Mangled Care

Chapter 3

Chapter 3

Before I had a chance to sit down at my desk, Susan brought in a UPS box. I opened it and was pleased to see the reprints of an article I had written which described the medical facts about traumatic brain injury. I was very lucky. I had submitted it to a journal that represented various managed care organizations. The article was a good one, as complete as I could make it. My luck was finding that the Senior Editor of the journal was going to retire soon. He believed in the article after he had reviewed it. Somehow, three other physician editors approved it and it had been published.
The joke was the fact that managed care organizations, and the insurance companies they represented, didn’t like the diagnosis of traumatic brain injury. It was expensive to treat. At least one national insurance company had made it plain that they would not accept the diagnosis, and therefore they would not pay for any treatment for a patient with a mild to moderate acquired traumatic brain injury.
It was one thing if a patient’s brain was oozing out of his or her ear. They couldn’t escape responsibility for paying for that. But the patients with a mild or moderate traumatic brain injury looked normal. That is, their heads were, for the most part, whole. The damage was on the inside, in the brain itself, on a microscopic level. So, even expensive radiological tests couldn’t see it.
The article had been written to explain medically what happens to these patients. I hoped someone would read it.
I chuckled to myself, remembering how The Chief, the Chairman of the Department of Neurology, had been exasperated by me more than once. I wanted to learn some things that were not in the Neurology Department’s curriculum. He shook his head, but had allowed me to take some training in three strange places. Strange to neurologists, that is.
First, he had allowed me to spend some months in the Department of Psychiatry. I was, back then, the only neurology resident who had spent time looking for the neurological problems that were being treated psychiatrically. That had created some difficulties when I had actually found some.
Then, I had spent some time in the Rehabilitation Department, or Physical Medicine and Rehabilitation. In the sixties and seventies, neurologists and everyone else looked down upon this medical specialty. In fact, it was going through some hard times. Almost all of the residents were foreign medical graduates, one reason for the turned up noses. I was the only Caucasian resident in the place. But, I learned about physical therapy, occupational therapy and speech and language pathology. I learned what these clinical specialists were supposed to do and how.
Finally, I received permission to spend some time in the ‘new-fangled’ pain center, which had been started by the departments of orthopedics. The Chief couldn’t understand my interest in these things, as neurologists, he told me, were just supposed to deal with brain tumors, Parkinson’s disease, seizures, multiple sclerosis and other incurable problems.
So, I guess I was a rebel with a cause from the beginning. I found that it was possible to help people with headache and pain. These problems were, if not curable, able to be markedly ameliorated, giving these patients back some quality of life. Not quite the neurological way of looking at things, but I wasn’t quite the neurologist everyone else wanted me to be.
I just wanted to help people.
The word had gotten out as early as my last year of residency. Earlier I had again almost lost my residency. Not once, but twice.
In my second year, I had come up against The Big M, one of the attendings whose specialty was dealing with multiple sclerosis, which was, and still is, a truly terrible disease. The body essentially eats away at its own nervous system connections in the brain and spine.
Well, to the Big M, everything was multiple sclerosis. And he could prove it, by using a pinwheel to test sensation on a patient’s arm or leg. He could use the tool to find sensory changes, secondary to, in his case, simple summation of nervous system sensory functioning; it was nothing necessarily abnormal.
One night when I was on call, I saw a patient from the emergency room with unexplained weakness. His neurological examination was abnormal, with real weakness on his right side. He also had a Babinski sign, a pathological reflex showing that the nervous system was in trouble, that something bad was going on. It was a busy night, but thanks to bringing some donuts to the technician who ran the CAT scan, she stayed late to run a scan on my patient.
The scan showed a brain tumor.
Like the good resident I tried to be, I got all my notes and the CAT scan pictures together and was ready to present the patient to the Big M at rounds the next morning. ‘Rounds’ is what happens in the morning when the residents, interns and medical students go from patient to patient and discuss the cases with the attending. It was the Big M’s turn to be the attending.
We went around to the old patients first, then to the newly admitted patients, of which there had been exactly one, the poor bastard with the brain tumor.
I presented the facts of the new patient. His symptoms, when he developed them, their onset and associated symptoms, then the findings on his neurological examination.
I remember saying, “So then I decided to get a CAT scan.”
