for the last ten years, and who’s like a hundred pounds

overweight, easy, and just sits there in his chair with his little television and stack of

crossword-puzzle books, getting fatter and fatter by the day. He’s like a cheap TV

stereotype of a county sheriff. But a guy like me who got put here for the wrong reasons,

that’s different—and people should be able to see the difference.

I was sitting here doing the usual one morning when Dr. Leonard came walking

down the hall with this guest, who I got to know pretty good by a few weeks later. This

guy Eric, a writer. I gave Dr. Leonard the Hi sign, but he basically looked right through

me, which was unusual. He’s the one guy around here who actually takes the time to say

hi and even chat with us a little.

He was pointing things out to this guy Eric, explaining everything. Then I hear

him start talking about us, in this voice what was totally full of contempt: “The county

has a policy that a sheriff’s officer has to sit outside every single inmate’s room, around

the clock, no matter what shape the inmates are in. Even if they’re in a coma! Some of

these officers are here every day, year after year after year. It’s an incredible waste of

money. And you’ll notice that almost all of them are fat.”

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 I should have been pissed off, but I wasn’t. For some reason, you can never get

pissed off at Dr. Leonard. He’s just different—I can’t really put my finger on it. And

normally he’s the one guy here who actually responds when you say hi to him or

whatever. Plus I’m not one of the guys he was talking about, really—the fat guys, the

guys with the little portable TVs. Who “work” here year after year after year. Those guys

really are pathetic. He never would have said that in my hearing if he thought I was like

them.

José

Very very sick man come to emergency room. Benjamin do initial examination

and admit him right away. Man tell incredible story: He own a pet shop. He wake up in

morning after camping outdoors and find tick on his stomach. Which he pick off. Then he

say he eat pork sausage that he cook over fire—Osmun and Benjamin and Brandon all

say it probably not cooked enough. Plus he say he drink water from stream that right by

outdoor toilet.

Then man say he go hunting and step on rusty nail, hurting his foot. But he keep

going and finally catch a rabbit, and skins it.

Man say he start to feel sick in afternoon, with fever and pain in joints and

muscles. He come here with high fever and red spots on chest. While he here, he get

disoriented, and after he admitted, he fall into coma.

No one know what wrong—it like, too much information! Like people always say

in America, as joke, only this time it true. So many things he tell us about that could

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made man sick like him. We all try to figure out what wrong. Brandon say brucellosis,

which seem most likely because of animals, but he also think it could be psittacosis. And

Osmun say he think it trichinosis or tetanus. But man too sick too fast for either one.

Other people just guessing: Rocky Mountain spotted fever, typhoid fever…. Then when

Benjamin say he think it could be Lyme disease, Dr. Leonard get mad and yell at him,

“Look at all symptoms!”

Then Dr. Leonard say, “Only two things can put healthy person in coma so fast.”

And he ask us what those are. No one say anything, and I finally say “spontaneous

intracranial hemorrhage,” but Dr. Leonard say, “Yes, that one of them, but that not what

this man have.” He tell us he probably have meningococcal infection, and make us do

gram stain of aspirate from red spot on man’s chest. Dr. Leonard right: culture grow

Neisseria meningitidis, and we give man antibiotics but we too late, and he die.

Dr. Leonard not mad, but he talk to us for very long time after man die, because

he say case teach us two important lessons. “Not one of you looked at all clues,” he say.

Instead, we all find disease for one of man’s symptoms. Coma tell us very important

thing. Plus man have petechiae on hands. Only condition that have every symptom man

have is meningococcal infection. Dr. Leonard say two things this case teach us is: Look

at everything. And that good doctor can diagnose this man’s illness without technology,

just with “diagnostic skill.”

Osmun and Brandon and Benjamin later say Dr. Leonard not fair—that case too

hard, disease work too fast, man come in too late and tell confusing story. But they afraid

to say to Dr. Leonard. He hate it when we defend our mistakes.

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Chapter 5

These Are the Days

By Dennis Leonard, MD

These are the days when interns have reason to gripe. Unless they demonstrate

unflagging commitment and indisputable integrity, they risk being fired—sometimes on

the spot and without warning. They have no formal contracts.

Their responsibilities are daunting and their schedule grueling. They work every

day and every other night. While on duty, they rarely find time to sleep. And when off

duty, they must remain in the hospital until all of their patients are in stable condition and

all studies planned for the next day have been ordered. Consequently, on their post-call

days, interns typically leave the hospital about 8 pm, and sometimes not until midnight.

Ward rounds on the inpatients begin sharply at 7 am, 7 days a week. In attendance

are the ward resident, the 2 interns, and the chief nurse. Medical students do not

participate. These rounds are sacred, generally last 2 hours, and only a bona fide

emergency can interrupt them. The intern on the case briefly examines the patient while

the resident examines the patient’s chart. Results of tests and procedures done the

previous day are discussed, and, with input from the chief nurse, the resident and intern

make decisions regarding additional testing or consultation, medication changes,

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discharge considerations, and other “housekeeping” matters. Similar rounds often take

place around 6 pm that same evening.

Aided at times by medical students and the resident, interns perform and interpret

all admissions and follow-up blood counts, peripheral blood smears, urinalyses, stool

guaiac tests, and electrocardiograms. Additionally, they start and maintain all intravenous

therapy; draw all blood cultures; stain and examine microscopically all pleural,

pericardial, peritoneal, spinal, and joint fluids; apply skin tests and search for ova and

parasites in stool specimens. The intern on call also draws the early morning blood

samples from about 20 to 30 patients—the team’s average number of patients at any

given time. That job—undertaken with frustratingly blunt, nondisposable needles and ill-

fitting, easily broken glass syringes—must begin at 5 am or earlier to be completed

before work rounds begin. Interns also fill out requisition slips for all laboratory tests and

procedures and are responsible not only for recording the results in the patients’ charts,

but also for reciting the results on command.

By carrying out these seemingly menial tasks—called “scut work” in housestaff

lingo—interns begin to realize the importance of accountability. They learn firsthand the

subtle factors that can influence test results. They learn to appreciate other members of

the healthcare team who ordinarily do such work—nurses, laboratory personnel,

phlebotomists, and ward clerks. And most important, perhaps, the scut work repeatedly

brings interns into physical contact with their patients, strengthening the doctor-patient

bond.

Interns make daily trips to the main hospital laboratory, radiology department,

microbiology unit, and other areas to obtain rest results, review x-ray studies with a staff

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radiologist, check on the growth of various cultures, etc. This important routine requires a

lot of physical effort, but it ensures timely and uninterrupted patient care.

In addition to the workload already described, interns must squeeze in time for

daily chart rounds. During this ritual, the intern and resident scrutinize each inpatient

record for missing data, illegible notes, disorganized inserts, and other common

deficiencies. “A sloppy chart indicates a sloppy doctor,” the department chairman says.

Not surprisingly, therefore, defective patient records provoke his wrath.

Interns occasionally are discussants at weekly Grand Rounds. This assignment

compels them to spend long hours in the medical library searching the stacks for pertinent

articles on their topic. In the process, they learn what it takes to research a subject

thoroughly, how to read with discrimination, how to critically evaluate what they read,

and how to give a formal presentation before a discerning audience.

They also prepare vigorously for teaching rounds, which take place at 10 am, 4

times a week—3 with an attending physician, and 1 with the chairman. The attendings

and chairman serve as consultants who simply offer opinions and make

recommendations. Responsibility for managing the patient—particularly all decision-

making and order-writing—rests solely with the intern and resident on the case. These

teaching sessions last 1½ to 2 hours and focus on 1 patient, who is presented, examined,

and discussed in detail. Interns must make certain beforehand that the patient is in bed,

properly gowned, and willing to have the teaching physician come by. Interns are also

expected to bring pertinent literature to the conference room and to have on hand all of

the patient’s past and current medical records; a microscope with which to look at

relevant urine sediments, blood smears, and tissue sections; and an x-ray view box for

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display of relevant radiographs. The case presentation must be clear, well-organized, and

free of ramblings and redundancies. Anything less is unacceptable and will earn harsh

reprimands. After the case presentation, the group goes to the patient’s bedside, where the

attending or chairman takes over. Observing these master clinicians in action is the best

part of the internship.

Once a week, the interns work a half-day in the outpatient clinic. This activity

always takes place in the afternoons so that it doesn’t interfere with the work rounds and

teaching conferences held in the mornings. On the other afternoons of the week, the

interns are busy performing work-ups of new patients, tending to patients previously

admitted, and completing other assignments and duties.

These are the days when a constant bed shortage limits admissions to the very

young, the very old, and the very sick. Because no Intensive or Coronary Care Units

exist, interns cannot transfer their severely ill patients to a specified area for close

monitoring. Instead, they must monitor the patients themselves, using the only monitors

available—their own eyes, ears, nose, hands, and brain. This situation forces interns to

observe their patients carefully and repeatedly, often for long periods of time. They must

also attend every operation on their patients and every autopsy performed on any patient

from the medical teaching service. From these various routines, interns gain competence

and confidence in their clinical skills, learn the pathophysiology and natural history of

disease, and understand when to treat and why.

The highlight of the workday actually occurs at night—midnight to be exact.

That’s when many of the house officers on duty throughout the hospital meet in the

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hospital cafeteria for a free meal. Although the food isn’t great, the camaraderie is.

Furthermore, this respite is just what it takes to recharge the interns’ batteries.

These are the days when the internship ingrains discipline, stimulates a taste for

continual self-education, and promotes mutual respect among all hospital personnel.

Indeed, these are the days when good patient care and the education of the intern are all

that matter.

What days are these? The days 56 years ago when I was a medical intern in the

main teaching hospital of a state university.

Since that time, the medical internship has changed significantly, bearing almost

no resemblance to the one I did. Given the ever-increasing emphasis on sophisticated

technology, the shrinking of government funding for medical services, and the

devastating impact of managed care, clinical teaching has suffered a serious blow. In

addition, medical schools are so strapped for money these days that they force the clinical

faculty to spend more and more time caring for paying patients and less and less time

caring for medical students and house officers.

Even more disturbing to me as a medical educator is the mandate that was

promulgated in 2003 by the Accreditation Council for Graduate Medical Education

(ACGME), imposing work-hour limits across all training programs, regardless of

specialty. Acting to promote patient safety, the ACGME sided with the widely held—but

still disputed—notion that sleep deprivation and physical fatigue in physicians lead to

harmful medical errors. As a result, interns now take call every 4th, 5th, or 6th night (but

only on required rotations; the other rotations are call-free). Moreover, they must leave

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the hospital by 1 pm on their post-call days, are not allowed to average more than 80

hours of work per week, and typically take 1 day a week off.

Thus, from its roots as a patient-centered, educational-oriented year of learning,

the medical internship has evolved into a laboratory-centered, algorithm-oriented,

technology-driven, computer-dependent, Internet-based, “treat first, diagnose later”

training program. Consequently, we are exchanging sleep-deprived healers for a cadre of

wide-awake technicians who cannot take an adequate medical history, cannot perform a

reliable physical examination, cannot critically assess information they gather, cannot

create a sound management plan, have little reasoning power, and communicate poorly.

Is this what patients want? Is this what patients need? Is this what patients

deserve? I think not. I also think that unless medical education undergoes substantial

reform, things will only get worse.

Meanwhile, we need to find a balance between policies of the past (which

emphasized compassion, empathy, and high-touch, direct patient care) and policies of the

present (which place a premium on high-tech machines and gadgets). But whatever the

future brings, we must always view medicine as a calling, not a business, and hold fast to

the patient-oriented traditions that have sustained our profession throughout its history.

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Chapter 6

Osmun

So we finally got our time with the consultant. It was Brandon’s idea, this whole

campaign, but I felt like we were taking a stand not just for him or even for the three of

us, but for all the residents and for the whole school. For Modern Medicine itself, for that

matter. Because no matter how hard you worked and no matter how hard you tried, Dr.

Leonard would screw you over. It made people give up on themselves even if they didn’t

know it. The guy is just a prick, plain and simple.

We had really good evidence, too—including an article of his that we found

where he basically says residents should be abused and abused and abused. Brandon’s

girlfriend found it—it was so perfect that it was like he wrote it just to give us

ammunition.

So we went in there and unloaded on the guy. Told him how Dr. Leonard swears

at us all the time, arbitrarily kicks us out of Morning Report for penny-ante shit, hates it

whenever we use “the computer”—that’s what he always calls it—in our sessions,

humiliates people just for the fun of it, prevents us from learning medical technology

properly, sets you up so that no matter what you do you fail in his eyes, and how he’s

holding the whole school back. We’re falling behind everybody else in the country when

it comes to true modern medicine.

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 I felt like the guy gave us a good hearing, too. He took a ton of notes, asked lots

of questions, and generally seemed like a good, thoughtful guy.

Dr. Leonard

God knows I’ve been through the accreditation grinder before. I’ve seen it all—I

remember when I was in medical school, we were put on probation once because nurses

were washing bedpans in the patient bathtubs. Once the ACGME gets fixated on

something, there’s no turning them away or distracting them or anything.

And this time they’re fixated on me. The good ol’ boys, from the administration

all the way on down, have it in for me. They’ve been going after the old docs like me all

over the country…I was pretty much the last one standing when the Council showed up

here.

And then I heard about those three residents actually getting a session with the

consultant, Cowan, after what the administration said to him about me. It’s not like I have

nowhere to go or anything—it’s not like I need this job anymore—but it really rankles,

the way they’re basically turning the solution into the problem.

Hell, I’m more or less ready for anything, I guess. One of my former students has

this great new idea for medical care, where he’s going to set up clinics that can deliver

good basic medical care for low cost, so people with bad insurance or even no insurance

can afford decent care. He wants me to be his director of medical operations—basically

plan and set these clinics up. And he’s going to pay me three times what they’re paying

me here.

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 What’s exciting about it, of course, is that it could potentially serve as a model for

the whole country.

So like I said—I’m ready for when the firing comes. I can walk out of here with

my head held high.

Eric

So basically, Dennis told me that our little project was most likely going to end

because he was going to get thrown out. Then he started talking to me about this idea he

had for a new kind of medical clinic, and how that might make for a better book anyway,

an inside look at a care program that might someday serve as a model for the whole

country.

But I couldn’t see it working. There was no journalistic there there, basically—no

scandal to expose, no payoff for a publisher.

Of course my first reaction to the news was to feel stupid. Berate myself over how

the whole idea of the kind of book we’d planned seemed too good to be true, I should

have known better, etc. etc. etc. And I probably got into the whole fantasy for the wrong

reasons, was more or less how I started thinking. It was just a way to distract myself from

my own burnout, my kids hating me, the Ex…if I hadn’t been so desperate, I would’ve

seen how nowhere the whole idea was—especially taking on a project like this without a

contract from a publisher.

It’s the kind of thing you do when you’re out of options—you start getting excited

about things that no sane person would touch.

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Joanne

I suppose it was bound to end this way, or something like it: Where they forced

Dennis out. He would never retire on his own, and the world these days seems to be

changing so fast, in ways that he just can’t tolerate. He’s such a fighter! But now it looks

like they’ve finally figured out a way to get him to retire, through this accreditation mess.

It’s like he told me the other night: They’ve been looking for a way to get rid of him for

years, and now with this loss of accreditation and the residents’ complaints, they’ve got

their way. Dennis told me that they had all their ducks in a row, after working for months

on getting Dennis to take all the blame for the department’s probation. All they have to

do now is bring down the hammer when they meet with the consultant tomorrow.

Letter

It has become apparent to the undersigned that Dr. Dennis Leonard is greatly

misperceived. We understand that given the current state of affairs, the administration is

actively trying to improve any shortcomings in the program, and we greatly appreciate

such efforts. However, we sincerely hope that the administration recognizes that Dr.

Leonard is an asset and not a liability to our program.

This petition is in response to Dr. Leonard being set apart as a topic of discussion

by the accreditation reviewer. In fact, he introduced the subject as the last and the “most

controversial”. As expected a few residents spoke their mind criticizing his teaching

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style, a few residents defended him, and the majority said nothing. To some of us though,

the fact that he was mentioned greatly concerned us. In light of the numerous citations

against our program, our paid consultant apparently felt that Dr. Leonard needs to change

or worse leave. For many of us, Dr. Dennis Leonard represents one of the best things

about the University, both before and after probation.

We, as residents, appreciate that now more than ever our program is “under the

microscope”, and that even one disgruntled resident is a threat to our program’s future if

they take their complaints to our official site reviewer. We also realize that our program

is in the process of change; however, it is unacceptable that Dr. Leonard serve as a

scapegoat. Few attendings, if subject to such intense scrutiny, would fare well in terms of

their contribution to resident education and patient care.

