"James, can you check to see if they're finished with the deeper levels on the Smith breast case?"
"I'll take care of it, Dr. Nomura." James dashed out the door, barely acknowledged by Nomura, buried beneath stacks of flats.
"Checking on case 23405, the breast needle biopsies, are the deepers ready yet?" James addressed the group of histotechnologists seated in front of their microtomes. A few seconds of silence prompted James to turn to the first histotech at the station nearest to him. "Do you know if the deepers are ready on this case?"
"If you don't have them, they haven't been done." she snarled.
"They were ordered yesterday. Any idea when someone might get to them?"
She stopped her work and rifled through the tray that contained the requests for the deeper levels and special stains. "What is the case number?"
"I don't see the request. You sure you requested it?"
"Well, give it to me again, I'll try to do it by the end of the day."
Two weeks have passed since James began his term at ULS. James had signed out the equivalent of 4 weeks of work at Memorial. The work seemed to grow exponentially, the slides were somehow reproducing on their own, he was now sure of it. Fatigue was not an option. Since coming to St. Louis, James usually kept complaints to himself; it would be dishonorable to voice any complaints. The experiences over the past two weeks shattered his resolve as easily as it had displaced his culture.
"It's not just the amount of work," James recounted to Deanna. "It's this attitude. I hate it. Everyone's too busy. Every answer has some snide comment. I'm always questioned. Why am I always called by my first name, even Nomura is called Masao, unbelievable! The typos I have to correct, and the-"
"...And everyday, I have to reorder the same studies and then when it doesn't come, it's my fault, or-"
"Hello? Dr. Deetan?"
James knew he was out of control but he didn't care. He didn't care if the entire lab knew. He didn't care if Deanna knew.
"I know James." Deanna's melodic voice broke through his frustration. "It's good to hear you vent."
"I'm sorry. Am I losing it?"
Deanna laughed. Even through the phone line, the butterflies followed, alighting in his stomach. "No, of course not." she continued, her voice softening. "Everyone who rotates at ULS feels like you do. Nothing you do will change any of that. All you can do is pace yourself."
"I wish you were here." James cringed. Why did he say that? Did she hear it?
"How's Nomura holding up?" Her voice was still carressing.
"I think he's close to losing it."
"Yeah, the other day, a patient accused him of fraud!"
"A patient? I don't believe it! How did that happen?"
"Apparently she had a bunion removed from her big toe by her podiatrist. When the podiatrist reviewed Nomura's report, he told the patient that Nomura was a terrible pathologist and that he was dry labbing his results."
"He said the clinical diagnosis which he submitted was the same as the final diagnosis and because he saw no microscopic description on the final report, he concluded that he never looked at the slide under the microscope. He simply agreed with the submitted diagnosis and signed out the case."
"I can't even begin to describe how ludicrous that sounds."
"I know, I know. I wouldn't have believed it but Nomura put the entire conversation on speaker phone because he was sure no one would believe him either. Anyway, he attempted to explain to the patient how he would never do something like that but she dismissed him and accused him of trying to cover up his error. When he tried to explain that a written microscopic examination is not a requirement of the final surgical pathology report, she accused him of patronizing her."
"But it isn't a requirement. Even if she can't understand or believe it, I can't believe that podiatrist. The gall of him to tell that to the patient! Nomura should report him to the medical board. How did it resolve...or did it?"
"Not really. Nomura told her that he would speak to her podiatrist. It was scary. He held his hand out in front of him-it was shaking. But his face, you know how he is, expressionless, even when the pressure is on."
"Whoa...I've never seen him lose it. That's scary."
"Deanna! I have six more weeks here!"
"Hang in there, James. What are you doing for dinner tonight? How about D'Angelo's?"
"Thanks but Nomura asked me to take pictures of the cases he is presenting for derm grand rounds tomorrow at Memorial."
"That's rough. He's still required to do service activities at Memorial while he's pushing all that glass at ULS. Listen, I'll try to stop by later this evening. Gotta go, James, I got a frozen."
James felt a heaviness on his chest as his eyes brimmed with moisture. The growing helplessness strangled his sensibilities. He dried his eyes and stole a quick glance to see if anyone saw him. It was a daily catharsis, calling Deanna, unloading the familiar issues. At first he was thankful for her sympathetic ear but he now desired it. Was it compassion or obligation from Deanna? Didn't he have other friends to cry with, she must have thought. Why should she care? She's heard it all before.