The Big M cut me off and whipped out his pinwheel. He motioned for me to be quiet and proceeded to examine the patient. He did his ‘special’ sensory examination and turned to all of us in his entourage and smiled benignly before he spoke.
“Yes, without question this is multiple sclerosis,” he told us. “There is no reason to obtain a CAT scan. It’s an expensive test and clinical examination alone gives us the diagnosis.”
“Uh, Sir, I already got the CAT scan,” I said.
“You did what? Dr. Stone, why would you waste the money for that? I guess your examination skills aren’t up to snuff.”
“Dr. M, can we talk about this in the hall?” I asked.
“What’s the matter, Stone, you can’t take criticism in front of a patient?”
“No Sir. I just think it would be better if we continued this discussion in the hall.”
I had followed the rules, you see, and I had not told the patient about his diagnosis. I was supposed to clear it first with the attending, to make sure that I was not wrong before telling the patient he had a brain tumor and would most likely die. His tumor was deep in his brain, and probably not easily treatable with surgery or anything else.
The Big M continued to berate me, so I stoically repeated my request to move the discussion into the hall. Finally, seeing that I wasn’t going to buckle, he brusquely waved at the patient and we followed him outside the man’s room.
“Ok Stone, let’s hear it. Just what didn’t you understand about what I told you in there?”
“Well, Sir, you didn’t let me finish before. I said I decided to get a CAT scan. I did get the CAT scan and it showed a two by three centimeter tumor near the internal capsule, a rather important area deep in the brain, I believe.
“Here is the CAT scan, Sir. You can easily see the tumor.”
I held it up for all to see. The third year resident noted that it was in a bad place. The students and the interns wowed, and the Big M looked past it and into my eyes.
“I don’t care what you did, Dr. Stone, the man has multiple sclerosis, and that’s it. I want him treated with intravenous steroids. See to it.”
“But Sir, what do we do about the tumor?” I asked, trying not to look aghast.
“We treat the patient the way I said, Dr. Stone. Have I made myself clear?
“I don’t want to hear anymore about some preported tumor.”
I had learned from the problem I had with the Professor Emeritus. I just nodded in agreement and kept my mouth shut.
After rounds were over I discharged the patient from the neurology floor and wheeled him down to the neurosurgical floor. I presented the case and the CAT scan to the Chief Resident there, who eagerly took the patient, as well as the chance to do surgery.
The Big M forgot all about the patient for three days, before he asked me what had happened to him. I told him that the patient had chosen to go home. The Big M went on to the next patient, and that was that.
The next year, my third and last as a neurology resident, I had my last encounter with University Pigheadedness, which in retrospect was pretty benign in comparison to what we have brought upon ourselves and our patients.
I was seeing patients in the neurology clinic. I saw a new patient who had a slightly suspicious story and a negative neurological examination. Over the past several years, I had learned to rely on my gut. When it spoke, I listened, and it was telling me that the patient had a problem.
I presented him to the attending, Dr. Johnny Walker, who, true to his namesake, drank his namesake, like a fish. When I was finished presenting the patient, I said that I wanted to follow up with a CAT scan. (Those were the days before MRI scans.) Dr. Walker laughed and said that there was no reason to do such an expensive test.
“But Sir,” I said, “I really think that there may be a tumor.”
Aside from being a hard drinking man, Dr. Walker was also a gambler.
He looked at me with his red fish eyes and told me, “I’ll let you do the CAT scan, Dr. Stone. But,” he paused, probably wondering when he could have another drink, “If the CAT scan is normal, and I am sure it will be, I will have your badge. You will not finish your residency, because you are not listening to me.
“So, Dr. Stone, do you still want to do a CAT scan on this patient.”
“Yes, Dr. Walker, I do.”
“So be it.” He looked at the rest of the residents, interns and students. “You will all learn how to learn. You must listen to your attendings. If not, you will end up like Dr. Stone over there. Remember this.”
No big secret, as I got my MD degree and finished my residency. The man had a brain tumor. Dr. Walker refused to talk to me again, for any reason.
I kept my reputation for being stubborn.
I remain thankful to this day for the rest of the attending physicians in the department of neurology. They taught me well, I think. What they didn’t teach me, however, not from lack of trying in at least one case, was how to back down when I truly thought I was correct about a patient care issue.
As I may have mentioned, the word had gotten out. I was astonished one day in my third year of residency when I received a request from Amnesty International to see a patient with pain.
