The Final Diagnosis

The Final Diagnosis Page 4

The monthly surgical-mortality conference was scheduled for 2:30 p.m. At three minutes to the half-hour Dr. Lucy Grainger, a little harried as if time were working against her, hurried into the administration reception office. "Am I late?" she asked the secretary at the information desk.

"I don't think they've started, Dr. Grainger. They just went in the board room." The girl had indicated the double oak-paneled doorway down the hall, and now, as she approached, Lucy could hear a hum of conversation from inside.

As she entered the big room with its pile carpet, long walnut table, and carved chairs, she found herself close to Kent O'Donnell and another younger man she did not recognize. Around them was a babel of talk and the air was thick with tobacco smoke. The monthly mortality conferences were usually looked on as command performances, and already most of the hospital's forty-odd staff surgeons had arrived, as well as house staff - interns and residents.

"Lucy!" She smiled a greeting at two of the other surgeons, then turned back as O'Donnell called to her. He was maneuvering the other man with him.

"Lucy, I'd like you to meet Dr. Roger Hilton. He's just joined the staff. You may recall his name came up some time ago."

"Yes, I do remember." She smiled at Hilton, her face crinkling.

"This is Dr. Grainger." O'Donnell was always punctilious about helping new staff members to become known. He added, "Lucy is one of our orthopedic surgeons."

She offered Hilton her hand and he took it. He had a firm grasp, a boyish smile. She guessed his age at twenty-seven. "If you're not tired of hearing it," she said, "welcome!"

"Matter of fact, I'm rather enjoying it." He looked as if he were.

"Is this your first hospital appointment?"

Hilton nodded. "Yes. I was a surgical resident at Michael Reese."

Lucy remembered more clearly now. This was a man whom Kent O'Donnell had been very keen to get to Burlington. And undoubtedly that meant Hilton had good qualifications.

"Come over here a minute, Lucy." Kent O'Donnell had moved back near her and was beckoning.

Excusing herself to Hilton, she followed the chief of surgery to one of the board-room windows, away from the immediate press of people.

"That's a little better; at least we can make ourselves heard." O'Donnell smiled. "How have you been, Lucy? I haven't seen you, except in line of duty, for quite a while."

She appeared to consider. "Well, my pulse has been normal; temperature around ninety-eight point eight. Haven't checked blood pressure recently."

"Why not let me do it?" O'Donnell said. "Over dinner, for example."

"Do you think it's wise? You might drop the sphygmomanometer in the soup."

"Let's settle for dinner then and forget the rest."

"I'd love to, Kent," Lucy said. "But I'll have to look at my book first."

"Do that and I'll phone you. Let's try to make it next week." O'Donnell touched her lightly on the shoulder as he turned away. "I'd better get this show opened."

Watching him ease his way through other groups toward the center table, Lucy thought, not for the first time, how much she admired Kent O'Donnell, both as a colleague and a man. The invitation to dinner was not a new thing. They had had evenings together before, and for a while she had wondered if perhaps they might be drifting into some kind of tacit relationship. Both were unmarried, and Lucy, at thirty-five, was seven years younger than the chief of surgery. But there had been no hint in O'Donnell's manner that he regarded her as anything more than a pleasant companion.

Lucy herself had a feeling that, if she allowed it, her admiration for Kent O'Donnell could grow to something more deep and personal. But she had made no attempt to force the pace, feeling it better to let things develop if they happened to, and if not - well, nothing was lost. That at least was one advantage of maturity over the first flush of youth. You learned not to hurry, and you discovered that the rainbow's end was a good deal further than the next city block.

"Shall we get started, gentlemen?" O'Donnell had reached the head of the table and raised his voice across the heads of the others. He too had savored the brief moment with Lucy and found the thought pleasing that he would be meeting her again shortly. Actually he would have called her a good deal sooner, but there had been a reason for hesitation. The truth was that Kent O'Donnell found himself being drawn more and more toward Lucy Grainger, and he was not at all sure this was a good thing for either of them.

