A Surgeon's Heart: The Choice

By R.W. Sewell, M.D.

The Choice is the story of the unrelenting effort of Dr. Jack Roberts to return to the pursuit of his life’s calling as a pediatric heart surgeon. To do so, he must first convince reluctant political powers and giant corporations to support his new, and innovative, patient-centered health care model. Meanwhile, his son, Dr. David Roberts, is embarking on his own journey, as he seeks to join his father in this noble profession. Along the way he finds that the core principles his father taught him are no longer embraced by many of his peers. As the world of health care remains in turmoil, Jack and David must each decide whether they can continue to follow... A Surgeon’s Heart.

• Language: English
• Publisher: R.W. Sewell, M.D.
• Release date: Feb 12, 2015
• ISBN: 9781310557408

R.W. Sewell, M.D.

Robert Walter Sewell was born on November 20, 1950, in Independence, Missouri, and moved to Texas with his parents at the age of twelve. He has lived in Texas since, attending Thomas Jefferson High School in Port Arthur and Lamar University in Beaumont, where he received a bachelor’s degree in biology. He went on to the University of Texas Medical Branch at Galveston, where he achieved his medical degree in 1974. He was accepted into the general surgery residency program at the University of Texas Health Science Center in San Antonio and completed his surgical training in 1979.After finishing his residency, Dr. Sewell immediately began his surgical practice in the Mid-Cities between Dallas and Fort Worth in North Texas. He moved his practice to its current location in Southlake, Texas, in 2003, and remains an active surgeon today, with an emphasis on minimally invasive general surgery at the Texas Health Harris Methodist Hospital Southlake.As a recognized specialist in the field of laparoscopic surgery, Dr. Sewell has lectured on various minimally invasive procedures throughout the United States and around the world. He is a member of the American Society of General Surgeons (ASGS) and was elected president of that organization in February 2008. He is also a fellow of the American College of Surgeons (FACS) and has served as a governor since 2013. Dr. Sewell maintains memberships in the Association of American Physicians and Surgeons, the Texas Medical Association, the Tarrant County Medical Society, as well as the prestigious Texas Surgical Society.Along with his wife, Donna, Dr. Sewell resides in Colleyville, Texas, where he enjoys golf, photography, computer graphics, video production, gardening and, of course, writing.

Book preview

A Surgeon's Heart:

The Choice

by

R.W. Sewell, M.D.

Smashwords Ebook Edition

Copyright 2015 R.W. Sewell, M.D.

All rights reserved.

(Robert Sewell, M.D.)

This ebook is licensed for your personal enjoyment only. This ebook may not be re-sold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each recipient. If you’re reading this book and did not purchase it, or it was not purchased for your use only, then please return to your favorite ebook retailer and purchase your own copy. Thank you for respecting the hard work of this author.

DEDICATION

This book is respectfully dedicated to the vast number of patients and their family members who have been adversely affected by recent changes to the American health care system. Your health and well-being remains the primary concern of most of America’s physicians, and as long as the Hippocratic oath remains a part of our creed, we will endeavor to find ways to advocate on your behalf. Thank you for your continued trust.

INTRODUCTION

A Surgeon’s Heart: The Choice is the fourth volume in this series, featuring a prominent pediatric heart surgeon in his quest to return to his life’s calling. After finding himself separated from his cherished profession due to his unwillingness to compromise, he is now determined to get back to work. Despite the label of retired surgeon, Jack Roberts feels a new calling that could change the course of modern heart surgery, and revive the entire medical profession.

In this ongoing fictitious story, Dr. Roberts has made his choice to pursue a new strategy with the same tenacity he has employed throughout his career repairing the hearts of countless children. His wife, Elaina, is his biggest supporter, but he recognized he cannot achieve his goal of building a modern children’s heart hospital in a third world country without help. His billionaire friend, Franco Gutierrez, uses his considerable connections to put Jack in front of the people who can either make or break his concept. The prospects of accomplishing his goals seem unlikely, as behind the scene there are forces struggling with whether or not to allow the kind of health care freedom he is seeking to introduce.

The story is filled with international intrigue as well as major social, political and economic questions as the characters deal with real life issues. As a first year surgical resident, Jack’s son, David, encounters an entirely different training process than his father, with emphasis on simulators rather than actual hands-on training. He recognizes the deficiency but is incapable of changing it.

Increasing government regulations on manufacturers make it increasingly difficult for new health care products to be produced while arbitrary guidelines act as rationing tools for the payers who control the American market. As a result, many of the major players seek refuge in unlikely places, where the economic climate is more suitable to their profit-driven enterprises.

A Surgeon’s Heart: The Choice offers the reader a unique forecast of what the American health care system may be destined to become. The story describes the transitional state where physicians play a subordinate role to big government and big business. Some, like Jack Roberts recognize that much of what is happening is contrary to the traditional ethical standard of his profession, while others simply accept the growing trend which ultimately leaves them, and their patients, in its wake. As the problems mount Jack offers an alternative based on a patient-centered philosophy, and fueled by his own ingenuity and entrepreneurial spirit. Please enjoy.

R.W. Sewell, M.D.

ACKNOWLEDGMENTS

Like all of the books in this series, A Surgeon’s Heart: The Choice is a work of fiction. It is the product of the author's imagination and is based, in part, on his own experiences as a practicing general surgeon for the last thirty-five years. With a few notable exceptions the characters described in this story are not real people. Any similarities with any real persons, either living or deceased, is purely coincidental. Likewise, each of the facilities and specific situations portrayed in this story are fictitious. In those situation in which the names of actual historical figures are used, it is purely to provide a realistic perspective for the story. The author has no personal knowledge of those individuals and all of the descriptions of their actions and opinions, as well as any and all quotes attributed to them are completely fictitious.