Dr. Dennis Leonard contributes an aspect to resident education which is hard to

replicate. First and foremost, he serves as a patient advocate. Unlike conferences or

textbooks, he teaches us to rely on ourselves, not only for our own education, but for

good patient care. Often times lost amidst lab values and various radiological studies, we

forget the most important element—the patient. Many times instead of treating the

patient, we treat lab values as Dr. Leonard likes to say “ourselves”. Furthermore, Dr.

Leonard insists that we provide better patient care by reviewing old medical records and

studies, personally contacting the patient’s primary care physician, and verifying our

history with the patient’s family. In the end, we have often either solidified or disproved

previous and/or current diagnoses. These habits engrained in us by Dr. Leonard further

emphasize the need for us to constantly question not only our methods but our diagnosis

prior to labeling a patient. Most importantly, Dr. Leonard encourages us to properly apply

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our M.D., i.e. Make Decisions. The end result is improved patient care, and a patient who

will continue to teach us for years to come.

It has been alleged that Dr. Leonard is averse to technology and the use of any

antibiotics. In actuality, however, his point relates more to physician accountability and

the obvious limitations of imaging and lab studies. For example, we cannot accurately

diagnose infection or malignancy from a CT scan, rather we also need fluid and tissue for

a final diagnosis. He stresses that in managing a patient, we should order each test or

procedure for a certain reason. In other words, medicine should not be an arena for “knee

jerk” orders, rather medicine is an art which we must develop and nurture. We should

administer antibiotics, or order a CT scan if we have a reason, otherwise both the patient

and the physician are potentially at risk or liable for adverse outcomes. These lessons of

accountability, professionalism and medical skepticism are profound, for they guide us in

our quest to attain wisdom.

It has also been alleged that Dr. Leonard is resistant to change. However, for the

record, Dr. Leonard went along with the administration when attendance at his morning

reports was made optional. Ironically, we enjoy his morning reports because we learn,

and thus we continue to attend. Similarly, in critiquing our medical decisions, Dr.

Leonard challenges us so that we can defend our decisions, as we will have to when we

enter the “real world”. He wants us to learn from our mistakes now—not repeat them in

the future. The passion evident in his teaching sessions is contagious, and that passion for

excellence, honesty, dedication and diligence produces superior residents. If some

misconstrue him as stubborn and intransigent, we stand united to contend that behind his

stern exterior is a heart of gold.

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 Finally, Dr. Leonard is a true resident advocate. He has devoted his career to

being an educator, and with his traditional style of medical teaching, he truly focuses on

each individual resident. Most of us prior to actually attending his sessions, are full of

trepidation, and we do not truly garner an appreciation for Dr. Leonard until we become

residents. He tells us from the beginning that he will not “spoon feed” us knowledge, and

that if we want to learn from him we will need to put forth the effort ourselves. Many of

us, at first, are not used to his Socratic method of teaching. However, as we progress

through the month, we actually look forward to defending both our thought process and

our management of the patient. He systematically identifies our weakness, thoroughly

examines our differentials, and subtly guides us to consider other options. Those of us

that prepare and read about our patients like we should, find his morning report and

Leonard rounds more rewarding than most of our experiences in training. Dr. Leonard’s

teaching, however, does not stop at morning report or Leonard rounds. He eagerly

involves himself in patient care by personally contacting the residents for follow up. He

makes himself available at anytime for questions or concerns, and he clearly establishes

an open door policy. Given the aforementioned, no other attending would have been able

to unknowingly motivate and mobilize “overworked” residents into writing and signing

such a letter.

In conclusion, Dr. Leonard inspires us to emerge from the trenches of mediocrity.

Dr. Leonard has always said that he would “rather be respected than liked”, and we can

expect that there are now (and probably always have been) residents who do not like Dr.

Leonard or just simply do not like his method of teaching. We think you will be hard

pressed though to find anybody who does not respect his medical knowledge or clinical

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experience. We greatly appreciate his contribution to our education and to our evolution

as physicians. We echo sentiments of residents who have gone before us when we

acknowledge a fondness for him which will be forever entwined with this institution. If

he is taken away from us, the administration will not only be showing disrespect to one of

our greatest teachers, but also to the residents who sign this letter in support of him.

[82 signatures]

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Chapter 7

Dr. Badger

I decided to have our senior faculty attend the meeting with Dr. Cowan, so he

could present his findings to all of us and give us a chance to respond to them. I didn’t

want to have it be too obvious what I was up to—to have the program director and

Dennis there with me, and no one else, would set off all kinds of alarms in Dennis’s

mind. This is more or less standard procedure anyway, to bring all the faculty in, even

though the truth of the matter is that I’d set up the meeting solely for Dennis’s benefit,

since he was the target, if you will. I wanted him to hear directly from the consultant why

he had to step aside. And it would give us the kind of leave to let him go that we can’t get

without this added credibility given us by the consultant.

Osmun

Of course we knew in advance about the meeting and how it was set up. Brandon

and Dr. Badger had been conferring. It was as good as a done deal, as we understood it.

Brandon and Benjamin and I, we met down in the cafeteria and just sat there waiting to

hear the good news when the meeting ended. There was going to be one massive party

after this one.

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Joanne

So on the day of the Big Meeting I just sat at home thinking and waiting to see if

Dennis would call right away, or maybe just show up here at home afterwards. I had no

idea how to prepare myself emotionally for what he’d be like when he came home.

I felt so funny! The few people I had talked to about it all had the same reaction,

which was that it would be kind of a blessing, in a way, because Dennis was way past the

age of retiring anyway, and now we’d be able to spend time together doing things we’ve

always wanted to do.

But all I could think about was how our life and our routine, which we both love,

would just be completely destroyed.

Back when Dennis started running—back in the 1960s—almost nobody ran like

that. Long distances every day. It wasn’t the kind of recreation for everybody that it is

now. It was really unusual. And Dennis was typically obsessive about it. That’s when he

got started on his one meal a day routine—it really was a kind of time management issue

with him. He figured out that if he went out and ran for an hour every day when he would

normally be having lunch, that that time spent running wasn’t any more than it took to go

down to the cafeteria, wait in line, get your food, eat your food, and so on. That’s how he

used to argue that it was on balance a better way to manage his time and his life.

Then of course he just got more and more obsessive about it, until he was running

more than 20 miles a day every day, and more than that when he was training for those

100-mile races he used to run. No one is as intense as Dennis—no one!

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 But boy, did I ever get a taste of what life with him is like when he isn’t working

all the time, when back in 1988 he was out running and got hit by a car and injured so

bad he had to stay at home for two months. My God, he was just in my hair all the time

about how I kept the house! Ever since then, I’ve been dreading the day he retires and

comes home.

Eric

I was waiting in Dennis’s office for the meeting to be over. The one where Dennis

was going to be fired. This “office”—I kind of use the term loosely, since it’s a tiny room

with a battered old gray metal desk in it—is off in some weird cul-de-sac in the hospital,

across from an elevator. There’s no way that this room was ever designed to be

someone’s office. I’m guessing it was for storage or janitorial supplies or something until

they exiled Dennis here.

There’s nothing else around, except for a set of double doors that leads off into

some labs or something. Nothing says more about how the administration here feels

about Dennis than this hole.

Dennis Leonard

So I went in and sat down and Badger had this impassive look on his face, like he

thought he could conceal what was going on until they lowered the boom. Acting all

polite, pretending to be a little nervous, even, like he didn’t know what the hell the

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consultant was going to say. He was being all solicitous where normally he wouldn’t

even give me the time of day. It was sickening.

I should have told him to go to Hell.

I got there first, of course, except for him. Then the program director, Dr.

Henry—another one of those good ol’ boys—he showed up.

We all sat around making small talk, and those two clowns—Henry and Badger—

were really careful not to look at each other.

I’ve been to a million firings over the years, so it’s not like I can’t feel it when it’s

in the wind. It was just that this was the first time I was the one who was the pigeon.

Then a bunch of senior faculty showed up, and finally Cowan walked in, all brisk,

all business, and he gave me this look just for a second. He sat down right away, hardly

even saying Hi to anybody. Then he just sat there for what I swear felt like an eternity,

just kind of looking down at the floor like he was trying to gather his thoughts. He pulled

a bunch of papers out of his briefcase, started thumbing through them. The room was

dead silent. Dead silent.

And then came the hilarious part: He looked right at Badger, then at Henry, then

back at Badger, and he said, just flat-out, “Dr. Leonard is not your problem.”

Eric

I was there about an hour before I heard the elevator door open and the tap tap tap

of Dennis’s cane. I’d gotten to where I could recognize that sound anywhere…it seemed

like I was always sitting somewhere waiting to hear it.

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 Anyway, Dennis came in and gave me that deep chuckle of self-satisfaction he

has. “That bastard Badger finally got what was coming to him,” he said right away.

“Cowan saw right through them, how they were trying to use me as a scapegoat in an

obvious attempt to deflect attention from all the real problems around here. And he came

down on the same squares as the accreditors did: incomplete medical records; inadequate

supervision of residents in emergency and ICU; too much service, too little education.

And so on. Now maybe they’ll clean house the way they’re supposed to, instead of the

way they want to.”

I’ll be honest—I was totally shocked. But then it turned out that this was only the

beginning.

Osmun

So Nancy came running down to the cafeteria where Benjamin and I were sitting

with Brandon, waiting to hear. And as soon as she came around the corner and saw us,

we could see that we were fucked. She didn’t even have to tell us anything—by the time

she started talking, I was already trying to figure out what the hell we were going to do

now. And that was before we knew the half of it.

Nancy

It just broke my heart when I came down to tell Brandon and everyone about how

Dr. Leonard wasn’t going to be leaving. Brandon looked so crushed! I just wanted to cry

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when I saw him—that’s how terrible he looked. Osmun and Benjamin, they just looked

furious, but Brandon looked truly, deeply sad. I wanted so much to make him feel better,

but I couldn’t think of anything to say, so I just sat down with them for the few minutes I

had, and listened to everybody vent. Everybody but Brandon, that is…he just sat there

without saying a word.

Dr. Badger

Those bastard residents…they undercut me with that damned letter they all

signed. Everything was in the works exactly the way it was supposed to be, then that

thing came out of nowhere. God, all the careful preparation, all the work I did! Those

bastards!

Dr. Cowan

I’m not sure when exactly it happened, but right at the end of my investigation—

not long after getting that letter signed by the eighty-two residents—I just had what can

only be called an “awakening.” Maybe it was the way such a large number of these

young people came forward when doing so presented them with far more risk than

reward. And to see them beg to be challenged that way…it’s really unusual, in this day

and age. I can safely say that there’s not another group of residents in the country like

that.

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 More to the point is the—for lack of a better way of putting it—behavior of the

faculty and administration in regard to Dr. Leonard. It was clear from the letter, which

was signed by almost 90 percent of the residents in internal medicine, that it’s not the

residents who have any problems with Dr. Leonard. It’s the powers at the medical school,

especially the powers in the department of internal medicine. And they tried to

manipulate me by leveraging the complaints of a small minority of their residents so as to

persuade me that Dr. Leonard was practically the sole cause of the department’s

problems. They were very careful—and I didn’t realize this until I got that letter—to keep

me away from Leonard’s numerous defenders and grant me easy access to those very few

malcontents.

It’s easy to see why, too, in retrospect. I think a good number of the other

attendings resent Dr. Leonard for the way he keeps pointing out their deficiencies, and for

his uncompromising attitudes toward their cutting corners for the sake of devoting more

attention to their lucrative private practices. They want him out of here so they can carry

on with business as usual at the expense of their residents’ education.

For that matter, it’s at the expense of Medicine in general, when you really sit

down and think about it.

And it really did get me to thinking. That maybe there’s a limit after all to the

degree to which you can let schools relax time-honored standards. That the profession’s

been on a slippery slope. Mediocrity may suffice in a good number of professions these

days, but in medicine it’s just not good enough. I’m not sure but that I’d been letting my

own guard down a little, now that I think about it.

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 And in the end, that’s all Dr. Leonard is trying to do: Keep the American

tendencies toward laziness and lax standards from poisoning the medical well, as it were.

The campaign against him, which the medicine department started in on as soon as I

arrived, had me bamboozled at first, but now I see that they’re just plain wrong.

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Chapter 8

Joanne

The funny thing was, Dennis wasn’t all that excited about the results of the

meeting with the consultant. Here he’d been getting himself ready for weeks to get fired,

and then when it didn’t happen, he acted like he’d been expecting all along to win this

battle. He didn’t even call me after that meeting—didn’t call me at all that day, in fact.

Just came home like he always does, at around midnight, and told me in this oh-by-the-

way voice, like it was just some silly little story from the office, that the consultant had

told the hospital that Dennis was essentially the solution rather than the problem.

It was what happened next that got his attention. Now that his job was secure—

maybe even more secure than it had ever been—he went to the president of the health

science center, who was newly appointed, and told him what was going on in the med

school, how they’d been treating him, how little he was paid—the whole story. This

gentleman was a former student of Dennis’s. Apparently, he was furious at what Dennis

told him. He fired the medical school dean and brought in another former student of

Dennis’s, and then they really boosted Dennis’s salary. Almost doubled it! And the next

thing everybody knew, Dennis was conferring almost constantly with the new dean,

which had Badger and all those residents who were trying to get him canned in an

absolute tizzy.

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 All I could think was that finally Dennis was getting the respect he deserved. And

now I figured he’d come to his senses and throw that writer out before he got him in

some new kind of trouble.

Eric

It was unbelievably weird, how fast it all happened. Suddenly Dennis went from

being on the outs to practically running the place. All hell broke loose, from what I could

see. Residents started tiptoeing around him, trying like hell to keep him happy, other docs

would go out of their way to say hi to him...it was hilarious.

Basically, Dennis went overnight from packing his stuff to being set for life. Now

there was no way he was leaving this place until he was dead. And all those back-

stabbing residents knew it, too. As far as I could see, they were screwed. Either they were

going to have to shape up or their lives would be a living hell.

I even heard that a couple of them went to talk to lawyers, like they were

expecting to be thrown out no matter how hard they tried to improve.

I mean, not to make this all about me or anything, but it’s kind of like all I could

think about was how this was going to make one hell of a story after all. It was a great

plot twist, this turn of events, and it seemed to me that it could only lead to more drama

and excitement.

I started thinking seriously again about how this could play out. The story was

getting richer by the day. The only thing I was missing was sex…which, in point of fact,

was the biggest surprise for me in diving into all this research: Where was all the Grey’s

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Anatomical steam? This place was rife with nothing but asexual tension, as far as I could

tell. I’d been hoping for page after page of bodice-ripper stuff, reeking of sex and

sterilizing agents: “At last, we were alone…. His hands—his doctor’s hands!” etc. etc.

etc.

Joanne

I know everything was just hunky-dory after the shakeup at the med school, with

Dennis finally getting the salary and the power that he deserved, and I thought for sure

that it would mean the end of his project with that writer. After all, the whole reason for

doing that project was to expose problems that now would be going away. What would

there be to write about now?

But Dennis was determined to keep going, for some reason. He insisted it was

important for the future of medical education to let people know how bad things had

gotten.

It was so maddening, trying to talk with him! Before, you could almost

understand it, even though it struck me as an exercise in self-destruction. But now? Now,

when everything was going his way? Why would he want to risk destroying all the new

good will he’d built up? I would have thought that with him and the school

administration being on good terms now, he wouldn’t want to risk everything by

consorting with this writer like this! It made even less sense now that it did before!

Dr. Badger

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 Well, when it all shook out, the comings and goings in the upper administration,

the “transfer of power,” if you will, to Dennis, I was still in this position for some reason.

I didn’t get fired, but I sure as hell lost the ability to control that old loose cannon. About

the only option I had left now was to keep as close tabs on him as I could while they

turned him loose, and hope he’d screw up so horribly that even his allies would see that it

was time to retire him. It just drives me plain crazy, how hypnotized these people are by

the old bastard. And now the damned president of the school is one of his former

students, for God’s sake. What chance do any of the rest of us have of bringing this

school—especially this department—into the twenty-first century?

Osmun

I suppose the weirdest thing after the consultant fucked us over was how

everything at the hospital just kept humming along—patients pouring in here, the frantic

pace, one crisis after another—and we had to keep working together and trying to

function like none of this had happened. Leonard pretended not to be even thinking about

how we tried to get him fired, even though I know he knew which of us were behind it,

and we all had to pretend we weren’t disappointed that he was still around. We just had to

stand there taking his abuse and being quiet and polite and calling him “sir” when all we

really wanted to do was strangle him. As much as we hated him, as much as we hated this

place, we had to put on our professional faces in front of the patients and everything.

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 And the patients—man, we really do get the dregs of society in here. Like this

old geezer—a raging alcoholic—who showed up here with fever, chills, chest pain, and

pleural effusion in one lung.