Deanna never made it to ULS that evening, a late night frozen section kept her at the hospital. James completed the picture taking by 10PM and uploaded the photographs to Nomura's laptop computer. He was exhausted but knew that Nomura relied upon him to assist him in this important task. The trust he placed in James energized him as he returned home that evening.
Dermatology grand rounds commenced at 8AM the next morning and was over by 10AM. By 10:30, Nomura was back at ULS.
"Good conference this morning. Thanks for taking those pictures for me, James. Great shots!"
James beamed. "Glad I could help out."
"So what do we have here?" Nomura lifted a pink note off his desk. Below it was a copy of a biopsy report Nomura signed out a week ago.
"Audrey, the transcriptionist, dropped this off this morning. The doc would like a call."
"Morris Vanley. I think he's a dermatologist but not in the St. Louis area, otherwise he would have been at the grand rounds this morning."
Nomura was connected to the dermatologist. "Dr. Vanley? Hi, Masao Nomura at ULS. You had a question on Cynthia Terrin's skin biopsy?" Nomura motioned to James to sit down as he quietly placed the phone on the loud speaker.
"Yes." The scraggly voice emerged. "You know, I don't know if you have experience reading out skin biopsies but your diagnoses are totally unacceptable."
Nomura smiled at James' widening eyes. "Dr. Vanley, I am a board certified dermatopathologist and have been doing this for over 20 years. What seems to be the problem?"
"Well, I'm a board certified dermatopathologist too. Trained with Shipley before he wrote all his textbooks."
"Great! I know Tom Shipley very well, good man-"
"And he would never make a diagnosis like this, " Vanley continued, ignoring Nomura's answer.
"Let's see...I diagnosed a subacute spongiotic dermatitis and suggested you rule out pityrasis rubra pilaris and guttate psoriasis."
"She was on a new beta-blocker, it started a few days after her internist put her on it. We stopped the drug and it resolved."
"Good for her! So what's the problem?"
"Why didn't you call it a drug reaction instead of reaching for all those other ridiculous diagnoses?"
Nomura smiled. "Dr. Vanley, since you are a dermatopathologist, you know I cannot possibly list every differential diagnosis that is suggested by a particular tissue reaction pattern."
"I'm not asking you to do that, just give me the correct diagnosis."
"Well, sir, that would be easier if you had provided some clinical history and a description of the rash."
"I would never do that."
"I would never do that. I wouldn't want to bias you."
"You wouldn't...want to...bias me?" Nomura's eyes opened wide.
"A good dermatopathologist can always make the diagnosis without the clinical history. Only rarely do you need the history to make the diagnosis. Shipley always taught that."
"Dr. Vanley, I will always look at a slide and formulate a differential diagnosis before I review the history. I never allow the history to bias me before I review a case, only to confirm or narrow the possibilities. It's like examining a patient for the first time. You wouldn't jump to a diagnosis based only on a history or physical examination alone, you would put the two together to arrive at the diagnosis."
"I see a lot more patients than you ever will as a pathologist. I can diagnose 99% of my patients the second they walk in my door."
"Well, sir, you are a better dermatologist than I am. I am board certified in dermatology as well, but I always take a history on my patients."
"When you practice as long as I have, you'll understand what I'm saying."
"No doubt. I will attempt to render more precise diagnoses on your patients. But if you could provide some clinical history on some of the cases, I would appreciate it."
"Don't worry about it. I'm going to send my cases to Birkman."
"I understand. I'm sorry to lose your support but I know you're doing what's best for your patients. Good day."
Nomura turned off the speaker phone and smiled at James.
"If he's a dermatopathologist, why doesn't he sign out the cases himself?"
"Because his patients are part of a managed care plan, all capitated. He gets nothing extra if he signs out the biopsies himself. That's why it comes to ULS." Nomura smiled and stroked his chin. "And that's why I don't see Dr. Vanley at the Memorial Dermatology Grand Rounds."
"Because of the managed care?"
Nomura shook his head. "All those other dermatologists around...wouldn't want to bias him!"
They shared a knowing glance. "Let's get started, we've got a lot to do."
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