Producing any single work of fiction poses some unique challenges, not the least of which is staying motivated. As this is the fourth book in this series, all written within a 24 month period, there were countless times when the motivation just wasn’t there. However, when my energy was at its ebb, someone would invariably post a positive review of one of the previous novels online, or tell me in person how much they related to the story, or a particular character. To those individuals I offer a heartfelt thank you for your words. They were just the motivational tonic I needed to keep moving forward.

I want to thank my friend Carol J. Peat for her continued willingness to offer her unparalleled expertise in composition, grammar, spelling and punctuation. She has been an indispensable asset in making this story readable, and I can truthfully say I could not have produced this book without her help. I also want to thank my good friend and colleague, Dr. Howard Harris as well as his son, Walker Harris, for portraying Jack and David Roberts on the cover. They fit my vision of the two main characters perfectly.

As everyone knows, projects like writing a novel, and particularly four novels in a short period of time occupies considerable time and energy, both physical and emotional. Only a saint could put up with the constant moodiness and hours of preoccupation of an author in the middle of crafting a story about which they are very passionate. My wife, Donna, is such a saint, and without her continued support I would have abandoned the computer keyboard long before completing this task. How she has put up with me for more than thirty-two years is a mystery known only to her and the good Lord.

CHAPTER 1

It had been five days since the arrival of the new year, and Jack had chosen this bright Monday morning to begin outlining his plans for 2015. He could only hope and pray the coming year would be less stressful than its predecessor. Nothing could be as agonizing as the month Elaina had lain comatose in the government hospital. As a heart surgeon, he knew just how close his wife had come to dying from a depressed skull fracture. Now, six months after the accident, Jack Roberts was finally ready to move on with the next phase of his life. His wife was fully recovered, and he felt free to begin again.

Sitting in his lounge chair on the back deck of their seaside home in El Transito, Nicaragua, he was typing intently on his new MacBook Pro. Elaina had given him the new computer for Christmas, but Jack suspected her gift was specifically to allow her to confiscate the one in his office for her own purposes. Today he was using the word processor to outline all the things he planned to accomplish over the next twelve months and beyond.

The couple had moved to the Pacific coast of the Central American country fifteen months earlier, amid a major controversy. Jack had decided to retire and leave his busy practice at the children’s hospital back in Fort Worth. That was all a distant memory, but he felt he had to find a way to return to his life-long calling. While officially retired, the sixty-six year old pediatric heart surgeon knew he still had a lot to offer. For him it was more than a desire to be busy, it was a physical need. His hands were aching to do what they had done most of his adult life, and his heart and his soul demanded that he get back to helping innocent children born with heart defects. He was determined to accomplish his goal no matter the obstacles.

Jack? Elaina said, as she stepped out the back door. Your cell phone was ringing, but I didn’t get to it in time to answer.

She handed him the phone and returned back to the house. He looked quizzically at the local number. It was not one he recognized, and the caller had not left a message. He tapped the recall feature and within a few seconds a woman’s voice answered. Spanish was Jack’s second language, but over the last year, it had become almost primary except when he and Elaina were speaking to each other.

This is the office of Director Cuero-Marquez. How may I help you? she asked.

Hi, this is Dr. Jack Roberts, he replied. Someone from your office just called my cell phone.

Yes, sir, that was the director. Please hold and I will see if he is available.

In a few seconds the familiar voice of the director of the government hospital in Managua said, Good morning, Dr. Roberts. How are you?

I’m fine, Jack replied, in a guarded tone. What’s up?

Thank you for returning my call, the director said in his always politically friendly voice. The reason for my call is regarding your wife’s hospital bill. It has been five months and we have yet to receive any correspondence from your insurance company.

Jack knew the claim had been filed and denied initially by the international division of BlueCross. He had purchased the BlueCard Worldwide policy shortly after they moved to Nicaragua, and Mary Anne, his former office manager and personal assistant back in Texas, had filed two separate appeals. He couldn’t imagine the insurance carrier not notifying the hospital.

They haven’t sent you anything? he asked.

No, the director replied emphatically. In fact, we have submitted the bill three separate times.

My office manager told me she received a letter indicating they had rejected the claim, but they didn’t say why. Are you telling me you have not received anything from them?

Not to my knowledge.

That is really strange, Jack said, wondering whether the correspondence might have been lost, or perhaps the director just wasn’t aware of it. I will contact them myself as soon as we get off the phone.

Please do. I would not wish for you to be saddled with paying such an amount.

Jack was aware the director had increased the amount of the hospital’s claim submitted to his insurance company to nearly three times the amount he’d originally quoted him, but he didn’t want to get into that discussion right now.

I will let you know as soon as I find out anything more.

Your assistance will be greatly appreciated, the director said, again employing his formal tone.

No problem, Jack offered, casually. By the way, he added, I’ve been planning to come in to speak with you about another matter. Are you available on Thursday or Friday afternoon?

Let me check my calendar, he replied.

The director had very little to do with the day-to-day operations of the hospital, so unless he had a meeting scheduled with the Minister of Health or some other high ranking government official, his schedule was always open.

Yes, he said after a brief pause. I can meet with you here at three o’clock on Thursday afternoon.

Great! I’ll see you then, Jack replied, and, I should have some information about the insurance claim by that time.

Thank you, Dr. Roberts. I look forward to seeing you on Thursday.

Jack touched the end button on his phone before searching through his contacts for another number.

Hi, Mary Anne, he said. It’s me.

Dr. Roberts, she replied excitedly. It’s good to hear your voice again. How are things in Nicaragua? She had visited their oceanside home two months before, and was eagerly awaiting his invitation to join him as his personal assistant.

