“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 deeper sections 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.”

“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?”

“23405.”

“I don’t see the request. You sure you requested it?”

“Positive.”

“Well, give it to me again, I’ll try to do it by the end of the day.”

Histotechs. There was Wilma and there were the rest, like ULS. No pecan pies here. At Memorial and ULS, the average histotechnologist was paid a starting hourly wage of $4.25, not much above the federal minimum wage of $3.35. At Memorial, the perks were better with an excellent health care plan and a 401K retirement plan, a rarity for many companies in 1988. The highest-paid laboratory personnel were at Riverside, a private hospital across town. James learned this from Franklin who knew all the inside information at every laboratory in St. Louis, pointing out the disparity in compensation when he was in Boston. Uncertain if they would be downsized out of a job, the hostility of the ULS histotechs towards the pathologists was stoked by their lower compensation and the culture inculcated by management. A toxic combination.

Two weeks have passed since James began his rotation at ULS in November. He had signed out the equivalent of 4 weeks of work at Memorial. The work grew exponentially and he was certain the slides were reproducing on their own. Ten-hour days, every weekday. No time to even do his laundry, dosing a shirt he wore the previous week with an extra splash of cologne. Yesterday, he dozed off in his car while waiting for a traffic light to change.

“It’s not just the amount of work,” he confided to Deanna. “It’s this attitude. I hate it. Everyone’s too busy. Every answer has some snide comment. I’m always questioned. I am always called by my first name, even Nomura is called Masao, unbelievable! The typos I have to correct, and the-“

“Whoa!”

“…And everyday, I have to reorder the same studies and then when it doesn’t come, it’s my fault, or-“

“Hello? Dr. Deetan? I know James.” Deanna’s melodic voice broke through his frustration. “It’s good to hear you vent.”

“I’m losing it”

Deanna laughed. Even through the phone line, he smelled the jasmine. “No, of course not.” Her voice softened. “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.”  Why did he say that? Did she hear it?

“How’s Nomura holding up?” Her voice caressed.

“I think he’s close to losing it.”

“Really?”

“Yeah, the other day, a patient accused him of fraud!”

“A patient? I don’t believe it! How did that happen?”

“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.”

“Huh?”

“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 speakerphone so I could hear it. 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 dishonesty. 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. Except for that twitch above his left eyebrow.”

“Whoa…I’ve seen the twitch but I have 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.”

“Bye.”

James’ eyes burned. Strangled. He dried his eyes and stole a glance to see if anyone saw him. It was a daily catharsis, calling Deanna, and unloading the familiar issues. At first, he was thankful for her sympathetic ear but he now craved it. Was it compassion or obligation from Deanna? Didn’t he have other friends to cry with, she must have thought.

Deanna never made it to ULS that evening, a late-night frozen section kept her at the hospital. James completed the picture-taking by 10 PM and uploaded the photographs to Nomura’s 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 8 AM the next morning and were over by 10 AM. By 10:30, Nomura was back at ULS.

“Good conference this morning. Thanks for taking those pictures for me, James. Great shots!”

“Glad I could help out.”

“So what do we have here?” Nomura lifted a pink note off his desk. Underneath 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 phoned 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 loudspeaker.

“Yes.” The scraggly voice emerged. “You know, I don’t know if you have experience reading out skin biopsies but your diagnoses are completely unacceptable.”

Nomura smiled at James’ widening eyes. “Dr. Vanley, I am a board-certified dermatopathologist and have been doing this for over 30 years. What seems to be the problem?”

“Well, I’m a board-certified dermatopathologist too. Trained with Shipley, even before he wrote all his textbooks.”

“Great! I knew Tom Shipley very well, good man, great teacher.”

“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 zebra diagnoses?”

“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.”

“Excuse me?”

“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 correct 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 patient’s history to bias me before I review a case, I only use it 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 Labs.”

“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 speakerphone 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.”

James admired Nomura but not everyone belonged to this fan club, particularly some physician groups, and now surprisingly, even a dermatologist. Nomura was smart, maybe too smart. He could be unyielding, especially when he knew he was correct. Stubborn was what his detractors labeled him. He was a perfectionist, no detail, no data point was too insignificant. Surgeons were notorious for not including a complete history when submitting their specimens. It led to several confrontations with one major surgery group and Nomura would not back down. Frustrated, they took their business to Riverside Hospital, to the ire of the ULS management. Medicine used to be built on personal relationships and trust between physicians. It had evolved into rivalries competing for the last dollar. A toxic combination.

Next Chapter: Chapter 19-Pillow Talk