By now he had become fairly set in his own mode of life. Living alone and being independent grew on you after a while, and he doubted sometimes if he could adjust to anything else. He suspected, too, that something of the same thing might apply to Lucy, and there might be problems as well about their parallel careers. Nonetheless, he still felt more comfortable in her presence than that of any other woman he had known in a long time. She had a warmth of spirit - he had once described it to himself as a strong kindness - that was at once soothing and restoring. And he knew there were others, particularly Lucy's patients, on whom she had the same effect.

It was not as if Lucy were unattractive; she had a mature beauty that was very real. As he watched her now - she had stopped to speak with one of the interns - he saw her raise a hand and push back her hair from the side of her face. She wore it short, in soft waves which framed her face, and it was almost golden. He noticed, though, a few graying strands. Well, that was something medicine seemed to do for everyone. But it reminded him that the years were moving on. Was he wrong in not pursuing this more actively? Had he waited long enough? Well, he would see how their dinner went next week.

The hubbub had not died and, this time more loudly, he repeated his injunction that they start.

Bill Rufus called out, "I don't think Joe Pearson is here yet." The gaudy necktie which O'Donnell had observed earlier made Rufus stand out from the others around him.

"Isn't Joe here?" O'Donnell seemed surprised as he scanned the room.

"Has anyone seen Joe Pearson?" he asked. Some of the others shook their heads.

Momentarily O'Donnell's face revealed annoyance, then he covered up. He moved toward the door. "Can't have a mortality conference without a pathologist. I'll see what's keeping him." But as he reached the doorway Pearson walked in.

"We were just going to look for you, Joe." O'Donnell's greeting was friendly, and Lucy wondered if she had been wrong about the flash of irritation a moment ago.

"Had an autopsy. Took longer than I figured. Then I stopped for a sandwich." Pearson's words came out muffled, principally because he was chewing between sentences. Presumably the sandwich, Lucy thought; then she saw he had the rest of it folded in a napkin among the pile of papers and files he was carrying. She smiled; only Joe Pearson could get away with eating lunch at a mortality conference.

O'Donnell was introducing Pearson to Hilton. As they shook hands Pearson dropped one of his files and a sheaf of papers spilled out on the floor. Grinning, Bill Rufus collected them and replaced the file under Pearson's arm. Pearson nodded his thanks, then said abruptly to Hilton, "A surgeon?"

"That's right, sir," Hilton answered pleasantly. A well-brought-up young man, Lucy thought; he shows deference to his elders.

"So we have another recruit for the mechanics," Pearson said. As he spoke, loudly and sharply, there was a sudden silence in the room. Ordinarily the remark would have passed as banter, but somehow from Pearson it seemed to have an edge, a touch of contempt.

Hilton was laughing. "I guess you could call it that." But Lucy could see he had been surprised by Pearson's tone.

"Take no notice of Joe," O'Donnell was saying good-naturedly. "He has a 'thing' about surgeons. Well, shall we begin?"

They moved to the long table, some of the senior staff members going automatically to the front rectangle of chairs, the others dropping into the row behind. Lucy herself was in front. O'Donnell was at the head of the table, Pearson and his papers on the left. While the others were settling down she saw Pearson take another bite from his sandwich. He made no effort to be surreptitious about it.

Lower down the table she noticed Charlie Dornberger, one of Three Counties' obstetricians. He was going through the careful process of filling his pipe. Whenever Lucy saw Dr. Dornberger he seemed to be either filling, cleaning, or lighting a pipe; he seldom seemed to smoke it. Next to Dornberger was Gil Bartlett and, opposite, Ding Dong Bell from Radiology and John McEwan. McEwan must be interested in a case today; the ear, nose, and throat specialist did not normally attend surgical-mortality meetings.

"Good afternoon, gentlemen." As O'Donnell looked down the table the remaining conversations died. He glanced at his notes. "First case. Samuel Lobitz, white male, age fifty-three. Dr. Bartlett."