These were the days when President Carter had noted with some relish that executions of criminals were very infrequent.
I was asked to examine a patient who was on death row in President Carter’s own state. This “gentleman” had stated that he had been tortured by the prison staff and had called off his appeals. He stated publicly that he wanted to be executed to stop his pain.
The prisoner had killed a number of people. He had gone in to a store to commit a robbery and ended up shooting the store manager. Then he got into his car, got his girlfriend (I don’t remember if she was with him during the robbery) and then proceeded to kill a number of other people before he was trapped by the police and shot in the jaw by one of the officers.
Aside from the physical damage from the bullet, he went into spinal shock and was totally paralyzed for some time. When he recovered from this, he was sent to the really big, bad house, on death row.
I received the patient’s basic history and had gone over it prior to being flown to see the patient in prison. The area’s federal prosecutor picked me up at the airport and we drove for hours until we reached the prison. The Supreme Court in that region of the country had given written permission for me to see the prisoner.
We were practically strip-searched when we walked into the prison. Our fingerprints were taken. We were directed to a bench and told to sit down. We waited for several hours. The prosecutor tried to speak with the warden, but that didn’t help.
Finally, calls were made from the prison to the Supreme Court and back to the warden, who told us, “This here doctor can see the prisoner. That’s what the Court said. It didn’t say he could touch him.”
As in examine him.
The prosecutor left me alone while he went to the bathroom. As soon as he walked away, as if to fill the vacuum he had left, a large, beefy, red faced guard, a perfect Jackie Gleason in the same role clone, came up to me and got within two or three inches of my face. As he swung his dented and scarred baton from one hand to the other, he looked me in the eyes and asked, “You here to stir up trouble, Boy?”
I remember thinking that I hoped the federal prosecutor was taking a leak and nothing more. Or I was afraid I would be dead.
Thankfully, the fed came back as I was being intimidated by the goon and the Gleason clone immediately backed off.
I was taken to a little room in which there was an old wooden table rife with scars and embedded words. The prisoner was led into the room with his hands and feet shackled and thrown into a chair opposite me.
He was a Charlie Manson clone, at least physically. He had a cross tattooed on his forehead and wore a wispy goatee. His eyes appeared almost vacant. We spoke for about an hour, after which he was hustled off. I asked the guard if I could see his medical records, which were brought from the infirmary, immediately next door, about an hour later.
The prisoner’s story actually began years before. He was in a local jail cell for, he said, being drunk and disorderly. Another man was thrown into the cell with him. This guy was a local doctor who was well known for exchanging narcotic prescriptions for sex with his patients. Anyway, according to the prisoner, one of the girls he had had such an exchange with was his girlfriend. So, according to what rules folk like this follow, he admitted to me that he beat the hell out of the doctor.
Guess who was the doctor at the prison? Just one guess is needed, actually.
According to the prisoner, the doctor had it in for him.
Among the stories he told me, he had developed pain in his back that radiated around his body to his groin. He was peeing blood. He got another prisoner to take an x-ray and this man with a grade school education told me that the “picture showed the tube from my kidney to my dick was clogged up”. He was denied, he stated, any pain medication. It took weeks for this to pass he told me.
In terms of why I was there, his first problem, as he described it, was the fact that after he had been shot in the jaw, back when he had been captured, the bullet had shattered, with pieces going into his soft palate (the roof of his mouth) and his tongue. Once he had gotten to the prison, his tongue had become so infected and swollen that he couldn’t eat. The prison doctor wouldn’t help him. So one day when one of the local prison monitors arrived to perform a routine check on the prison, the prisoner had jumped down a flight of stairs and in front of the monitor. He was able to communicate his problem- he told me his tongue was so badly swollen that he couldn’t close his mouth, and the monitor told the warden to take care of the prisoner.
A written letter from one of the participants verified the next part of his story. The letter writer had gained national notoriety for kidnapping a woman and then burying her alive. He was working as a medical technician when the prisoner was taken in the middle of the night to the infirmary, where he was held down and the bullet fragments were cut out of his tongue and palate. Without anesthesia. According to the supporting document, the prisoner ‘almost drowned in his own blood’.
There was a lot more. I wasn’t naïve enough to believe that such things didn’t happen, but to see it up close and personal was truly incredible.