Just fine, he replied. It’s a sunny seventy-eight degrees here. How is it there?

It’s not bad, today, she said. It’s about forty degrees, and it has finally stopped raining. We’ve had rain mixed with freezing rain every day since Christmas.

Hopefully it won’t be much longer before we can get you down here. He was referring to his plan to have his trusted former employee move to Nicaragua permanently. The sixty-one year old widow had worked for him since he started his private practice in 1988. He’d arrived in Fort Worth, fresh out of the Air Force, and felt fortunate to have found her. She had proven to be detail oriented, completely honest, and trustworthy beyond his expectations. He thought she would be invaluable in managing the logistics of his new endeavor.

I bought one of those computer programs to help me learn Spanish, and I’ve been studying it every day for the last two months.

That’s great, he replied with a laugh. He started to speak to her in Spanish, but decided he didn’t want to embarrass her if she hadn’t progressed beyond learning numbers and the days of the week. The real reason I called was to check on the status of the claim for Elaina’s hospitalization. Have you heard anything more from Blue Cross?

No, I tried calling them last week, but I couldn’t get through. I suspected it was because of the holidays, she offered. I was planning to try again either today or tomorrow.

That’s all right, he said. I’m going to call them myself. Could I get you to text me the hotline and the claim number?

I don’t mind calling them, sir, she insisted.

I know you don’t, but I want to find out first hand what’s going on. The director of the hospital called me today and said they haven’t received any correspondence from BlueCross.

I find that hard to believe, she said. The letters we’ve received are merely copies of what they sent to the hospital.

I suspect that’s true, but I need to… He paused as an idea occurred to him. Come to think if it, would you mind scanning those letters and attach them to an email? I don’t have a dedicated fax line here, so email will be the quickest and easiest way for me to get them.

Sure, she said. Give me about five minutes and you’ll have them.

Keep up with your Spanish, he said. I’m hoping it won’t be much longer.

I will, she said before adding, "Adios."

After a few minutes he saw her emails in his inbox and he quickly opened each file. Armed with the required information he found the toll-free number and placed the call.

A computer generated female voice answered, stating, This is the BlueCross and BlueShield claims hotline. If you have a medical emergency you should hang up and dial 9-1-1.

Oh good grief, Jack said in disgust, addressing the answering machine. If I had an emergency do you think I’d be calling an insurance company?

The automated system ignored his brief rant and asked him a series of questions until finally directing him to what he hoped was the appropriate division. He remained on hold listening to another advertisement for the various services offered by the giant insurance company. Every three minutes the on hold message was interrupted by the recorded voice, saying, Your call is very important to us. Please continue to hold and the next available customer service representative will be with you shortly.

After he’d heard the same ad loop repeated eight times he checked the time. He’d been on hold for twenty-five minutes, with no indication how long it would be before an actual human would come on the line. Suddenly he heard, This is the BlueCross hotline for claims resolution. My name is Beverly. May I have your thirteen digit claim number?

Hi, he said. My name is Jack Roberts and…

I just need your thirteen digit claim number, sir, she interrupted.

Jack provided the number, but when she read it back to him she had transposed two of the numbers. Finally she entered the correct digits and said, This is an international claim.

Yes, he replied. I was calling to see…

We don’t handle international claims in this department, she interrupted again, this time indignantly. You will need to call the BlueCard Worldwide hotline.

I thought this was the BlueCard…

No, sir, she insisted, cutting him off again. This is the national claims resolution hotline. We only handle claims within the United States.

I got this number directly from the letter I was sent denying the claim, he spouted.

I’m sorry, sir, she said, speaking more calmly now than before he had raised his voice. Would you like me to forward you to the correct department?

Yes, of course!

Let me give you another number in case we get disconnected.

He didn’t have anything to write with, so he quickly typed the new number into his computer’s Notes program, hoping he wouldn’t need it.

I will transfer you now, she said. Have a nice day.

It wasn’t starting out all that great from his perspective, and it was soon made worse when he heard the call disconnect only seconds after she put him on hold.

*********

David was finally off the trauma surgery service after an exhausting three month stint. On January 1, 2015 he had started a two month rotation on the cardiothoracic surgery service. Finally he would get the opportunity to scrub in on what most of the guys called big-picture surgery. Cracking chests and operating on the heart: those were things he’d dreamed of doing for as long as he could remember. As a young boy he recalled making hospital rounds with his dad on the weekends. While technically Jack wasn't his biological father, he was the only dad he’d ever known. Jack had insisted on adopting him immediately after he and Elaina were married. She’d had sole custody of the blond-headed two-year-old whom Jack had operated on urgently to repair a worsening congenital heart condition. Following David’s surgery, his mother had fallen in love with the dashing six-foot three-inch surgeon, largely because of the compassion he’d shown toward her son. She welcomed the idea of David having a father in his life and Jack had filled that role beyond her expectations.

The boy had idolized his dad, and never considered any career options other than becoming a pediatric heart surgeon, like his father. Six months ago the handsome twenty-five year old had graduated from the University of Texas - Southwestern medical school in Dallas, just as Jack had done nearly forty years before. Now he was a first year surgical resident at Parkland Memorial Hospital where his dad had also begun his training. In those days they called the first year doctors interns, but now they were referred to as PGY-1s.

The name change was not the only thing different about the surgical training program. Today the young trainees spent more time in simulators and classrooms than they did in operating rooms, and their work hours were limited to a maximum of eighty per week. David had already seen how those restrictions were impacting his learning opportunities as well as the continuity of the care provided to his patients. However, those challenges only served to increase his determination to become the best pediatric heart surgeon possible. Of course that was going to take another seven-and-a-half years, assuming he could land the cardiothoracic fellowship after five years of general surgery training. Then he would need another year of pediatric heart surgery. He would be thirty-three years old by the time he finished his training.

