Month: September 2025

“I’m the P.A.!”

“You’re not a physician’s assistant.”

“Didn’t say I was, I’m the Pathology Assistant. The most important person in the department.”

This was Franklin Washington’s kingdom. The surgical pathology gross room was built upon decaying masses of tissue and discarded medical devices. He was a pathology assistant, a PA, a title he inflicted upon everyone within earshot. Hospital employees mistakenly interpreted PA as shorthand for a physician’s assistant, a far more common term. Franklin lost no time correcting their ignorance.

Franklin was 47 years old but his muscular build, accentuated by surgical scrubs a size too small for him, halved his age in the eyes of his admiring female associates. His café-au-lait complexion, a combination of a Greek mother and Puerto Rican father, was deepened by innumerable hours sunning himself on the front lawn of the hospital, much to the ire of hospital administrators.

Franklin introduced all the new pathology residents to his domain. “Any tissue removed from a patient must come through my surgical pathology gross room and to the pathologist’s attention.”

Franklin assisted the residents and attendings with the gross examination and dissection of surgical specimens, the frozen sections, cytology, and autopsies. New residents quickly tired of his pedantic chatter, as he reminded them of his former position at a prestigious hospital in Boston. It was the gold standard for the training of pathology assistants, he boasted to disinterested ears. “At Boston, I had my own office with a phone. They treated me with respect.”

“Then go back there!” Dan once shouted back during an orientation session.

“Who would make sure you don’t screw up, Doc?”

It was the end of James’ second month in surgical pathology. At 7:30 AM, the operating rooms began the day’s cases.

“Dr. Deetan, I highlighted all the cases on the OR schedule that may require an intra-operative consultation or frozen section,” Franklin announced.

“Thanks, Franklin.”

A thyroid lobectomy arrived at 9 AM. Franklin hummed “I Love Rock and Roll” as he inked the specimen, while James bread-loafed the tissue, finding a gritty nodule.

“Don’t eat it all at once, Doc!”

James ignored him, focused on the scrape prep. By the time Carlos and Dan joined at the multi-head scope, the diagnosis was already taking shape.

“Follicular neoplasm…capsule looks intact,” Dan said. “But getting a papillary feel. Got a scrape prep?”

James handed him the slide.

“Good job. Ah, there it is — little Orphan Annie eyes.”

James feigned understanding until Carlos explained the cartoon reference. He forced a smile. Another idiom to file away. Another gap to close.

“Tell the surgeon it’s papillary carcinoma,” Dan said. “They’ll do the total thyroidectomy.”

James made the call. The operation proceeded.

Afterward, Carlos lingered. “Good frozen section. More importantly, good scrape prep. You saved that case. Don’t forget it.”

Franklin smirked. “Yeah, Doc — but remember: when you screw up too often, it’s sayonara.”

James shot back, “So why are you still here?”

“Because Haas likes my eyes!” Franklin fluttered his lashes, flexing his biceps. Carlos rolled his eyes. “Ignore him. He’s a pain, but he’s good. More than you realize.”

Then Carlos leaned closer, lowering his voice. “Speaking of frozen sections…you ever hear about Lucas Harris?”

James shook his head.

Carlos told the story in hushed tones: the senior resident who missed a metastasis on a lymph node frozen, urged a junior to destroy the slide, and was caught by Franklin and Haas. Fired that very day.

James felt the weight in his gut. He had never heard of such treachery.

Carlos’ voice dropped further. “Haas told the department: ‘In all my years of practice, I’ve never seen anything so despicable. The patient always comes first. If you screw up, you own it.’”

James sat in silence. The moral was clear. Haas was merciless, yes — but she also drew lines that could never be crossed.

Back in his office, James stared at his hands. They were surgeon’s hands, steady and sure, but could they shoulder the weight of judgment? Carter’s words came back to him: There is always a patient at the other end of the slide.

And then another voice — Deanna’s — replayed in memory from conference: You’re smarter than you think, James.

It was that encouragement, not Haas’ tirades, that kept him steady.

Wilma had also brushed against his hand in the histology lab earlier that week, whispering with her playful Cajun lilt, “Only for a gentleman.” Her teasing was flattering, but it wasn’t an anchor — it was a temptation he couldn’t afford to misread.

Two women lingered in his mind that night: Deanna, who grounded him, and Wilma, who unsettled him.

But Lucas Harris’ ghost walked beside them. In this world, one mistake — or one lie — could end it all.

Next Chapter: Chapter 11-A Patient Is At The Other End

“Who’s on call?” Dr. Elliot, chief of ENT surgery, bellowed into the resident sign-out room. Residents scattered like mice. Dan pointed toward James. It was five o’clock on a Thursday afternoon — time for Elliot’s weekly commando procedure.

But tonight’s case was different. Not an old alcoholic with a fungating face tumor. A boy.

The CT showed a mass filling the right orbit of a ten-year-old child. “I’ll need frozens,” Elliot said. “Lymphoma, rhabdo, PNET, maybe neuroblastoma. Haas knows the case.”

James’ stomach dropped. He thought Nomura was on call. But Haas had switched.

In Haas’ office, she looked up sharply. “Differential?”

“Small round blue cell tumor: lymphoma, rhabdomyosarcoma, Ewing’s, PNET, neuroblastoma.”

“And how do you differentiate?”

“Immunohistochemistry…electron microscopy.”

“Which immunohistochemical stains?”

James froze. “I’ll look it up.”

“Do that before the frozen.”

Her voice cut like a scalpel. James scurried out, textbook in hand, and wolfed down a tray dinner in his office. As he ate, Carter’s voice whispered in memory: There is a patient at the other end of the slide. Never forget that.

He scribbled the stains — cytokeratin, desmin, CD99, LCA, WT1, S100. His heart pounded, not from the food but from the weight of Carter’s admonition. He thought briefly of Deanna — her gentle encouragement after last week’s conference — and steadied his breath.

The first frozen came. James cut, stained, and carried the slides to Haas.

“Crush artifact,” James said carefully. “Small round blue cell tumor. Adequate for diagnosis, but I think we should ask for more tissue for cytogenetics.”

Haas nodded. A rare smile. She dialed the OR. “Stan? Irene. Yes — small round blue cell. Adequate. Send more tissue for cytogenetics.”

James rushed to the OR. Elliot handed him the tissue. “You escaped my midnight madness. When can I have an answer?”

“Tomorrow, once we have the immunostains.”

Elliot pressed. “Could be lymphoma or rhabdo. What do you think?”

James swallowed, then offered a pearl he’d read by chance. “It might also be an extraskeletal mesenchymal chondrosarcoma.”

Elliot raised an eyebrow. “Interesting…you may be right. Keep me posted.”

The next morning, Haas reviewed the immunostains. “CD99, S100 positive. Likely PNET. Call Elliot.”

