Cora Hamilton, chair of the Department of Pediatrics for the past three years, was a tall, thin, stoop-shouldered woman with graying black hair pulled back in a tight bun. Labeled by her detractors ― peers for the most part ― as severe, gaunt, or American Gothic, she regarded charm as a useless frill. Conventional ideas that didn’t match her own were ignored.  In appointing house staff to her service, she paid more attention to the applicants’ character than their grades or research interest. Knowledge could be acquired, she reasoned; humanity either was or was not there. She also took issue with the prevalent attitude that valued publications over clinical practice. The credo “Publish or perish” made for bad research, bad literature, and bad doctors. If she had had her way, publishing an article in a medical journal would have ranked equal with restoring productive life to a disabled patient, no higher.

On the subject of medical malpractice she was even more unyielding, if that was possible. If doctors practiced with competence and caring, there would be no lawsuits. It followed that the burden of proof lay with the doctor. In the case of Eden Avery, she saw not only the potential for a lawsuit, but inevitable ― and totally justified ― victory for the plaintiff.

Cathy Cross and Calvin McCrae had been her choices; Mort Friedman’s appointment preceded her elevation to the chair.

She called the mortality conference to order.

“We had only one fatality in the past two weeks, but that one’ll give us more than enough to think about. Doctor McCrae, please present the case.”

Calvin made the best of a bad situation. In a subdued but clear voice, he told of his diagnosis and the urgency of treatment, of persuading Nurse Bader to fill orders without review by the resident on call, of his abbreviated visit to the cafeteria, and the disaster in progress on his return. He gave credit to Cathy Cross for cautioning him about drug allergy and then coming to his aid later. He made no reference to Mort Friedman.

The audience, already in possession of the facts through the all-reaching grapevine, had anticipated a confrontation between intern and resident; so far it had not happened.

“So much for the facts,” Cora said. “Do you wish to add anything?”

“Yes, I do, Doctor,” Calvin replied. “It’s my fault that Eden Avery died.”

Cora studied Calvin’s face. “You did commit an error, and a costly one it was. Learn from it. And everyone else learn from it. That’s why we have these conferences.

“Now, we also have fail-safe mechanisms to protect our patients from errors like this. An intern’s orders have to be countersigned by the resident on call and the nurse is not supposed to carry them out unless they have been. Isn’t that your understanding, Ms. Brown?”

“Yes.” Alice Brown, the nurse for whom Connie Bader had substituted, was back.

“Of course, you weren’t here when this happened.” Alice was relieved not to be put in the uncomfortable spot of criticizing her colleague.

“So, Doctor McCrae, how did it happen?”

“I persuaded Nurse Bader to start the antibiotics right away. I thought I could get the order countersigned later. I had no right to do that.”

Cora did not drive home the point. She turned her focus to the resident.

“Doctor Friedman,” she said, her expression blank.

“I didn’t get a page. My beeper had a dead battery, for the second time this month.”

“Did you stop by any time during the evening, just by way of checking up on things?”

Mort was beginning to squirm. “No, I did not.”

“Did the name Eden Avery mean anything to you prior to this admission?”

“Yes.”

“How did you learn about her?”

“She had a previous admission.”

“Many of the people here may not know about that. Tell them about it.”

“Anaphylactic reaction to Bicillin.”

Half the audience sat with eyes downcast; the other half gasped.

“May I ask where you were during the time Eden Avery was dying?”

“In the sleep laboratory.”

“You’re doing research there?”

“Yes.”

“And are your results encouraging?” Cora’s tone was totally dispassionate. Mort had no choice but to answer likewise, knowing he was digging his own grave.

“Yes, quite.”

“Tell us about them.” Cora wrote the words “drug allergy” on the blackboard.

Mort gritted his teeth. He had envisioned presenting his research at a different kind of conference, to the kudos of other researchers. He knew there were major discoveries in his future; publications that would be cited by others; invitations to speak at national, even international, meetings. And, of course, top-notch academic faculty appointments. Now this!

