The Final Diagnosis

The cafeteria of Three Counties Hospital was a traditional meeting place for most of the hospital grapevine, its stems and branches extending tenuously to every section and department within Three Counties' walls. Few events occurred in the hospital - promotions, scandals, firings, and hirings - which were not known and discussed in the cafeteria long before official word was ever published.



Medical staff frequently used the cafeteria for "curbstone consultations" with colleagues whom they seldom saw except at a meal or coffee break. Indeed, a good deal of serious medical business was transacted over its tables, and weighty specialist opinions, which at other times would be followed by a substantial bill, were often tossed out freely, sometimes to the great advantage of a patient who, recovering later from some ailment which at first had proven troublesome, would never suspect the somewhat casual channels through which his eventual course of treatment had come.



There were exceptions. A few staff physicians now and then resented this informal use of their arduously acquired tal�Ûnts and resisted attempts by colleagues to draw them out in the discussion of specific cases. In such instances the usual rejoinder was, "I think we'd better set up a consultation in my office. I'll have the meter running then."



Gil Bartlett was one who disapproved of such approaches and at times could be a good deal blunter in refusing off-the-cuff opinions. One story told about his personal tactics of resistance had its origin not in the cafeteria but at a cocktail party in a private home. His hostess, a grand dame of Burlington society, had buttonholed Bartlett and bombarded him with questions about her illnesses, real and imagined. Bartlett had listened for a while, then announced in a loud voice which brought a hush to the crowded room, "Madam, I believe from what you say you have a menstrual problem. If you'll strip right now I'll examine you here."



Mostly though, much as they might resist informal consultations outside the hospital, the medical staff accepted the cafeteria exchanges on the basis that they had as much to gain as lose; and a good many physicians around the hospital used the mildewed quip on leaving their contact points, "If you want me I'll be in my second office." Normally no further explanation was required or given.



Generally the cafeteria was a democratic area where hospital rank, if not forgotten, was at least temporarily ignored. An exception, possibly, was the practice of setting aside a group of tables for the medical staff. Mrs. Straughan, the chief dietitian, hovered over this area periodically, knowing that even minor shortcomings in hygiene or service could bring testy complaints at some future meeting of the hospital's medical board.



With few exceptions the senior attending physicians used the reserved tables. House staff, however, were less consistent, residents and interns sometimes asserting their independence by joining the nurses or other groups. There was nothing unusual, therefore, in Mike Seddons dropping into a chair opposite Vivian Loburton who, released from an assignment earlier than some of her fellow student nurses, was eating lunch alone.



Since they had met ten days ago in the autopsy room, Vivian had encountered Mike Seddons several times in the hospital and on each occasion - seeing his thatch of red hair and wall-to-wall grin - she had increasingly come to like the look of him. Intuitively she had expected that soon he might make a direct approach to her, and now here it was.



"Hi!" Seddons said.



"Hullo." The greeting came out awkwardly, Vivian having just bitten, with healthy appetite, into a chicken leg. She pointed to her mouth and mumbled, "Excuse me."



"That's perfectly all right," Seddons said. "Take your time. I'm here to proposition you."



She finished the mouthful of chicken, then said, "I thought that was supposed to come later."



Mike Seddons grinned. "Haven't you heard? - this is the jet age. No time for formal frills. Here's my proposition: theater the day after tomorrow, preceded by dinner at the Cuban Grill."



Vivian asked curiously, "Can you afford it?" Among house staff and student nurses poverty was a time-honored, rueful joke.



Seddons lowered his voice to a stage whisper. "Don't tell a soul, but I'm on to a side line. Those patients we get in autopsy. A lot of 'em have gold fillings in their teeth. It's a very simple matter . . ."



"Oh, shut up; you'll ruin my lunch." She bit the chicken leg again, and Seddons reached over for two of her trench fries.



He savored them. "Um, not bad. I must eat more often. Now here's the story." He produced two tickets from his pocket and a printed voucher. "Take a look at this - compliments of a grateful patient." The tickets were for the road show of a Broadway musical. The voucher covered dinner for two at the Cuban Grill.