He was actually kind of a funny guy, very forthright about his alcoholism: He told

us he’d been feeling fine except when he was on one of his binges, but that he could tell

the difference between “normal” feeling bad—from drinking—and whatever was going

on with him now. He also had had this dull pain in his stomach two months ago that

eventually went away on its own, and about six weeks before he came to see us he’d been

to his regular doctor because of shaking chills and fever. That doc gave him antibiotics

and his symptoms went away.

This time around, he had bad pain on the right side of his chest and all this crap in

the lung on that side. Plus he said the pain had spread to his shoulder. His fever and chills

were back, and he had a bad dry cough—no matter how much and how hard he coughed,

he couldn’t get anything up.

He seemed really sick, too, when we examined him. Leonard had us all take our

shot at him—me, Brandon, Benjamin, and José. There was definitely something wrong

with his right lung—the breath sounds on that side were really low.

We tested for everything—the fluid in his lung was clear, there wasn’t any

malignancy in there, and all the cultures we took from it came back negative. We did a

barium exam of his whole GI tract and couldn’t find anything wrong, and nothing other

than the fluid showed up in his chest X-ray. We couldn’t figure out why.

Even that suck-up José couldn’t figure it out—much to Leonard’s disappointment,

I’m sure.

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 Usually what happens in these situations is that Leonard keeps asking us

questions in a way where you get the feeling he knows what’s going on but wants to put

you through the usual humiliation. But this time, he couldn’t figure it out either—which

was a blast—and he ended up sending the guy to surgery. That’s what you do when you

run out of options—you cut the guy open and see what you can find.

And sure enough, they found something: a toothpick, of all things, stabbed into

the guy’s lung. It was basically embedded in his diaphragm and sticking into the lower

lobe of his lung. It was surrounded by these dense adhesions and all this pus. They took it

out and cleaned him up and he got well almost immediately.

Of course the guy had no idea how the toothpick had gotten in there. But it was

pretty clear that at some point when he was drinking, he’d swallowed a toothpick, and

then, instead of just passing it, he ended up having it perforate his bowel and work its

way through the diaphragm and into the lung. Totally, totally weird. Toothpicks are

insanely dangerous because they’re indigestible, sharp at both ends, and don’t show up in

X-rays. They can get in there and take off for God knows where.

Leonard was amazed by this case—he said it was the first case he’d ever heard of

where pleural disease was attributable to ingestion of a toothpick. He said he was going

to write it up, it was so interesting.

But that wasn’t what got me about the case. What got me was that it made me

realize something about Leonard that I’d never realized before: the guy could be

stumped. It was like having a light-bulb go off in my brain when that realization hit me.

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Chris Richards

You have to actually experience this duty to understand how crushing the

boredom is. Sitting outside a hospital room for eight hours, guarding someone in a coma.

Day after day after day. I know I could bring a radio or something to read or whatever,

but I just don’t like the idea. For one thing, it gives us a bad image with the public. So I

try to look alert at all times, basically.

Besides, I feel like it’s a police officer’s duty, whether he’s a sheriff or a patrol

officer or a Texas Ranger or whatever, to be watchful whenever and wherever he’s on

duty. Even here, you can keep an eye out. You never know when you’re going to see

something suspicious.

And you can learn things, too. Like I sometimes get up and go over to one of the

other rooms near where I’m at and read patients’ charts if no one’s around to see me. Just

a little while ago, I saw two docs—these two guys that I swear to God look like movie

stars—go into this young woman’s room across from me and come out looking really

disturbed. They stood there and argued about something in really quiet voices—it was

obvious they didn’t want me to hear. I don’t know what they were talking about, but I

could tell they were really mad at each other. When you’re trained like I am in police

work, you’re a good observer of human behavior. Then they just stopped talking and took

off in different directions.

I went over and looked at her chart. Man, those guys that write that stuff are really

into abbreviations! It’s like a secret language—all code. CA…SOB…LGFTD…a whole

bunch of others. It’s like half the stuff in there was coded like that.

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 I was able to figure out that the woman was in there recovering from a gall

bladder operation. You get better and better at reading these charts when you practice,

like I do, and try to learn things.

She also was having some kind of minor bleeding that she wasn’t supposed to

have, as far as I could tell.

Hard to believe that’s what got those two guys so upset, but around here, who

knows? Something weird is always going on, it seems like. I made a little note about it,

just in case it ended up being interesting.

Brandon

Nancy and I were sitting downstairs with Osmun the other night, having our usual

bitch session—Dr. Leonard this, Dr. Leonard that—when I start talking about that weirdo

sheriff that you see all over the place around here. These sheriffs—there must be at least

twenty of them sitting outside patient rooms all the time—are always just kind of zoned

out, sitting there all fat and sleepy, day after day after day. Except for this one guy who’s

always looking around, making little notes, acting all suspicious of everything, like he’s

some kind of low-rent Detective Robert Goren. You feel like he thinks all the time that

he’s on the verge of cracking some big case.

What’s really weird about him is how he just kind of always appears wherever

you are. Most of these guys just sit and sit and sit…but this guy—he never seems to be

sitting in the same place. Any time anything happens that seems a little weird, you turn

around and he just seems to have materialized there behind you, staring at you with this

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creepy intent gaze that he has. I was telling Osmun that we ought to goof on him one of

these times, really freak him out. He’s such a pathetic earnest little dumbass that he’d

probably fall for just about anything.

Eric

There are days here where I absolutely can’t believe what I’m seeing. There’s so

much going on, so many patients with really bad and bizarre conditions, that you wonder

how any one of them ends up standing out at all. Even the deaths get to seem kind of

routine after a while.

Just consider this roster of patients I saw come through the ER here in one

afternoon: a cocaine addict who had worn a hole in his palate, which Dennis says

happens a lot; a guy whose face and torso was covered—completely!—with pustules,

who turned out to have secondary syphilis, which Dennis said is on the rise again; a

nineteen-year-old who showed up with a bluish-black face and bulging eyes, who turned

out to have had a jet fall on his chest while he was working on it; and a woman with this

suppurating little hole in her jaw that turned out to be caused by an abscess in her tooth

that had been there so long that it kind of…I don’t know…ate its way through her face or

something.

You’d have people—like the one with the abscess—come in here with symptoms

they’d had for two years or more without ever seeing a doctor. One old woman who

turned out to have an obstruction in her inferior vena cava came into the emergency room

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with what she called “snakes” all over her stomach that she said had been there for twenty

years.

I asked Dennis about it, and he said cases like that are common at East Loop,

where the patients are all poor. “Rich people go to the hospital as soon as they have a

headache,” he told me. “Poor people don’t go to the hospital until something gets bad

enough to damn near kill them.”

It leaves my head spinning, the huge number of these really bizarre cases that just

keep coming and coming and coming. I can’t for the life of me understand how anybody

can pay enough attention to a single one of them—you never seem to get the time to slow

down and focus on anything.

Dr. Leonard

Of the three kinds of patients in medicine—private patients, indigent patients, and

veterans—we get almost entirely indigents. Our patients are generally poor, jail inmates,

alcoholics, drug addicts. Lower-class, socially disadvantaged patients. And we see a lot

of patients where the family just dumps them here. It’s part of life and part of medicine.

Now, as luck would have it, the one patient we get in here who isn’t like that, we

manage to screw up on. She may be the only patient in the whole place at the moment

who actually has some family that cares about her. God only knows how she ended up

here, but here she is. She was in a great deal of pain when she came in, and it turned out

she needed her gall bladder taken out. Benjamin apparently screwed up when he scoped

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her preoperatively looking for gallstones in her common bile duct. He ended up

perforating her duodenum, and now she needs surgery to repair that damage.

It’s a classic example of the consequences of carelessness. A woman comes in for

a routine gallbladder operation and now she’s in here indefinitely, in pain, scared, and

prohibited from taking anything by mouth because of her accidentally perforated

duodenum. We had to put a catheter in a large vein in her neck, for her nutrients—the

catheter tip sits right where the vein enters the heart, which then pumps the nutrients

throughout the body.

I wanted Benjamin fired on the spot. But when I went to Badger, he told me, “I

know him well—he’ll sue.” I said I didn’t care, that that didn’t matter as much as letting

him loose in the world would, but Badger reminded me that the board doesn’t indemnify

us against lawsuits, and he asked me to take some time to think about that. And he made

it clear that if I were to have him fired and got sued, I’d be on my own.

That shouldn’t have mattered. But I’m ashamed to say that it did, and I backed

down. It’s a sick society, so to speak, and our department of medicine is no exception.

I let Benjamin know what I wanted to do to him, though. And I put him on notice

that I was watching him like a hawk.

Brandon

Osmun and I ended up with this monster case that came to us after Benjamin

damaged this woman’s duodenum. It was what happened after that—after we got her

back to her room and stabilized—that we couldn’t figure out: I had ordered parenteral

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nutrition for her since she couldn’t use her stomach until we repaired the damage

Benjamin had done, and she should have been doing OK, but she kept having problems

breathing and none of us could figure out what was wrong. We kept getting chest X-rays,

and they showed fluid building up around both lungs, but no one could see why. And we

didn’t want to deal with Leonard, who knew we had tried to get him fired, and who was

already all over Benjamin’s ass because of the endoscope nightmare, so we got one of the

other attendings to work with us, and he was totally baffled, too. Totally. He called in just

about everybody for consultation, and they didn’t get anywhere either. We kept running

her down for X-rays, CAT scans, everything we could think of, but we couldn’t see

anything at all that could be causing that fluid build-up.

And then in the middle of the night, she just died. A nurse came in at four or so in

the morning and the patient was just lying there dead. It was kind of like she’d drowned,

basically.

Chris Richards

So I’m sitting here on the night shift thinking about ways to ruin my boss’s life

when a nurse comes hurrying out of the room of that woman who got those two docs so

upset. She comes back with those two guys, and when they come back out, they’re

looking grim as hell. They go off down the hall and come back with a ton of people. It

turns out the woman’s dead…they haul her off in a hurry, and I sit here for the rest of

night wondering what kind of hell is going to break loose in the morning.

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Dr. Badger

We have patient deaths here all the time—last year, we had 259. So it’s not

ordinarily a big deal. We hardly ever even do autopsies on them—they just go right away

to the funeral home and that’s it. A week or two later, we get a chart for final signature, a

death certificate gets made, and whether the certificate is right or wrong, nobody knows

or cares. Especially about our patients, who seldom have anybody in their lives to care

about them. All anybody knows about these people is that they were sick, they had a fatal

illness, they died. No one’s much interested in the minutiae.

But then we get a nightmare like this woman up on 2E. Young, healthy, in here

for about as routine and simple an operation as there is, and something goes wrong. Then

she dies with absolutely no apparent cause.

Worst of all, she’s the one patient in here who’s got an involved family, and now

those people are all over the hospital, demanding answers.

We have a procedure for situations like this, and I’ll tell you if anybody deviates

from it, they’re out of here. No ifs, ands, or buts about it. In this day and age, you can’t

equivocate—you have to manage these things with an iron fist, or the hospital’s toast.

Dennis Leonard

I wish I could say I was surprised to hear that a patient who had Osmun, Brandon,

and Benjamin working on her suddenly died, even though she was basically healthy. The

only reason she was even in the hospital when she died was because they screwed up.

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 But here’s the thing—this isn’t the usual death from malpractice, as far as I can

tell. To begin with, we didn’t know why she died. Even the autopsy didn’t help us. All it

showed was that fluid around the lungs—absolutely nothing else.

And now just when we should be figuring out what happened, why it happened,

just when we should be diving into this thing with everything we’ve got, instead the

administration presses the panic button and now everybody’s under the supervision of

lawyers instead of doctors. We get this directive not to say a word about this to anyone.

The case went directly from the patient’s deathbed to Risk Management. The first thing

they did was secure the patient’s chart and all the other evidence, get it the hell out of the

mainstream. They called Benjamin and Brandon and Osmun in and told them to keep

their mouths shut. It’s a sure sign they’re expecting to be sued. And let’s face it—if ever

there was a case where it looked like there was some questionable medical activity, it was

this one. Talk about reasonable doubt about whether the patient got reasonable care! She

comes in here for a routine gall bladder operation and ends up dead by asphyxiation a few

days after we botched her endoscopic procedure.

Chris Richards

Okay now, I’ve been in police work for a long time and I’ve seen everything. But

get this: When those two docs came out of that dead woman’s room—this was before I

knew what the hell was going on—the one they call McDreamy, he saw me looking at

them. At least I thought he did. Even though I thought I was being pretty discreet. And

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when they took off down the hall, I swear to God, the guy high-fived me when he went

by. Swear to God.

Eric

Dennis had to have me kind of lie low for a few days, staying away from the

hospital until things settled out a little. We decided just to meet every night at Luk’s

rather than have me spend my days at the hospital with him until he felt like it’d be okay

for me to resume our routine.

The trouble started when this basically healthy patient died from progressive

respiratory failure, and all these doctors were frantically trying to figure out what the

cause was. They couldn’t find any reason for the fluid build-up in her chest, even when

they did the autopsy.

I guess the whole hospital goes into panic mode in a case like this. The lawyers

take over, and the medical people don’t dare make a move of any kind without their say-

so.

Dennis was kind of weird about it with me, too. I mean, even though he was up

front with me and everything about how the hospital was handling the problem, how it

was all about lawyering instead of doctoring now, I just had the feeling that he wasn’t

telling me everything—like there was something on his mind that he was keeping secret.

I can’t really put my finger on it except to say that when he talked about it—and he kept

coming back to it for weeks, it seemed like—this kind of inner-directed look would come

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over his face, like he was deep, deep in thought about something he was afraid to say out

loud.

I tried asking him about that once, but he just growled and waved his hand like I

was an insect he was trying to shoo away. Then we just went back to feasting on our ribs

in silence for a few minutes. I swear to God there’s something therapeutic about those

damned ribs at Luk’s.

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Chapter 9

Nancy

Brandon and I finally got the same night off…I was so excited! It was our first

real time together in more than a month—finally a chance for us to reconnect and me to

show him how much I love him. Brandon’s been under so much stress at the hospital that

I wanted to make this a really special night for him, so I got back to my place before he

got off work and got everything ready. When you keep the kind of hours you keep in

your residency, practically living at the hospital, your place isn’t exactly…I mean, you

can’t keep up with everything at home, and you end up living in a place that looks like a

guy’s place. So it was a lot of work to make it look nice and welcoming and romantic.

Plus you really have to work hard to “set the mood” when Brandon’s been having

trouble at work, because he takes everything so hard—especially if something bad

happened with Dr. Leonard, which something usually does. This was my chance to take

care of him and be with him and show him how we could have a wonderful life together

once we were through this hard period in his life.

But everything fell apart as soon as he got here! He came in and just sat down on

the sofa and stared at the floor with this furious look on his face. I just felt my heart sink

when I saw how upset he was.

He sat there silent for the longest time! Not saying a word! Then he started talking

about what Dr. Leonard did to him that day, right in front of everybody else.

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 What happened was, a woman came in who had suddenly come down with

dizziness, and Brandon got a CT scan of her head done right away. It showed lytic lesions

in her skull, which Brandon was worried might be caused by cancer. So he sent her back

to get scans of her chest and abdomen to see if he could find the primary tumor. Plus he

had her tested for myeloma.

When all the tests came back normal, a neuroradiologist took another look at the

scans of the woman’s head and said the lesions looked like venous lakes, which are

benign—a normal variant. By then, Brandon was off and the woman got handed off to

José, which Brandon totally hates José, who ended up being the one who brought the case

to Morning Report. What José did was ask the woman all these questions after he saw the

test results, and her health history made it obvious that she had benign postural vertigo,

which comes and goes in people and is basically harmless.

Dr. Leonard just blew up at José, which Brandon thought was really funny at first

because José is totally Dr. Leonard’s pet. Plus all the other residents hate the way he

follows Dr. Leonard around like such a total suck-up, pretending to be fascinated by

everything he says or does. So it was fun to watch José finally get the treatment

everybody else gets from Dr. Leonard all the time.

But then Dr. Leonard figured out that José wasn’t the one who ordered all the

tests. When he made José hand him the patient’s chart instead of just the card

summarizing the case, he saw that poor Brandon had had her first, and he just jumped all

over him for ordering tests before taking the woman’s health history. He even said

Brandon had “mental inertia”! That’s exactly what Brandon said he said in front of all the

other residents at Morning Report: “Your mental inertia and reliance on technology

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exposed this poor woman to a whole bunch of potentially harmful radiation. And all that

testing cost her $26,000 and didn’t do a damned thing for her dizziness!” It’s just not fair

to blame Brandon for doing what just about anyone else would have done, which was

rule out the really awful things first!

Brandon wouldn’t even hardly talk to me or look at me or anything. He just sat

there and stared at the floor. And if he talked at all, it was just about Dr. Leonard—what a

loser he is, how we’d never be able to get rid of him now, how there was basically no

hope, how every time he had anything to do with him Brandon ended up feeling

embarrassed, how Dr. Leonard was going to be even worse now that they’d given him all

this power and made it clear they’d never, ever get rid of him. Our whole romantic night

that I had planned was just totally ruined.