Elliot appeared at the door before James could move. “So — PNET? What about that chondrosarcoma you mentioned?”

James froze. Haas bristled. “That was his speculation. When you hear hoofbeats, think horses, not zebras.”

“But Pittman at Children’s had an identical case last year,” Elliot countered. “Run it by him.”

Haas’ cheeks flushed. “Fine.”

By evening, Pittman had reviewed the case. It was a mesenchymal chondrosarcoma. Cytogenetics later ruled out PNET. James had been right.

Word spread like wildfire. Elliot praised James publicly, telling anyone who would listen that his resident had nailed the diagnosis. Everyone in pathology congratulated him — except Haas. She rearranged the sign-out schedule to exclude him for a month.

That night, James sat alone in his office, case folders stacked like sandbags. He stared at the phone, tempted to call his mother, or Carter, or even Deanna. Her laugh, her faith in him, replayed in memory like a lifeline.

Then Wilma appeared at his door with a tray of slides. “Working late again, Dr. Deetan?” Her eyes glinted as she brushed a strand of auburn hair from her face. “Careful — the hospital eats people alive who don’t watch their backs.”

Her words echoed Franklin’s warning. Someone is always sacrificed in this department.

James pressed his hands flat on the desk. Haas had made her move. But he was still standing.

Next Chapter: Chapter 12-A Surefire Plan

“It can’t fail, I guarantee it.” Carlos jumped up and walked to the bulletin board in the resident’s hall. “See, the patients come in, get registered here, get their blood drawn here, and they’re in our database.” He walked along the board, illustrating with his finger as he gestured, seeking approval from his audience.

“Only you would think of this.”

“Don’t tell me you don’t think this is a good idea, Rosenthal.”

“Let’s just say it would probably close the hospital down if anyone found out.” Dan crossed his arms. “But you’re right, it is a good idea.”

“You have to do it quietly. Covert operation.” Franklin added.

“Of course, and the hospital doesn’t have to know.” Carlos glanced at Dan.

“Why not, though? Why not keep them in the loop? This way, everyone is happy.” James entered the resident’s hall, still in surgical scrubs. “Hey James, join us!”

“I thought you would all be home by now.”

“All finished for the day, but Carlos is telling us about his business proposal.”

“James, you should be very interested in it.”

“Let’s hear it.”

Carlos lifted both hands in the air and pointed to the ceiling. “A blood bank dating service!”

The confused look of James fueled Carlos’ animation. “James, it’s a surefire plan!”

“Couples are going to meet in the blood bank?”

“In a sense. We’re going to utilize the database of blood bank donors to create a dating service. Think about it. What’s the one thing everyone fears about dating a stranger?” Carlos opened his arms to an imaginary audience, launching into his sales pitch. “Do they have AIDS? Do they have some weird disease? Everyone who donates blood has to get tested for AIDS and hepatitis and if they’re positive, the unit of blood is rejected and they’re barred from donating. If they’re negative, they remain in our donor bank database. It’s foolproof! They can donate every two months and get tested each time. Who wouldn’t want to date someone who’s been cleared of these diseases?” Carlos kept his arms extended, waiting for the applause.

In some twisted way, it did make sense to James. “But how are you going to get past the patient confidentiality issues?”

“We have them sign a waiver, giving approval to be included in this service. Of course, we would never share it with anyone outside the hospital.”

“Maybe you should, Carlos.” Dan got up and joined Carlos at the bulletin board. “If we combined our database with other donor centers, think of the size of our service area. We could go national, even international!”

“Ah so! Maybe even to the Philippines. Even James could get a date.” The room erupted into laughter over Carlos’ comment. James laughed, joining in the ribbing. In the four years he had been in St. Louis, he had only been on a few dates. Usual tourist stuff. Seeing a St. Louis Cardinals baseball game. Visiting the Arch. A walk in Forest Park. All casual, nothing serious. There were many women, eager to date a doctor. He had encountered similar women in the Philippines, all seeking a Mrs. degree. In St. Louis, he was initially flattered that a white woman would be willing to date an Asian man. As the days progressed to months, the demands of the research lab served as a continual reminder that these priorities took precedence. The flirtations of a histotech and an unspoken longing for a beautiful resident were pale substitutes for genuine love.

“I gotta go, guys, see you in the morning.” Franklin waved and headed for the elevator.

“You know he would be the first in line to sign up for the service, ” Dan snickered as he waved goodbye. “He’s always so paranoid about the women he dates.”

Dan nodded. “James! We miss your loud voice!”

“Good to see you too, Dan. Just catching up on my mail. Is Haas around?”

“No, she’s gone for the day. Why do you ask?”

“I need to do something, explain the situation to her. I don’t want to keep avoiding it or her.”

“You’re going to have to face her sooner or later. Good idea to try to clear the air with her.”

“Maybe you should leave the program,” Carlos added. “Deetan, you impress me! You humiliated Haas, never thought I’d see the day.” Carlos was no help.

“Dan, how do you think I should do this?”

Dan paced the hall, his eyes roaming the empty offices. “You need to be careful. She won’t go for the apology. She needs to be seen as the best.” Dan smiled. “Carlos, we need another surefire plan!”

“I’m only good once a night.” Carlos winked.

“I heard that about you. Big help you are. James, let me think about this and I’ll get back to you.”

James was grateful for Dan’s offer. “Please call me when you think of something.”

Dan and Carlos both left the resident’s hall. It was 8 PM, the cafeteria closed an hour earlier and James still did not have dinner. He fished around his desk for a granola bar, anything to appease the gnawing in his stomach, which announced its growing displeasure with a growl.

“Someone’s hungry!”

“Deanna!”

“Didn’t think anyone would be here this late.”

“I stopped by to pick up my mail. What are you doing here?”

“I was in the library photocopying some journals.”

“Have you eaten?”

“No. D’Angelo’s?”

“I’ll meet you there.”

With a raise in his salary as a resident, James could finally afford to buy a car. A used Subaru, sold to him by the sister of one of the research technologists in Dr. Carter’s lab. D’Angelo’s was tucked away in a part of the city affectionately known as Dogtown to the locals. In St. Louis, he assumed he would be eating Southern cooking-catfish and grits, which the hospital cafeteria regularly featured. Querying the locals, he was surprised to learn that many were adamant that Italian food was the best culinary cuisine offered in the city. Dogtown earned its nickname at the turn of the century when St. Louis was home to the World Fair in 1904. The athletes were housed in different parts of the city and the Koreans were housed in their now infamous surroundings. When neighborhood dogs began to disappear, it was suspected the Koreans were eating them. The charge was never proven and other locals stated it was named by miners in the 1800s who built shelters there. Regardless, the moniker stuck. This story replayed whenever James ate in Dogtown as he dodged the inevitable query of whether he was Korean on every visit.