The cardiothoracic surgery program at the university hospital had recently fallen on difficult times. The head of the heart transplant program, Dr. John Fremont, had unexpectedly retired the previous year, and he’d been replaced by a young inexperienced woman by the name of Barbara Kramer. Another young surgeon had also left the department after less than a year on the faculty. He had gone job hunting, somehow believing his credentials were worth more than the entry level pay offered by Southwestern.

Perhaps the single biggest reason the heart program was struggling was the serious cutbacks in Medicare payments. The Patient Protection and Affordable Care Act, the law everyone referred to as Obamacare, was now fully implemented. Along with sweeping reforms in the insurance industry and massive new regulations on hospitals and physicians, the new law was being funded in part by decreases in the federal Medicare budget. Before 2014, hospitals had consistently made a modest profit on major surgical procedures paid for by Medicare. With the recent cuts, government payments no longer covered the cost of many complex procedures like major heart surgery. The very operations that had once provided a significant revenue stream were now draining hospital reserves. Administrators across the country were looking for ways to cut their losses, and they found an unexpected ally in the federal government.

In an effort to reduce payments for many high volume procedures, like coronary artery bypass, the Centers for Medicare and Medicaid services had begun tightening the criteria which must be met before the procedures could be approved. If the requirements were not met and the procedure was performed anyway, Medicare simply wouldn’t pay for it. Hospitals, both public and private, had implemented stringent protocols based on the CMS criteria, and physicians were compelled to abide by them. The net result was a significant decline in the number of cardiac procedures being performed, and in teaching institutions, it meant fewer cases and less training for resident surgeons.

For decades Medicare had also provided additional funds to support residency programs, and under the new law those payments had also been slashed. This particular training program had once turned out two cardiothoracic surgeons every year, but now they could only accept one new fellow per year. There was even talk about having just a single cardiothoracic fellow in the two year program, reducing the number of these specialty surgeons completing the training to one every other year.

The economic concerns were not the only issues facing the heart surgery program. Each year more procedures were being performed by the interventional cardiologist. Using catheter-based techniques, these non-surgical specialists were performing a variety of procedures without even consulting their surgeon counterparts. The combination of all these factors was a recipe for the eventual collapse of the heart surgery program.

David had been on the cardiothoracic service for four days and had yet to see his first heart operation. He’d been told it was because of the holidays and that things would pick up. This was the first scheduled operating day of the new year, so he was excited to scrub in on a four vessel coronary bypass.

At 7:00 a.m. David accompanied his patient from the preoperative holding area back into the operating room, along with the anesthesia resident and the circulating nurse. The seventy year old man on the stretcher was extremely nervous and had remarked several times how young everyone around him appeared.

Dr. Makowski will be here for your operation, David said, hoping to calm the man’s fears.

Who the hell is he? the patient asked angrily.

He is the faculty surgeon who will be doing your operation, David said, even though the statement was not entirely true. The chief cardiothoracic surgery resident would be performing the operation with Makowski assisting.

I just hope you guys don’t kill me, the man said as the team moved him onto the operating table.

The anesthesia resident seemed nonchalant as he turned on the oxygen and placed the mask over the man’s face without speaking to him. It was the nurse who said, Just relax. We’ll take very good care of you, Mr. Lewis.

Her voice had a robotic tone as the patient continued staring nervously at the ceiling. When the stretcher was rolled away, David moved to the head of the bed and leaned over slightly, his face hidden by a paper surgical mask. I’ll see you in the recovery room when you wake up, Mr. Lewis.

The man’s gaze softened slightly, as he glanced over at David. With those encouraging words the patient seemed to relax as he said, Okay. I’m gonna hold you to it.

It seemed an eternity from the time they entered the room until the team was ready for the initial incision. It had taken more than an hour for the senior anesthesiology resident to place the multiple monitoring catheters in different parts of the man’s body. As he was working, the nurse removed the patient’s hospital gown along with the sheets and blankets that were covering him, exposing his naked body to the cool air of the operating room. Each person in the OR went about their business very methodically as if preparing a stage for a star performer.

Dr. Makowski prefers the internal mammary arteries to perform the bypasses, she explained to the new member of the heart team, but we still prep both legs in case he needs to harvest one of the saphenous veins.

David understood the plan to use the small arteries located just under the ribs to bypass the areas of blockage in the coronary arteries and restore normal blood flow to the heart muscle. If those vessels weren’t adequate they would need to use the veins of the patient’s legs, so as instructed he used the surgical clippers to remove the hair from both the patient’s legs, up to and including the groin areas. The nurse used another battery operated clippers to remove the sparse gray hair from the man’s chest.

The temperature in the room was a cool sixty-two degrees, and the fully exposed, motionless body would quickly become hypothermic without the warming blanket which had been placed under him. However, maintaining a normal body temperature was of little concern to the team at this point, since a lower core temperature would actually help protect the patient’s vital organs during the time he was on bypass.

A second nurse came into the room to assist with the surgical prep, which would include washing the man’s entire body from the neck down except for his arms, which were placed on small extensions of the operating table, which extended out at ninety degree angles from either side. The nurses could not complete the cleansing of the patient until the anesthesia resident finished placing the last of the monitors, but eventually they began the ten minute scrub.

Your job is to hold the legs up while the nurse scrubs them, the fourth year resident instructed. The thirty-three year old Kenyan, Dr. Jamil Onyango, was charged with getting the patient ready for surgery. He was three years ahead of David in the training program, but eight years his elder. The East African had struggled to gain admission into the United States during the post 9-11 era. In 2003, as a twenty-one year-old, he finally managed to get a sponsor through the American embassy in Nairobi and he’d been living in the US for a dozen years. He’d come to Parkland for his surgical training after graduating from the University of Pennsylvania school of medicine in Philadelphia. Prior to that he’d attended Dartmouth University with the assistance of an international student grant. Onyango was a likable man whom everyone called Jamie, and the Southwestern faculty considered him an outstanding resident. He was slotted for the cardiothoracic fellowship once he finished his general surgery training in another eighteen months.