“And you know what else?” Brandon said after he was done yelling at me about

Dr. Leonard. “You know that skuzzy-looking guy who’s always hanging around him?

The bald guy with the big gut?”

I knew who he meant—I was always catching him staring at me, it seemed like, in

this really creepy way.

“ Well, he’s a writer. José told me that he’s working on some kind of book about

the hospital or Dr. Leonard or something. Just what I need—not only am I getting

humiliated every day at work, but now all my embarrassment’s going to end up in some

asshole’s book that everybody on earth will end up reading. Like today, he was sitting in

on Morning Report and taking notes like crazy when Leonard was yelling at me.”

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 Then he looked at me for a really long time. “That guy seems like he’s really

interested in you, Nancy. I see him checking you out all the time. Do you think you could

start…you know…talking to him or whatever, and find out what he’s up to?”

It made me feel so creepy when he asked me that! But I really wanted in the worst

way for Brandon to feel better, so I said yes.

Dennis Leonard

We had a patient here once who underwent twenty-six CAT scans. Twenty-six!

That’s enough to kill you from radiation! The misuse of these things is rampant and

routine across America. But of course there’s a huge financial incentive in the real world

for using those machines, which is why doctors are being trained now to be lazy and just

order the tests instead of using their brains.

This is what happens throughout medicine now. What used to be the basic

principles of good patient care are now destined for oblivion, because technology has

overwhelmed the profession. Doctors who were trained after the mid-seventies have only

seen high technology in action. Before the early 1970s, when CAT scans were invented

and technology really burgeoned, you had to know how to take a history and you had to

have a lot of knowledge. Nowadays, you don’t have to have much knowledge because

you can often get by just ordering a lot of tests and having a lot of consultations.

Ultimately, someone might come up with the right diagnosis, but it isn’t necessarily

because the person was well informed or used his brain. And every time you order an

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unnecessary test that the insurance company pays for, it raises the cost of medical

insurance.

This is why I keep hammering at these guys. It doesn’t do any good, but I keep

trying it anyway.

Eric

I’d been kind of nosing around other people at the hospital, trying to figure out

how to get an in with the residents, when all of a sudden this hot little nurse girlfriend of

one of them—Brandon, who basically lives in Dennis’s doghouse—came up to me when

no one else was around and started talking to me. We kind of hit it off—just this

unexpected kind of connection, I guess. She was a lot more interesting than I expected—

usually, someone looks that good, you just write her off as a bimbo. But she was really

bright and thoughtful, and I got this feeling when I was talking to her that she could

actually help me understand a lot about what it was like out there for the people Dennis

was always pissed off at. It occurred to me, looking at her while we were talking, that she

was really misunderstood and underappreciated.

I ended up telling her a little bit about what I was doing out at the hospital. She

actually seemed really excited about it, and started going on and on about how

“romantic” and “fascinating” it must be to be a writer.

I felt like I suddenly, finally, had my in to the residents who hated Dennis so

much. So I asked if she wanted to get together and talk about what she does, how she fits

into the big picture, and all that. Which of course got her all excited because now she felt

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interesting. We ended up arranging to meet a couple nights later, on her night off, at this

bar she likes called Valhalla.

Nancy

It was icky in a way, going out to meet this creepy old guy in a bar, but Brandon

and everybody really wanted to know what he knew about what Dr. Leonard was

thinking and doing about all of them now that he was more or less in charge. Before, he

was just a pain—now, he was truly dangerous.

I just felt so funny walking in there and having everybody check me out the way

they do wherever I go, then having them see me look around and go over to this old guy’s

table! I don’t even want to think about what people thought of someone like me meeting

someone like him in a place like that.

But anyways, it wasn’t as bad as I thought, even though he kept staring into my

eyes like we had some kind of “soul connection” or something when he was talking about

himself. And all I had to do to get him to open up more was give him the wide-eyes, or

touch him on the arm whenever it seemed like he was clamming up, and he’d get all

talkative again.

One thing I noticed is that he really drinks a lot—he had like three or four drinks

while I was still sipping my first one. But what was weird about him is that the more he

drank and the drunker he got, the quieter he got. Usually, guys get really sloppy and loud

and are all over you. But all he did was get quieter and quieter and just kind of stare at me

when I was talking, like he was really concentrating on what I was telling him. It wasn’t

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like creepy staring, either, which was also weird; it was like, the more he drank, the less

obnoxious and creepy he got. The weird thing about someone like that is that you end up

talking and talking and talking, and they just sit there not saying anything, and you end

up talking more and more because the silence is so embarrassing.

He did say one thing that was really important, though, and that made me realize

that Brandon was right to ask me to do this. I asked him how he as a writer would handle

something like the case that Brandon was in so much trouble for with Dr. Leonard, that

girl who died for no reason, and one of the things he ended up telling me was that Dr.

Leonard secretly made a copy of the whole case record before he got it turned over to

Risk Management.

But the rest of the time it just seemed like he got quieter and quieter the more he

drank—except for one really sad part where he went on and on about how being a writer

cost him his family and everything. That was so sad! But mostly I just kept blabbing

because I didn’t want to just sit there “in silence” with him, like we were…I don’t

know…I just kept telling him all about how hard a resident’s life is, how hard we all

work, how hard it was for Brandon and me to make a life together, and he seemed really

interested. So in that sense, it was worth it, too, to go out like that with him and

everything.

I think he was used to drinking a lot, too, and being careful about everything,

because I noticed that he came to the bar and went home in a cab. Like he knew before he

got there that he wouldn’t be able to drive back. That was kind of sad, when you think

about it…how he lives all alone and everything, and knows he drinks so much that he

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can’t even trust himself to go out at night in his car. And yet he can’t do anything about

it. It’s really sad!

Chris Richards

First it was that resident giving me the high-five, then it was Dr. Leonard actually

asking me for some help. I finally felt like maybe people here were seeing me as

something other than a fat lump of taxpayer-money–sucking flesh.

I was assigned by my asshole boss—and you should have seen the shitty little grin

he gave me when he gave me this assignment—to sit outside the room of a prisoner in a

coma, and who was probably going to be in a coma for weeks. The bastard had had some

kind of heart attack, got treated for it, then after he went back to jail started having huge

seizures, and when they brought him in this time I swear they just wanted to use him for

an experiment, because they put him under, opened his chest up, did some kind of major

surgery, then said they had to put him in an induced coma and keep him there so they

could keep his chest open for weeks or whatever. So I was stuck outside this guy’s room

for this indefinite period.

Anyway, Dr. Leonard comes to me one day when no one’s around and he asks me

if I’d be willing to look in on a patient he wanted to put in the room across the hall. I’m

like, what’s the deal? And he explains that he figured out there’s something suspicious

about her. Then he tells me the woman’s some kind of has-been actress in her sixties who

did a few movies about forty years ago or whatever, and has been in and out of doctor’s

offices for the last four years with the same thing, which is this fever that nobody can

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figure out what’s causing it. Dr. Leonard says it’s called a “fever of unknown origin.” He

told me that she’d paid thousands of dollars to all these fancy clinics out in Hollywood,

and that no one had been able to diagnose her problem, and now she was coming back

home, basically, where she grew up, to see if Dr. Leonard and them can figure it out.

“Shit,” I figured, “at least this gives me something to do.” So I say sure, I’ll keep

an eye on her.

It turns out that they had this plan where they put her in the room, then have a

nurse go in every once in a while to check her vital signs and shit—the normal policy

here is to check those three times a day no matter what’s going on with the patient—and

then right after the nurse leaves the room, I’m supposed to kind of peek through the door-

window there without her noticing, and basically look in there as long as I can without

getting caught.

So they bring her up and she’s this really wired old dame, tense as hell and talking

a blue streak. The tiniest person I’ve ever seen—I swear she wasn’t even five feet tall.

Skinny, nervous, with this kind of chopped-looking haircut dyed one ugly shade of red.

And so pale she looked like she’d been living in a barrel.

She gives me this look on the way into her room like she’s expecting me to know

who she is.

In the nurse goes after a while, then out she comes, and I sidle up to the door and

look in. They’ve got this old-style thermometer in the woman’s mouth—the nurse told

her she’d be back in a minute or two to take it out—so its pretty obvious I’m supposed to

just watch her for that little moment she’s alone in there.

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 And get this: I was watching and the woman took the thermometer out, whipped

out a lighter, and held the flame right up by the part that goes in her mouth. She popped it

in again after thirty seconds or so, then the nurse came in and sure enough, it showed she

had this monster fever. The nurse came out and asked me what I saw and I told her, and

that’s pretty much all she wrote. Dr. Leonard confronted the patient after that, and she

and her husband threw a conniption fit. Dr. Leonard told me that the husband was the one

who was really upset—either because he’d already spent a fortune on her care when she

turned out to be faking everything, or because he thought she really was sick and the docs

here were just wrong.

I’ll tell you this—that Dr. Leonard is one sharp old buzzard. He figured out what

the deal was with her almost as soon as she showed up, which I guess makes him smarter

than all those Doctors to the Stars out where she was living. I swear to God, the guy’s just

like a detective!

The weird thing is, Dr. Leonard, when he came up to thank me, told me it’s not

that uncommon in medicine, and that if doctors these days weren’t so brain-dead, they

would have figured it out. He even told me there’s a term for these fake conditions:

“factitious disease.” How weird is that? He told me the woman had people bamboozled

for years. He waved this huge thick file at me and ranted at me about all these referrals,

tests, trials, she’d been through, costing her insurance company a fortune. He was pissed

as hell—he told me the whole medical profession now suffers from some kind of

“medical inertia” or something like that. It’s really funny how worked up he gets when he

talks about how stupid so many doctors in the world are.

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 Anyways, I ended up thanking him for giving me something to do. I told him that

him and that high-fiving resident guy were the only people around here who ever give me

the time of day.

Dennis Leonard

I tried to make it clear as I could to Eric what I’m always trying to tell my

residents: You have to approach every new patient with a completely open mind. That

means being open to considering even the most outlandish possibilities, first of all. And

second, it means thinking and asking questions and doing some real detective work

before you start ordering tests! We’re teaching residents to do medicine ass-backwards

now when we have them order up every conceivable test in the hopes that one of them

will tell the resident what’s wrong without the resident having to do any thinking at all. A

proper doctor rules out possibilities, narrows in on the culprit, then orders only the tests

that are appropriate—the ones that can let him know whether his preliminary diagnosis is

correct. That’s what cases like the venous lakes and fake fevers are all about: using your

brain first, instead of all this inferior machinery that only serves to make doctors lazy.

Not that any of that was of much help with the poor young woman who had that

breathing problem. I can’t for the life of me figure out why she had the fluid in her

chest—nothing in her case makes any sense! The whole thing is just starting to reek of

something even worse than carelessness or stupidity.

José

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 Funny thing happen with Dr. Leonard. Something I not understand. He ask me to

come to his office and sit down so he talk to me. He not act like he professor and I

student—he talk like he really need my help. Like he need my help! That like patient

helping surgeon do operation!

I just listen—not say anything. Because I think if I listen I understand why Dr.

Leonard talk like this to me. But I get frustrate—what he want make no sense! He ask me

to take patient chart of young girl who die here and study it. He say he think maybe I see

something he miss. I no think possible but at same time I very flatter, because maybe it

mean he think I good student after all. But I also think maybe he do this to test me. That

he see problem or error in chart and want to see if I find it too.

I say, “No problem, Dr. Leonard.” And I take copy of chart and go. But not before

he tell me not to tell anyone what he do.

Joanne

Dennis was like a new man after the accreditation consultant saved his job and he

ended up with that huge raise. It was like he was completely reinvested in medicine and

medical education again. “Now I’m in a position where I can actually get some things

done that need to be done,” I remember him saying after they told him about the new

arrangement. “I can actually do something about all the crap I’ve been complaining

about.” Oh, he was so excited!

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 But then this girl died who was in the care of some of his residents—some of the

worst ones, he said. And there was no reason for her death! He just seemed to plunge into

a new kind of gloom, like it was the first time in his life he’d had to face the fact that

some problems were just too big for him to solve. It was sad, how the happiness over all

those changes he’d fought so hard for only lasted for a few days before this thing got him

back to his old ornery self again.

Actually, it’s not that he was ornery. He’s always ornery. It’s that he was—it

seemed like he was shocked. Like he was confronted with something he’d never seen

before. And at his age—well, he and I both thought he’d seen everything, so he was

really over a barrel with this case.

Eric

It just seemed like everything got a little more complicated after I had that

meeting with Nancy, where she unloaded on me a little bit about how hard it is to get

through medical residency. One thing she said was totally in agreement with what Dennis

told me: that the attending physicians don’t really do much by way of keeping track of

things and guiding the residents, and that the hospital just uses the residents as cheap

labor. She said that all the residents feel like they have to work as if they were full-

fledged doctors, with no supervision, but that they don’t get paid anywhere near what a

doctor would. And she said that on top of that, guys like Dennis—well, there aren’t any

other guys like Dennis, what she meant was just Dennis—are too hard on people like

Brandon and Osmun and Benjamin. He wants them to learn all this stuff they’ll never use

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in the real world, and tries to get them punished when they won’t. She said that if they

did everything by his methods, they wouldn’t be trained for the kinds of jobs people will

want to hire them for.

I didn’t bring any of this up with Dennis or anything, just because I didn’t want

him going off on me about the stuff they said. I didn’t even tell him I’d had that meeting

with Nancy. It wasn’t like it was some kind of big secret or anything, it was just easier

not to, I guess. I would have had to do all this explaining about my obligation as a writer

to be fair and all that, and I’m not sure Dennis would have understood. Plus he would

have been asking me a million questions about what we talked about, what I told her

about what I was doing and everything. I didn’t see any point in getting into all that with

him, is what it comes down to.

José

Chart Dr. Leonard give me from girl patient who die very confusing. It make no

sense that woman who come in for gall bladder surgery end up dead from respiratory

failure. No sense! And chart show doctors panic, try everything.

Also. Chart have entry in it—“IVP”—that completely wrong for this case. I want

to ask nurses who care for patient about it but I can’t because Dr. Leonard no want people

to know he have copy of chart. Everything suppose to be at Risk Management—I not

allowed to see file Dr. Leonard give me. Dr. Leonard not even allowed to have copy. This

why I worry—Dr. Leonard never ask me to look at anything for him before; and he never

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go against Risk Management procedure before. So something very bad going on with

case.

But other strange thing: I show him “IVP” in chart and he say it not there before.

He sure it not there when he read chart before he give it to me. He sure!

Dennis Leonard

It’s eating away at me, that “IVP” popping up after the fact in this woman’s chart.

It’s not just that someone might have made misinterpreted the abbreviation, like I’ve seen

before: It’s that neither interpretation, neither course of action, is even remotely

appropriate in this case. There’s no medical reason for it being there.

And in any event I swear that instruction wasn’t in the original chart! I never

would have let that pass unnoticed. Never!

I’m telling you, something is deeply, deeply wrong here. You even have to

wonder if someone might have deliberately killed this poor young woman.

Neglect, carelessness, stupidity…you expect that—especially with the particular

residents involved in her care here. I’ve always said that they’d end up killing patients.

But even I never suspected that they’d end up killing them on purpose.

Still, the more I think about it, the more it seems like that’s the only explanation

that makes sense. But at the same time, it just can’t be…there must be something here

that I’m not seeing.

Eric

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 Here’s an interesting thing: After they made Morning Report with Dennis

optional, hoping to further contribute to his misery, I showed up at the second one and he

had more people in there than he did when they were mandatory. Even the three guys

who tried to get him fired were there.

That’s what I can never figure out about the residents around here: They’re

terrified of Dennis, but at the same time so many of them revere him. Or at least respect

him. And even the ones who don’t like him at all seem to feel afraid to stay away from

him, like they’re going to miss—what? That’s the part I don’t get. It’s like they hate the

way he humiliates them, but they all seem to secretly sense or suspect that he’s making

them better doctors.

And then the Brandon guy actually tried bringing up the case he’d just had where

the girl died for no reason. There was this sudden hush over everything when people

realized what he was talking about, because the case had “malpractice suit” written all

over it, and when Brandon finished talking, everybody was staring at Dennis like they

were afraid of what he was going to do. But all he did was stare at Brandon like he was

looking for something in his face. Then he said, “I wish we could delve into that case, I

really do. Because I know—I know—we could find the answer. I know we could. And

I’m betting you wouldn’t much care for it.”

Boy, it got so quiet in there then that you could have heard a stent drop. But

Brandon didn’t register any reaction at all.

“There are no unsolvable mysteries in medicine—just careless doctors,” Dennis

went on. “But the fact is, we can’t do or say anything about that case now. Once it goes to

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Risk Management, we’re all but forbidden even to think about it, let alone discuss it out

in the open.”