When I reviewed his records, it was quite obvious that the chart had been “doctored”. There was white out all over the pages. They had forgotten to take out the urine analysis which showed more than enough blood in it to make the story of the prisoner’s renal colic (kidney stones) believable.
That was all that could be accomplished at that time. I was driven back to the airport and flown back to the Medical School.
I produced a written report that had enough validity to it to enable the prisoner to get a second chance.
Two months later I was flown back to examine the prisoner. This time, he had been transferred to a prison ward in a University Hospital. The same federal prosecutor picked me up and we got to the hospital early. That’s when he told me that there had been a change. He assured me that the new Supreme Court document stated specifically that I could examine the prisoner.
The little change was that I, a third year resident, would examine him in front of the chairmen of the University Departments of Neurology and Neurosurgery, as well as a handful of attorneys.
Was I intimidated? You bet I was.
I was all set to examine the man, who was brought into the large hospital room in arm and leg chains. He took one look at the audience and turned around and hobbled out of the door.
I followed him into the hall, along with a half dozen guards. The prisoner shook my hand and thanked me; but, he refused to be examined in front of an audience.
I told him that if he didn’t, he was going to be Southern Fried.
He told me good bye.
I went back to the University wiser only in the ways of the inevitability of some things. He was executed within the year, but my heart didn’t bleed for him. Some people just don’t deserve to live, like mass murderers.
At the opposite end of the spectrum were my patients, who were being brutalized by problems not of their making.
The afternoon began with a half dozen patients who had followed me from the HMO. I tightened up their medication regimens and, for several, ordered physical therapy to deal with their chronic muscle spasm induced headache, called tension-type headache. I had been unable to refer them for physical therapy while they were in the HMO. The bean-counters in charge of making the HMO money had dictated that treatment for pain was cheapest when drugs were used, particularly pain killers.
I think that I have already mentioned the problems that specific brand of stupidity breeds.
Either way, the HMO was not about to pay for physical therapy for a headache problem. Why, the genius’ there thought, should they fix the problem with expensive therapy, when they can mask the problem for 1.2 cents a pill? Aside from saving themselves a lot of money in the long run, which they didn’t consider, they could actually help the patients.
God forbid.
I met Melinda Canfield at about three fifteen, as I was running a bit late. Mel, as she wanted to be called, had a problem called, back then, reflex sympathetic dystrophy, or RSD. Now it’s known as Complex Regional Pain Syndrome or CRPS. This is an agonizing pain problem that is secondary to abnormalities in the sympathetic nervous system. To understand it, suffice it to say that the pain is so intense that even the light caress of a breeze will bring on paroxysms of agony.
Mel was an extreme case of an extreme problem. When I first met her, she was wearing a plastic bubble around her right hand to protect it from any physical encounter with anything.
Every three months or so, the doctors at the University would put her under general anesthesia so that they could clean her hand and cut her finger nails. This had been going on for three years.
You should know that the most dangerous part of surgery is not a bad surgeon; it’s the anesthesia.
Mel had been placed on Methadone, 120 mgs of the drug, every day. This is an extremely large dose of a very powerful and long lasting narcotic. It was also the mainstay of her treatment. As the doctors at the University couldn’t fix the CRPS, they did their best to narcotize the patient, to diminish her perception of pain.
Melinda was a fighter, and I liked her for that. In spite of the bubble, she had continued to work, as well as do whatever she could physically manage.
She was knowledgeable about her problem, and had come to see me to find out if there was anything else that could be done to help her.
I went over her history, paying special attention to the medications she had been given in the past. To my surprise, she had never been treated with the most appropriate medications, specifically anticonvulsants, which can help by changing the way the nervous system perceives the pain. They work actively, not passively like narcotics, which are used to just dull the symptoms.
Because of the duration of the problem, the bones in her wrist had developed problems of their own, including osteoporosis induced weakness: the calcium that made bones hard had been leached away by the lack of movement of her fingers and hand. This, and the fact that her knuckle bones had slipped up and over her wrist bones, making it virtually impossible for Mel to physically move her fingers, even if she could stand the pain, had helped make her life pure hell.
The woman wanted to regain the function of her hand, not just to stop the pain.
Well, the impossible takes just a little longer. Besides, this was a problem which was challenging, as well as worth the effort to achieve the goal. And a lot of effort it would be.