David dutifully held the patient’s ankles, suspending his feet well above the thin rubber mattress and the waterproof warming blanket, as one nurse washed the man’s legs with a hexachlorophene soap rather than the brown iodine-based antiseptic David was accustomed to seeing.

Why aren’t you using Betadine? he asked.

As of the first of the year the hospital has converted over to this stuff, the nurse replied. Dr. Makowski is not gonna be happy about it, but dem’s da rules. I don’t make ‘em, I just follow ‘em.

The rules? David wondered what she meant, but soon he nodded that he understood. Like his dad always said, just follow the money.

Before the prep was completed, Dr. Makowski and Dr. Brandon Minchew entered the room. They held their freshly scrubbed hands up at shoulder level as water dripped periodically off their elbows.

So that’s what I want you to do, Makowski said, continuing his instruction from the scrub sink as they entered, prompting the younger surgeon to offer a silent nod of agreement.

Minchew was in his seventh year of training, and was now the senior cardiothoracic fellow with a considerable reputation around the hospital. He was an excellent surgeon, but his operating talents were definitely exceeded by his ego. He rarely spoke to any of his subordinates except to criticize or belittle them, and the faculty said nothing. He also had a reputation for being quite the ladies’ man. David wondered whether the stories circulating around the hospital might be exaggerated just a bit. There was no way anyone had the time or the energy to allegedly entertain every available nurse in the building and still remain the darling of the surgical department. The only way the rumors could be true is if he were one of those guys who could get by on three hours of sleep per night.

As the two surgeons draped the patient, Makowski made a point of criticizing the absence of the brownish prep material.

You know I no longer have a choice, doctor, the nurse said. Hexachlorophene is all that we have in the department.

I know, he replied, angrily. The switch saves the department about ten bucks per case. I just wonder how much an extra wound infection will cost?

All the studies suggest that the new hexachlorophene based solutions are just as effective in preventing wound infections as the older iodine compounds, Minchew offered. He was the only resident who could get away with engaging Makowski in such a debate, but he wasn’t above reproach.

I don’t give a damn what the studies say, he offered in response. I’m sure those studies were paid for by the people who make this new crap. They pay for the results they want. All I know is Betadine has worked very well for forty years and it just pisses me off that some damned bean counter has decided that I can’t use it any more on my own patients. If this guy gets a wound infection, who do you think will get the blame?

David lowered the patient’s legs onto the sterile sheet and he and Jamie went out into the corridor to scrub their hands. As the two doctors stood at the sink, Jamie spoke to David with his thick East African accent. Do not ask any questions, he advised. Makowski will do all the talking during the procedure. You are not to speak unless he asks you a specific question. Do you understand?

Sure, David replied. He wondered for a moment what would happen if he broke this unwritten rule, but since he’d already had three separate run-ins with senior faculty in the first six months of his training he didn’t plan to find out. He would keep his head down and his mouth shut.

David and Jamie quickly joined the two primary surgeons at the patient’s bedside. The experienced scrub nurse stood next to Dr. Makowski on the opposite side of the table from the primary surgeon. From that position she could quickly hand either of them the instruments they requested. Jamie stood next to Dr. Minchew, prepared to do whatever tasks he might be assigned, but in reality there wasn’t much for the second assistant to do in the chest. As the third assistant David was truly a fifth wheel. He stood next to Jamie with his gloved hands on the patient’s right lower leg trying to see what was going on over the shorter man’s shoulder.

Are you ready? Makowski asked the anesthesiologist. When he received an affirmative response he nodded toward Minchew, indicating he should begin.

The surgeon declared, Time-out, followed by stating the patient’s name to the entire group as well as the planned procedure. David wondered what would happen if someone were to raise an objection. In a way this new operating room tradition seemed silly. Surely, if the wrong patient were on the table, someone would have recognized it long before now, but apparently stranger things had happened, so the time-out ritual was now one of those rules the nurse referred to earlier.

Minchew called for the scalpel and drew it expertly down the center of the man’s chest. David watched intently as the senior resident used an air powered saw to split the patient’s sternum. He placed a large metal device into the space and turned the handle, slowly separating the two halves of the breast bone to expose the well-protected organ. David could see the rhythmic movements of the heart through the pericardium, but it wasn’t until Minchew cut through the tough sac surrounding it that he could see the target, not only of this procedure, but also of his life’s ambition.

Roberts? Makowski’s voice pierced the silence, startling David.

Yes, sir, he replied, trying not to sound surprised.

I understand your old man is a heart surgeon? the professor asked. To David his tone seemed almost too casual given the situation.

Yes, sir, David replied. He recently retired.

Yeah. That’s what I heard from Dr. Wilkinson. Makowski continued to assist the resident as they prepared to put the patient on the heart-lung bypass machine. He tells me you’re wanting to follow in your dad’s footsteps.

Yes, sir, David replied, realizing he sounded like a broken record.

Where do you intend to do your training?

I was hoping right here, sir.

This is a highly competitive program, you know, Makowski said, as he looked down the table over his glasses which were equipped with additional magnifying lenses.

Yes, sir, David acknowledged. I plan to also do a pediatric heart surgery fellowship.

Pedi hearts? Makowski exclaimed with a laugh. You really are a glutton for punishment.