Nancy

Right in the middle of all the trouble over the girl who died, they brought another

girl with breathing problems up onto our floor. Her chart was really thick—she’d had

surgery, then kept checking back into the hospital with really bad shortness of breath that

kept getting worse. She had a shunt in her arm for medication—she was being

administered a lot, and on top of that was taking oral medication for chronic pain—but

she just kept worsening.

No one could figure out what was wrong with her! X-rays showed all these

infiltrates in her lungs, but there was absolutely no clue about what was causing them.

Osmun and Brandon and them were going crazy trying to turn her around—it seemed like

everybody was working on her at one time or another—but she kept having more and

more trouble breathing. Whatever was going on with her just kept marching along at a

steady pace no matter what anybody tried.

And then we ended up with another nightmare: she died, too! Progressive

respiratory failure.

Two respiratory failure deaths that didn’t make any sense, of these really young

women, only a couple weeks apart! And both of them patients that Brandon and all had

been responsible for! I thought, “This is really terrible,” but Brandon—I don’t now

why—was completely calm about it, especially after he talked to the girl’s boyfriend,

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which usually that kind of conversation just leaves him depressed for days, having to tell

somebody that their loved one has passed away.

Chris Richards

Even though Dr. Leonard wasn’t directly asking for my help like before, I started

keeping more of an eye out after solving that one patient mystery for him. You learn in

my line of work how to tell when something isn’t quite right, even if you can’t put your

finger on it. It’s what separates the good detective from the average policeman: that sixth

sense, where you can be looking into something, or talking to someone, and even though

on the surface everything looks “normal,” you just know something’s secretly wrong.

So here I was just down the hall from another death of another young person who

should have been basically healthy and just recovering from something routine. That

alone was pretty noteworthy. Same drill—this air of worry around the room, then at the

end all these people running in and out of her room, alarms going off, and then it turns

out that the person died.

Having two deaths so much alike so close together, in more or less the same

place—pretty damned weird. And then just out of that sixth sense, I guess, I kind of

decided to follow the two docs—residents—down to the lounge, where they went to tell

the boyfriend that the patient had died. There’s no way I could get close enough to hear

anything, of course, but I was able to watch, and I have to say it wasn’t like any meeting

like that that I’d ever seen. The body language was all wrong. Instead of just like talking

with the guy a little bit, then letting him cry and vent, these two guys were all over him,

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looking from down the hall where I was like they were really questioning him hard. He

was in a chair and they were standing on either side of him, for one thing, instead of

sitting down with him. It looked more like a police interrogation than a doctor telling a

loved one a patient had died.

And when they were done, they came walking back by me looking basically

relieved. Seriously. I was just looking at them out of my peripheral vision because I’d

turned around and bent over the drinking fountain there, but I could see that they were

anything but unhappy, which was pretty damned strange, given the circumstances.

I decided to say something to Dr. Leonard about it, mostly because he’d asked me

to keep my eyes peeled before. And he listened this time very quietly, then thanked me

and asked me to “keep keeping your eye on those clowns.” I’d had no idea he had such

strong feelings about them, but I have to say it made me feel pretty good about my old

policeman’s sixth sense there.

Eric

I wasn’t in the hospital the night the second young girl died, but when I got there

the next morning, Dennis met me out in the hall and asked me to come into his office and

close the door. He looked stricken. After he told me about the new death, he said, “I don’t

know what we’re dealing with here, but it might be the most serious thing possible. I

don’t think these deaths were caused by some kind of natural process or mistake or

neglect. I can’t say that I know what’s going on exactly, but I do know that the three

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worst residents in this place were involved with both those patients. You need to tell me

if you learn anything—anything—that strikes you as suspicious about those guys.”

I hate even admitting to myself what I thought after he told me I could leave. I

walked down the hall trying to feel properly horrified, trying to appreciate the gravity of

the situation. And trying to figure out if he was trying to tell me something really chilling.

But in truth all I could think about was how I might have lucked into a best-seller

scenario: That something big was going to break in this hospital while I was here

watching. I even caught myself thinking the M-word.

It’s disgusting, I know, looking at tragedy like this as an opportunity for fame and

fortune. But that’s the way it is for journalists, authors, producers…whatever. You stay in

this business long enough and you don’t have normal reactions to the horrible anymore.

Dennis Leonard

I suppose I could have been more explicit with Eric about what I think might be

going on here, but you want to be absolutely sure—or at least as absolutely sure as you

can be in a situation like this, where everything’s a little bit murky—before you start

saying too much out loud. You don’t want people running around in a panic making

things worse, and you certainly don’t want that kind of publicity coming down on the

hospital. So you definitely have to make sure you’re not wrong. For that matter, you

desperately want to be wrong. Incompetence is bad enough, but this…this possibility is

terrifying.

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 But the more I think about it, the more I’m convinced that I’m right: That we have

a murderer on the loose in here. These two cases just don’t make any sense without that

explanation. And if I’m right, we have to find him as quickly as possible.

Because there will be more, I can guarantee you that: These kind of people never

stop until you stop them. There was a veteran’s hospital in Michigan, I remember, back in

the 70s, where forty men died from Pavulon injections before people figured out what

was going on. And even then they couldn’t get a conviction—the two nurses they put on

trial were exonerated, and they never went after anyone else.

It can be maddening, trying to detect these people, because they prey on the

elderly, the terminally ill—the deaths are too easily taken for natural. Particularly these

days, when doctors are so clueless. And with these old people who tend to linger, it’s not

like anyone’s paying that much attention to what happens to them.

But that’s where our guy here screwed up: These were fundamentally healthy

people he went after. That was a big mistake because it calls attention to you right away.

Although come to think of it, it’s such a monumental blunder that you almost

have to wonder if he’s looking for it, the attention. No killer in his right mind….

Good God: “in his right mind”? Did I really just say that?

No killer trying to stay under the radar is going to pick victims like this—there’s

just no question about that.

Joanne

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 This new twist at the hospital, just when things finally started to go Dennis’ way,

has just been terrible. Dennis comes home every night and just sits there in his chair in

the living room. Thinking. He barely talks to me and some nights he doesn’t even go to

bed. Just comes home, sits up in that chair, in the dark, and goes back to the hospital after

a few hours. He told me what’s on his mind, of course—Dennis has never been one of

those men who doesn’t talk to his wife about what’s on his mind. I told him how

imperative it is that he not do anything rash until he’s absolutely sure.

Hospitals are huge, chaotic places. When you think about it, you have to wonder

how they function at all, really. Hundreds of patients being tended to every day, and

every day countless life-or-death decisions, dramatic situations, split-second reactions to

crises. And over all that an administration that is trying to keep some kind of order,

looking down at this boiling mess that is so big and so complicated that they can never

see anything in detail from their perspective. The last thing those guys want is someone

like Dennis, who they don’t like anyway, coming up to them and telling them something

this horrible. All they’ll care about is the hospital’s reputation: Even if Dennis is right, all

they’ll do is blame him for bringing scandal down on the institution.

Now he looks so sad sitting there in that Barcalounger. Not saying a word. And

“sad” isn’t even the right word for it—it’s more like he looks beaten, for the first time in

his professional life. Bewildered—I’ve never seen him that way, either. Wondering how

on earth he could have ended up like this, after devoting his life to his calling the way he

has.

Benjamin

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 Much as Dr. Leonard rants about how all of medicine is a disaster these days, it’s

pretty much me, Osmun and Brandon that he’s focused on as being the only thing that’s

really wrong with this place, as far as I can see. And just our luck that we’re tied up with

these two deaths—I caught him staring at me the other day, at Morning Report, when

José was presenting a case. Man, he was looking right through me—it really gave me the

willies. I swear the guy would stop at nothing to get me fired if he could swing it.

Brandon and Osmun were having coffee with me and I told them we had to be

careful—that if we couldn’t figure out the proper cause of death in these two women,

Leonard would find a way to use them against us. I reminded them that all three of us had

enough of a hand in those cases to take the blame for them. Osmun told me I was too

fucking paranoid, but Brandon got really, really quiet. He looked as freaked out as I felt,

which made sense, I guess. Leonard never stops looking for ways to fuck us over. But

Osmun, I don’t know—when I told him about Leonard giving me the Evil Eye, he just

laughed. Like I was completely stupid for being worried about it. Which is totally weird

for Osmun, who’s usually depressed as hell over Leonard.

Eric

It seemed like Dennis just kind of withdrew into himself after that second girl

died. We kept up our routine and everything, including our weekly rib dinners at Luk’s,

but even on those nights he hardly said anything to me. I finally just flat-out asked him if

he was thinking about ending our arrangement, but he said no, not to worry about that.

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Then I asked him if he thought there was foul play involved in those two girls’ deaths,

and he just looked right at me for what felt like several minutes. “I shouldn’t say this to

you,” he finally said. “And God forbid that you should repeat it. But I think they were

murdered. I can’t begin to prove it, but I believe it to be true. For the life of me, I can’t

come up with any explanation short of murder for those two deaths. What I can’t figure

out is why. They don’t appear to have anything in common other than that they had the

same residents caring for them, and they don’t fit the profile of the typical victim in cases

where some killer gets loose in a hospital. Normally, a hospital killer looks for victims

that people won’t notice—the whole game with those types is to see how many they can

get away with. Or sometimes they have some demented notion that they’re performing

acts of mercy. But this guy—you couldn’t have picked two victims more designed to call

attention to the fact that they were killed. You really couldn’t.”

It kind of sent a chill up my spine. I mean, it’s not like I hadn’t thought that this

was on his mind—like I said before, it made me kind of ashamed the way I reacted the

first time I realized what he suspected—but to have him actually say it out loud like

this…I don’t know. It made me a little scared to think that he was involved with someone

who was potentially that ruthless.

“What are you going to do?” I asked him—mostly out of fear that he was going to

do something dangerous, like go after this guy himself. “I don’t know,” he said. “The

only thing I know for sure is that I can’t sit here and let more people get killed. But I also

don’t have enough to go on to go to the police or the administration with my suspicions.

Especially this administration: Between their own incompetence and their hostility to me,

I wouldn’t stand a chance at getting through to them.”

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 I asked him if he had any idea who might be behind such a thing, and he gave me

that long stare again. I honestly believe he was about to tell me, but then decided against

it. I just definitely had the feeling that he had a name on the tip of his tongue.

José

Dr. Leonard call me in and talk serious talk to me. He say what he about to tell me

so terrible I must say nothing, even to my wife. He say I right about “IVP,” that it make

no sense. And that second young girl death make no sense, either. I ask him, “How we

find who responsible? Who make mistakes?” But he say it not “mistake,” either one. He

say somebody kill these patients. Kill them on purpose. He say it “murder.”

I say, “Dr. Leonard! How that possible?” He say there “madman” in hospital. And

he tell me he “very sorry” he have to make me one he tell. But he say he need my help,

because he say he think—he know—killer somebody we know. He say he sure it one of

residents.

Dr. Leonard brilliant man. Best doctor I ever see. But I tell him I not able to

believe it, what he say. But when he ask me to listen and watch Osmun, Benjamin,

Brandon—especially Brandon—I say I do what he ask.

Dr. Badger

After this new administration came in and tied my hands the way they did, you’d

think Dennis would be the happiest man on the planet. It’s not just that they gave him that

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massive raise—it’s that they also made him invincible, at least as far as I’m concerned.

They took away every ounce of leverage I had on him.

But no—at our last faculty meeting, which was the first time, really, that we’d sat

down in the same room together since the big shake-up—he looked thoroughly

depressed. And he didn’t say a word. Before, he would come into those meetings loaded

for bear, just looking for a fight. Now you almost wonder if that’s what kept him going,

that sense of being aggrieved. It’s like as soon as he gets his way, all the fight just goes

out of him. Like he can’t stand prosperity.

I don’t know—I could be jumping to conclusions here. It’s possible that

something horrible’s going on in his personal life, I suppose. But it would have to be

something positively catastrophic: As far as I know, he’s never let himself be distracted

by anything outside of his job, ever. But my God, looking at him now, you’d think he’d

lost everything. I would never expect to see him that subdued, except for maybe if he

could finally be forced out of his job.

Chris Richards

Just like Dr. Leonard seemed to think it would, everything started coming up

McDreamy for me. It was like the guy was following me around, I swear to God. The

more I watched for things to report to old Dr. Leonard there, the more I’d see something

involving this McDreamy guy and his various little pals. Like last night, right after I

came on shift, I saw McDreamy come down the hall the way I’d just come and go into

this room next to my prisoner’s. Then a couple minutes later he came out and just stood

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there like he was waiting for a bus or something. Totally calm. Then I saw the other

handsome guy come walking along and all of a sudden McDreamy got all agitated and

gave his pal the Evil Eye as he got closer, then just totally went off on him right there in

front of me. Vein-popping-out-of-his-neck mad, too. The other guy just listened to him,

real quiet, but got madder- and madder-looking, too. McDreamy was going, “Two-tenths

of a gram? You can’t be serious! You cannot be serious!” And then they just walked off

together without talking, like they were running off to get someone to settle whatever the

hell their argument was about.

I took out my little notebook and wrote down that “two tenths of a gram” thing,

which was the only sort of technical thing I heard him say, so that I could pass it along to

Dr. Leonard in case it was important.

And here’s the weird thing: the woman in that room they were arguing in front

of? She was dead and gone. I wasn’t here—it was during the afternoon—but my guy

Willie, the guy on shift before me, he told me all about it. He saw a nurse come running

out of the room like ten minutes or so after she walked in there with a big bag of blood or

something, and it turned out the woman in there’d just suddenly died on her. I guess the

nurse was crying and everything, like whatever happened was a way more than normal

shock, even for this place. He saw them take the body away, too. And I looked in there

after those two guys had walked away, and sure enough—the room was still empty.

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Chapter 10

Brandon

So now Nancy’s practically a basket case after she transfused that old woman

with the wrong blood type. And Leonard and them are all over the patient’s chart, trying

to figure out who’s to blame. I don’t see what Nancy has to worry about—all she had to

do was administer whatever the doctor ordered. She should be nice and free and clear no

matter what they find out—it’s not like anyone’s going to blame her when everything

shakes out.

Especially the way they’re—well, Leonard is, anyways—always focused on me

and Osmun. And Osmun’s being kind of shifty about how the order for the transfusion

even came about in the first place. True, I’m the one who actually ordered it, but he

basically made me do it.

They’re giving Nancy a couple days off anyways. She said she couldn’t handle

what happened, and needed to not be doing anything important here for a while. She’s

not really the strongest person, it turns out, which is a pretty serious problem—in this

profession you have to learn to live with catastrophe. You can’t just collapse every time

something adverse happens, or you won’t survive for very long.

Eric

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 I can’t say I had any really coherent idea about what I might be getting into when

I decided to take on this project, but I can safely say I never expected even the possibility

of anything remotely like this. All these people who routinely deal with drama, disaster,

horror, and death all of a sudden completely freaked out. Given what they see every day

in this place, you’d think nothing could freak them out.

At first it was just Dennis, it seemed like—at least among the people I was

keeping an eye on. But then the bad actors—all of them—started throwing conniption fits

and tantrums and walking around with looks on their faces like they were expecting the

roof to fall in.

I even had—I mean, I just ran into Nancy, in the middle of the night, down in the

cafeteria—the first time I’d run into her alone since that night we met at the Valhalla—

and I said Hi, asked how she was doing, and she asked me to sit down with her for a

minute, which I thought was kind of interesting since she generally doesn’t even

acknowledge that she knows who I am when we run into each other here.

I could tell something was bothering her—she was practically crying—but I knew

better than to ask her what it was. One thing I’ve learned from years of interviewing

people is that they clam up out of this mindless, reflexive fear whenever you ask them

explicit questions. They’re convinced that there’s some hidden meaning to the exchange

that they can’t pick up on. Better just to sit there and let them talk—they’ll just go on and

on and on if you don’t say anything. For some reason, people being interviewed can’t

stand silence.

I didn’t even ask her what was wrong—I just sat down and looked at her, giving

her my “interviewer’s stare.” Like you’re incredibly interested in what someone’s saying,

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like you can’t wait to hear more, like your interlocutor is the most fascinating person

you’ve ever been around.

And sure enough—she told me. She’d set up a blood transfusion earlier that day

and the patient got the wrong blood type or something, and almost immediately died. I

felt like she had more to say, too, but she just sort of forced herself under control and got

up and ran off, more or less.

Dennis Leonard

And now another suspicious fatality.

Death is a normal part of medicine—we all know that. But this little cluster or

whatever you want to call it of three deaths like this just doesn’t pass the smell test,

period. True, we normally have almost a death a day in here, but seldom do you see three

in a row that defy explanation in one way or another, or that have some anomalous

circumstance around them.