Deanna sat in a secluded booth in the back of the restaurant when he arrived. The solitary candle, housed in a small red glass, cast a soft glow on her face. He paused, soaking in the memory.

“Waiting long?”

“I just got here.” Deanna smiled and glanced out the window. “Fall is my favorite time of year. I have to remind myself it’s fall and not spring. Remember, the seasons are opposite in Brazil.”

Deanna grew up in Brazil. She had no accent, no mannerisms that hinted she grew up anywhere else but in the States.

“In the Philippines, there are only two seasons, hot and hotter.” James replied.

“Almost the same in Brazil, but I found pockets of fall foliage that I loved. But when I went to school in Switzerland, it was glorious!”

“When were you in Switzerland?”

“Most of my teen years. My dad was appointed ambassador to Switzerland so we moved when I was 14 and remained there until I left for college in Boston. And then I fell in love with their fall foliage!”

“You stayed in Boston for college and medical school, right?”

“I did. It was the first time I lived in America. I loved it. Still do!” Her eyes danced. Magic.

“America is so different from the Philippines. I’m still adjusting to the changes.”

“What’s the biggest change?”

“It’s so big, everything’s so big! Cities, supermarkets, cars…people. Lots of big people!!” Their laughter loosened the shackles of residency.

“Are you ready to order?” The server politely stood next to the table, until the break in the conversation.

“No carbs for me, too many big people!” Deanna puffed her cheeks and blew it out, laughing as she exhaled.

“Very good, Madam. May I offer you something from our wine selections?” James was intimidated by the list and looked over at Deanna who raised her right eyebrow and flashed a mischievous grin. “I feel like champagne, how about you, James?”

“Sure!” nodding, hoping the server would suggest something. “Do you have something special for us?”

The server smiled as he looked into both of their eyes. “I have just the bottle.” Within a few minutes, he returned, held the bottle out for inspection, and being given approval by Deanna, popped the cork. As he poured the glasses, he smiled and whispered. “A very special champagne…for a very special couple.”

A couple. James hoped Deanna didn’t see him blush as he quickly lifted his napkin to his cheeks. She raised her filled glass. “To pushing glass!”

“Pushing glass!” Their glasses clinked as they imbibed the love potion.

“I would like to visit the Philippines someday.” Deanna held her glass at an angle, watching the bubbles rise.

“I would love to show you my home. It’s probably just as humid as Brazil, not as big, though. There’s also a big Spanish influence.”

“Like the Portuguese influence in Brazil.”

“Yes. You know, until I met you, I didn’t know there were Jewish people in Brazil.”

Deanna nodded. “A lot more than you would ever imagine. Actually, all over South America.”

“I would never have thought that.”

“I would never have thought there were so many Chinese in the Philippines. You know there are a lot of Japanese and Chinese in Brazil, especially Sao Paolo, where I grew up.”

“Yes, in Peru also. I heard a Japanese politician is even running for president.”

“Yes, Alberto Fujimori. My father knows him very well through his diplomatic connections. Growing up, I had a lot of Chinese and Japanese friends.”

“Me too!”

The polite server reappeared from the shadows. “May I tell you of our specials this evening?” He rambled on for a few seconds. Deanna twirled a lock of her brown hair between her fingers, as the server presented the details of the various dishes. The champagne in James’ empty stomach made his head spin.

“What do you think, James?”

He couldn’t hear a word. “Yes…yes…that sounds wonderful. I’ll have the same.”

“Excellent choices.” The waiter gathered the menus from them. “I can see you are enjoying your champagne.” A knowing look passed between James and the waiter.

“Have you spoken to Haas?”

“No.”

“It’s a sad situation, James. It’s obviously a misunderstanding but Haas doesn’t view it that way.”

“I know she wants me out of the program. Dan said he would think of something I could say to her. What do you think?”

Deanna pursed her lips and stared at the glowing candle. “It’s a tough call. I have a pretty good relationship with her, let me feel her out and see if I can put in a good word for you.”

“Would you, Deanna? I would appreciate that.”

“It will work out, James.” Deanna reached across the table and grasped his hand. James’ ears filled with blood, veins dilated by the alcohol. His head was moving, rhythmically bobbing with his pounding heartbeat. It was only a few seconds, but it was an eternity. James spoke but had no recollection. The restaurant dissolved. Only their joined hands remained, dissolving the frustrations of the past weeks. It was the anchor for his soul, the only reality that made any sense.

“What are your favorite sounds, James?” Her words were melodic.

“What do you mean?”

“I like to collect sounds…they bring back memories for me, take me to special places…with special people.”

“Tell me some.”

Deanna closed her eyes and lifted her head, throwing back her hair. “The gurgle of a baby…the crackle of a campfire…the heartbeat of my mother as I lay against her chest.”

It was perfect.

“Let me try.” James closed his eyes and let his thoughts drift back to home, thousands of miles away. He was in the kitchen. A lavish spread of food lay before him, surrounded by flowers. The smell of noodles and pork filled his nostrils. He sat at the table and looked around. Something was missing. And then, he heard it. “The sound of my father’s slippers as he comes to the dinner table!” James opened his eyes to see Deanna smiling at him.

“You miss him, don’t you?”

James swallowed and nodded. The pain of the last phone call was still too close. He never spoke of his father in such endearing tones. Tonight he was another person.

“We’re very blessed to have our families.” Deanna closed her eyes, as if she were praying. The dinners soon arrived, Cacio e Pepe. Pasta. She made an excellent choice. Anything with noodles made James happy. It was home and he was sharing it with Deanna. Not St. Louis. Not Memorial. Not this restaurant. The recent events of the past two weeks provided the gist for a lively conversation. Restaurant patrons politely passed as their laughter filled the emptying restaurant.

“Will there be anything else?”

Deanna looked up at the server and then scanned the vacant restaurant. “Oh my goodness, what time is it?”

“11:30, Madam.”

“I’m sorry, Deanna. I completely lost track of time.”

“I’m glad.”

James snatched the bill from the server. “I’ll take care of this.”

“Dr. Deetan, you may have forgotten that I am your superior. When you’re out in practice, you can return the favor.” Deanna handed her credit card to the waiter, over James’ outstretched arm.

“Deanna-“

Deanna lifted her finger to her lips and smiled. “Next time, we’ll plan a special dinner at my place.” Her eyes twinkled, reflecting the flickering candle flame.

“A surefire plan.” James whispered.

Back at the hospital, James unlocked his office. A folded pink note sat on his microscope.

“For the gentleman. Don’t let Haas eat you alive.” — Wilma.

James smiled despite himself. Deanna’s hand still lingered in his memory, warm across his skin. But Wilma’s handwriting burned just as vividly before his eyes — teasing, daring, dangerous.

Two women, two paths. Both saw him. But only one touched his soul.