"What did you do?" Vivian was frankly curious. "Heart surgery?"



"No. Last week I filled in for half an hour for Frank Worth in emergency. A guy had a bad gash on his hand and I stitched it. Next thing I knew, these were in the mail." He chuckled. "Worth is furious, of course. Says he'll never leave his post again. Well, will you come?"



"I'd love to," Vivian said, and meant it.



"Great! I'll pick you up at the nurses' residence at seven o'clock. Okay?" As he spoke Mike Seddons found himself regarding this girl with even greater interest. He was suddenly aware that she had a good deal more than a pretty face and a good figure. When she looked at him and smiled it conveyed the feeling of something warm and fragrant. He thought: I wish we were meeting today instead of the day after tomorrow; it's a long time to wait. Then a faint warning voice inside him cautioned: Beware entanglements! Remember the Seddons policy: love 'em and leave 'em - happy with their memories; parting is such sweet sorrow but, oh, so very practical for staying unattached.



"Okay," Vivian said. "I might be a little late but not much."



A week and a half had passed since Harry Tomaselli had told O'Donnell that construction of the hospital's extension was planned to begin in the spring. Now, in the administrator's office, he, Kent O'Donnell, and Orden Brown, the board chairman, were meeting to discuss immediate things to be done.



Months before, with an architect at their elbows, the three had worked over the detailed plans for each section which would have its home in the new wing. The wishes of heads of medical departments had had to be balanced against the money likely to be available. Orden Brown had been the arbiter with O'Donnell as medical liaison. As always, the chairman had been crisp and incisive, but with a humor that seasoned his basic toughness. Sometimes they had gone along entirely with what was asked; at other times, when they suspected empire building for its own sake, the inquiries had been more searching.



One section head, the chief pharmacist, had pressed hard to have a private toilet included in his own office design. When the architect had pointed out that more general facilities were available a mere forty feet down the corridor, the pharmacist had gone so far as to observe that forty feet was a long way when he was suffering one of his periodic attacks of diarrhea. Orden Brown had dryly referred him to the department of internal medicine.



A few worth-while projects had had to be vetoed solely on the grounds of cost. Ding Dong Bell, the senior radiologist, had made out a convincing case for creation of a cine-radiography unit - its purpose to improve diagnosis and treatment of heart disease. But on learning that the equipment alone would cost fifty thousand dollars the plan had regretfully been ruled out.



But now, with the main planning completed, the focus of attention was on the practical matter of getting the money. Strictly speaking, this was the responsibility of the board of directors; but the medical staff was expected to help.



Orden Brown said, "We're suggesting some quotas for the doctors - six thousand dollars for senior attending physicians, four thousand for associates, two thousand for assistants."



O'Donnell whistled softly. He told the chairman, "I'm afraid there'll be some complaining."



Brown smiled. "We must do our best to endure it."



Harry Tomaselli put in, "The money can be spread over four years, Kent. As long as we have written pledges we can use them to borrow from the bank."



"There's another thing," Brown said. "When word gets around town that this is what the doctors themselves are giving, it will help our general fund raising a good deal."



"And you'll see that word does get around?"



Brown smiled. "Naturally."



O'Donnell reflected that it would be his job to break the news at a medical staff meeting. He could visualize the pained expressions he would face. Most medical men he knew, like the majority of people nowadays, lived right up to their incomes. Of course, there would be no compulsion about the quotas, but it would be hard for an individual to take a stand against them, especially since the medical staff had a lot to gain from the hospital's growth. A good many certainly would give the full amount asked and, human nature being what it was, they would bring pressure on others to suffer equally. A hospital was a breeding ground for politics, and there were many ways in which a nonconformist could have life made difficult for him.



Harry Tomaselli, intuitive as usual, said, "Don't worry, Kent. I'll brief you thoroughly before the staff meeting. We'll have all the selling points lined up. In fact, when you're through some people may even want to exceed quota."



"Don't count on it." O'Donnell smiled. "You're about to touch a number of doctors on their tenderest nerve - the pocketbook."