And now with this last one—this 72-year-old woman in here for a

thyroidectomy—the story they’re telling me about how and why this death was an

accident is just not credible. I confronted Brandon about it, since he had called for the

transfusion, and I’m convinced he lied to me about it. He told me that the patient had a

significant hemoglobin deficit and needed the transfusion to ensure she’d survive the

operation. I noted that there was no such test result in the patient’s chart, but he insisted

he’d seen those results, and had good reason to order the transfusion.

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 But here’s what he didn’t know: that Chris Richards, the sheriff’s officer I have

keeping an eye on the hallways here—told me that he saw two residents arguing right

outside this woman’s room after she’d died, and that he distinctly heard them say “two-

tenths of a gram.” And he’s sure one of the residents was Brandon.

Now there is no possibility other than that they were talking about her

hemoglobin concentration! I think that this moron decided to go strictly by the book and

order a transfusion in a case where a thinking doctor never would have.

Meaning that first of all, he had her transfused unnecessarily—because she was

all of two-tenths of a gram per deciliter short on what the anesthesiologist wanted her

pre-op hemoglobin concentration to be. That’s undeniable. Because of a tiny, completely

insignificant deficit Brandon put her through a transfusion, which is always risky, and she

got the wrong blood type and had a severe transfusion reaction, and died.

And second of all Brandon is lying to me about it. He’s claiming to me that the

deficit was much worse than two-tenths of a gram per deciliter, which is infinitesimal,

basically—within the margin of error for a test like that. But that officer definitely

overheard them talking about the amount—he has absolutely no doubt about what he

heard.

Why would you do something that dangerous over a “shortage” that’s practically

imaginary? Do you mean to tell me that they didn’t run another test? Or consult with a

different anesthesiologist? That’s just not possible, even for these bozos. I think

something much more sinister is afoot here. Much more sinister.

Nancy

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 I hate talking to that awful writer! I can’t even imagine why I asked him to sit

down…I was just so upset, I wasn’t thinking straight. It seems like you never know when

he’s going to turn up, and when he does he always seems to catch you off guard! You’re

going about your business and you suddenly feel someone looking at you and you look

up, and it’s him. He’ll just suddenly pop up—you don’t see him coming or anything—

and he just looks at you in the most creepy way!

Dr. Badger

Just when you think you’ve reached some kind of place where you can deal with

Leonard, he up and catches you yet again completely by surprise. He had actually toned

down his complaints about the department here and everything after the Dean essentially

brought him back on board and gave him back some input and influence over how we

teach, what we teach, and all that. I figured we’d maybe have an uneasy peace with each

other, which is better than the way it was before. I knew it would be harder on the

residents with him more or less in charge, but it would at least be easier on me because he

wouldn’t be bitching at me all the time.

If you can’t get rid of the guy, you can at least co-opt him.

But now today he comes in here and tells me we have to do something about what

he insists are a series of murders in the hospital! And I’m thinking, “Are you out of your

mind?” He lays out the evidence, and I have to say I’m not seeing anything very

compelling. Maybe he’s got more than he’s telling me, I don’t know, but all he did was

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say there were three deaths in short succession that shouldn’t have happened, and that

he’s convinced they can’t be explained any other way than that someone’s deliberately

killing patients. He actually asked me to bring the police in!

“Based on what?” I asked him. And I told him in no uncertain terms that we were

not to call attention to this theory of his. For one thing, the first case is in Risk

Management, and no one is allowed even to think about that case, let alone talk out loud

about it. And the other two are under medical investigations that have barely begun. “For

God’s sake, Dennis,” I said. “Let the investigations run their course before you go off on

some half-assed crusade! After what we’ve been through with the accreditors, the last

thing on earth we need is more bad publicity.”

He wasn’t happy, but I think I got him to back off—at least for now. But knowing

him, this isn’t the last of it.

Nancy

Because Dr. Leonard is so mean to everybody, and especially to Brandon, I never

thought I could feel for him. But I saw him yesterday in the hall, walking all by himself

toward me from far away, all bent over his cane, looking so little and so frail! And so

sad! The only word I could think of to describe him was “forlorn.” His lab coat comes

almost down to his ankles now, and he just shuffles along, looking down at the ground.

When he walked by me, I could see the most mournful look on his face, like his wife had

died or something! He looked so awful that I just had to ask him if he was all right—I

think it was the first time I was ever brave enough to say something to him.

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 He stopped and looked up at me, just for a moment. His eyes were all red-

rimmed, like he’d been crying. Which of course I knew that was impossible. But he

looked so beaten! And all he did was look at me without saying a word. Then he just

lowered his head and went back to walking down the hall.

I thought later that even Brandon would be touched by how sad Dr. Leonard was.

But when I told him about it, he just snorted. He hates Dr. Leonard so much! Which you

can’t blame him, I guess, because of all the suffering he’s caused Brandon. Even so…it

really made me feel bad when I saw Dr. Leonard like that.

Eric

Dennis had me come out to Luk’s with him a couple nights ahead of our normal

session this week, because he said he had something important to talk about and didn’t

want to talk about it on the hospital grounds. He was already there when I arrived, and as

soon as I sat down he started talking. He was really distraught—I’ve seen him angry, I’ve

seen him doleful, I’ve even seen him depressed, but I’ve never seen him so stricken. He

actually seemed a little bit in shock, which for a guy who’s more or less seen everything

there is to see in medicine is pretty…well, shocking.

Anyway, he got right to the point. He told me that these three people who had

recently died had, in his view, been murdered by somebody on staff. He’d kind of hinted

about this before, but to hear him actually saying it out loud, so explicitly, and without a

trace of doubt in his voice, was really scary. I mean, it gave me the creeps, thinking that

someone I’d been hanging around with at the hospital was quietly and cold-bloodedly

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killing people. All those best-seller fantasies I’d been having—all of a sudden they

seemed just kind of embarrassing. I mean, looking at him looking like that, I felt pretty

ashamed.

But Dennis said it’s not unheard of in hospitals for things like this to happen. The

strange thing, he said, is that the patients he thought had been killed didn’t fit the normal

victim profile. Usually they’re very old and very sick people who are lingering at the end

of their lives, and the killer persuades himself that the killings are acts of mercy. They

can talk themselves into the idea that they’re euthanizing needlessly suffering people

rather than committing murder. “It’s a pure rationalization, of course,” he said. “These

killers are psychopaths—they may say to themselves that these are mercy killings, but

really it’s just that they pick their victims because the murders of such people are harder

to detect. They know that nobody’s going to look too long at the sudden death of a

terminally ill ninety-year-old because a death like that is basically a relief to everybody—

the victim, the family, the hospital…everybody.”

But the first two victims were young, healthy people, and the third was basically

healthy, even if she was a little older. None was the kind of victim who kind of slides by

under the radar. “It’s almost like the killer wants to be noticed, which is really

disturbing,” he said. “I just don’t understand it—I can’t understand what we’re dealing

with here. But I can tell you in no uncertain terms that I’m not wrong about this.”

I asked him why he was telling me this—did he want me to publicize it? Write a

story about it? “Good God, no!” he said. “But you’re around all the time, watching

everything. Just tell me if you see something that looks suspicious—especially if it

involves one of my residents. I can’t tell you why, but I have reason to believe, based on

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what some other people have told me, that one of the residents under my supervision is

behind this. I can’t say anything definite yet, but have some pretty firm ideas about who

could be responsible. What I can’t figure out is why. I’ve got three residents under me at

the moment who are so godawful that they don’t have to bother killing people on

purpose. They’ll kill plenty just from sheer incompetence—it’s not like they have to do

anything proactive, for God’s sake.”

I would have killed to get a name out of him—not that it wasn’t a tad obvious

which three he was talking about—but he just wouldn’t go there. He’s ethical as all get-

out that way: he won’t make an accusation until he’s got absolute proof.

I have to admit that two of the people who died really did seem like victims of

something deliberate. I mean, I could sort of entertain the possibility, even though I

couldn’t begin to understand how it had been done. But the third one was a woman who

died after getting a transfusion of the wrong blood type. I thought that was a not

uncommon occurrence, actually—I mean, not that it happens all the time, but that it’s

normally not regarded as suspicious. And I’d just read that 98,000 people a year in this

country die from errors in their medical care. A pretty staggering number, if you ask

me—and one that kind of forces you to point to mistakes rather than murder when

someone dies mysteriously.

“That transfusion screwup,” I said. “Couldn’t that have been an accident?”

“Possible, but not interesting,” Dennis said.

Then he just kind of seemed to lose interest in the topic. I asked him a couple

more questions, but he turned oblivious all of a sudden, thoroughly distracted by the ribs.

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He just tucked into them like he hadn’t eaten in weeks. I couldn’t get another word out of

him about this for the rest of the evening.

Dr. Badger

Good God—that damned Dennis Leonard is just the gift that keeps on giving! It

just seems that nothing he complains about ever gets resolved to the point where he

ceases being a problem. He gets fixated on some perceived shortcoming here on the part

of the institution or some individual and you just cannot get him to let it go! He’s like a

runaway train: You can’t stop him, you can’t derail him, you can’t distract him. He just

singlemindedly charges ahead, completely obsessed.

Now I’ve got this resident—I’m really not at liberty to say who it is—coming to

me and saying that Dennis is out to get him and a couple of his colleagues. It’s hard not

to believe him, given that these are the same people Dennis has been in here with me

about before, constantly trying to talk me into expelling them. But now apparently he’s

gone way beyond just complaining about their abilities. I’m told that what he’s saying is

that he thinks one of them is intentionally causing these patient deaths!

It’s one thing to come in here and talk to me the way he did in the past, but if he’s

running his mouth in public about something like this…I just can’t allow that to continue.

He could end up getting us shut down for good.

Joanne

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 Dennis came home last night with his head just spinning over what happened in

the hospital. He was called in by Badger—the same guy who’s been out to get him for

years—and accused of publicly accusing some of his residents of a crime. Now, he’s the

first to admit that he really does think someone’s deliberately killing patients in the

hospital, but he hasn’t said a word about it to anybody at the hospital except for Eric and

José, both of whom he has complete trust in. So how did word about his concerns get to

Badger?

I asked him over and over and over again if he was sure—absolutely sure—that

that writer didn’t blab to someone or other. Because I know Dennis talked to him about

his suspicions, and I know how untrustworthy he is, even if Dennis doesn’t. I just have

never felt good about his letting that fellow into his life the way he did. But Dennis

swears up and down that it’s impossible for him to be the problem. “He knows the rules,”

Dennis kept saying. “And he knows better than to get in the way of his own story.” By

which I assume he meant that this Eric didn’t want some bombshell hitting the papers

before his book was ready.

I see what Dennis means by that, of course, and it does make a certain amount of

sense. But isn’t it just as possible that a writer would want some big juicy scandal

erupting while he was there covering the story? Isn’t it really in his interest to foment

something like this? I’m betting that he’s sitting there thinking about how many more

books he could sell if he had an exclusive on a serial murder scandal. And even if he

wasn’t, he drinks so much that it wouldn’t be all that unimaginable of him to get drunk

enough to forget himself and shoot his mouth off at the wrong person.

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 But Dennis is just so blind about this gentleman! He won’t hear of anything bad

about him. If you ask me, I think he just hates the possibility that he might have

misjudged someone’s character.

Osmun

So the word started going around that Leonard thinks he’s on the trail of a

murderer here in the hospital, and that no one can talk him out of the idea that there really

is one—that someone really is killing patients on purpose. It doesn’t take much to get that

guy’s imagination running.

Then Nancy told me that Leonard thinks it’s one of us: me or Benjamin or

Brandon. That’s rich, I told her. That’s really fucking rich.

José

I very worry about Dr. Leonard. He look bad. I think something he worry about so

much it make him physically sick.

Brandon

Just try to imagine the kind of pressure we live with in a medical residency. First

of all, we have to make split-second life-or-death decisions every day. Every single day.

When we’re still learning our trade. Second of all, there really isn’t anybody around to

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lead us—the attendings are never here, except for Leonard, and he spends all his time

tearing you down and destroying your confidence, so you don’t want him around you at

all. Plus he’s hell-bent on having us learn stuff we’ll never use in the real world.

We’re tired all the time, under enormous stress, trying to save lives, and the

patients with their crises just keep coming and coming and coming. There’s never any

relief, and on top of all that you have someone constantly watching you, waiting to catch

you screwing up.

And now on top of all that I have two patients die on me—three, really, if you

count that transfusion screwup—and as if that isn’t bad enough, I’ve got Leonard walking

around letting it be known that he thinks I killed these people on purpose. How much

worse can this place get? I mean, this is way beyond the worst nightmare scenario about

med school you could ever dream up.

I swear, if he mentions his suspicions about me out loud to a single person, I’ll

have a lawyer on his ass before he knows what hit him.

Eric

It occurred to me to question Dennis about motive. Let’s say, for the sake of

argument, that he’s right about one of his residents being a killer. Why would he be doing

it? Given what a microscope Dennis has them under, why would these residents in

particular run any risk at all, let alone something as super-risky as murdering patients?

Especially young and relatively healthy ones? It really doesn’t make any sense when you

actually sit down and think about it. What’s at stake for them and everything.

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 It wasn’t that I was doubting Dennis was right or anything like that, it’s just that I

didn’t understand. I figured he had a motive in mind, actually, and that he could explain it

to me.

But I was wrong. This has to be the only time in all the time I’ve spent with

Dennis, asking question after question after question, that he just plain didn’t have an

answer. He really didn’t! All he could do was stare at me with this look on his face like

the look Popeye Doyle has at the end of The French Connection: Furious, obsessed,

infinitely frustrated, determined. Ahabesque. It completely weirded me out.

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Chapter 11

Chris Richards

God, how many days had I been sitting outside this damned comatose prisoner’s

room? Ten? Twelve? Enough to have switched between days and nights a couple of

times. And enough to have seen God knows how many patients come and go from the

rooms around me.

There’s an Asian doc here—a resident—whose name for some reason is José. I

don’t know what his deal is, but he always seems to be around a lot more than the others.

I think he cheats on his hours or something, stays around when he’s supposed to be

taking time off, and I think it pisses the other residents off.

Anyway, they brought in this tiny old woman who he seemed to take a particular

interest in. From where I sit, she looked a little loony. He spent way more time in her

room than in anyone else’s, near as I could tell. He brought old Dr. Leonard in there, too,

a couple times. And when other residents came on duty, when you’d expect him to take

off, he’d still be around, checking in on her, trying to talk to her. She must have had

something really interesting.

Anyhoo, he was standing outside her room the other night, going through her

chart, when this other resident came up to him and said that he better skedaddle, that he

needs to take his mandated time off or the department could get in trouble again. So this

José guy took off, the other guy—the McDreamy guy—checked in on her a couple times,

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and one other guy, this pal of his, went in there for a second in the middle of the night.

They were coming and going so fast I kind of couldn’t keep track of them.

And then they found her dead early in the morning.

It didn’t seem like that big of a deal to me, that she’d died. She looked like she

was half-dead when they brought her in, and as far as I know she was hardly ever

conscious or anything. But I made a note about the whole thing anyway, just in case.

José

I working ER in middle of night when old woman brought in by ambulance. She

here in ER three nights before with bad pain in legs when Osmun on duty. He decide she

have arthritis and send her home with medicine for pain. He note in chart that she

“belligerent.”

This time, she almost unconscious. No talking. Eyes barely focus. We find large

tumor in her breast. We admit her, find her primary doctor, get her records, and it turn out

she have long sad health history.

Cancer found in her breast two years before. She refuse treatment. Now tumor

huge, and cancer spread through abdomen, and up into brain. She very, very sick.

She also have long mental health history. She 81 now. Spent time in mental

hospital when she in her 30s. Then she live with parents until they die, then live alone in

same house until now. She have no family—only cousins and nieces and nephews.

Nephew tell me whole story when he visit.

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 When she awake enough, I try to talk to her about condition. First time, she try to

hit me. Second time, she quiet and seem to listen. I go very slow, tell everything. I draw

picture to show where cancer spread. I tell her no treatment can work now.

She very quiet. Then she say, “So, what the score, Doc?” I no understand. I ask

Osmun later, and he stare at me for long time, then he say it just mean she no understand

what I tell her. But Osmun can’t explain how “what the score” mean that. It another

strange English phrase, like “antideiotic.”

She also have bad infection. I present case in Morning Report, and Dr. Leonard

say it OK to not treat infection—to “let God take her.” He say it “merciful”—that if we

treat infection, we just keep her alive for more horrible and painful death.

This woman—she touch my heart. She so frail! We have…connection. She talk to

no one but me. She even smile when I come in her room. Nurses think it funny how she

like me so much when she so mean to everybody else.

And sometime she seem to understand everything. She say something to me one

day and I tell her I no hear, ask her to say again. She say, “I talking to God.” Like she

ready.