Next Chapter: Chapter 13-Morbidity and Mortality

“The noon time Morbidity and Mortality Conference is now beginning in the fourth-floor conference room.”

The hospital speaker blared as James scurried up the fire exit stairs. Hospital elevators were always too slow, especially when he was already late. He carried a slide carousel and a small folder summarizing the biopsy results of one of the cases that was being presented. Haas would oversee his presentation but it was his show, his time to shine or flop. She would be scrutinizing his every word, ready to interrupt the discourse if he missed an important point. His stomach muscles tightened as he envisioned the audience of attendings, fellows, residents, and medical students all listening to his explanation. Why did the patient die, Dr. Deetan? What do you mean you don’t know? Aren’t you the Doctor’s Doctor? It was only the third month of training but James needed to own the title.

“You’re late.”

“I’m sorry, Dr. Haas. It was a frozen section, we ran over.” James placed his slide carousel on the projector and took the seat next to Haas, in the front of the room. This was his first encounter with her since the frozen section with Dr. Elliot.

Haas frowned. “Next time, get someone else to cover. The chief resident should have been there. Are you ready?”

“Yes ma’am.”

“Speak slowly and clearly…” Haas pursed her lips. “Sometimes people have difficulty understanding you when you speak quickly.”

“Let’s get started. The first case is being presented by the Department of Surgery. Dr. Morris?”

“Can we review the pathology?”

The moderator, Dr. Silverstein, chief of medicine, motioned in the direction of James and Haas. James attempted a confident stride and kept his hands tucked in his lab coat pockets, hoping no one could see the shaking. Heads in the audience bobbed and whispers of “He’s just an intern,” and “He looks so young,” followed each step. Just don’t trip, James kept repeating to himself.

As he stood at the podium and surveyed the audience, the room seemed so much larger, a sea of white coats and green surgical scrubs. The doors were also packed with late arrivals, unable to find a seat. James braced his hands on the sides of the lectern and fingered the control for the slide carousel. The first slide appeared on the large screen pulled down behind him to his right. An image of a neatly dissected pancreas appeared, recognizable only to about three knowledgeable physicians who were not pathologists or surgeons.

“We received the Whipple resection containing the head of the pancreas, a portion of the duodenum, stomach and accompanying omental tissue. Dissection of the main pancreatic duct revealed a tumor measuring 2.5 cm in diameter that extended into the surrounding pancreatic tissue.” James flashed his laser pointer on the tumor. “Dissection of the peripancreatic lymph nodes revealed grossly metastatic disease in 3 of the 17 nodes.” The slide advanced. “On microscopic sections, a poorly differentiated adenocarcinoma was identified with extensive areas of perineural invasion.” The laser danced around the screen as James pointed out the sinister course of the tumor. “Final diagnosis is adenocarcinoma of the pancreas, poorly differentiated, metastatic to 3 of 17 lymph nodes.”

The lights flipped on and James waited for the accolades, like his first M&M in medical school. Hurray for the Doctor’s Doctor! Bravo!

“Thanks, Pathology. Dr. Harvey, you saw this patient in consultation for radiation oncology. What was your impression?”

James stood motionless at the podium, uncertain whether to remain. A glance over at Haas as she pointed to her empty seat next to her answered his confusion. Disinterested looks followed his descent. Why no questions? Was it good or confusing? James looked to Haas for feedback.

“Next time, hold the laser pointer with both hands. You were so nervous it looked like a flea jumping from one dog to another.”

“Yes, ma’am.”

The conference was over, and James slunk back to surgical pathology where Wilma was cleaning up for the day.

“Conference didn’t go well? That was a lot of slides I pulled for you.”

“Thanks, Wilma. You are always so helpful.”

“Let me guess, Dr. Haas embarrassed you at the conference?” James said nothing.

“Listen, Dr. Deetan. It seems that every year there is always a resident she picks on. I’m afraid you may be the one. It’s the same with the histotechs, except she’s never stopped picking on me, she just kept right on going.”

“You? Why would she do that? You’re great at your job.”

“Ah, you’re a sweetheart, Dr. Deetan. The thing is, it is not about competence, it’s about giving her what she wants, much harder to predict. Kind of like a marriage.”

“I wouldn’t know about that!”

“All the life lessons you need can be found in this department.” Wilma pointed at the now empty histology laboratory. “Keep your eyes and ears open and watch your back.”

“Will do.”

“And if you don’t, I will.” Wilma stared into his eyes. Her olive eyes were a striking contrast to her auburn hair.

For a moment, James felt a charge—Wilma’s gaze was different than Deanna’s gentle encouragement. Deanna anchored him, giving him hope for a future. Wilma tested him, pulling him toward temptation and risk. He wondered which version of himself each woman saw: the fumbling intern or the doctor he wanted to become.

“We all have to look out for each other,” James blurted. The moment was gone.

“Of course, Dr. Deetan. Let me put those slides away for you.” Her hand brushed against his, as she turned and left.

James lingered in the empty room. Wilma’s words and Deanna’s laughter at Dogtown both echoed in his mind. Two women, two mirrors, each reflecting a different possible path.

Next Chapter: Chapter 14-Bad Needle Day

“James! Thanks for coming.” The ENT resident motioned to the bearded man in the examination chair. “This gentleman comes to us with a one-month history of a rapidly growing mass in his left neck. Night sweats and low-grade fevers, no recent travel history.”

“Got it.” James nodded as he prepared his aspiration setup. “I will take a sample for cultures, including tuberculosis.”

It was October, his fourth month of residency. James was on the cytopathology service. The pathologists were called by various departments in the hospital to perform a fine needle aspiration (FNA). Today, the call came from the ENT clinic for an FNA of a neck mass. James was flying solo, with no senior resident overseeing his performance. As the ENT resident emerged from behind the drawn curtain of the examination room, James positioned a small cart carrying a microscope, slides, and bottles of stains.

The patient reclined in the examination chair which resembled a dentist’s chair. His grey beard was scruffy and unevenly trimmed. His face was long and furrowed, with deeply ingrained wrinkles encircling his eyes, nose, and mouth. His receding hairline accentuated the length of his face.

“Hello Mr. Krause…” James simultaneously looked at the patient and his chart which he held. “I am Dr. Deetan from pathology. Did Dr. Samuelson explain to you what we are going to do today?” The patient stared at James, carefully following his every move. No response. “Well then, today, we will be doing a fine needle aspiration biopsy. I will be placing a small needle into the lump that you have in your neck, remove some cells, and smear them on these slides. I will stain the slides and look under the microscope to make sure we have enough material to make a diagnosis. I will also be taking a small amount for cultures to see if you have an infection. I understand you have been sweating at night and have some fevers?”