Gil Bartlett, impeccably dressed as ever, opened a ring notebook. Instinctively Lucy watched the trim beard, waiting for it to move. Almost at once it began bobbing up and down. Bartlett began quietly, "The patient was referred to me on May 12."

"A little louder, Gil." The request came from down the table.

Bartlett raised his voice. "I'll try. But maybe you'd better see McEwan afterward." A laugh ran round the group in which the e.n.t. man joined.

Lucy envied those who could be at ease in this meeting. She never was, particularly when a case of her own was being discussed. It was an ordeal for anyone to describe their diagnosis and treatment of a patient who had died, then have others give their opinion, and finally the pathologist report his findings from the autopsy. And Joe Pearson never spared anyone.

There were honest mistakes that anybody in medicine could make - even, sometimes, mistakes which cost patients their lives. Few physicians could escape errors like this in the course of their careers. The important thing was to learn from them and not to make the same mistake again. That was why mortality conferences were held - so that everyone who attended could learn at the same time.

Occasionally the mistakes were not excusable, and you could always sense when something like that came up at a monthly meeting. There was an uncomfortable silence and an avoidance of eyes. There was seldom open criticism; for one thing, it was unnecessary, and for another, you never knew when you yourself might be subject to it.

Lucy recalled one incident which had concerned a distinguished surgeon at another hospital where she had been on staff. The surgeon was operating for suspected cancer in the intestinal tract. When he reached the affected area he had decided the cancer was inoperable and, instead of attempting to remove it, had looped the intestine to bypass it. Three days later the patient had died and was autopsied. The autopsy showed there had, in fact, been no cancer at all. What had really happened was that the patient's appendix had ruptured and had formed an abscess. The surgeon had failed to recognize this and thereby condemned the man to death. Lucy remembered the horrified hush in which the pathologist's report had been received.

In an instance like this, of course, nothing ever came out publicly. It was a moment for the ranks of medicine to close. But in a good hospital it was not the end. At Three Counties nowadays O'Donnell would always talk privately with an offender and, if it were a bad case, the individual concerned would be watched closely for a while afterward. Lucy had never had to face one of these sessions herself, but she had heard the chief of surgery could be extremely rough behind closed doors.

Gil Bartlett was continuing. "The case was referred to me by Dr. Cymbalist." Lucy knew that Cymbalist was a general practitioner, though not on Three Counties' staff. She herself had had cases referred from him.

"I was called at my home," Bartlett said, "and Dr. Cymbalist told me he suspected a perforated ulcer. The symptoms he described tallied with this diagnosis. By then the patient was on the way to the hospital by ambulance. I called the surgical resident on duty and notified him the case would be coming in."

Bartlett looked over his notes. "I saw the patient myself approximately half an hour later. He had severe upper abdominal pain and was in shock. Blood pressure was seventy over forty. He was ashen gray and in a cold sweat. I ordered a transfusion to combat shock and also morphine. Physically the abdomen was rigid, and there was rebound tenderness."

Bill Rufus asked, "Did you have a chest film made?"

"No. It seemed to me the patient was too sick to go to X-ray. I agreed with the original diagnosis of a perforated ulcer and decided to operate immediately."

"No doubts at all, eh, Doctor?" This time the interjection was Pearson's. Previously the pathologist had been looking down at his papers. Now he turned directly to face Bartlett.

For a moment Bartlett hesitated and Lucy thought: Something is wrong; the diagnosis was in error and Joe Pearson is waiting to spring the trap. Then she remembered that whatever Pearson knew Bartlett knew also by this time, so it would be no surprise to him. In any case Bartlett had probably attended the autopsy. Most conscientious surgeons did when a patient died. But after the momentary pause the younger man went on urbanely.

"One always has doubts in these emergency cases, Dr. Pearson. But I decided all the symptoms justified immediate exploratory surgery." Bartlett paused. "However, there was no perforated ulcer present, and the patient was returned to the ward. I called Dr. Toynbee for consultation, but before he could arrive the patient died."