Before David could answer, Makowski began giving instructions to the scrub nurse in preparation for passing off the sterile tubing which would be connected to the heart-lung machine. The pump tech began the process of rolling the complex apparatus into position immediately behind the surgeon. The process of placing the patient on bypass was routine for this team, but this was the first time David had participated, and he was thoroughly fascinated by the process. Two large plastic tubes were inserted into the superior and inferior vena cavae, the huge veins which brought blood from the entire body into the right atrium. Once on bypass, all the patient’s blood would be diverted through those tubes into the heart-lung machine. The blood would pass through a membrane oxygenator, which would replace carbon dioxide with oxygen. The blood would then be pumped back into the patient through another clear plastic tube inserted into the aorta.

Once all the tubes had been inserted, Minchew announced to the team he was ready to go on bypass. The technician turned a dial on the control panel and the machine’s roller pumps slowly began to turn, rhythmically squeezing the tubing, drawing the blood out of the man’s body and into the machine. David could see the tubing gradually filling with dark red blood while the heart was still beating.

The burgundy colored fluid passed through the oxygenator where it quickly turned bright red as hemoglobin molecules gave up their carbon dioxide burden and became filled with oxygen. A second roller pump returned the life sustaining fluid back to its rightful owner.

We’re on partial, the technician stated as the patient’s body was being supplied with blood from two separate and very different pumps. Minchew began placing an icy slurry around the heart to cool it in anticipation of stopping it entirely. The heart slowed perceptibly under the influence of the chilled bath, and as the rate continued to slow Minchew tightened the tapes around the vena cavae, effectively shunting all the venous blood to the machine. At the same time he partially clamped the aorta above the increasingly ineffective heart.

Cardioplegic solution, Minchew demanded as he held out his hand. The scrub nurse handed him a large syringe filled with a solution designed to paralyze the man’s heart. He injected the bloody fluid directly into the base of the aorta where it quickly made its way through the coronary arteries and into the heart muscle. Minchew waited for a moment then tightened the clamp on the aorta, completely isolating the heart.

We’re on full, he said, as the heart attempted one last feeble effort to continue its assigned task. For the first time in seventy years it was no longer keeping this man alive. The anesthesiologist switched off the ventilator eliminating another familiar sound of life. Mr. Lewis was no longer breathing and his heart was lying motionless surrounded by an icy slush tinged with blood. The rhythmic motion that had fascinated David earlier was absent, and the dark red muscle, covered with streaks of yellow fat, looked totally lifeless in the chest, replaced by the thumping sound of the roller pumps mounted on the machine manned by a technician.

Over the next ninety minutes the resident heart surgeon identified four separate areas in the arteries that coursed along the surface of the heart. Each critical blockage was bypassed by opening the artery beyond the obstruction, and suturing one of the internal mammary arteries directly to the vessels. The process offered a new source of blood to the oxygen-starved muscle.

Okay, Minchew proclaimed. All four jumps are complete. Let’s get ready to come off pump.

Each of the steps he’d used to stop the heart would now be reversed, including replacing the icy bath around the heart with a warming solution. Minchew injected another syringe of fluid into the aortic root to reverse the paralyzing effects of the cardioplegic drugs. He then loosened the tapes around the huge veins, allowing the chambers of the heart to fill with blood again. Almost immediately the heart muscle contracted once, then again. Slowly the rhythmic beating resumed, influenced in part by medications given by the anesthesiologist to strengthen the force of the contractions and to speed up the rate. Within two minutes the characteristic rhythm was back.

Reduce your flow to half, Minchew instructed the pump tech. The thumping of the pump slowed significantly as the heart gradually took over the function of the machine.

How’s his pressure?

One hundred, was the response from above the drapes. I’ve started him on a little something to support it.

Within five minutes the pump was turned off and the anesthesiologist indicated he was satisfied the heart was doing its job once more. Soon the tubes were removed and the procedure was deemed a success by Makowski.

Good job, he said. I think you could have been a little smoother doing the circumflex, but overall, good job.

It was Makowski’s style to always find fault with something. In this case he decided to point out how Minchew had struggled getting into optimal position to perform one of the more challenging bypasses. To Minchew’s credit he took the criticism in stride. He knew what it was about, because he used the same technique on those residents beneath him, making sure they understood he was their superior.

Minchew placed two large clear plastic drainage tubes through separate incisions in the skin of the upper abdomen, positioning them in the space above the heart. He then pulled the sternum back together with heavy wire sutures passed around both halves of the protective bony plate. Makowski stepped back from the table and pointed to Jamie. You come around here and help him close. He then added, Roberts, you come with me.

*********

After nearly an hour, Jack was ready to hang up when a foreign sounding male voice came on the line. This is the BlueCard Worldwide Hotline, to whom am I speaking?

My name is Jack Roberts, he said.

What can I help you with, Mr. Robert?

I’m calling about a claim that has been inappropriately denied, Jack spoke hastily, mostly out of frustration. He allowed his anger to bleed through into his words. And it’s Roberts, with an s.

Do you have a claim number? the man asked.

Jack gave him the number one digit at a time, anticipating this individual was just as likely to get it wrong as the woman he’d spoken with earlier.

Just one moment please, the man said. Then without waiting for a response he placed Jack on hold. The same advertising message returned, and Jack was actually relieved. At least he hadn’t been cut off again, and this time the wait was brief. When the man returned after less than a minute, he said, I found your file in our records. I need to verify your identity. Could you please give me your full name as it appears on this account and tell me the last four digits of your social security number?

Once the man confirmed Jack’s identity, he asked, What can I help you with, Mr. Roberts?

I want to know why the claim for my wife’s care at the hospital in Managua, Nicaragua has not been paid? Jack asked.

Exactly which claim are you referring to, sir?