The stare answered. “Ok…I need to tell you about some of the risks. There is a small chance of bleeding but we use a needle that is smaller than the one we use to draw your blood. Also, there is a small chance of infection but we perform the aspiration with a sterile technique, minimizing the risk. Do you have any questions?” Another stare. “Ok…I will take that as a no.” James grabbed the consent form and placed it on the clipboard, positioning it in front of the patient. “Mr. Krause, I need you to sign and date this consent form authorizing me to perform this procedure and that all the risks and benefits have been explained to you.” No movement. James was losing patience. “Mr Krause…”

“What kind of name is that? Japanese?”

Startled by his voice, James blurted, “It’s Chinese.”

“You don’t look Chinese.”

“Well, I am. Could you please sign this consent?”

Signing the consent, he momentarily removed his stare. “I was at Pearl Harbor when the Japs attacked. I could see the pilots in their cockpits. You don’t look Chinese.”

“I assure you sir, I am Chinese. My family is from the Philippines and we fought alongside the Filipinos against the Japanese.”

“I was in Saipan and had to fight them bastards face to face,” the patient continued, ignoring James’ efforts to defuse the patient’s diatribe.

“I need to examine you. Please lean your head back…it’s on the left side, correct?”

“You don’t look Chinese…”

“Yes, we’ve established that fact. I’m going to be gently pressing your neck, tell me if any of this hurts.” James palpated the firm nodule below the skin just below the angle of the left jaw. “Feels like a lymph node. Let me clean the area up with some alcohol and we will be ready to go.” A few wipes of the alcohol pad, a drape of a surgical cloth on the patient’s shoulders, and James was ready to enter the nodule with his needle. The needle and syringe were held in a device that allowed the plunger of the syringe to be withdrawn while holding the needle in place. As James inserted the needle into the soft tissue of the neck, the syringe was pulled back creating a negative pressure, sucking the cells into the needle hub. After a few movements of re-positioning the needle within the tumor, the negative pressure was released, and the needle was retracted.

James quickly removed the syringe and needle and carefully positioned the needle over a clean slide. With a gentle motion, he forced air into the needle which produced a small drop of blood onto the slide. Picking up another slide and placing it on the blood drop, he smeared the two slides together, placing one in an alcohol fixative and the other left to dry in the air, to be stained by a rapid Diff-Quik stain. So intent on performing his task, James failed to notice the growing anger of the patient. “Don’t you stick that in me again!” He yelled. “You didn’t tell me you were going to stab me!”

“Sir, I explained the procedure to you. I didn’t stab you; I used a very small needle to take a sample of the tumor for my tests.”

“HE’S STABBING ME!”

The ENT resident bolted over from the next room. “Mr. Krause, everything is okay.” He quickly grabbed the patient’s hand and motioned to several orderlies.

“HE’S NOT CHINESE!”

“James, are you finished?”

James shook his head as he reviewed the Diff-Quik stained slide. “It looks like a reactive lymph node, probably infectious. I need to stick him one more time to get cultures.”

The ENT resident intervened. “All right, let me help you. Mr. Krause, we need to do this one more time. We are not stabbing you, it is just a simple blood test. No one is going to hurt you, understand?”

“I don’t trust him. I don’t trust JAPS!”

“Mr. Krause, please hold still, this will only take a few seconds.”

In his haste to prepare the new needle and syringe, James forgot to remove the safety cap on the needle. Positioning himself close to the patient, Mr. Krause lunged forward causing James to push the syringe forward. The positive pressure in the syringe forced the needle to shoot off the syringe, propelling it like a missile past the patient’s face, and implanting it into the cork bulletin board next to him. The orderlies and the ENT resident stared at the embedded needle and then at James.

“Oops.”

“WHAT THE HELL ARE YOU DOING?”

“Mr. Krause…settle down. Let me take a quick blood test to make sure you don’t have an infection.”

“WHAT THE HELL ARE YOU DOING?”

The ENT resident motioned to James to confer behind the curtain. “Bad needle day, huh? Look, let’s let things cool down a few minutes then I’ll stick him for the cultures. You obviously remind him of some nasty war experience.”

James nodded his head. Anything to get out of there. After a few minutes, a muffled laugh emerged from behind the curtains, and within a few minutes, the resident produced a syringe with the tell-tale drops of blood. “Got it, you can use this for the cultures.”

“Thanks.”

“You know, funny thing, the guy’s wife is Chinese. So I guess he really did know what a Chinese person looked like.”

James rolled his eyes. Gathering the microscope and slides, James drew the curtain aside and peered in.

“GET OUT OF HERE!”

Just another day in St. Louis. James trundled back to cytology where Franklin was preparing the specimen receiving area for the next case.

“Dr. Deetan, let me help you.”

“Thanks, Franklin.”

Franklin paused before he reached for the flat of stained slides. “I know that look, seen it lots of times. Doesn’t matter if I’m in Boston or St. Louis. Feeling overwhelmed?”

“Bad needle day.” James repeated the ENT resident’s sardonic comment.

“Have you figured it out yet?”

“What do you mean?”

“Every new place, it takes time to figure everything out. Who are the decision-makers? Which egos to stroke?” Franklin paused. “And there is always the scheming. The things I’ve seen. One time there was this resident who missed a diagnosis on a frozen section and…”

James shook his head, interrupting Franklin. “I know. Back home, I always felt like I was in control. Here, it’s one step forward and two steps backward. Everything I do, is never good enough, especially for Dr. Haas.”

“Yes. Dr. Haas. She will take some time. It took me a year before she made small talk with me. I had to be patient. Lots of smart people here. That’s what happens as you keep advancing in your training. Your circle becomes smaller and more competitive. More intense. You are working with the cream of the crop.” Franklin looked over James from head to toe. “You may not be able to be the smartest but you can make it seem that way. You set up intellectual barriers to entry. You find your niche. That’s what I did. No one does autopsies as well as me. No one cuts a frozen section as quickly as I do.”

James nodded. “You are good at what you do, Franklin.”

“Thanks. I’ve worked hard to get here. I’ve seen many residents come and go. The ones that succeed are the ones that look around, find a need, and fulfill it.”

“Like what? How do they do that?”

“Take Dr. Berkowitz. She’s so good at languages—Portuguese, Spanish, French. I think she even speaks some Chinese. When she was a first-year resident, she recognized the need for the hospital staff to have a quick reference guide to explain pathology results to their patients in their respective languages. So that’s what she did.” James had used these guides, conveniently placed at nurse’s stations. Deanna. James didn’t think he could be even more impressed with her.

Franklin watched him drift. “Yeah, she’s special, isn’t she? But watch your step, Doc. Special can be dangerous too.”

James forced a laugh, but when Franklin left, his thoughts lingered. Deanna inspired him to rise above Haas’ criticism. Wilma, meanwhile, was a different challenge: her eyes, her playful brush of his hand, haunted him even here, in the fluorescent-lit cytology suite. One grounded him, the other tested him.