Gil Bartlett closed his ring binder and surveyed the table. So the diagnosis had been wrong, and despite Bartlett's outwardly calm appearance Lucy knew that inside he was probably suffering the torments of self-criticism. On the basis of the symptoms, though, it could certainly be argued that he was justified in operating.

Now O'Donnell was calling on Joe Pearson. He inquired politely, "Would you give us the autopsy findings, please?" Lucy reflected that the head of surgery undoubtedly knew what was coming. Automatically the heads of departments saw autopsy reports affecting their own staff.

Pearson shuffled his papers, then selected one. His gaze shot around the table. "As Dr. Bartlett told you, there was no perforated ulcer. In fact, the abdomen was entirely normal." He paused, as if for dramatic effect, then went on. "What was present, in the chest, was early development of pneumonia. No doubt there was severe pleuritic pain coming from that."

So that was it. Lucy ran her mind over what had been said before. It was true - externally the two sets of symptoms would be identical.

O'Donnell was asking, "Is there any discussion?"

There was an uneasy pause. A mistake had been made, and yet it was not a wanton mistake. Most of those in the room were uncomfortably aware the same thing might have happened to themselves. It was Bill Rufus who spoke out. "With the symptoms described, I would say exploratory surgery was justified."

Pearson was waiting for this. He started ruminatively. "Well, I don't know." Then almost casually, like tossing a grenade without warning: "We're all aware that Dr. Bartlett rarely sees beyond the abdomen." Then in the stunned silence he asked Bartlett directly, "Did you examine the chest at all?"

The remark and the question were outrageous. Even if Bartlett were to be reprimanded, it should come from O'Donnell, not Pearson, and be done in private. It was not as if Bartlett had a reputation for carelessness. Those who had worked with him knew that he was thorough and, if anything, inclined to be ultra-cautious. In this instance, obviously, he had been faced with the need to make a fast decision.

Bartlett was on his feet, his chair flung back, his face flaming red. "Of course I examined the chest!" He barked out the words, the beard moving rapidly. "I already said the patient was in no condition to have a chest film, and even if he had - "

"Gentlemen! Gentlemen!" It was O'Donnell, but Bartlett refused to be stopped.

"It's very easy to have hindsight, as Dr. Pearson loses no chance to remind us."

From across the table Charlie Dornberger motioned with his pipe. "I don't think Dr. Pearson intended - "

Angrily Bartlett cut him off. "Of course you don't think so. You're a friend of his. And he doesn't have a vendetta with obstetricians."

"Really! I will not permit this." O'Donnell was standing himself now, banging with his gavel. His shoulders were squared, his athlete's bulk towering over the table. Lucy thought: He's all man, every inch. "Dr. Bartlett, will you be kind enough to sit down?" He waited, still standing, as Bartlett resumed his seat.

O'Donnell's outward annoyance was matched with an inward seething. Joe Pearson had no right to throw a meeting into a shambles like this. Now, instead of pursuing the discussion quietly and objectively, O'Donnell knew he had no choice but to close it. It was costing him a lot of effort not to sound off at Joe Pearson right here and now. But if he did he knew it would make the situation worse.

O'Donnell had not shared the opinion of Bill Rufus that Gil Bartlett was blameless in the matter of his patient's death. O'Donnell was inclined to be more critical. The key factor in the case was the absence of a chest X-ray. If Bartlett had ordered an upright chest film at the time of admission, he could have looked for indications of gas across the top of the liver and under the diaphragm. This was a clear signpost to any perforated ulcer; therefore the absence of it would certainly have set Bartlett thinking. Also, the X-ray might have shown some clouding at the base of the lung, which would have indicated the pneumonia which Joe Pearson had found later at the autopsy. One or another of these factors might easily have caused Bartlett to change his diagnosis and improved the patient's chances of survival.

Of course, O'Donnell reflected, Bartlett had claimed the patient was too sick for an X-ray to be taken. But if the man had been as sick as that should Bartlett have undertaken surgery anyway? O'Donnell's opinion was that he should not.

