Chasing a Light Beam – Chapter 7: “Sexual Medicine”
SEXUAL MEDICINE
The dog is man’s best friend; the buddy-fucker is not.
-Richard A. Stein
The malpractice lawsuit, or even the threat of it, is the darkest aspect of a surgeon’s life. Its claws reach down to tear at the very marrow of his dignity and self-worth. To a professional accustomed to identifying and correcting problems swiftly, the inexorable drudge of the legal system only adds to his feelings of helplessness and frustration. For the surgeon, there are only two possible outcomes in a lawsuit: lose, or lose big. There is no such thing as winning, and since such actions are mostly without merit, an attitude of embitterment is unavoidable. Most surgeons begin practice with the feeling that only the “bad” doctors get sued. They look forward to a career of happy patients and good results, for they have the highest standards and most rigorous training imaginable. It usually requires less than two years for their bubble to burst.
One Monday morning in the mid-’80’s, shortly after Ben Bob’s “eureka moment” on the weekend call when he realized the inefficiency of the system, a gray-haired sheriff’s deputy strolled into the Bascomb office, papers in hand. He greeted the receptionist, “Mornin’, cher. I got a gift for Dr. Ted and Dr. Ben. Just sign right here.” He wasn’t wearing the required bullet-proof vest, as his duties were simply that of a messenger, but he adjusted his Glock semi-automatic anyway, as if to remind both the young woman and himself of the gravity of his position. The task accomplished, he tipped his cap with a, “Thanks, babe,” and strolled back out, apparently either unaware or unconcerned about the explosiveness of the missile he had just delivered.
“Ms. Martha, I think you better look at this,” the young woman said nervously. She brought the papers over to the office manager’s desk. Martha knew that no good news came from the occasional deputy’s visit, and she confirmed the fact by her initial perusal of the stamped and sealed document. Bascomb wasn’t in the office, but she knew Boyle was working on some dictation, and she approached and stood before him.
“I’m so sorry to have to give this to you, Dr. Boyle.” And she meant it. Ben had become a part of her family. He opened the papers and began reading, at first not understanding their meaning. It was a malpractice complaint against Dr. Bascomb and him, filed by a Doreen Latiolais.
“What is this, Martha?” he asked in bewilderment. “I don’t even know a Doreen Latiolais.”
“She’s one of Dr. Bascomb’s patients. Her husband owns a big oil-service company. Dr. Bascomb did a ureteroscopy on her to remove a stone, and she ended up losing her kidney.” Martha looked at least as chagrined as Ben Bob himself.
Ben Bob stood and leaned forward, balancing himself with his hands on the desktop. “How come I didn’t know anything about this?”
Martha had a number of bosses in the practice, and she was loyal to all of them, but she wouldn’t lie for one to fool the other. “Dr. Bascomb didn’t want you to know. He knew if you found out there had been another ureteroscopy complication, you’d react badly.”
Ureteroscopy is a procedure performed with a narrow, stainless steel tube about thirty inches long, containing a tiny open passage and a fiber-optic lighted telescope. In order to use it for removing stones from the tube leading from the kidney to the bladder, the operator must first insert the device up the urethra into the bladder. The opening of the urinary passage, the ureter, is identified where it joins the bladder, and dilated with a special balloon. Then the ureteroscope is introduced into the ureter and carefully worked upward until the stone can be grasped and removed. Not the least of the problems facing the operator is that the device is straight and rigid, while the ureter is soft and tortuous, and easily torn.
Ben Bob had performed the first several of such procedures ever done in Lafayette, and had been featured in a local newspaper article. Ted Bascomb felt he could surely do as well, and began offering the approach to his patients. He had a wealth of experience with other urologic telescopic procedures, generally using much larger instruments restricted to the urethra and bladder, a far more forgiving environment. His attempts at ureteroscopy generated one complication after another, as the delicacy required was not suited to his bull-in-a-china-shop manner. Ben Bob finally confronted him, after carefully considering the least ego-damaging approach. Since they were equal partners, Ben pointed out, and since they split the income evenly, why not let Ben handle this newer procedure for which he had extensive training? Bascomb surprised him by agreeing with no apparent reluctance, and promised that all future ureteroscopy cases would be sent to Ben. Doreen Latiolais was from an influential family, and apparently an exception.