“I’ve seen you work. You can do this, Dr. Deetan. You have that drive, something I see in everyone who succeeds.” Franklin sighed. “Just be careful, watch your back. Someone is always sacrificed in this department.”

“I will.” It was the second time he heard this warning. “Thanks for helping me out.”

Next Chapter: Chapter 15-Face Of The Enemy

The fourth month of residency was proving to be James’ most difficult yet. Haas had not spoken to him since the chondrosarcoma case. When she saw him in the hall, she would turn her head or briskly pass. It was not subtle. The other attendings and residents noticed too. Even Deanna.

At noon, James sat at a cafeteria table alone, stirring his soup but not tasting it. The seat across from him filled without warning.

“Cheer up, Dr. Deetan.” Deanna slid her tray in front of her. “Even Haas can’t ignore talent forever.”

James smirked. “She’s doing a pretty good job of it.”

“She’ll come around.” Deanna broke her bread roll and handed half to him. “You’re still standing. That says something.”

Her easy kindness disarmed him. He wanted to tell her about the phone call from his mother, his father’s illness, the shame, the exile. Instead, he just nodded and chewed in silence.

“Tell you what,” she leaned forward conspiratorially, “come by my office later this week. I’ll show you the slides for next week’s unknowns before Dan gets his hands on them. That way, you’ll be three steps ahead.”

James chuckled. “You’re going to get me in trouble.”

“Maybe. But it’ll be worth it.”

The cafeteria noise dimmed as her jasmine perfume mixed with the scent of baked bread. For a moment, there was no Haas, no fear of failure, just Deanna.

“Mind if I join?” Wilma’s New Orleans lilt broke the spell. She dropped her tray next to James and smiled like she owned the table. “I saw you moping from across the room. Don’t let her—” she jerked her thumb toward the ceiling, in Haas’ direction—“get under your skin. Woman’s got ice water in her veins.”

“Wilma,” Deanna greeted with a polite smile, but her eyes cooled.

James tried to bridge the sudden chill. “Wilma’s right. I need to toughen up.”

“Not toughen up,” Wilma corrected, stabbing her fork at her salad. “Play the game. You’re not in Manila anymore. Around here, politics is half the diagnosis.” Her eyes lingered on him. “I can teach you.”

Deanna took a slow sip of her iced tea. “Or you can keep your focus where it belongs—on the patients. That’s how you win respect.”

The air between them was charged. James shifted in his seat, caught between the grounded grace of Deanna and the playful boldness of Wilma. Both women saw something in him; both demanded a different kind of loyalty.

Before he could speak, Dan dropped his tray on the table. “What is this, the Deetan fan club? No wonder you look distracted, my man.”

The table erupted in nervous laughter, but James wasn’t laughing. He realized in that instant that his training wasn’t just about glass slides and diagnoses. It was about alliances, perceptions, and the faces people wore in battle—Haas’ icy glare, Wilma’s mischievous grin, Deanna’s steady gaze.

The real enemy wasn’t just disease under the microscope. It was everything outside of it.

Next Chapter: Chapter 16-Condyloma Queen

Among the residents and histotechs, there was a whispered nickname for Dr. Irene Haas: the Condyloma Queen. It was never spoken in her presence. She was famous for spotting even the subtlest HPV-related changes on Pap smears, and her tirades during cytology sign-out were legendary. If you missed a koilocyte, you paid for it in humiliation. The irony wasn’t lost on James when, later that week, someone else claimed the same title—loudly, and with pride.

James wheeled the cart back to the cytology department, still rattled by his encounter with the Pearl Harbor veteran. Three flats of slides sat stacked on his desk, awaiting his return. The FNA had taken longer than expected; there would be no time for lunch and barely enough to review the Pap smears before his 1 PM sign-out with his attending. Fishing through his backpack, he came up with a granola bar, then headed to the end of the hall for the coffee pot — its contents brewed six hours earlier and bitter as tar. Refueled, he settled at his microscope.

The Pap smear had revolutionized the early detection of cervical cancer, a public health success story rivaling the eradication of smallpox. Now James was part of that chain of prevention. Each morning he received about forty Pap smears, pre-screened by cytotechnologists. Their careful dots of ink marked suspicious cells, silent testimony to the hours they’d spent scanning each smear. His task was to confirm or amend their impressions. Tedious work, yes — but James stayed focused. Every abnormal cell was a map, a breadcrumb trail to cancer. He was determined to follow it, however long or arduous.

After half an hour, he’d worked through a third of his stack. On one slide, he instantly recognized the cytologic hallmarks of HPV infection.

“Condyloma. Venereal wart,” he murmured, checking the box on his worksheet and setting the case aside.

The overhead speaker interrupted.

“Dr. Deetan…line one!”

“This is Dr. Deetan.”

“Are you the pathology resident looking at my case?”

James straightened. “I’m sorry — who is this?”

“This is Dr. Louise Treacher. I told the cytotechs I wanted the Pap results on Madison, STAT. She’s sitting in my office and I need the report. The computer system’s down, so I decided to call.”

James shuffled his paperwork. “Yes, Dr. Treacher — I have it here. Donna Madison, 34 years old, correct?”

“That’s her! Does she have the wart?”

“I’m afraid so. I’ll still confirm with my attending, but it looks like a classic condyloma.”

“I knew it! Honestly, I can’t believe how many of my patients have condyloma. It’s an epidemic! I’m the Condyloma Queen!”

James blinked. “…Yes, ma’am. I’ll call if there are any changes after sign-out.”

“Well, aren’t you polite. What’s your name again?”

“James Deetan.”

“Is that Chinese?”

“Yes, ma’am. Chinese-Filipino.”

“My nurse is Chinese — Shirley Kwok. Maybe you know her?”

“I’m afraid not.”

“Well, very nice talking with you, James.”

James hung up, shaking his head. “Nice talking with you, Condyloma Queen,” he muttered. Two queens, one whispered, one proclaimed. Either way, the computer system was still down.

He dialed IT.

“Information Systems. Jake speaking.”

“Hi, this is Dr. Deetan in Pathology. Any update on when our system will be back online?”

“Who is this?”

“Dr. James Deetan. First-year resident.”

“Oh right — I remember setting up your login. Good to meet you, Doctor. The system should be up in about fifteen minutes. One of my coworkers accessed the wrong file; I traced the error and corrected it.”

“Thank you, Jake. Nice to meet someone so efficient. Sorry, what was your last name again?”

“Thompson. Jake Thompson.”

“Appreciate your help, Jake. Hope to meet you in person sometime.”

“You can count on it.”

James refreshed his screen — the system blinked back to life. Relief washed over him, but the reprieve didn’t last.

“Thought I forgot about you?”

He turned. “Wilma!”

The chief histotech set a small stack of surgical slides on his desk. “Here are the companion slides for your cytology cases. And I couldn’t help noticing you drinking that stale, scorched coffee.” From her bag she produced a thermos and styrofoam cup. “Try this.”