O'Donnell knew that when an ulcer perforated surgery should normally be begun within twenty-four hours. After that time the death rate was higher with surgery than without. This was because the first twenty-four hours were the hardest; after that, if a patient had survived that long, the body's own defenses would be at work sealing up the perforations. From the symptoms Bartlett had described it seemed likely that the patient was close to the twenty-four-hour limit or perhaps past it. In that case O'Donnell himself would have worked to improve the man's condition without surgery and with the intention of making a more definitive diagnosis later. On the other hand, O'Donnell was aware that in medicine it was easy to have hindsight, but it was quite another matter to do an emergency on-the-spot diagnosis with a patient's life at stake.

All of this the chief of surgery would have had brought out, in the ordinary way, quietly and objectively, at the mortality conference. Indeed, he would probably have led Gil Bartlett to make some of the points himself; Bartlett was honest and not afraid of self-examination. The point of the discussion would have been evident to everyone. There would have been no need for emphasis or recriminations. Bartlett would not have enjoyed the experience, of course, but at the same time he would not have been humiliated. More important still, O'Donnell's purpose would have been served and a practical lesson in differential diagnosis impressed on all the surgical staff.

Now none of this could happen. If, at this stage, O'Donnell raised the points he had had in mind, he would appear to be supporting Pearson and further condemning Bartlett. For the sake of Bartlett's own morale this must not happen. He would talk to Bartlett in private, of course, but the chance of a useful, open discussion was lost. Confound Joe Pearson!

Now the uproar had quieted. O'Donnell's banging of the gavel - a rare occurrence - had had effect. Bartlett had sat down, his face still angry red. Pearson was turning over some papers, apparently absorbed.

"Gentlemen." O'Donnell paused. He knew what had to be said; it must be quick and to the point. "I think I need hardly say this is not an incident any of us would wish to see repeated. A mortality conference is for learning, not for personalities or heated argument. Dr. Pearson, Dr. Bartlett, I trust I make myself clear." O'Donnell glanced at both, then, without waiting for acknowledgment, announced, "We'll take the next case, please."

There were four more cases down for discussion, but none of these was out of the ordinary and the talk went ahead quietly. It was just as well, Lucy reflected; controversy Eke that was no help to staff morale. There were times when it required courage to make an emergency diagnosis; even so, if you were unfortunate and guilty of error, you expected to be called to account. But personal abuse was another matter; no surgeon, unless grossly careless and incompetent, should have to take that.

Lucy wondered, not for the first time, how much of Joe Pearson's censure at times like this was founded on personal feelings. Today, with Gil Bartlett, Pearson had been rougher than she remembered his ever being at any mortality meeting. And yet this was not a flagrant case, nor was Bartlett prone to mistakes. He had done some fine work at Three Counties, notably on types of cancer which not long before were considered inoperable.

Pearson knew this, too, of course, so why his antagonism? Was it because Gil Bartlett represented something in medicine which Pearson envied and had never attained? She glanced down the table at Bartlett. His face was set; he was still smarting. But normally he was relaxed, amiable, friendly - all the things a successful man in his early forties could afford to be. Along with his wife, Gil Bartlett was a prominent figure in Burlington society. Lucy had seen him at ease at cocktail parties and in wealthy patients' homes. His practice was successful. Lucy guessed his annual income from it would be in the region of fifty thousand dollars.

Was this what griped Joe Pearson? - Joe Pearson who could never compete with the glamor of surgery, whose work was essential but undramatic, who had chosen a branch of medicine seldom in the public eye. Lucy herself had heard people ask: What does a pathologist do? No one ever said: What does a surgeon do? She knew there were some who thought of pathologists as a breed of hospital technician, failing to realize that a pathologist had to be first a physician with a medical degree, then spend years of extra training to become a highly qualified specialist.