Ben turned to Martha in exasperation. “Why would Ted do that? He gets the same money either way.” Martha looked at him sympathetically, but did not offer an answer. She would not take sides.
Ben turned his attention to the really disturbing part of the situation. He picked up the legal papers, and waving them in front of him, asked, “How in hell did I get named in this thing? I never even saw the woman.”
Martha took a moment to evaluate her options. Dr. Bascomb had hired her out of high school, with no qualifications, and had allowed her to work her way up to the position of office manager. On the other hand, she was always underpaid and under-appreciated, and treated as Bascomb’s personal servant. Dr. Boyle had recognized right away that she was the oil that lubricated the machinery, the behind-the-scenes force that kept the office and the egos on track. He had been instrumental in getting more money and more vacation for the employees, as well as their first-ever participation in the retirement fund. She respected his honesty and resented the secrecy of her own knowledge of things that went on behind his back. She chose to speak.
“When Dr. Bascomb told the Latiolais’s that it was necessary to remove her kidney, he asked me to step into the office to witness the signing of the consent form. I heard him tell them that you were on call during the night of the leak, instead of him, and that if you had come right in and fixed it, she would not have lost her kidney.” Martha didn’t look directly at Ben Bob as she reluctantly gave up this information.
Ben Bob was furious. “I never got a call from anyone about Doreen Latiolais, and I didn’t even know she was in the hospital!” It was one of those moments when throwing a chair seemed appropriate, and no acceptable substitute response would come to mind.
Ted Bascomb was a duality. For all his gregarious charm and apparent generosity, there was a selfish outlaw lurking inside. One of his favorite sayings was, “If I fuck you once, shame on me; if I fuck you twice, shame on you.” One of his business partners in a deal of questionable transparency was murdered, and there was no investigation. Without an autopsy, the event was signed out as a “heart attack”. Bascomb had lured both Ben Bob and another of their young partners into “can’t miss” deals in apartments, office buildings, and oil-field tools. They had lost every cent, and in each instance they later discovered that Bascomb was using the ventures as fundraisers for others of his failing schemes, with no apparent conscience.
Ben had been left hanging up to dry for any number of Bascomb’s surgical dalliances. On one occasion, Bascomb approached Ben and told him that he had to be absent on a Wednesday, the usual day that Bascomb pushed the ethical envelope of itinerancy by going to a hospital in a nearby small town and performing ghost surgery. He wanted Ben to substitute. All the cases were scheduled to be transurethral resections of the prostate, the so-called “roto-rooter” surgery done through a telescope under spinal anesthesia. As always, Ben agreed, and presented himself at the operating room on Wednesday morning. After meeting the personnel and the patient, the OR nurse asked Ben how he would like to have the patient positioned. The procedure is always done with the patient in the “lithotomy” position, as in a woman having a pelvic exam.
“You know, just the usual lithotomy position,” Ben Bob said, as he sipped his last pre-op taste of coffee.
“I know that, cher,” the nurse almost giggled. “I meant for giving the spinal.” Spinal anesthesia sometimes is administered with the patient on his side, and at other times, with the patient sitting up.
“Doesn’t make any difference to me,” Ben replied, absolutely not catching the drift of her question. “However the anesthesiologist prefers.”
The nurse now laughed out loud. “Mai doc, the anesthesiologist is YOU!”
This got Ben’s attention, and he put down the cup. “Whattaya mean, ME?”
“Yeah, cher. The hospital don’t have no anesthesiologist, and the nurse anesthetist works in the main OR on Wednesdays, never in urology. Dr. Ted does all the spinals himself. Didn’t he tell you?”
Ben Bob had down one “spinal tap”, a diagnostic procedure, as a medical student, and two others on his moonlighting job in the ER as a resident. He had never given a spinal anesthetic, a procedure fraught with possibly terrible repercussions in the hands of a novice.
“Don’t worry, babe,” the old nurse cooed. “The instructions are in the spinal anesthesia kit.” And so they were. Ben considered apologizing to the patients and their families, and returning to Lafayette ASAP. But the Bascomb group received a lot of referrals for “open” urologic surgery from the doctors in that little town, and by having the “roto-rooter” procedures done on site, the local doctors got a chance to keep the patients in their own hospital and charge a post-op care fee. It was a quid pro quo. Bascomb apparently had been doing it for years. The decision was made.