She poured. The aroma was richer, sweeter than anything he’d ever tasted. James took a sip — smooth, nutty, almost chocolatey.

Wilma grinned. “You like it?”

“It’s incredible. What is this? Hazelnut?”

“That, Dr. Deetan, is a New Orleans specialty — chicory coffee. Back home there’s a famous café, Café du Monde. I brew their recipe every morning. Told you I’d take care of you.”

James laughed. “You did. Thank you. Wish I’d had this instead of that granola bar.”

“Well, maybe a piece of pecan pie will find its way to your desk later.”

“Ooh, the famous Rousseau pecan pie? It can find its way here anytime.”

“If you come to New Orleans, I’ll take you to Café du Monde — coffee and their famous beignets. Ever had one?”

“No, but it sounds wonderful. Is it a pastry?”

“Better. It’s—”

“Oh, sorry to intrude. Didn’t know you were here, Wilma.”

Deanna.

James quickly set the cup down.

“Dr. Berkowitz,” Wilma said smoothly. “I was just leaving. Dropping off slides for Dr. Deetan.”

Deanna’s eyes flicked to the thermos, then to James. “That doesn’t smell like regular coffee. Hazelnut?”

“Deanna,” James stammered, “Wilma brought me some of her New Orleans chicory coffee. It’s fantastic. You should try it.”

“Maybe I should,” Deanna said coolly. “If I were ever offered a cup.” She shot Wilma a sidelong glance.

“I’ll get you one,” Wilma offered quickly.

“It’s all right,” Deanna replied. She studied James’ refreshed screen. “Just checking to see if the system’s back up. Seems everything is… back to the way it should be.”

Next Chapter: Chapter 17-Blood Brothers

Dan’s heels clattered like ball bearings against the linoleum, echoing down the hall. He spotted James twenty feet away.

“Dr. Deeeeeetaaaaan! I need you now!”

James had just entered his office and closed the door when it swung open again.

“James, it’s November. You were scheduled to be on hematopathology with Haas this month, but we need to juggle the schedule. You’re going to ULS with Nomura.”

“Lots of juggling going on recently. Thanks.”

“Don’t thank me—you’ll probably be cursing me before the month is out. You’ll be pushing glass 24/7.”

“I can push glass.”

“Yeah, right. Nomura’s expecting you. Drive’s ten minutes. You know where the lab is, right?”

James nodded, though he was hoping to stay at Memorial, even if it meant enduring Haas. He also hadn’t cleared the air with Deanna after the awkward encounter with Wilma and the chicory coffee.

He headed straight to the morgue. Located in the basement, near the kitchen and dining room, the autopsy suite was hidden from the public eye. The sharp odor of formalin mingled with the smell of frying bacon. Deanna sat in the resident cubicle, reviewing charts.

“Hey.”

“Hey.”

“Deanna, everything okay?”

She closed the folder. “Yes…no, not really.”

“What’s wrong?”

“This patient—she died of cancer, so young. I was thinking about her family, the life she never had. You know, in med school I got so attached to patients it clouded my judgment. I thought pathology would buffer me from that. But I’ll never be completely removed. I grieve like any doctor does.”

James sat beside her. “I wish I could do this autopsy for you. Take away the pain, just for a little bit.”

She smiled faintly. “You’re sweet, James. Usually I don’t mind autopsies—just this one. Thanks for listening.”

“Always. I’ve got your back.”

“That means a lot. Why are you here—were you looking for me?”

“Dan just reassigned me to ULS. Starting today. I wanted you to know—especially since you offered to help me with heme.”

“Condolences. Not sure which is worse—Haas or ULS. At least you’ll be with Nomura.”

“My thoughts exactly.”

“Call me. Or stop by. It’s a different world there.” She winked. The jasmine of her perfume lingered as James walked out.

ULS was a sprawling one-story complex in a warehouse park. The sliding glass doors bore bold white letters: United Laboratory Services.

Behind the reception desk sat a young man with spiked blond hair and tattoos. “Sign in and drop your lab order in the box.”

“I’m Dr. James Deetan, pathologist. Dr. Nomura is expecting me.”

“Hang on.” He punched the intercom.

“Yes?” Nomura’s voice answered.

“There’s a James Deetan here to see you.”

“Send him in.”

“Third door on the left,” Spiky-hair instructed, giving James a curious once-over.

Relieved, James entered Nomura’s office, nearly buried behind towers of slides and paperwork.

“Welcome to ULS,” Nomura said.

“Bit different than Memorial,” James replied.

“Big business. Pathology is a commodity here. Look at this—” Nomura gestured at the piles. “They expect us to do a day’s worth of work in half the time, with half the reimbursement. Everything is capitated. Better get used to it.”

“I’m ready to start.”

“Good. No time for previewing. We’ll double-head cold.”

They signed out dozens of cases, Nomura dictating nonstop as James frantically matched paperwork to slides.

“Dr. Nomura—I think we have a mismatch. Slide says ‘Smith, Jake,’ requisition says ‘Smith, Jack.’ Looks like they were filed wrong.”

Nomura checked. “Good catch. Distractions happen all the time here.” He sighed. “Let’s grab coffee.”

They passed rows of maroon cubicles, the clatter of keyboards echoing. “Transcriptionists,” Nomura explained. “I’ll introduce you later.”

Before they reached the pot of coffee, a booming voice stopped them.

“Well, a new pathologist?”

A short, round man with thinning hair approached.

“Gene, this is one of our residents, James Deetan,” Nomura said.

“Pleased to meet you, James. Eugene Carlisle—president of ULS.”

Carlisle beamed. “Can I borrow him for a bit?”

“Be my guest,” Nomura said.

Carlisle’s office was spacious, lined with shelves of books, framed photos of horses and family, and an open folder of multicolored graphs.

“Masao’s dermpath, right? Someone told me dermpath’s easy—99% of cases are five diseases.”

James hesitated, searching for a safe answer. “I don’t think it’s that easy. Even if it were, it’s the 1% that bounce back—the ones that lead to lawsuits. That’s why you need Dr. Nomura.”

Carlisle grinned. “I like you. Let me show you something.” He pointed to the revenue graphs. “Red line—St. Louis. Our top performer. Do you know why?”

James shook his head.

“You. Pathologists at Memorial. Haas, Nomura—best in the business. Easy to sell our services with names like that. We’ve doubled volume in a year, cut costs 40%. Memorial followed suit—laid off 30% of their lab staff after seeing our numbers.”

James thought of Carter’s lab, and the whispers of cuts.

Carlisle pulled another chart. “It’s us and Birkman now. We’ve swallowed every small lab in the Midwest. They’ve got the West Coast. East is up for grabs. Managed care—it’s war. And we’re winning.”