Mel was also depressed. She had all of the clinical signs of depression- sleep disorder, loss of appetite and loss of libido, or sex drive.
We discussed the treatment plan. First, we needed to try to help neuropharmacologically, using medications that would help re-direct the brain and spinal cord’s ability to perceive and receive pain impulses. After a little while, the pain problem of CRPS becomes centralized, which means the pain is generated by nerve cells in the spinal cord, with problems also found in the brain itself.
I placed her on an anticonvulsant to help deal with the pain itself. I gave her suggestions for, initially, physical therapy to deal with the massive muscle spasms I had found in her neck and shoulder. These occurred because she instinctively immobilized her arm by using her shoulder and neck muscles to keep her arm close to her body. We would have to slowly desensitize her hand, by taking it out of the bubble for short periods of time, and eventually exposing it to various stimuli. But that would not happen until I could pharmacologically deal with the pain.
I also suggested that she meet with the psychologist, Dr. Sidel, to deal with her depression and the fear she had about eventually removing the bubble from her hand and her life.
As much as chronic pain patients want to relieve their pain, you had to be careful, medically, to do it in an appropriate fashion. Constant pain becomes a major part of their lives and suddenly separating someone from it can be devastating for the patient. As their life is totally focused on their pain, to suddenly rip it away, if such a thing could be done, would be very traumatic. How, and on what could they suddenly focus their lives? It’s sort of like the Stockholm syndrome where captives begin to sympathize with the terrorists who have taken them hostage. When the siege is over, they become very solicitous over their captors. Pain is like that.
It can be a bit draining to deal with patients like Mel. They want so much to believe that a physician can help them; you have to be very careful not to make blanket claims that you can. Yet, even with every disclaimer comes a look of hope in their eyes. And, more than anything, I want to help them. But hey, there’s no pressure at all.
Right.
While I was dictating my consultation, Susan buzzed me.
“Dr. Stone, there’s a Mr. Neil Landers on the phone. He says it’s important.”
“What does he want to talk to me about?” I asked.
“He wouldn’t tell me.”
From experience, I knew that Mr. Landers wanted to sell me something, or, even worse, he was an attorney.
I picked up the phone, hit the button, said hello and was greeted with a great gust of total obnoxiousness.
“Ah, Dr. Stone, I represent the Great Burde Insurance Company. We are going to be litigating the case of your patient John Pepperidge. I was calling to tell you we will be taking your deposition.”
“Well, thanks, I appreciate it,” I said. “Usually I get a letter.”
“Yeah, well, we have to move real fast here, doctor. My client wants to finish dealing with your patient as soon as possible. Frankly, we know he’s a phony. I don’t know about you; not yet.
“What do you charge for your testimony?”
“Excuse the hell out of me, Mr. Landers, but did you just say that John Pepperidge was a phony? And that I might be one too?”
“Yeah, I did. What of it?”
I counted to ten, silently.
“You realize that I haven’t seen Mr. Pepperidge for about two years, right?”
“So what? What do you charge for your testimony, doctor?”
“Five hundred dollars an hour, Mr. Landers.”
“You got to be kidding me! I will recommend to the Great Burde that we don’t pay that. It’s too much. You’re not worth it. I’ll just subpoena you; that will fix you.”
I couldn’t believe what I was hearing. Of all the bullshit I had heard from attorneys, I wasn’t going to let myself deal with this joker without making some things perfectly clear.
“Mr. Landers, I’ll tell you what. If you object to my hourly rates, I will have my attorney prepare a love letter you can take to a judge. It will show that I have charged five hundred dollars an hour for a decade, and have gotten paid. Even Great Burde has paid me. So, I suggest you take your bluster with you and talk to the judge. Until you settle this, don’t expect to find me at a deposition.
“Now good bye, and have a nice day.”
I slammed down the phone. What an asshole!
I had two more calls to make. First, I strained to remember the name of John Pepperidge’s attorney.
I remembered John. He was a nice guy who had the misfortune of being rear-ended while his car had been stopped at a traffic light. His head was thrown forward and backwards several times, in what’s called an acceleration/deceleration injury. I had met him about five years ago, when I was carrying a second job, as Medical Director of a private rehabilitation hospital. His attorney, Jerry something, had sent him to see me. Jerry, Jerry Franklin was John’s attorney.