Money sometimes was a sore point too. On Three Counties' staff Gil Bartlett ranked as an attending physician, receiving no payment from the hospital, only from his patients. Lucy herself, and all the other attending physicians, were on staff on the same basis. But, in contrast, Joe Pearson was an employee of the hospital, receiving a salary of twenty-five thousand dollars a year, roughly half of what a successful surgeon - many years his junior - could earn. Lucy had once read a cynical summation of the difference between surgeons and pathologists: "A surgeon gets $500 for taking out a tumor. A pathologist gets five dollars for examining it, making a diagnosis, recommending further treatment, and predicting the patient's future."

Lucy herself had fared well in her relationship with Joe Pearson. For some reason she was not sure of, he had seemed to like her, and there were moments she found herself responding and liking him also. Sometimes this could prove a help when she needed to talk with him about a diagnosis.

Now the discussion was ending, O'Donnell winding things up. Lucy brought her attention back into focus. She had let it wander during the last case; that was not good - she would have to watch herself. The others were rising from their seats. Joe Pearson had collected his papers and was shambling out. But on the way O'Donnell stopped him; she saw the chief of surgery steer the old man away from the others.

"Let's go in here a minute, Joe." O'Donnell opened the door to a small office. It adjoined the board room and was sometimes used for committee meetings. Now it was empty. Pearson followed the chief of surgery in.

O'Donnell was elaborately casual. "Joe, I think you should quit riding people at these meetings."

"Why?" Pearson was direct.

All right, O'Donnell thought, if that's the way you want it. Aloud he said, "Because it gets us nowhere." He allowed his voice to take on an edge. Ordinarily in dealing with the old man he deferred a little to the gap of years between them. But this was a moment to exercise his own authority. Although, as chief of surgery, O'Donnell had no direct control of Pearson's activities, he did have certain prerogatives when the work of Pathology cut across his own division.

"I pointed out a wrong diagnosis - that's all." Pearson was aggressive himself now. "Do you suggest we keep quiet about such things?"

"You know better than to ask that." O'Donnell slammed out the answer, this time not bothering at all to keep the ice from his voice. He saw Pearson hesitate and suspected the old man knew he had gone too far.

Grumblingly he conceded, "I didn't mean that; not that way."

Despite himself Kent O'Donnell smiled. Apologizing did not come easily to Joe Pearson. It must have cost him quite a lot to say that. Now O'Donnell went on more reasonably, "I think there are better ways to do it, Joe. If you don't mind, at these meetings I'd like you to give us the autopsy findings, then I'll lead the discussion afterward. I think we can do it without getting tempers frayed."

"I don't see why anybody has to get in a temper." Pearson was still grumbling, but O'Donnell sensed he was backing down.

"All the same, Joe, I'd like to do it my way." I don't want to ram it down his throat, O'Donnell thought, but this is the time to make things clear.

Pearson shrugged. "If that's the way you want it."

"Thanks, Joe." O'Donnell knew he had won; it had been easier than he had expected. Maybe this would be a good time to raise the other thing. "Joe," he said, "while we're here, there's something else."

"I've got a lot to do. Couldn't it wait?" As Pearson spoke, O'Donnell could almost read his mind. The pathologist was making it clear that though he had conceded one point he had not abandoned his independence.

"I don't think it can. It's about surgical reports."

"What about them?" The reaction was aggressively defensive.

O'Donnell went on smoothly. "I've had complaints. Some of the reports have been a long time coming through Pathology."

"Rufus, I suppose." Pearson was openly bitter now. You could almost hear him saying: Another surgeon causing trouble.

O'Donnell determined not to be provoked. He said quietly, "Bill Rufus was one. But there have been others. You know that, Joe."

For a moment Pearson made no answer, and O'Donnell reflected that in a way he felt sorry for the old man. The years were slipping by. Pearson was sixty-six now; at best he had another five or six years of active work ahead of him. Some people reconciled themselves to change like that, to younger men moving into prominence and taking over leadership. Pearson had not, though, and he made his resentment plain. O'Donnell wondered what was back of his attitude. Did he feel himself slipping, unable to keep up with new developments in medicine? If so, he would not be the first. And yet Joe Pearson, for all his disagreeable ways, had a lot to commend him. That was one of the reasons why O'Donnell trod circumspectly now.