“Like Cain and Abel,” James muttered.

Carlisle chuckled. “Which one are we?”

“I wouldn’t guess.”

“I like you even more. Welcome to ULS, James.”

Leaving Carlisle’s office, James followed glowing red letters down a hall to a massive call center, buzzing like a telethon.

“Yes, Doctor, sorry we missed the pickup—yes, we’ll send someone right away—”

A tall woman with tousled hair and octagonal glasses approached. Her badge read: DORIS STANLEY, Supervisor Client Services.

“Can I help you?” she asked warmly.

“Just looking. Dr. James Deetan—new resident.”

“First day? I’m Doris. We handle all the complaints. It’s… entertaining.” She smiled, then sighed. “Though with half the staff gone, it’s more grueling than fun.”

James nodded. “I hope I’ll see you again.”

“You will,” she said, smiling knowingly.

Back with Nomura, James recounted the encounter.

“So you got the sermon from Carlisle.”

“This isn’t Memorial. I feel sorry for all those who lost their jobs.”

“Bottom line rules here. When I first came to St. Louis, there were dozens of little labs. Now it’s just the two blood brothers, ULS and Birkman.”

“Like Cain and Abel?”

Nomura chuckled. “Maybe. Let’s break for lunch—the roach coach should be here.”

James thought of the Philippines, where families stayed with sick relatives, bringing food instead of dealing with insurance and managed care. Here, efficiency had replaced compassion.

As they passed the front desk, Spiky-hair called, “Hey James! Don’t forget—HR for your badge!”

Nomura lifted his hand. “And remember—don’t forget to have fun.”

Next Chapter: Chapter 18-No Bias

“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

“You know Haas did the autopsy on her own miscarriage.”

“Get out of here!” Carlos nearly dropped his burger, but Dan stayed cool, stealing fries from his plate. “You want those?”

It was 11:30 AM sharp in the cafeteria—the prime hour when the first wave of doctors swarmed in. The pathologists and dermatologists always claimed the early tables. Too cold for the patio in December, the noise indoors was deafening.

“She didn’t trust any of the residents,” Dan went on. “Brought the fetus in herself, cleared the morgue, did the autopsy alone.”

“Whoa. How could anyone be that cold? On her own child?” Carlos slapped his hand away.

“A child? It’s a macerated fetus,” Dan replied in his usual pathological precision.

“Guys, it’s Christmas season. Do we really need to talk about this?” James pushed his plate of spaghetti aside. “It is a child. Doesn’t matter if it’s a fetus, two months, or a term infant.”

“Are you gonna eat your pudding?” Dan reached for James’ tray just as the dermatologists filed in.

“Late today,” Carlos said, feigning interest. “Must’ve been a conference.”

“Guys, looks like fun!” Deanna slid in next to Dan, the scent of jasmine preceding her. “Quiche! One of the few things they actually do right here.”

“Father Deetan was just giving us a sermon on the sanctity of life,” Dan teased, hands folded in mock prayer.

“It’s about time someone gave you that talk. Hope you learned something.” Deanna winked at James.

“Ah, Dr. Berkowitz, I know more about life than you could ever imagine.”

“Life is more than jazz, Dan. Karen hates jazz, remember?”

“I have other talents that keep Karen interested.”

Carlos laughed. “I don’t think we want to know.”

“Seriously, she told me last night I was a sex god.”

Deanna choked on her quiche. “If I come across roadkill, I’ll offer it up in your honor.”

“I accept your worship. So why were you late, Deanna?”

“Nomura and I were at derm grand rounds.”

“Did you present my hemangioma case?”

“Yup. The child was there—impressive lesion. You know, I can present at tumor board, breast conference, anywhere. But these derm rounds, seeing the patients… especially the kids—it still gets to me.”

“Deanna, you’re great with patients.” James spoke before he realized.

“That’s sweet, James, but sometimes it’s hard to draw the line. In med school, they taped our interviews with pediatric patients. If the kids cried, I cried. My professors hated it. They said I’d make a better minister than a pediatrician.”

“Father Deetan and Mother Superior Berkowitz!” Dan smirked. “Imagine that—a Jewish nun!”

Deanna flicked a breadcrumb at him. “Purgatory welcomes deceivers like you. Carlos, how’s cytology?”

“Saving lives every day!” He pumped his fist. “But Deanna, if you’re so bothered by seeing patients, how do you handle FNA service? You’re aspirating breast, thyroid, chest wall masses—talking to patients while knowing your smear could seal their fate in five minutes.”

“It bothers me. Of course it does. But less than when it’s a child.”

“Don’t forget bone marrows,” James added.

“Especially bone marrows!” Carlos threw up his hands. “Patients hate that Jamshidi needle in the hip. The hematologists turf the cases to us because insurance doesn’t pay them. We’re the ones left with furious patients.”

“Yeah,” Dan said. “We make the diagnosis, but the surgeons and oncologists get the credit.”

They all nodded. The clang of trays and dishes swelled around them. Carlos grinned. “I guess it’s time for pillow talk.”

Deanna groaned. “Must you reduce everything to sex?”

“What? We just had an intense encounter. Now comes the five minutes of comforting our woman.”

“Five?” Deanna shot back. “Twice as long as you spend with yours?”

“No, that’s how long before my girlfriend notices I’m gone.”

Dan slapped his hand. “As a fellow sex god, I approve! It’s a guy thing. Right, James?”

James froze, glancing at Deanna. Dan smirked. “Oh, sorry. Forgot priests are celibate.”

“Come on, James,” Deanna said, standing. “Show me that lymph node case Nomura gave you to review with Haas.”

They left together, turning the corner by the library.

“Carlos and Dan—ignore them. Frat boys.”

“I know. I didn’t grow up here, so I miss a lot of their references.”

“They’ve both been through a lot. Did Carlos ever tell you what happened when he was a first-year?”

“Dating a beauty queen or something?”

Deanna laughed. “Not quite. He was on frozens with Lucas—Morris’ case. Lucas missed the cancer. Carlos caught it afterward. Lucas told him to destroy the slide so there’d be no evidence.”

James stared. “Did he?”

“No. He refused. They nearly fought. Franklin stepped in—and Haas walked in at that moment. Carlos told her everything. Lucas was fired. Dan hated Lucas, so he and Carlos bonded after that. That’s why they’re inseparable now.”

James remembered the incident when Carlos told him. Now there were more details he didn’t share. It was years ago. No one left to protect.

“Thanks, Deanna. I’d never heard that. So much happens behind the scenes.”

“Too much,” she agreed. “Medicine, business, politics—it’s all the same. Every time I hear a new story, I think, not again. Hopefully Carlos’ drama was the worst we’ll see in residency.”

“Hope so,” James said. “Can’t imagine worse than that.”

Next Chapter: Chapter 20-No Excuses.