Tomaselli grinned back. He knew that when the chief of surgery made his appeal to the staff it would be as incisive and thorough as everything else O'Donnell did. He reflected, not for the first time, how good it was to work with someone of O'Donnell's character. In Tomaselli's last hospital, where he had been assistant administrator, the president of the medical board had been a man who courted popularity and trimmed his sails to every wind of opinion. As a result there had been no real leadership and hospital standards had suffered accordingly.



Harry Tomaselli admired forthrightness and swift decisions, mostly because those were methods he used himself as administrator of Three Counties. With swift decisions you sometimes made mistakes, but on the whole you got a lot more done, and your average of hits unproved as time went on. Quickness - of speech and thought, as well as action - was something Harry Tomaselli had learned in courtrooms long before he ever thought of finding his destiny behind a hospital desk.



He had entered law school from college and bad begun to lay the foundations of a good practice when war intervened. Anticipating the draft, he had enlisted in the U.S. Navy where he had received a commission and a job in medical administration. Later, as the navy hospitals filled with wounded, Lieutenant Tomaselli had proven himself an able administrator with an instinct for sensing the invisible border line between the practice of medicine and the business of hospital management.



After the war, faced with the choice of returning to law or remaining in hospital work, he had chosen the latter and enrolled in the School of Hospital Administration at Columbia University. He had graduated from Columbia at a time when there was growing recognition of hospital administration as a specialized field of endeavor in which a medical degree was neither necessary nor particularly useful. This had opened up a brisk demand for good administrators, and after two years as an assistant he had accepted Orden Brown's offer of the top post at Three Counties.



Now Harry Tomaselli was in love with his work. He shared Kent O'Donnell's views about the standards of good medicine and respected the business acumen and caginess of the board chairman, Orden Brown. As administrator, it was Tomaselli's business to see that all hospital services - nursing, housekeeping, engineering, building, accounting, and their subsidiaries - measured up to the standards the other two men required.



He did this by delegation - he had a happy faculty of appointing good department heads - and also by an intense personal interest in everything that went on within the hospital. Almost nothing of importance escaped Harry Tomaselli. Each day his short, stocky figure could be seen bustling along the corridors but pausing frequently while he talked with nurses, patients, janitors, clerks, cooks - anyone who could tell him something about the hospital or make a suggestion on how to run it better. New ideas excited him; his own enthusiasm engendered more in others. Sometimes, head thrust forward, eyes gleaming behind his big black-rimmed glasses, he would talk volubly, his thoughts moving at a gallop, his hands underscoring points as he made them.



In all his peregrinations Harry Tomaselli seldom made a written note. His lawyer's training enabled him to carry assorted facts readily in his head. But after each inspection tour he fired off a barrage of staccato memoranda on all points, big and little, where he felt the administration of Three Counties could be improved.



Yet, for all this, he had a diplomat's sense of tone and language that seldom gave offense. Verbally he would hand out a reprimand, then talk cheerfully of something else. And though he never wasted words, his written memos were always gracious. He hated to fire a hospital employee unless the provocation were really strong. He frequently told his department heads, "If anyone has worked here more than a month, we have an investment in their experience. It's to our advantage to mold them if we can, rather than try for someone new who may have other faults we haven't thought of." Because this policy was known and respected, employee morale was high.



There were still things about the organization that worried him. Some departments, he knew, could be made more efficient. There were areas where service to patients could be improved. A good deal of old equipment needed junking and replacement. There was newly developed equipment - the cine-radiography unit was an example - which, under ideal conditions, the hospital should have. The new building program would make good some of these deficiencies but not all. Like O'Donnell, he knew there were years of work ahead and that some objectives perhaps would remain beyond reach. But, after all, that was the road to achievement; you always tried for a little more than you knew you could accomplish.



His thoughts were brought back to the present by Orden Brown. The chairman was telling O'Donnell, "There'll be a good deal of social activity, of course, once the campaign gets going. Oh, and something else. I believe it would be a good thing, Kent, if we put you in as a speaker at the Rotary Club. You could tell them what the new building will do, our plans for the future, and so on."