I meet with relatives and try to tell them how sick she is. They know—they try for

two years to make her get treatment. But when I ask if we should resuscitate if heart stop,

they seem shocked—they hesitate. Like they not expect this situation.

And then they not all agree. I tell them about infection and explain that it up to

them to treat or not, and that she have more peaceful death from infection than from

cancer. She fall asleep and not wake up. Cancer bring headaches, seizures, much pain.

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 But here again strange thing about America. Because hospital can do nothing for

her, she must be discharge—Medicare no pay bills if she just here to die. But she too sick

to go home. Need nursing home. But insurance not pay for nursing home unless she get

medical treatment there. So family forced to treat infection with antibiotic to get

insurance to pay.

But then it not matter. Family tell us to treat infection, and hospital work to find

nursing home so we send her there. It called “skilled nursing” home, where she supposed

to go. But that night—she die. Heart just stop.

I know it good thing for her. I know. But something not right about her death—it

like others with no cause.

Chris Richards

I don’t know why so many days passed before I got a chance to talk to Dr.

Leonard again. After he asked me to keep an eye out for suspicious events or behavior, I

didn’t see him again for a couple weeks. And then the time or two that we caught a

glimpse of each other, he was with other people, and I couldn’t tell if he caught the little

signal I gave him, a little wink and a tap with my finger on my notebook.

Anyways, he finally turned up one night when no one else was around and I was

having my usual quiet meltdown from boredom outside the comatose inmate’s room. I

swear to God, I’d been sitting on my ass so long I was as brain-dead as that poor

sonofabitch. Dr. Leonard came walking up and stopped and flat-out asked me what I’ve

noticed lately. And even though I didn’t really need it, I whipped out my notebook and

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took a quick look in it—it just seems to give people more a sense of your authority when

you do that—then I told him about how I saw the two handsome guys kick that José guy

out one night just before this other patient died.

It’s funny how your instincts can be so right on sometimes. It comes with years of

doing this kind of work, honing your skills, getting better and better at spotting suspicious

behavior in what looks to the untrained eye like the most normal of circumstances. And

you get this eye for the telling detail, too. Like when I had mentioned that “two-tenths of

a gram” thing before, for instance: Dr. Leonard’s eyes popped wide, even though he

didn’t say anything. And this time when I told him about that José guy spending so much

time with that one patient, then being sent away by McDreamy and then having that

patient die, he was all over me with questions. “Who went in there after José took off?”

“What exactly did they say to him to make him leave?” “How many times did they go in

her room after that?” You would have thought he was the detective, the way he kept

hammered away at me.

José

At first I think Dr. Leonard mad at me. He track me down in hall, ask me about

old woman who die. “Why she die?” he say. I say I not sure because Brandon and Osmun

make me go off duty. And when I come back, she gone. Nurse tell me she die—that her

heart stop beating. I tell Dr. Leonard that I confused. Yes, woman very sick. But heart

very very strong. Very strong. Woman tough. I never see someone so tough, I say.

Infection under control and cancer not advanced to where heart should stop. Especially

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her heart. She old, she sick, and no one in family upset when she die. But her death make

me feel uneasy, even though I not sure why.

I so sorry to tell Dr. Leonard this. Because I feel there must be explanation I not

understand, and I not want to stress him when he so unhappy. But he ask—and I have to

tell truth. I think he have explanation, but he say nothing. Just thank me and leave.

Dennis Leonard

For me, the death of this old woman that José told me about was the straw that

broke the camel’s back. Four deaths was four too many and I was determined that there

not be a fifth. I also knew that there would be a fifth if I didn’t do something, and do it

fast.

Now I’m the first to say that any one of these deaths on its own definitely

suggests carelessness or stupidity or malpractice, but when you have four clustered like

this, with each one raising serious questions of its own, you have to look for a killer. You

don’t have accidental deaths in a hospital at this rate, and you certainly don’t have deaths

so far out of the ordinary like this. The last one may be the only one that fits the profile of

a typical euthanasia event, but put them all together and you have a killer on the loose in

here. There’s simply no question about it.

Eric

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 Dennis just seemed to come alive all of a sudden when he discovered there’d been

a fourth death defying explanation. At our next night at Luk’s, he laid them all out for me

and told me he had to do something fast. “You watch,” he said. “I’ll get him. And I’ll get

him soon. I’ve got to bring this bastard down before someone else gets killed.”

He told me that when you really sat down and thought about it, it wasn’t that hard

to figure out how the patients were killed. The first death, he said—the one where fluid

filled the patient’s chest cavity—was caused by an intravenous injection of potassium.

Dennis explained to me that you can easily kill someone that way—you give them a big

enough dose and it stops their heart. The great advantage to the murderer is that it leaves

no trace. “I’m convinced that in this case the killer didn’t do the killing himself,” he told

me. “He put an instruction in the chart for the nurses to inject that poor girl. He knew

what would happen when he wrote that ‘IVP’ in there for them: That they would give her

an injection that would prove fatal. It was a very clever ploy, particularly as whoever

engineered it knew it would go unnoticed once everybody started scrambling around

dealing with the aftermath, with Risk Management clamping down on it and everything.

There’s so much storm and confusion around a case when it gets to that point that no one

can ever see through to what really happened, largely because they’d have to assume the

worst in order to find the truth, and they don’t have the imagination to assume the worst.

So they end up looking for a mistake when in fact there was no mistake at all.

“It doesn’t help, either, that what they’re really looking for is a defense against

malpractice, so they’re marshalling a case to exonerate the hospital and the staff rather

than trying to find fault with themselves. And on top of all that, they will say that the

handwriting was so sloppy that someone misread it. You could even argue that someone

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was ordering a pyelogram, which is harmless, even though there’s no real reason to run

that test. With this test-crazy world that medicine’s turned into, who would ever question

running an unnecessary test like that?”

He believed the second murder was more overt, in that the killer himself just

injected some kind of impurity into the victim’s shunt, from where it would go directly

into her lungs. “That impurity then sticks in the lungs, and she can’t breathe, and there’s

nothing anybody can do,” Dennis said. “I can’t prove that that’s what happened, but

there’s no question she died from her lungs being full of some foreign substance, and

there’s only one way for it to have gotten in there.”

The third one was the easiest one to see, according to Dennis, because “once you

know someone is in there looking for ways to kill patients, these cases just start to leap

out at you. Someone deliberately arranged for a transfusion of the wrong blood type.

Such a mismatch would automatically be considered an error. I’m convinced that

someone manufactured the reason for the transfusion in the first place, and then made

sure that the wrong blood type was administered.”

It was the fourth death that seemed to rile him the most, because—as he said—it

signaled a turn for the more sinister, the harder to detect. “I’ve seen this in other

hospitals, this serial preying on the elderly.” He was really worked up. “Somebody

slipped this woman a potassium injection, I’m sure of it. She was sick as hell, and within

weeks of dying, but our guy just couldn’t wait for her to die on her own. And he knew he

could get away with it because who’s going to take a second look at a sick old lady,

terminally ill, with no immediate family? It’s sickening, this kind of murder…you tell

me where to draw the line between a thrill killing and a mercy killing. Because that’s

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what we’re talking about here: someone who kills for the thrill of it, the thrill of getting

away with murder, while telling himself all the while it’s just euthanasia.”

I really did try to be properly appalled, and it was clear that Dennis was beside

himself with horror. But it was just flat-out impossible not to think about what this meant

for me and my project. I had started out working on something that was potentially

interesting—a chance to look behind the scenes at the hospital industry at a time when

the whole country was roiling in a health-care debate—but that would in all likelihood

find a publisher only because of the timing. Now, though, I was potentially sitting on a

gold mine: I mean, here I was on the inside, tracking all the comings and goings in a

hospital, when all of a sudden a serial killer goes on the rampage. And I’ve got this

amazing, colorful character in the form of Dennis going after him. And an administration

that isn’t all that interested in anything he says, let alone something like this. This was

turning not only into a story that could write itself, but one that could sell itself.

It’s shameful, I know, but writers can never keep that best-seller fantasy at bay.

You picture the New York Times list, your name on it, your picture all over the place,

your making the talk-show circuit, the hordes crowding in at your readings, the sudden

burst of fame and fortune. And, in my case, the redemption in the eyes of the Ex and the

kids, who all but threw me out of their lives for being a loser. What are they going to

think of me when they see me on Oprah?

And talk about a book that was more interesting to write! This was like writing a

real-life thriller, a whodunit with a cast of colorful characters who were all the more

interesting because they were real. And I was watching it live instead of coming in after

the fact and dredging people’s memories.

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 I was getting the break of a lifetime here, and all I had to do was watch…as long

as I kept my mouth shut and my eyes open, I’d get this bestseller handed to me on a silver

platter.

I didn’t say anything like that to Dennis, obviously. I just told him I’d do

whatever he wanted me to do, to help, and stay out of his way in the meantime. And I

told him I was wishing him all the luck in the world in catching this guy. Then I went off

to fantasize about my fame and fortune in private. And yes yes yes, I know it’s

disgusting. I’m just telling you that that’s what it’s like to have the soul of a writer.

Dennis

I’m trying to do things as much as possible within the rules here, but it’s

frustrating. Hospitals these days are set up to protect their own interests and reputations

rather than to heal the sick first and foster business interests later. And God forbid they

should ferret out the real truth when something bad happens to a patient.

I’d been to Badger to air my suspicions before, to no avail, and should have

known that it would be futile to keep trying. But with this fourth death I felt like I had no

choice. So I cornered him in his office again and told him I no longer had any doubts at

all about there being a killer loose in the hospital, and that I was very close to figuring out

who he was. I told him that three of my residents—Brandon, Osmun, and Benjamin—

were all involved with all four of these patients who had died, and that there were too

many anomalies with these deaths to chalk them up to incompetence or innocent medical

error. I also said that I was very close to figuring out which of these clowns was

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responsible for these deaths. I told him unequivocally that I believed these four women

had been murdered, and that the killer had been very careful either to cover his own

tracks or to manipulate patient records in a way that led others to inadvertently administer

the death. I told him that the first death was particularly egregious, and that someone had

left instructions to administer an intravenous push that caused a nurse to give the patient a

fatal potassium injection.

That practically brought him out of his chair. “How do you now that?” he asked. I

told him that I had a copy of the patient’s chart with the instruction to administer an

“IVP.” For once, he actually seemed interested—really interested—in what I had to say.

We didn’t even get to my evidence about the other deaths. “I need to look into this,” he

said. Then he made it clear it was time for me to leave.

Nancy

It made me feel so creepy, having to go looking for that Eric person again, but

Brandon really wanted me to talk to him—to ask him something important. Dr. Badger

called Brandon into his office, and Brandon says he was really upset. Dr. Badger asked

him if he had ordered an intravenous push to be given to that poor young girl who died

after coming in for gall-bladder surgery, and Brandon said that of course he hadn’t—why

would anyone? And Dr. Badger told him that he’d been told by Dr. Leonard that the

patient’s chart contained an order for an “IVP.” And Brandon got really upset! He said

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that he’d never done any such thing, and he should know what was in that chart because

he was the one in charge of that case, and he saw every order that went in there!

“I know he hates me, I know he does,” he kept saying to me after that meeting. He

was talking about Dr. Leonard, not Dr. Badger. “But why would he say something

completely untrue about me—especially when he thinks the truth about me is bad

enough?” Then he asked me if I could just try to run into that writer again and see if he

knew anything, because he knew he wouldn’t get anything out of Dr. Badger and that I

could get anything out of that writer. It was creepy the way he said it, but I kind of knew

what he meant, too.

What I did was, I came up to Eric in the hallway and asked him if he had a

moment—which I knew he’d say yes—and then I told him…I wanted him to be open

with me…so I told him it was about me and not about Brandon. I told him I might be in

trouble for something that happened to that patient who died, and did he know if Dr.

Leonard was saying anything about me giving that woman the wrong kind of shot or

anything like that?

He really didn’t want to say anything, I could tell. I just kind of put my hand on

his arm and looked right at him and said, “Please? It could be the difference for me

between being allowed to stay here and being fired.” Plus I let myself get a little teary.

He took a big deep breath and closed his eyes and then he said, “It’s really

important not to tell anybody how you found this out, but there’s an order for something

called an IVP in that patient’s chart, and Dr. Leonard says that’s what killed that patient.

That whoever ordered that IVP did it so that the patient would be killed.”

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 My first thought was that Dr. Leonard must be insane to think that someone

would do something like that! And then when I thought about it some more, I was sure

there had never been any such order in that patient’s chart. But there was no way to

check—or at least for me to check—because we couldn’t get access to those records now

that they were in Risk Management. But I know there was no order like that!

Dr. Badger

It was clear after yet another day where Dennis came storming into my office

making these wild accusations that I had to do something. This was turning into a daily

occurrence, and he started seeming bound and determined to go public with accusations

that would destroy the department and the hospital unless I made a show of believing the

nonsense he was spouting.

So I got Risk Management to send the records on that patient he was fixated on up

to me. And it turns out, coincidentally, that they were very close to a resolution of that

mystery. When I got all the records, the answer was right there in black and white.

I had Dennis in here again, the day after I’d learned what I’d learned, and this

time he was flat-out threatening to go public. It was the first time he’d made that threat

explicitly, and I told him in no uncertain terms that if he did that I’d get him fired. “And

don’t think I can’t do it, either,” I said. “I don’t care how many friends you have in high

places now—if you get the press going after a story about how we’ve got a murderer on

staff, you’ll be gone in a heartbeat.”

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 That set him back. I think he really thought that I believed the nonsense he was

spouting at me.

Eric

Boy, was Dennis ever steamed when I sat down with him last night. I mean,

spitting mad. He said he was at his absolute wit’s end with the hospital, that they were

determined not to act on what he knew.

Dennis is without a doubt the most obsessive man I’ve ever met. Once he gets an

idea in his head about something that has to be done, he just cannot let go of it even for a

moment. Anything anyone else has to deliver to help him finish a job, he’s all over them

until they’re done. He’ll call and call and call and call until you feel like you’re losing

your mind.

So it’s not like I’d never seen him like this before. It’s just that he was so

emotional, so torn up, so desperate. He knew we were sitting on a time bomb with this

person out there, and that it was only a matter of time before another patient was killed.

“I just can’t let this continue!” he said. “I can’t! But I can’t get through to Badger—he’s

stonewalling me—and even the new guys in the administration are turning into the same

kind of good ol’ boy that always ends up running things in this hospital. Once they get to

where they have to think about money all the time, it’s all over with principles and

excellence and what have you. So none of them wants to believe me now. I swear that’s

what it is—not that they don’t believe me, or that I don’t seem credible, but that they

don’t want to believe me.”

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 I sat there thinking and listening for a long time, wrestling a little with my

conscience. It’s imperative, really, that a writer not become part of the story he’s

chronicling. But it also occurred to me that in this instance, we were dealing with a set of

circumstances exceptional enough to allow me to maybe step in and move things forward

a little. Just to sort of bring the story to the appropriate conclusion.

“So, Dennis,” I finally said. “What would you think of having me call up Badger

and saying I’m a reporter working on a story about allegations regarding a serial killer in

the hospital? Do you think that once he suspected that the media was onto this thing that

he’d act? He’d have to, wouldn’t he?”

It wasn’t really until the words were out of my mouth that I realized what a

brilliant idea it was. One phone call would be all it would take to set the whole story in

motion again, rushing toward the ending I needed—that is, toward apprehension of the

killer, redemption for Dennis, everything. It was basically a win-win, from where I was

looking.

“It’s not like I’d actually be writing a news story,” I said to Dennis. “It’s just a

way to force Badger and them into action. What do you think?”

He didn’t answer right away, but with Dennis you can tell when he’s excited

about something. This light just flat-out dawns over his face…it’s really funny to see. “It

should work,” he said. “So yes—go ahead.”

Dr. Badger

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 I got a call last night from a Chronicle reporter—a guy named Eric Lander. He

told me he was working on an investigative piece concerning suspected murders in the

hospital. I told him he’d best be very, very careful before making that kind of allegation

in print. I asked him who approached him with this “information,” and he wouldn’t tell

me. All he said was that his source was “very well placed in the hospital.” I came right

out and asked him if it was Dennis Leonard, and he said he “couldn’t comment either

way.”

What a prick.

I told him that I knew that Leonard was his source and that if he was determined

to go public with an allegation made by a senile old faculty member years past his useful

life, and with no corroborating evidence, then he was going to get him and his paper in a

world of trouble. I also told him that I had already looked very carefully into Leonard’s

allegations, and had thoroughly examined each of the cases he’d brought to me, and that

he was just plain wrong. Then I waited for the guy to follow up with a question, but there

was just this long silence on the other end of the line. So I said goodbye and hung up on

him.

And then I sat, and sat, and sat at my desk. I couldn’t bring myself to move. I just

sat there concentrating on getting my rage under control. And then I came around to the

inevitable: That I could no longer let Leonard work at this medical school.