Ben opened the anesthesia kit and pulled out the package insert. After reading it, he pulled on the sterile gloves and mixed the anesthetic solution, considering the patient’s weight and the duration of anesthesia desired. The nurses placed the patient on his side, in a tight fetal position. Ben saw a long surgical scar over the lumbar portion of the man’s spine. His name was Abshire. “Mr. Abshire,” Ben asked. “What kind of surgery have you had on your back?” No answer. Then came a string of Cajun French from the old OR nurse, and a reply from Mr. Abshire.
“He don’t talk English, cher, and he says he had a spinal fusion.” Neither lumbar fusions nor French-speaking-only old men were unusual in Acadiana, the area of Lafayette and its surrounds. Ben Bob had seen the anesthesiologists struggle on many occasions to administer a spinal anesthetic to a patient with a lumbar fusion. Surgically placed bone grafts covered the preferred area of needle penetration. The firm, cylindrical spinal cord ends at the level of the second lumbar vertebra, and from that point downward, spindly nerves float in the spinal fluid, making it safe to penetrate the area with a needle, sort of like poking strands of spaghetti in a pot of water. Ben Bob cleansed the area and injected local anesthetic with a small needle to deaden the skin sensation. He then advanced the large spinal needle at the proper level, and crunched into solid bone. Bummer.
You may be a board-certified surgeon, having performed all sorts of radical cancer surgery, kidney transplants, and emergency trauma procedures, but when a gaggle of nurses and OR personnel are standing around watching your every move as you suavely attempt something you’ve never done before, that’s pressure. “Thanks, Ted,” Ben thought. He had seen the anesthesiologists perform a “lateral approach” in such cases. This is more or less an educated guess as to the line which would pass the needle from the side of the spine, under the bone graft, and between two vertebral bodies into the spinal fluid. I say, “educated,” but in Ben Bob’s case, it would at best be pure luck. He had seen the experts require pass after pass of the needle in this approach, and as he anesthetized the new entry area, he settled in for a long match. Imagining the interior anatomy, he slid the large-bore needle through the numb area and, meeting no resistance, continued to advance it. He felt a subtle “pop”. “Could that be the dura mater?” he wondered in amazement, referring to the covering of the spinal canal. He removed the obturator from the needle, and voila! Clear, yellowish spinal fluid, with no blood. He had blundered into perfection. He injected the anesthetic, instructed the nurses to lay the patient supine, and a few minutes later began what other people would consider the dangerous part: the actual surgery.
It’s all relative: Ben Bob had performed this surgery hundreds of times, but it was his first spinal anesthetic. By the end of the day, he was four-for-four. Bascomb had sent him, with no warning, to perform on live and uninformed people something for which he was neither qualified nor insured. Ben remembered the words of his former chairman of surgery: “The bold surgeon recognizes that it is the patient taking all the risks.” Ted and Ben were of diametric mindsets.
Doreen Latiolais did not represent the first occasion of a complaint of malpractice against Ben Bob. But to have it instigated by his own partner in an attempt to shift blame tested the limits of egregiousness. Ben looked at his loyal office manager, changed his voice to one of calm, and said, “Martha, I’m gone.” It must have seemed to Martha like a snap decision, poorly considered, but Ben had been contemplating it for over a year. He had even inquired about available office space, just in case. The Bascomb group’s lease was up for renewal in six weeks, and the hospital’s new office building was scheduled to be completed about the same time. “I’m moving to the MOB,” he continued, referring to the acronym for the medical office building.
“Do you want me to come with you?” For Martha to ask such a thing surely did seem extemporaneous, but she had come to realize her worth little by little over the time since Ben had joined the practice. No matter how wonderful the surgeon, he will not succeed without an office manager familiar with all the minutiae that constitute Medicare, Medicaid, and the third-party payment system. Martha finally knew that she was such a person.
For Ben, her question was like being chosen Man of the Year, or some such. He was surprised, and honored. “You bet I do,” and he smiled broadly. “We’re going to do something new in Lafayette, and I hope you become the best-paid medical office manager in town.” He took her to dinner to explain.