O'Donnell, who disliked public meetings, especially the regimented bonhomie of service clubs, had been about to grimace but checked himself. Instead he said, "If you think it will help."



"One of my people is on Rotary executive," Orden Brown said. "I'll have him fix it up. That had better be the opening week of the campaign. Then the following week we might do the same thing with Kiwanis."



O'Donnell considered suggesting that the chairman leave him some time for surgery, otherwise he might have trouble meeting his own quota. But he thought better of it.



"By the way," Orden Brown was saying, "are you free for dinner the day after tomorrow?"



"Yes, I am," O'Donnell answered promptly. He always enjoyed the quiet, formal dignity of dinner at the house on the hill.



"I'd like you to come with me to Eustace Swayne's." Seeing O'Donnell's surprise, the chairman added, "It's all right - you're invited. He asked me if I'd tell you."



"Yes, I'll be glad to come." All the same, the invitation to the home of the board of directors' most die-hard member was unexpected. Naturally O'Donnell had met Swayne a few times but had not come to know him well.



"As a matter of fact, it's my suggestion," Brown said. "I'd like you to talk with him about the hospital generally. Let him absorb some of your ideas if you can. Frankly, at times he's a problem on the board, but you know that, of course."



"I'll do what I can." Now that he knew what was involved, O'Donnell did not relish the thought of getting close to board politics. So far he had managed to steer clear of them. But he could not say no to Orden Brown.



The chairman picked up his brief case and prepared to leave. Tomaselli and O'Donnell rose with him.



"It will be just a small party," Orden Brown said. "Probably half a dozen people. Why don't we pick you up on the way across town? I'll phone before we leave."



O'Donnell murmured his thanks as, nodding pleasantly, the chairman went out.



The door had scarcely closed on Orden Brown when tall, slim Kathy Cohen, Tomaselli's secretary, came in. "I'm sorry to interrupt," she said.



"What is it, Kathy?"



She told the administrator, "There's a man on the phone who insists on talking to you. A Mr. Bryan."



"I'm busy with Dr. O'Donnell now. I'll call him back." Tomaselli sounded surprised. Normally he would not have to tell Kathy anything so elementary.



"I told him that, Mr. Tomaselli." She sounded doubtful. "But he's very insistent. He says he's the husband of a patient. I thought you ought to know."



"Maybe you should talk with him, Harry." O'Donnell smiled at the girl. "Take him off Kathy's mind. I don't mind waiting."



"All right." The administrator reached for one of his two telephones.



"It's line four." The girl waited until the connection was made, then went back to the outer office.



"Administrator speaking." Tomaselli's tone was friendly. Then he frowned slightly, listening to what was coming from the other end of the line.



O'Donnell could hear the receiver diaphragm rattling sharply. He caught the words, "Disgraceful situation . . . imposition on a family . . . should be an inquiry."



Tomaselli put his hand over the phone's mouthpiece. He told O'Donnell, "He's really boiling. Something about his wife. I can't quite make put . . ." He listened for a moment more, then said, "Now, Mr. Bryan, supposing you start at the beginning. Tell me what this is all about." He reached for a pad and pencil, then said, "Yes, sir." A pause. "Now tell me, please, when was your wife admitted to hospital?" The phone rattled again and the administrator made a swift note. "And who was your physician?" Again a note. "And the date of discharge?" A pause. "Yes, I see."



O'Donnell heard the words, "Can't get any satisfaction," then Tomaselli was talking again.



"No, Mr. Bryan, I don't remember the particular case. But I will make some inquiries. I promise you that." He listened, then answered, "Yes, sir, I do know what a hospital bill means to a family. But the hospital doesn't make any profit, you know."



O'Donnell could still hear the voice on the telephone, but it sounded calmer, responding to Tomaselli's conciliatory approach. Now the administrator said, "Well, sir, it's the physician who decides how long a patient remains in hospital. I think you should have another talk with your wife's physician, and what I'll do meanwhile is have our treasurer go over your bill, item by item." He listened briefly, then, "Thank you, Mr. Bryan. Good-by."