There’s only one, Jack replied with a growing frustration in his voice. Her name is Elaina Roberts, and she was in the hospital from July 5 to August 7, 2014.

Yes, sir, the man replied calmly. I see that we received three separate claims for an Elaina Roberts. Which one are you referring to?

They are all the same, Jack replied. It is my understanding that the hospital resubmitted the claim two additional times when they failed to receive payment.

Well, sir, each of these claims is slightly different. They each have different dates of service and different amounts.

You’re kidding, Jack replied.

No, sir, we received a claim on August 11 for the service dates you gave me. It was rejected as incomplete, and a notice to that effect was sent to the provider on August 27. A second claim was received on October 8 for a different amount and the dates of service were from July 5 to August 8. It, too, was rejected as being incomplete. Another letter notifying the provider of the denial was sent on October 15. Then we received a third claim on December 18. The dates of service were July 4 to August 6, and it was also rejected as incomplete.

What was it that was incomplete?

I don’t have that information, sir, the man explained. You will need to take that up with our claims processing department.

I thought you were the hotline, Jack spouted.

This is the hotline, sir, the man answered robotically. I am only authorized to provide you the status of your claim. You will need to speak to someone in claims processing about why these claims were denied.

Jack’s patience was wearing thin. He had been on the phone this time for seventy-five minutes with little to show for it. Can you transfer me to that department?

Yes, sir, the man answered, but let me give you their direct number in the event we get cut off in the process.

Jack typed in the number on his computer as he had the previous time, then waited on hold again. What an incredible waste of time this process was, he thought. He recalled the countless times Mary Anne talked about the hours she spent on hold with various insurance companies and how frustrated she was at the end of each day.

When the claims processing representative answered the phone, she went through the same identification process to pull up the claims. Each of these claims was denied because they were incomplete, the woman said.

Can you tell me what it was that was incomplete? Jack asked.

Yes, sir, none of them included an itemized list of billable hospital charges, and there were no diagnostic or procedure codes provided for the specific physician services listed on the form. We cannot process a claim without that information.

You do realize this is a third world country, right? Jack reasoned.

That may be, she answered, but BlueCross World Card has certain standards that must be met. Our policies and procedures are very clearly explained in seventeen different languages in the claims submission section of our website.

So, you’re saying you won’t consider this claim unless all that information is provided?

That is correct, sir, she replied.

Okay, Jack sighed. Can I get you to send me an email outlining the deficiencies so I can get everything submitted properly?

I’m afraid not, she said.

Why? Jack pleaded.

This account is currently under investigation by our security division for potential fraud.

You’ve got to be kidding me! Jack exclaimed.

No, sir, anytime we receive conflicting claims with overlapping dates or other irregularities we place a lock on the account until it can be determined whether or not the claim or claims are legitimate. Clearly she was reading a script that had been prepared by their legal department. He wasn’t going to get any usable information.

I just have one more question, Jack offered with more than a hint of sarcasm in his voice. Can you explain why you paid the claim submitted by the same hospital for care they provided to me as a result of the same accident? I’m certain they used the same inadequate process when they filed it.

I don’t have any information regarding any other claims on this account, she said, sounding as though she was searching through the computer records. Oh, wait, I do see here where we paid on a claim for hospital care provided on July 5, 2014 to a Jackson Roberts. Is that what you are referring to?

Yes, my wife and I were both injured in the same accident, and you paid on my claim but not hers.

The phone was silent for a moment as the woman scanned the file. I see what you are saying, she said, hesitating briefly once again. It appears the claim for your care did not meet the threshold that would trigger a denial.

What do you mean, trigger a denial? Jack asked skeptically.

It was under ten thousand dollars, she replied.

Now I understand, Jack replied. As long as the claim is small it is paid without question, but if it’s more than ten thousand dollars it gets denied automatically, right?

That’s not what I said, she objected, realizing that like every customer service call, this one was being monitored for quality and for training purposes, and she could be disciplined for having implied there was some directive to deny certain claims.

*********

So your dad is living in Nicaragua? Makowski asked as they walked out of the operating room together.

Yes, sir, David replied, unsure why he’d been pulled out of the procedure by the senior staff cardiac surgeon.

I heard a little bit about what he went through over in Fort Worth, he said. That was more than a year ago, wasn't it?

Yes, sir.

What is he doing now?

He’s working with a friend of his a few days a week in a free clinic, but he’s planning to build a children’s heart hospital near Managua.

Really? the older surgeon sounded skeptical. I’d be surprised if anything worthwhile can be built in that backwater country.

It’s really very nice down there, David offered.

Oh, I’m sure it is, but I can’t imagine dealing with all the regulations and restrictions that would be imposed in that part of the world on anyone attempting to build a real hospital. Plus, their economy couldn’t possibly support a decent facility.

David started to engage his professor in a debate over the massive regulations and restrictions that had been imposed on American hospitals and the entire healthcare system over the last few years, but thought better of it. He remembered what his dad said about faculty members. He’d told him not to challenge them even when you are certain you're right. They’re generally too insecure to allow those beneath them to show them up.

Makowski led the way toward his office with David in tow. When they arrived he said, Have a seat.

David sat cautiously in one of the hard wooden chairs facing the professor, wondering what kind of trouble he could possibly be in now. He’d been a doctor just over six months and to the best of his knowledge he was the only PGY-1 to have been called on the carpet at least once in each of his first three rotations. Here he was, only five days into his fourth rotation, sitting across the desk from yet another division chief.

The reason I wanted to talk with you, Roberts, Makowski began, is to see if you might be interested in a new accelerated heart surgery program. When we move across the street into the new hospital we are planning to begin a new training track that could get you to your goal of becoming a heart surgeon a couple of years quicker than the traditional five years of general surgery and two years of cardiothoracic.