“Most interesting,” said Cora when he had finished. “Yes, we do need good research, and good research does take dedication. And time too. We may all be thankful one day that you gave both to your project. Sleep is such an important part of all our lives.”

As she was speaking, still with her back to him, Mort heard her matter-of-fact tone but could not see her face. He could not tell what she was accusing him of ― if anything. Against such an elusive attack he could not defend himself. She slowly turned round to face him.

“You must have been glad the evening was so quiet,” she continued in the same tone.

Mort blushed deeply. He had indeed been glad ― had, in fact, openly expressed his hope for just such an evening. Cathy would remember. How could he own it without seeming not to care about his patients? How could he deny it without being caught lying?

“My beeper didn’t go off,” he said.

“Did you check the battery before going where you couldn’t hear the public address?”

“It was less than two weeks old.”

“Do you check the warning lights on your dashboard before driving your car?”

Mort stood mute. “That is not a rhetorical question,” Cora said.

“Yes, I do.”

“Every single time?”

“Yes.”

“And do you check your equipment in the laboratory before making a measurement?”

Silence.

“Doctor Friedman?”

“Yes.”

“Every single time?”

“Yes, Doctor Hamilton.”

“You may sit down.”

He sat down. Cora had dangled before him the option to hate her instead of himself, but he was in no state to choose.

“The lesson is obvious,” she said to the audience at large. “Being on call means just that.” As a calculated afterthought she added, “A patient’s life may depend on it.”

In the silence that followed, breathing risked drawing unwanted attention.

“Doctor Cross, you were off duty but you stepped in. Is there anything you wish to add?”

“Not really, Doctor Hamilton. I’m afraid I was no help to the patient.”

“But you were to Doctor McCrae. I’m sure he’s very grateful for your help—”

“I am,” Calvin said, “I cannot thank her enough and I’ve told her so.”

“I thank you, too,” Cora said to Cathy. To the others, she added, “That’s the kind of example I want you to take from here. . . . Alice, I don’t want to put you on the spot, but do you have any comment?”

“This does show how a nurse can make a real difference. I knew Eden, and I’d have been able to remind Doctor McCrae that she was allergic. Connie didn’t know her and had no basis for questioning the orders. But I’d like to ask you a question, Doctor Hamilton, if I may.”

“Go ahead, and you’re right in what you said. We never appreciate nurses enough.”

“If I’d been on duty and had carried out the order, would I be held liable?”

“Morally and ethically, without a doubt. Legally, I don’t know, since you were carrying out orders. Perhaps you could take refuge in there being nothing about allergies in the new chart, and the old one wasn’t up yet. Does anyone want to speculate?”

“It’s clear she’d be held liable.” It was the voice of Homer Radcliffe, a pathologist. “If she were put under oath, she’d have to admit that she knew of the allergy ― or she’d be committing perjury. So she couldn’t take shelter in the chart not being up.”

“I’ve heard you can’t be forced to remember. If it’s not in writing, it doesn’t count.”

“Lying is lying.”

“Thanks, Homer. Nowadays physicians have to know something about law too. That makes us smarter than our forebears; we know the rules of liability. So what do we do in our wisdom? Gamble that nothing will go wrong when we violate those rules. Well, we’d better add another rule: You don’t stake a patient’s life on the odds, no matter how long the odds.”

Calvin’s and Cathy’s eyes met in a moment of private understanding.

“The other point,” Cora continued, “is that this case has all the makings of a malpractice suit. Our lawyers will caution us not to discuss it with anyone. Not even among ourselves where others might hear us. I’d much rather encourage open discourse, but we have to make concessions to reality. And as long as we’re all here, let me give you a piece of my own mind. Whether we get sued or not, we deserve to. And we deserve to lose.  And losing should be a lesson to us, not to vilify the lawyers who sue us, but to remind ourselves how much power we hold in our hands. I’m talking about our patients’ trust, not the latest technology. Every negligent act is a betrayal of that trust. You think malpractice awards are too high? You think malpractice premiums are too high? How would you like to lose your child because the doctor forgot to ask a question ― or was busy elsewhere with a dead beeper?” She paused before delivering the coda. “I have no desire to repeat this lecture. Don’t give me reason to.”