He hung up the phone, tore off the page of notes, and put it in a tray marked "Dictation."



"What was the trouble?" O'Donnell asked the question casually. In a busy hospital complaints about service and charges were not unique.



"He claims his wife was kept in too long. Now he has to go into debt to pay the bill."



O'Donnell said sharply, "How does he know she was in too long?"



"He says he's checked around - whatever that means." Tomaselli said thoughtfully, "It may have been necessary, of course, but she was here nearly three weeks."



"So?"



"Normally I wouldn't think much about it. But we've had an unusual number of these complaints. They're not always as strong as this - but on the same lines."



Something flashed through O'Donnell's mind: the word Pathology. Aloud he said: "Who was the attending physician?"



Tomaselli glanced at his notes. "Reubens."



"Let's see if we can get him and clear this up now."



Tomaselli touched an intercom set. "Kathy," he said, "see if you can locate Dr. Reubens."



They waited in silence. From the corridor outside they could hear a soft voice on the hospital public-address system. "Dr. Reubens. Dr. Reubens." After a moment the phone buzzed. Tomaselli lifted the receiver and listened. Then he passed it to O'Donnell.



"Reub? It's Kent O'Donnell."



"What can I do for you?" O'Donnell could hear the thin, precise voice of Reubens, one of the senior surgeons, at the other end of the line.



"Do you have a patient" - he looked at Tomaselli's notes which the administrator had pushed toward him - "a Mrs. Bryan?"



"That's right. What's the matter? Has her husband been complaining?"



"You know about it then?"



"Of course I know about it." Reubens sounded annoyed. "Personally I think he has good reason to complain."



"What's the story, Reub?"



"The story is that I admitted Mrs. Bryan for possible carcinoma of the breast. I removed a tumor. It turned out to be benign."



"Then why keep her here for three weeks?" As he asked, O'Donnell remembered that you always had to go through this question-and-answer performance with Reubens. The other man seldom volunteered information.



Now he answered, "You'd better ask Joe Pearson that!"



"Be simpler if you told me, Reub." O'Donnell was quietly insistent. "After all, she's your patient."



There was a silence. Then the thin, clipped voice said, "All right. I told you the tumor was benign. But it was two and a half weeks before I found out. That's how long it took Pearson to get it under his microscope."



"Did you remind him about it?"



"If I called him once I called him half a dozen times. He'd probably have been longer if I hadn't kept after it."



"And that's why you kept Mrs. Bryan in - for three weeks?"



"Naturally." The voice on the phone took on a note of sarcasm. "Or are you suggesting I should have discharged her?"



There was reason for Reubens to be sour on the subject, O'Donnell thought. Unquestionably he had been put in a difficult position. If he had discharged the patient, he might have had to call her back for more surgery, as had happened to Bill Rufus. On the other hand, every additional day in hospital meant an extra financial burden for the family. He answered noncommittally, "I'm not suggesting anything, Reub. Just making some inquiries."



The thing had obviously been on Reubens' mind. "Then you'd better talk to some of the other men," he said. "I'm not the only one this has happened to. You know about Bill Rufus?"



"Yes, I know. Frankly, I thought things had been improving a little."



"If they have, it's not so's you'd notice it. What do you propose to do about Bryan's bill?"



"I doubt if we can do anything. After all, his wife was here for three weeks. Hospital money is tight, you know." O'Donnell wondered what Reubens' reaction would be when he heard he was being asked to give six thousand dollars himself to the hospital building fund.



"It's too bad. Husband's a decent little guy - a carpenter or something like that, works for himself. He didn't have any insurance. This'll set 'em back for a long time." O'Donnell made no answer. His mind was already running ahead, thinking of what came next. Again the thin voice on the phone: "Well, is that all?"



"Yes, Reub; that's all. Thanks." He handed the telephone back to Harry Tomaselli.



"Harry, I want a meeting this afternoon." O'Donnell had made up his mind what had to be done. "Let's try to get half a dozen of the senior people on staff. We'll meet here, if that's convenient, and I'd like you to be here too."