David’s jaw dropped slightly and his eyes flew open with surprise. He stared intently at the man across the desk. I… he stuttered. Of course I’d be interested, he said excitedly.

As you may have heard, we are being forced to cut back significantly on the number of residency slots.

I’ve heard the rumors, sir, David replied. He’d been told by more than one senior resident that budget cuts were the reason the department hadn’t made any effort to accommodate Sandra Jenkins. When she was forced to resign to take care of her ailing father, they hadn't filled the opening her departure created. It was one salaried position that no longer had to be funded.

This new track will concentrate almost exclusively on general and cardiothoracic surgery with few if any electives like orthopedics, urology, or ENT, he explained. You would get the same amount of experience in the core elements of surgery, maybe even a little more, and it would allow you to be eligible to take the general surgery board exams after your fourth year and the cardiothoracic boards the following year.

What about pediatric heart training, sir? David asked.

I can’t guarantee that, Makowski said. That’s in another division of this department, but this new track will get you to that point two years faster.

It sounds great, David said. When do you need to know?

You are the first candidate I’ve spoken to about this, and there are a couple of other PGY-1s who have expressed an interest in heart surgery, so if you don’t want to go this route I will need to offer it to the next one on my list.

Can I let you know tomorrow? I’d really like to discuss it with my dad.

That will be fine. Just let me know when we meet for rounds tomorrow morning.

Thank you, Dr. Makowski. I really appreciate this opportunity, David said, as he stood and reached across the desk.

You’re welcome, and tell your dad I wish him luck getting anything going down there in Guatemala, or wherever it is he’s thinking about building a hospital. Makowski leaned forward and shook the younger man’s hand.

David quickly left the office and started to call his dad right then, but realized he needed to get to the post-anesthesia care unit. He’d promised Mr. Lewis he would be there when the old man woke up.

*********

Hey, Dad, David said excitedly. He’d called using the FaceTime on his iPhone, usually reserved for calls to his mom. Jack could see his son was sitting in the living room of his small apartment.

Hey, buddy, he replied, his surprised smile matching his son’s. How are things on the cardiothoracic service?

Great! I scrubbed in on my first four vessel bypass today. It was really cool, but that’s not why I called.

What’s up? Jack asked, his mood sobering somewhat.

Dr. Makowski called me into his office today. He’s the chief of the cardiothoracic division.

Yeah, I think I may have met him once, Jack replied. I’m not sure.

He asked about you and I told him you were planning to build a hospital down there. He said to wish you luck.

That was nice of him. What else did he have to say?

He told me they are going to start a new accelerated track for cardiothoracic surgery.

Really? Jack exclaimed. For years he’d heard rumors of plans to shorten the seven year program, dating back to when he was president of the Association of Thoracic Surgeons. He’d been asked to comment on a plan being considered at both the Massachusetts General and Thomas Jefferson University Hospitals. Both programs ultimately decided not to implement the idea at that time, but it had not been totally abandoned.

He said it would cut two years off the training.

Wow! Two years? How do they plan to do that? The argument Jack had made in his comments to Mass General included the fact the majority of general surgery residents were not prepared to practice independently after five years of training. How could they expect them to be competent heart surgeons in the same amount of time?

He said they were eliminating virtually all the electives like urology and ENT. This new track focuses exclusively on the core elements of general and cardiothoracic surgery.

Jack paused before he offered a response. This was no longer some theoretical idea being tossed around in Boston or Philadelphia. This was his own son’s training they were talking about.

When are they planning to start? he asked, trying to buy some time to formulate a rational response.

Makowski said it would start with the opening of the new Parkland hospital. Originally that was supposed to be later this month, but from what I hear it’s been moved back to March first.

That soon? Jack asked, realizing his son was under some pressure to make a decision, and based on the excitement in his voice and on his face, what David really wanted was his dad’s approval.

Yeah. Makowski said I was first on his list, but there are a couple of other PGY-1s who have expressed an interest, so I need to let him know tomorrow morning.

I see, Jack said, his tone reflecting the seriousness of this decision. If David didn’t get exposure to all the surgical disciplines it could significantly impact his overall ability to provide quality care to his patients. On the other hand, he recognized the volume of medical information had increased several fold since the days when he was a resident. There was no way anyone could become proficient in all the various aspects of surgery, so early specialization seemed appropriate.

So, what do you think? David asked, hoping to hear the advice he wanted, rather than what he feared his dad might say.

Well, that’s a big decision, Jack replied. Did he say whether or not the current seven year program would still be available if you decided not to go this route?

He didn’t say, but I got the impression this is going to be the new program. He talked like this is one of the ways they plan to cut back on the total number of residents, so I can’t imagine they would be keeping both tracks. I’m guessing that if I don’t take it, I will probably have to go somewhere else when I finish general surgery.

What about pediatric hearts? Did he say anything about that opportunity?

I asked him about it, and he said that decision would be up to another division within the department, so he couldn’t guarantee me a spot, but obviously that’s no different than it is now.

Jack was tempted to raise other questions that were circulating in his mind. Would David miss something vitally important by focusing too narrowly on one area of medicine? The training program was already too short, wasn’t it? What if this experiment didn’t work? He’d be left with few options.

Remember what we talked about a few months ago, about being responsible for your own education and training? Jack asked.

Sure I remember, David replied. I am very aware that Makowski doesn’t really care about me, and I’ve certainly thought about the fact that taking this route could make me vulnerable to criticism. Some people will assume I’m not as well trained as guys in a seven or eight year program, but I’m afraid if I pass up this opportunity, I will regret it. There may not be another option.

There was a long pause as David watched his dad struggling with his thoughts.

You don’t think I should do it, do you? he asked, trying to urge a response.

Jack looked squarely into the screen as his