With that, the conference ended. As the assemblage left the room, a voice was heard. “Quite a sermon! I wonder whether she preaches on the side.”

“Shut up, Friedman!” Doctor Hamilton was out of earshot.

~~~~~~~~~~

Before returning to her office, Cora went to the administration suite. “Is Mr. Small in?”

“Yes, Doctor, let me see if anyone is with him.”

A moment later she motioned Cora into an office bearing the name “Patrick Small, Esq.”

“Good afternoon, Cora. Going to keep me from my wife and kids again?” Pat Small rarely passed up an opportunity to tease the doctors about the hours they spent in the hospital. His work as legal counsel involved fairly mundane matters such as contracts, regulations, and the necessary dealings with labor unions. Malpractice litigation was outside his expertise.  For this ever more important area, the hospital’s insurer had engaged the firm of Burns, MacAdoo & Ferguson. Still, Pat knew enough about liability to offer informal comments. He and Cora enjoyed each other’s respect and friendship. In his presence she sometimes laughed.

She closed the door behind her and said, “There’s no reason for your family to be so privileged. I don’t see myself getting out of here any time soon, so you can suffer with me.”

“Why not make that ‘supper’? I’ll call my wife and say I’ve had a late admission.”

Cora laughed “You could probably make her believe it ― unless she’s a better lawyer than you. But I don’t want you to get in trouble with her. I’m sure you know why I dropped in.”

“It’s all over the hospital. Too bad the bottle couldn’t have been corked right away. I don’t lack in sympathy for the family, but that loose talk could come back to haunt you.”

“I know. I just told them that at the mortality conference, but it’s a little late, obviously.”

“If my information is correct, you don’t have a leg to stand on. But I know those boys at Burns and company. They don’t give up without a fight. McCrae, Friedman, and Bader are hospital employees, but they’ll try to dump it all on Rick Harmon. The more Harmon pays, the less the hospital’s share of the damages. I’ll bet you three to one they put Bruce MacAdoo on the case. He’s their toughest.”

“Well, I hope Rick’s carrier has a lawyer even tougher than MacAdoo and dumps it right back where it belongs. To use your words, I’m not lacking in sympathy for my own house staff, far from it, but that’s where the liability is. And I’m no less to blame than Rick. . . . And will you kindly stop taking notes. This is supposed to be off the record.”

Pat had made a pretense of taking notes as Cora implicated herself. “Listen, Cora. What’s between you and me stays between you and me. But I get an occasional urge to do something to shock you. I just don’t trust you not to say things like that to the wrong people. For God’s sake, don’t even hint at such a possibility, or you’ll get your nose rubbed in it under oath.”

“How do you think it’ll come out?”

“My best guess? MacAdoo will try bluffing first ― emergency, too sick to give history, records not up yet. In other words, terrible tragedy but can you blame the hospital? Now that’s where the plaintiffs’ lawyer comes in. I’ve learned that the girl’s mother is, guess what? a lawyer ― a goddam medical malpractice plaintiff’s lawyer! Can you beat that?”

“You move fast,” Cora said admiringly. “All I knew was that her father’s on staff here.”

“It’s my job to be informed. Anyway, they’re not going to buy those excuses. There’ll be a settlement. MacAdoo won’t let it go to a jury. Their best hope is to get the damages downgraded because of the girl’s limited life expectancy. She had heart disease, you know.”

“But with modern surgery, who knows? In any case, there’s the stigma of culpability.”

“The question is culpability, not the stigma thereof.”

“I guess I’ll be making the acquaintance of Bruce MacAdoo all too soon,” she sighed.

“Don’t sound so depressed about it. He’s on your ― our ― side.”

Cora Hamilton smiled as she got up. “Give my apologies to your wife for keeping you.”