Chapter 26 – Change of Season — Part 3

Nomura found the error.

A pathologist at a surgicenter in Ladue had performed a frozen section on an excisional biopsy of the left breast of a 34-year-old woman. A month earlier, a radiologist’s needle core—read by Nomura and James at ULS—had been diagnosed as ductal carcinoma in situ (DCIS), a non-invasive cancer treated with complete excision. The surgeon and the outside pathologist expected DCIS. Instead, on both frozen and permanents, the lesion was a fibroadenoma—benign.

Per protocol, the surgicenter pathologist asked ULS to recut and review the original case. ULS would recut the blocks, photocopy the original report, and have the signing pathologist review before sending out.

When Nomura examined the recuts, his stomach dropped: the diagnosis didn’t match the slide. He cross-checked the slide against the original block—no mix-up. Which meant the report was wrong.

He met with Bryce Collins, ULS’s lab manager. They pulled every breast biopsy from that day—six needle cores—and matched slides to reports. Two patients leapt out. Paula Jackson, who’d just had her left breast excised in Ladue, and Marilyn Tarsus, who’d had a right breast core the same day. On paper, both reports carried identical microscopic descriptions and the same diagnosis—DCIS—differing only by side. Under the microscope, Jackson had a fibroadenoma; Tarsus had DCIS.

Had Nomura somehow swapped slides? Unlikely—ULS presented breast cases on separate flats to prevent it. Had he misdiagnosed? He reviewed again. No. “Even a dog off the street could make these calls,” he muttered.

He retraced the path of his words. Each diagnosis began as a cassette dictation placed with the requisition in a folder, then queued in the transcription room and typed in receipt order. He scanned the two reports. Same typist initials on both: AJ. Audrey Johnson.

Scenarios skittered through his mind. Could Audrey have swapped tapes, transcribing the wrong dictation to the wrong case? If so, Tarsus’s report should have said fibroadenoma. More likely: she was distracted while transcribing Tarsus’s DCIS, then resumed with Jackson’s paperwork in front of her and retyped the same description. He’d seen her sloppiness before. Once, a prostate report he’d dictated as “No malignant cells present” came back “Malignant cells present.” Another time a microscopic paragraph duplicated itself. When he’d asked Audrey how, she’d shrugged: “I haven’t a clue.”

His desk filled with flowcharts. Every path bled red toward transcription error. But could he prove it? He slept two hours.

The next morning he called James to his Memorial office. The look on Nomura’s face tied James’s stomach into a knot.

“James, we have a problem.”

“Was it one of my cases?”

“You looked at it, yes.” Nomura laid out the timelines and possibilities, the red line leading to Audrey.

“I agree,” James said. “It looks like a transcription error—either duplicated text or a cut-and-paste fail in their system. Do you remember when ‘No malignant cells present’ got typed as ‘Malignant cells present’? We almost missed it on sign-out.”

Nomura nodded. “I mentioned patterns like that to Bryce. Usual lip service. I should’ve pushed harder, but the volume… the culture…”

ULS’s arrogance still stung, but fear now surfaced. “Do you think the patient will sue?”

“Anyone can sue anyone for anything,” Nomura said. “The question is trial versus dismissal or settlement. You never want trial.”

“Have you ever been sued?”

“Thankfully, no. I’ve testified as an expert, but never as defendant. We’ll see. Sometimes it fizzles. Sometimes it doesn’t.”

The answer arrived a week later by certified mail:

Goldstein & Stewart, LLP
 for Paula Jackson
 Re: Paula Jackson v. Ladue Surgicenter; United Laboratory Services; Masao Nomura, M.D.; James Deetan, M.D.

Nomura and James met with Morelli, who alerted the malpractice carrier. Within an hour, hospital counsel Jerome Moynihan called. James listened on speaker as Nomura walked him through the events. Forty-five minutes later, Moynihan sounded satisfied.

“Straightforward,” he said. “We’ll need depositions from Audrey, Bryce, and Dr. Deetan. Send me your flowcharts and a written summary.”

“No problem,” Nomura said.

“I’ll contact plaintiff’s counsel,” Moynihan continued. “Don’t know them—young, maybe. That helps us.”

“What timeline?” Nomura asked.

“Once we schedule depositions, this moves. I’m also bringing in a computer-transcription expert to review ULS’s system.” His voice softened. “I know it feels like the world is collapsing. I’ve done this 30 years. It never gets easier, but transcription errors are common and defensible. Work with me and we’ll be fine.”

“Thank you,” Nomura said. “James?”

“No questions. Thank you, Mr. Moynihan.”

“Good. We’ll be in touch.”

Afterward, Nomura looked over. “I don’t think you’ll be a target,” he said. “You’re a resident. Plaintiffs go for deep pockets. ULS has the deepest.”

“Really?”

“Very. Remember their Medicare overbilling case? A few years back. Settlement north of $200 million.”

James exhaled. “Deep pockets.”

Moynihan proposed a unified defense with ULS’s attorneys, courtesy-inviting Ladue’s counsel and recommending Ladue be dismissed. “Discovery is the heart of it,” he told them. “Both sides dig for facts and share what they find. Sometimes discovery changes everything; sometimes it just sharpens the same outline. We’ll line up our experts. They’ll line up theirs.”

He packed his brief. “You didn’t go to med school for this, I know,” he said to James. “But honestly? Better to learn it early. The world can be cruel.”

“Dr. Deetan is an excellent physician,” Nomura said.

Moynihan offered a half-smile. “I’m sure he is.”

Through Nomura’s window, snow began to feather the sill, thin white trying to cover dirt and pigeon scat.

“It’ll be cold tonight,” Nomura said. “Leave early if you want to beat the storm.”

James studied the heavy sky. “I may not beat it,” he said, “but I’ll survive.”

He turned for the door.

“Thank you for your support,” he added.

Nomura nodded. “We support each other,” he said. “We’re on the same side.”

Next Chapter: Chapter 27-Discovery