Ben Bob’s thoughts turned to his self-created career, and as he was about to click the “record” button once more, a hummingbird flew in to the feeder outside the sun-room’s glass walls, the first one since the rain had stopped. Lafayette was situated on a bayou near the coast, and the little creatures stopped here in hordes twice a year, on their trips to and from South America. Almost as soon as the bird lit, another one buzzed down from a nearby shrub and dive-bombed him. The second bird spent most of his waking hours either eating from the feeder himself, or spying from the bush to keep others away from his prize. They were beautifully evolved; the entirety of their lives was laid out for them from the moment of emergence from the egg. “How about that,” he thought. A sip, and a click, and he resumed.
Maggie thought I was crazy to give up all my practice for the Male Sexual Center. Looking through the retrospectoscope, I’ll bet her sphincter was puckered, worrying about the loss of her lifestyle. Male sexual medicine was only about five percent of my practice when I was with Bascomb, but I had a hunch that men considered their sexual problems to be as important as their health. They just needed a place to go and a doctor who was concerned. Of course, I had some “insider” information. Mary Anne Carter and all the women between my marriages made me an expert at understanding what men go through because of their sexual problems. It was a combination of unusual training, some skills, my personal experiences, and my brain that made me part of the solution. A big part.
I knew things about these men that even medical device manufacturers and pharmaceutical companies never dreamed. If big business had ever had any idea what men were willing to do to maintain or restore their sexuality, they would have set their goals MUCH higher. It’s almost incomprehensible that marketers use sex to sell everything to men from cigarettes to deodorant, yet somehow the businesses that are involved in producing methods for restoring male sexual function don’t think there is enough interest to justify marketing their products at all! If they don’t have any confidence in their own business, doesn’t it seem kinda stupid to give up ninety-five percent of my practice to focus on that one thing? Not to me, it didn’t.
I would never suggest to anyone that I know the first school-learned thing about business, but I knew the answer to an important question. And I knew it from the heart. Suppose there was a man who could not ever achieve an erection, and the tests showed that he never would never be able to have intercourse again unless he had penile implant surgery. Suppose that he was told that the result would look and feel as natural as the one God gave him, but the erection would be under his control: it would get hard when he chose, and stay hard for as long as he wished, and it would go down and be soft when he chose. Suppose it would eliminate the pain of ever hearing a woman say that he didn’t last long enough for her, yet his climax would be the same as ever. Suppose the surgery had a one percent complication rate, did not involve hospitalization, and his insurance would pay for the entire thing. Suppose the alternative was never to have sex again. Do you think there are any men who would be interested? If you didn’t answer “yes”, you may be qualified to be the CEO of a penile prosthesis manufacturer.
Besides my own experience with “member” dysfunction, something else gave me a clue that this was the road to success. When I was still in the Bascomb group, a cardiologist friend referred a man to me. He had contracted a virus that had severely damaged his heart muscle, a disorder called “cardiomyopathy”. He was estimated to have less than two years of life expectancy without a heart transplant, and he was doubtful his name would ever come up as a recipient, especially because of his age of sixty-one. He came to me because he was completely unable to have erections. He told me his wife was ten years younger, a nurse, and that he loved her to death. He said he would do anything to be able to have sex that was satisfying for her until he died. There’s a safe injection that can be self-administered into the penis, and if the native circulation is adequate, an erection occurs for thirty minutes or more. He failed that test. There were no pills for erections in those days, but even if there were, he would not have responded because of the poor circulation. I told him his only hope was a penile implant, but that it would require the approval of his cardiologist. He came back, with his wife, and told me that his cardiologist felt he would die on the operating table. He told me that he preferred death to the way he was, and his wife wanted him to be happy. That’s when I knew that everyone had grossly underestimated the field of male sexual medicine! By the way, I did his implant, he didn’t die, and he and his wife started having intercourse daily. Some new heart medicines came out to improve heart muscle contractility, he was able to undergo bypass surgery, and his heart got stronger. His first penile implant wore out after eight years, and I replaced it. He died three years later. His wife said it was a wonderful eleven years, all things considered.
Ben stopped for a moment. Such people as these had comprised the bulk of his professional life, but for some reason, he primarily remembered the others, the unhappy ones, and the ones who filed lawsuits. The seed for this negative attitude was probably planted during his internship, when his cardiovascular surgery chief told him, “You get no special credit for getting it right.” The seed found fertile soil, and grew to dominate his career.
He raised the glass for one more sip, but the liquid courage was gone. He popped one of the olives into his mouth, and headed for the refrigerator.