Jerry was a nice guy and seemed to be an excellent attorney. He cared about his clients and wanted them to get the medical care they needed. He even picked up the fact that John might have had a traumatic brain injury. The last time I had spoken to Jerry was several years ago. At that time, he was working solo, after extricating himself from a large firm which milked personal injury cases for everything they could get. Underline ‘they could get’. They didn’t care about their clients, or even the physicians treating them. Many times they had shafted physicians by not making good on the liens filed on the case.
A lien is like a promissory note, which says if the insurance won’t pay for the patient’s medical care, if a settlement is reached in court, the money’s would be paid to the treating doctor at that time. Some attorneys, after a settlement, would call the doctor and tell them they had to write off their bill, as the settlement wasn’t big enough to pay them. Unfortunately, someone told the truth, and the fact that the law firm was keeping the physicians fees hit the newspapers. I can just imagine the rats scurrying for cover when that happened. The state bar association also had some things to say to them after that.
Anyway, Jerry sent John to see me. John was 28 years old, and had been working as the engineer for a local radio station. After his injury, he could no longer remember which button to push for the simplest of things. He was recently married, and the loss of income really hurt his family.
His history and neurological examination showed the symptoms and neurological signs of a traumatic brain injury. I had him tested by a neuropsychologist, who found significant deficits. A neuropsychological test is an all day affair, which can pin point many, but not all the damaged areas in a patient’s brain. It is not functional in nature, that is, it doesn’t tell what a patient can or can’t do on a day to day basis, so speech and language pathology and occupational therapy evaluations were then done. The bottom line was that John had indeed sustained or acquired a traumatic brain injury when his car was struck from behind.
Treatment took almost a year, but at the end of that time, John was retrained and working in a computer store, fixing broken computers. His life had changed dramatically, as he was totally unable to maintain the type of job and the associated lifestyle he had made for his family prior to his injury.
I lost track of him when I left the rehabilitation hospital, as the HMO wanted me to work there full time, and didn’t want me seeing patients elsewhere.
I called information and got Jerry Franklin’s number, which I immediately dialed.
“Hey, Jerry, it’s Jason Stone. Good to talk to you!”
“Thanks, Jason. I’ll bet this is about Landers and Great Burde Insurance Company.”
“You always were a smart guy,” I said, “When did you get into mind reading?”
He laughed.
“Landers just called me. You really pissed him off, Jason.”
“Tell him it’s better than being pissed upon.”
“Listen, Jason, Landers is one bad guy. He will make your life miserable.”
“Hey,” I said, “Remember, I’m not on trial here.”
“The way Landers works, you are on trial,” Jerry told me. “He will try to make you seem incompetent, so that Great Burde won’t have to pay any settlement.”
“Hell,” I said, “I was working for the hospital when I saw him. They did the billing. I don’t even have a copy of his chart.”
“I’ll send you one,” Jerry said. “You better take Landers seriously. He works directly for the Insurance Company as their hired gun. Word is he did better than a million five last year. If he loses a case, it makes him look bad. Trust me when I tell you that he won’t allow anything to get in the way of his contract with the Great Burde.”
“Hey, do me a favor,” I asked him. “Landers thinks I charge too much for my deposition fees. I told him to take it to the judge. Since I represent your client, can you write up something telling him he’s full of shit?”
“Sorry, Jason, you know I can’t represent you. That would be a conflict of interest. You’ll have to use your own attorney.”
“I thought you would say that, but I was hoping you wouldn’t. So, now I have to pay for my attorney to deal with this pus bag, just so I can get paid to do the deposition? What a load of crap.”
“I know, Jason, it is, but if you want to be paid, you’d better do it.”
“Jerry, I asked for the same thing I’ve been charging for over a decade!”
“Yeah, just remember I told you that Landers will try to make your life miserable.”
“That’s just great. OK, then, I better call my attorney.”
“Good idea,” he said. “Look, I’ll get back to you when I know something about Landers’ plans. Oh, I think it would be a good idea for you to see John before this goes anywhere.
“His life has changed again. You should probably see him so you can testify as to what’s going on now.”
“No problem. Have him call and make an appointment.”
“I will, Jason. Talk to you soon.”
So, at the end of my first day in private practice, I placed a call to my attorney, John Rickles.
So much for a positive ending of my first day in private practice.