Tomaselli nodded. "Can do."



O'Donnell was checking over names in his mind. "We'll want Harvey Chandler, of course, as chief of medicine. Better have Bill Rufus, and Reubens should be included, I think." He paused. "Oh yes, and Charlie Dornberger. He might be useful. How many is that?"



The administrator checked the names he had written. "Six with you and me. How about Lucy Grainger?"



Briefly O'Donnell hesitated. Then he said, "All right. Let's make it seven then."



"Agenda?" Tomaselli had his pencil poised.



O'Donnell shook his head. "We won't need one. There's just one subject - changes in Pathology."



When the administrator had mentioned Lucy Grainger's name, O'Donnell had hesitated for one reason only: it had reminded him of a meeting between himself and Lucy the night before.



They had met for dinner - the outcome of O'Donnell's invitation to Lucy the day of the mortality conference - and in the Palm Court of the Roosevelt Hotel they had had cocktails, then a leisurely meal. It had been a pleasant, relaxed occasion, and they had talked lightly of themselves, of people they had known, and their own experiences in and out of medicine.



Afterward O'Donnell had driven Lucy home. She had recently moved into Benvenuto Grange, a large, fashionable apartment block on the north side of town. She had said, "You'll come in for a nightcap, of course?"



He had left his car for the uniformed doorman to park and followed her. They rode the gleaming, silent elevator to the fifth floor, then turned down a birch-paneled corridor, their footsteps silenced in deep broadloom. He had raised his eyebrows and Lucy smiled. "It is a little awesome, isn't it? I'm still impressed myself."



She had used her key to open a door and inside touched a switch. Tasteful, subdued lighting sprang up around an elegant interior lounge. He could see the partly opened door of a bedroom directly ahead. "I'll mix us a drink," she said.



Her back was to him. Ice clinked in glasses. O'Donnell said, "Lucy, you've never married?"



"No." She had answered without turning.



He said softly, "I've sometimes wondered why."



"It's very simple really. It's quite some time since I was asked." Lucy turned, carrying the drinks she had mixed. She gave O'Donnell his, then moved to a chair. She said thoughtfully, "Now I think of it, there was only one occasion - at least, only one that mattered. I was a good deal younger then."



O'Donnell sipped his drink. "And your answer was 'no'?"



"I wanted a career in medicine. At the time it seemed terribly important. That and marriage didn't seem to go together."



He asked casually, "Any regrets?"



Lucy considered. "Not really, I suppose. I've achieved what I wanted, and it's been rewarding in many ways. Oh, sometimes one wonders how things would have turned out with a different decision, but after all, that's human, isn't it?"



"I suppose so." O'Donnell was conscious of being strangely moved. There was a sense of depth and tenderness about Lucy, a feeling of peacefulness and coming home. She should have children, he thought. He had asked, "Do you still feel the same way about marriage and medicine - for you, that is?"



"I'm no longer dogmatic about anything." She smiled. "That, at least, I've learned."



O'Donnell wondered what, from his own point of view, marriage to Lucy would be like. Would there be love and mellowness? Or had each of their careers gone parallel too far and too long for change and adjustment now. If married, how might they spend their hours of leisure? Would the talk be intimate and domestic? Or would it be of hospital affairs, with charts on the table at dinner and diagnostic problems for dessert? Would he perhaps, instead of gaining sanctuary, find merely another offshoot of medicine and his daily work. Aloud he said, "I've always thought, you know, that we have a good deal in common."



"Yes, Kent," Lucy answered, "so have I."



O'Donnell had finished his drink, then risen to leave. He realized they had both said a good deal more than had passed in words. Now he wanted time to think and to reason things through. Too much was involved for hasty decisions.



"There's really no need to go, Kent. Stay if you wish." Lucy had said it simply, and he knew if he stayed it would be up to him what happened next.



Part of his mind had told him to remain, but caution and habit won out. He took her hands. "Good night, Lucy. Let's think about all this."



When the elevator doors had closed she was still standing at the open apartment door.