I mean, for God’s sake! Is he just determined to shut this place down out of spite?

Because we won’t run things in this outmoded way he insists on?

God, these accusations! He’s all but got me backed into a corner, where I’m

defending the hospital against a serial murder charge by saying, “No, no, we’re just

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incompetent!” That’s the last fucking thing we need—to be going public with the

“defense” that we routinely kill people by mistake, not on purpose! “We’re not evil!

We’re just stupid!”

You can’t exactly build a resident recruitment campaign around that, can you?

Eric

So this Badger really throws me a curveball. After he basically stalls with me on

the phone, he calls me back two days later and asks if I’m willing to meet with him and

with Dennis. I’m thinking, “Whoa! Way to go, Dennis!” And that the ploy—calling this

guy Badger—worked even better than I expected.

I told him I’d be there whenever he and Dennis could arrange the meeting.

Then I started getting ready for my closeup.

Dennis Leonard

It’s clear as hell now that Brandon is the culprit here. Brandon and that cute little

number of his, that nurse. One or both of them was dealing directly with each one of

these patients before they died. You can tell from the charts, from what José told me, and

from what Richard observed. And it makes sense: Brandon is a twisted soul in addition to

being incompetent. I’ve just never liked anything about that guy—and I believe he’s

more than capable of rationalizing his way to killing patients. In medicine, that’s not all

that much different from rationalizing your way to carelessness, laziness, ignorance. It’s

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all on the same slippery slope. Once the patient is no longer your only priority, anything

is possible, morally speaking. And in today’s medicine, the patient is way down the list of

priorities.

And there’s no question his little girlfriend would be more than happy to

administer the coup de grâce for him whenever he asked. I don’t know what it is about

women getting involved all the time with such losers. But there you go…I’ve seen it

again and again and again.

Dr. Badger

This was going to be ugly. But it’s the kind of ugly that comes with the territory

when you run an enterprise like this. And I was more than ready: I had all the

documentation I needed on these cases, I had legal staff lined up, Human Resources on

board. Everything was covered—everything.

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Chapter 12

Eric

Dennis and I decided it would be best to arrive separately. The meeting was in

Badger’s office, at five. I hung back a little, mostly because I wanted to make sure

Dennis was already there when I arrived. It seemed like everyone in the whole suite of

offices up there in administration had cleared out before I got there, except for Badger’s

receptionist, who ushered me right in. It turned out the meeting was in a conference

room, and there were a lot more people in there than I expected—not doctors, either,

except for one gentleman I didn’t recognize—but guys in suits.

No one was talking when I came in. Dennis had this little pile of files with him,

and was sitting opposite the guy I took to be Badger, in the middle of one side of this

long conference table. There was a screen at one end of the room with an X-ray image up

on it. The other four people were arrayed along Badger’s side of the table. I decided to sit

down alone at the foot of the table, opposite the screen—I was a little confused by the

presence of all these other people, and I didn’t want to make it look like I was taking

sides or anything.

I introduced myself to Badger, he introduced me to the other people in the room,

Human Resources types, legal types, and then I sat down and took out a notebook. Then

Badger said, “We may as well get started,” and asked Dennis to describe his suspicions

and tell what gave rise to them.

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 Dennis started in on the first murder by explaining what the woman had come in

for, how complications arose from the scope they ran, how eventually she died without

any apparent cause. He said that it was clear from the beginning that there was something

deeply wrong with this case, that under no circumstances should a patient in that

woman’s condition die, and he decided he had no choice but to try to get to the bottom of

it. He had several residents who were highly problematic, terribly incompetent, and of too

defensive a mindset to allow themselves to improve or to learn, and he was convinced

that this death was caused by one of them. He had long believed that these residents

would end up killing patients, and now it looked at last like he was right.

“I never expected to find out that one of them would be purposefully killing

patients,” he said. “But when I went through these charts, I found a smoking gun, so to

speak, in the form of a disastrous instruction to the nursing staff: an order for an ‘IVP,’

which clearly now, in retrospect, was taken for an ‘intravenous push,’ and resulted in a

fatal potassium injection. I believe I can prove that the writer of that instruction intended

for that misunderstanding, and that result.”

There was a long silence then, the only noise in the room being Badger’s ballpoint

pen—for some reason, he kept clicking it open and closed.

Dr. Badger

So there it was—I had him at last. “Dr. Leonard,” I asked—and I pointed then

with a little extra dramatic flair at the X-ray we had already up on the screen—“have you

seen this X-ray before? This chest X-ray of the patient in question?” I knew he had, but

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of course he claimed he hadn’t. He went on to say that in all likelihood it was flawed, or

had gotten mixed up in the system somehow with someone else’s image—this was one of

his fixations, how you couldn’t trust “the computer” to manage and store radiological

images—because he would have certainly seen it otherwise, and remembered it.

Eric

I knew as soon as I walked in the room that the meeting wasn’t going to be what I

was expecting. But this was a shocker, what happened next. This other doctor―a

radiologist―got up and used a laser pointer to highlight this almost invisible white line in

the chest cavity that you could see just behind the breast bone in the lateral view. He

explained that the line was a catheter that had been put in the patient’s neck vein for

feeding purposes after her duodenum had been ruptured. Then he said, “You can see

here how the catheter has inadvertently broken through the vein’s wall and is lying free in

the chest cavity. Its contents are going directly into the chest cavity instead of through

the vein into the heart. So obviously, the fluid continued to build until it surrounded and

compressed the lungs, essentially drowning the patient.” He went on to say that they

couldn’t find the cause of the fluid at autopsy because the catheter had been removed

immediately after the patient died. And not until the autopsy provided no answer did a

careful review of the chest X-ray solve the mystery.

Only in retrospect―after the patient had died―did someone recognize the

misplaced catheter. And Dennis had never seen the telltale X-ray—I know he hadn’t. But

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now everything was set up to make it appear that he’d seen it and missed something he

shouldn’t have, settling instead for some outlandish murder fantasy.

When the enormity of all this hit me, all I could do was look at Dennis. This was a

trap, basically—thoroughly horrifying.

Dr. Badger

What I was trying to point out here, by starting things off with this X-ray, wasn’t

just that Dennis was wrong about the cause of this poor woman’s death. I wanted not just

the other people in the room but also him—most of all, him—to see that he’d just plain

gotten too old for this line of work! In his younger days, he’d have been the first to see

that misplaced catheter on the chest film—it’s the kind of detection he was known for

when he was younger. But now...well, it was clear that his eyes and his judgment were

starting to fail him.

I let that sink in for a minute, then I went into the legal niceties. I asked him why

he had a set of the patient’s records when no one outside of Risk Management was

allowed to have them, and I pointed out that that was one of the most serious breaches of

procedure here at the hospital. He went into a rather weak “desperate times call for

desperate measures” rant, and pointed out that the “IVP” in those records more than

justified what he’d done. He still was insisting, even after being shown the irrefutable

evidence in that X-ray, that the patient had been murdered.

This was where I finished him off: I had one of the Risk Management attorneys

produce the original records, and we pointed out to him that there was no “IVP”

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instruction anywhere in them—and sure enough, when he compared his set to the

originals, that instruction was in his copy alone.

All I can say about what happened next is that—and I can’t think of a better way

to say this—you’ve never heard such silence.

Eric

I felt like the room was spinning. I mean, I felt really, really sick. I could hardly

keep my head on straight enough to follow what happened next. This Badger guy was all

over Dennis like a tiger on a carcass. It was like, the first little moment of hesitation on

Dennis’ part gave this guy his opening to go in for the kill.

Now I could see how the whole thing was set up, like he’d rehearsed it with all his

cronies there: Badger told Dennis that the duplication of the patient records alone was a

firing offense; that even worse was the clear evidence that he had falsified his copy of the

records in order to go after a resident he’d long harbored hostility toward; that he was just

as wrong about the subsequent cases as he was about this one; and that at the conclusion

of this meeting he was fired, for his violation of protocol and for his having gone public

with false allegations that were potentially disastrous for the department and the hospital.

They listed about ten thousand rules Dennis supposedly had broken.

Somewhere in the middle of all this crap one of the suits stood up and opened a

file to show Dennis the statement they had in there from the boyfriend of the patient who

had died from having all that stuff in her lungs. It turns out that the girl was a drug addict,

and she was making her boyfriend take her oral pain medication and crush it up and cook

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it, then inject it directly into her shunt, for the rush it gave her. The residents working on

that case had figured it out almost immediately, confronted the boyfriend, and got him to

fess up.

This was yet another part of their coming down on Dennis for being so careless in

airing false accusations to a reporter—in this case, me.

I didn’t even have the heart to listen to them go through the third case—

something about that “two-tenths” being another one of Dennis’s fictions or whatever.

And it was like the fourth case didn’t even exist—it didn’t come up at all. I guess they

didn’t feel like piling on.

They finally put an end to the misery by telling Dennis that he was to be relieved

of all his duties, effective immediately, and two security guys showed up to escort him

out of the room.

Just like that. Kaboom. It was sudden as hell, how it ended—like a guillotine

coming down.

Joanne

Oh, my poor heartbroken husband. All the fight gone out of him. In all our years

together, I’ve never, ever, seen him give in to anything: pain from running,

incompetence, impossible diagnoses, evil administrations…anything. But now it’s as if

he’s faced a monster he hadn’t even imagined existed. What’s that phrase you hear all the

time these days? “Shock and awe”? That’s what happened to him—and now he’s just

overcome.

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 If you ask me, this is the first time he’s realized—really believed, believed in his

heart—that medicine has actually become as incompetent and self-interested and evil as

he’d been saying it was becoming. It’s like everything is not only worse than he’s been

saying it is, but even worse than he was capable of imagining.

I don’t care what they showed him at that meeting, I just cannot and will not

believe that he made all these mistakes they say he made. I know that “love is blind” and

all that, but I know—I know—that this man is not capable of the lapses they accused him

of having. He is a fair, fair man, even to those he disapproves of. And he is pure of heart,

as they say. Completely pure of heart.

He told me that the whole thing was triggered when Eric made some kind of

threatening call to Badger. I didn’t say anything, of course, because my husband was so

beaten and so heartbroken. But I will never, ever, ever forgive that writer! He turned my

husband’s head with all these ridiculous visions of fame and fortune and God knows what

else. And then he waded into a situation he couldn’t begin to understand and just ruined

everything. I hold him completely responsible. Completely!

José

Not know how I know this—I just do. Know it in my heart. Osmun know before it

happen what happen to Dr. Leonard. I can tell! He too happy when I tell them Dr.

Leonard know something about strange deaths here. I tell him and Benjamin and Brandon

that Dr. Leonard going to administration with informations, and Osmun not ask single

question. He just look at Brandon and smile. And tell everyone not to worry.

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 Now I feel like I lose my father. Like he die. Dr. Leonard mean everything to

me—everything. He only doc here I look up at, want to be. Now I wonder if there any

place for me in profession. Medicine a business, like Dr. Leonard say. Not a “calling”

any more. What I do?

Osmun

How can I tell you how insanely happy it made me to tell the old bastard the

whole story?

There was a whole parade of residents who trooped by his office the day he was

packing up his stuff, all of them wanting to say goodbye, wish him well, tell him how

much they’d miss him—the usual sentimental horseshit. Some of them were even crying.

I made sure I was the last one in, seeing as how it was so late and everything and

he was pretty much packed up, just waiting for his wife and some other people to come

haul him and his stuff away.

He wasn’t too happy to see me. He looked at me kind of bleary-eyed—I swear to

God, he actually looked like he’d been crying, too.

“Dr. Leonard,” I said, “you know why I’m here, right? You figured it out?”

He just stared at me without saying anything—a first for him, that’s for sure. Dr.

Leonard at a loss for words! I honestly think he had no idea what I’d done.

“I know you thought all along it was Brandon doing those patients in, killing

them, but you were wrong: It was me from the beginning—and not doing them in, but

doing you in.”

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 Then, since he still wasn’t saying anything, I just unloaded on him. I told him all

about how much we all hated him, how Medicine had left him and his kind, his ideas, his

“principles,” behind. How we were preparing ourselves for a world he couldn’t begin to

understand. I told him how angry we were when he was promoted instead of being forced

out, after we’d thought the consultant was all set up to help us get him removed, and how

we had no choice after that but to lead him down the primrose path, as it were. I told him

how easy it was to plan out when I sat down and thought really hard about it, and how

fortuitous it was when that botched surgery patient died on us, with no apparent cause.

“From then on,” I said, “I orchestrated everything.” I told him all about how I slipped that

“IVP” into his copy of the patient’s charts, knowing that that tiniest little anomaly in a

weird patient death would get noticed by him and him alone in the middle of all that

minutiae. It was ridiculously easy from then on to make it look to him and to no one else

like there was a killer loose in the hospital. Like with that transfusion reaction case, just

altering that hemoglobin concentration figure enough to turn the transfusion from the

reasonable to the insane. Who but him would bother noticing? And I couldn’t help but

tell him how much fun I had staging little “performances” for that ridiculous sheriff who

snoops around here all the time like he’s some kind of real detective. It was just like

Leonard to consort with a bonehead like that, too.

Four little cases that didn’t amount to shit until he started nosing around in them

and found my little “messages” for him.

Of course, I knew it was just a matter of time before he got to the bottom of those

first three deaths—much as I hate the guy, there’s no getting around his genius at

diagnosis—so I threw that fourth death in there just to distract him and to more or less

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push him over the edge. It helped that it was the only actual killing, the one death that

couldn’t be found in the end to have had a natural cause. “Once you laid eyes on that

one,” I told him, “I knew there was no way in Hell you’d ever be able to find the real

cause of death in those other three—you’d be blinded by your conviction and your

disdain for us.”

I didn’t get into the moral ins and outs with Leonard of deciding to end that poor

old woman’s misery. I know it’s self-serving as hell to say this, but talk about an act of

mercy! Shit—that was legitimate euthanasia. She’d all but said she wanted to die by

virtue of her refusing treatment from the time she was first diagnosed, and the only

family members involved with her were half-estranged, as far as any of us could see. It’s

not like anybody was in there begging us to do everything possible to save her life. Her

physical condition probably just added to her mental misery, anyway.

I was in and out of her room in seconds—an injection of potassium in her shunt,

and that was that. I was just helping God take her, like Leonard said in Morning Report

that day.

“And you know what the easiest part of all that was?” I said. “Getting you to

suspect us. I knew that you’d be the only one to look closely enough at these cases to see

what was ‘wrong’ with them. And I knew you’d seize on the first indication that one of

us had done something egregious, and not bother looking for any kind of benign

explanation. You were just so desperate to find a way to get us fired. Even you can let

emotions cloud your judgment, hard as that is for you to believe.”

I got up to leave, and left him with this zinger: “Your job now is to guess how I

got my first opportunity—it shouldn’t be that hard to figure out.”

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 Then I turned and walked out. He was just sitting there with his mouth and eyes

wide open, like I’d just put a bullet through his chest. The happiest fucking day of my

life. And I’ll bet he spends the rest of his life going insane trying to figure out how we

figured out how to start this whole thing in motion.

Eric

How could something that started out with so much promise end up at such a

dismal dead end? The months and months of material I amassed, all of it through Dennis,

who is now so thoroughly discredited I couldn’t even sell a proven cancer cure with his

name attached to it. I guess I was just so blinded by his charisma that I didn’t do the kind

of due diligence any cub reporter would have the sense to do: check his source’s

assertions and statements of fact against the observations of these other people—

particularly the residents he was out to get. I should have thought more about how old

Dennis was, how much he’d declined, and how profoundly his judgment was affected by

his bitterness.

All that work for nothing—all these months of following people around, and in

the end I can’t come up with the material I need. I mean, there’s just no story here,

period. What a pisser.

Dennis Leonard

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 I’ll leave it to others to decide how all this looks—but I don’t think you can say

that I wasn’t up to the challenge, for what that’s worth.

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Epilogue

Dr. Stangler

It was heartbreaking in the end, to see Dennis crash and burn that way. He just

seemed to grow increasingly obsessive about the people under his tutelage. What started

out as a more or less general sorrow about the state of medical education turned into a

vendetta against his own students. It’s like something out of classical tragedy, really.

You have to wonder if there might not have been an easier way for him to find a

way into retirement. Instead, he clung to his work too long, his obsessions grew ever

more powerful, his judgment ever more clouded. You see it so often in medicine, the

Type A doctor who can’t find a way to let go. But in Dennis’ case, it took a uniquely

tragic turn, really, where he drove himself into a personal scandal and had to be forcibly

retired in ignominy. I wish I’d taken a stronger hand when he came to see me—I should

have seen that it would come to something like this, where the combination of his

diminishing skills and inability to admit to any kind of weakness would effectively do

him in. What a sad, sad shame it had to come to such an end.

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