"Yes, I know." Pearson's reply held a tone of resignation. He had accepted the fact though. That was typical of him, O'Donnell thought. Right from the beginning at Three Counties he had liked Pearson's directness and at times had made use of it in raising surgical standards.

O'Donnell remembered that one of the problems he had faced in his early months at the hospital had been the elimination of needless surgery. Under this heading had come an unnatural number of hysterectomies, and in too many cases healthy, normal uteri were being removed by a few staff surgeons. These were men who found surgery a convenient and profitable remedy for any female pain, even those which might have responded to internal medication. In such instances euphemisms in diagnosis like "chronic myometritis" or "fibrosis of uterus" were resorted to as a smoke screen to cover up the pathology report on the removed tissue. O'Donnell remembered telling Pearson: "When we're reporting on tissue we'll call a spade a spade and a healthy uterus a healthy uterus." Pearson had grinned and co-operated fully. As a result most of the unnecessary surgery had stopped. Surgeons found it embarrassing to have tissue they had removed from patients listed for all their colleagues to see as normal and uninfected.

"Look, Kent." Pearson was more conciliatory now. "Just lately I've been up to my ears. You've no idea how much work there is."

"I do have an idea, Joe." This was the opening O'Donnell had hoped for. "Some of us think you've too much to do. It isn't fair to you." He was tempted to add "at your age" but thought better of it. Instead he added, "How about getting some help?"

The reaction was immediate, Pearson almost shouting. "You're telling me to get more help! Why, man alive, I've been asking for months for more lab technicians! We need three at least, so what am I told I can have? One! And stenographers! I've got reports that have been piling up for weeks, and who's going to type them?" Not waiting for an answer, he went storming on. "Me? If the administration would get off its fanny we might get a few things done - including faster surgicals. By God! When you tell me I should get more help, that's really something to hear."

O'Donnell had listened quietly. Now he said, "Finished, Joe?"

"Yeah." Pearson seemed chastened, half ashamed at his outburst.

"It wasn't technicians or office staff I was thinking about," O'Donnell told him. "When I meant help I meant another pathologist. Someone to help you run the department. Maybe modernize it here and there."

"Now look here!" at the word "modernize" Pearson had bridled, but O'Donnell brushed the objection aside. "I listened to you, Joe. Now you hear me out. Please." He paused. "I was thinking of maybe some bright young fellow who could relieve you of some duties."

"I don't need another pathologist." It was a flat statement, vehement and uncompromising. "Why, Joe?"

"Because there's not enough work for two qualified men. I can handle all the pathology myself - without any help. Besides, I've already got a resident in the department."

O'Donnell was quietly persistent. "A resident is with us for training, Joe, and usually for just a short time. Sure, a resident can carry some of the work. But you can't give him responsibility and we can't use him for administration. That's where you need some help right now."

"Let me be the judge of that. Give me a few days and we'll be caught up in surgicals."

It was obvious that Joe Pearson had no intention of giving way. O'Donnell had expected resistance to bringing in a new pathologist, but he wondered about the other man's forcefulness. Was it because he was unwilling to divide his personal empire, or was he simply protecting his job - fearful that a new and younger man might undermine him? Actually the idea of removing Pearson had not occurred to O'Donnell. In the field of pathological anatomy alone Joe Pearson's long experience would be hard to replace. O'Donnell's objective was to strengthen the department and thereby the hospital organization. Perhaps he should make this clear.

"Joe, there's no question of any major change. No one has suggested it. You'd still be in charge . . ."

"In that case let me run Pathology my own way."

O'Donnell found his patience ebbing. He decided that perhaps he had pressed the point enough for now. He would let it go for a day or two, then try again. He wanted to avoid a showdown if he could. He said quietly, "I'd think it over if I were you."

"There's nothing to think over." Pearson was at the door. He nodded curtly and went out.

So there it is, O'Donnell thought. We've laid the lines of battle. He stood there, considering thoughtfully what the next move should be.