Winner of Honorable Mention in our Doctors' Writing Contest

Was I doing my duty—or ratting on a colleague?

The author had to weigh breaking patient confidentiality against the possibility that a physician would harm himself and others.

By David L. Klocke, MD
Emergency Medicine/Rochester, MN

"Code blue in the garage!" an anxious voice barked over the emergency room PA system.

For a moment, I froze. As an emergency medicine specialist, I was supposed to react with poise and composure. But, just a few years out of residency, I still hadn't developed the knack.

"Someone bring a cart!" shouted Becky*, a staff nurse, the first person to rush to the ambulance entrance.

Taking a deep breath, I began jogging toward the receiving area. As I neared the scene, I assumed a mask of indifference. This was one skill that I had learned to master: burying my feelings in order to function effectively in times of crisis.

Nevertheless, my mouth dropped open when I saw who the patient was: Allen Van Kirk, an orthopedic surgeon on our staff. Van Kirk was 10 years my senior, but, in his mid-40s, he was still youthful. And, at six 6 feet 4 inches and 225 pounds, he was as imposing as an NFL linebacker. Clad in a tux, he was half-lying, half-sitting on the rubber mat between the automatic glass doors to the ambulance bay. Supported by Becky and his wife, Marge—a stately middle-aged blonde, also in evening attire, her eyes red-rimmed, her cheeks streaked with mascara—he appeared conscious but disoriented.

"I'm okay. Stop fussing, will you? I just slipped, that's all," Van Kirk protested, while helping hands lifted him onto a gurney. As he was wheeled into the ER's stabilization and resuscitation room for evaluation, I ran through my mental checklist of what could be wrong. Too much to drink? A heart attack? Both?

We peeled off Van Kirk's jacket and shirt and applied cardiac monitor leads to his broad chest, wrapped a blood pressure cuff around his bicep, slid a pulse oximeter onto his thick index finger, and inserted an IV into his forearm. He objected all the while. We ignored him. The team was on autopilot.

After a few minutes, the commotion subsided. Van Kirk's vital signs and a cursory physical exam revealed that he was in no immediate danger. I proceeded to take a more detailed medical history. "So, Allen, what happened?" I began.

He blinked at the concerned faces peering down at him. His eyes settled on me. "I want everyone out of the room but you," he said.

There was a moment of mystified silence. "I need them to help take care of you," I reminded him.

"I only want to talk to you." His tone was adamant.

I glanced at the monitors. His sinus rhythm was steady. His vital signs were normal. I gave my co-workers the nod, shrugging. "I'll call if I need you."

Exchanging looks, they hesitantly left the room and closed the door.

When we were alone, Van Kirk declared, "There's nothing wrong with me."

"Allen," I replied, suggesting by my tone: Who's kidding who?

He saw that I wasn't buying it. I don't think he expected me to. Then his eyes locked on mine. "What I'm about to tell you is strictly confidential," he said. My expression remained impassive. I said nothing. In response to my silence, Van Kirk restated his demand more emphatically. "You hear me, Dave? This is privileged doctor-patient information."

Still, I made no reply. Van Kirk looked away with what I took to be embarrassment. Gazing at his lap, he paused a moment, as if screwing up his courage. I braced myself for an awkward revelation.

"Demerol," he said at last.

"I beg your pardon?"

"I've been shooting up Demerol."

I was stunned. Van Kirk was a fellow physician, a colleague, a surgeon. This sort of thing didn't happen to one of us. We doctors are like priests—disciplined, virtuous, untemptable, beyond the frailties that afflict lesser mortals.

"I've been using it for years," Van Kirk admitted. "This evening, when Marge and I were going out, I just needed a pick-me-up, that's all. I guess I overdid it." His voice was matter of fact, as though he was trying to minimize what had happened. "It was an accident; not a big deal."

When I still didn't respond—frankly, I was at a loss for words—he rushed to fill the silence with background details. Because he frequently performed in-office procedures that left patients in pain, Van Kirk habitually kept a stock of Demerol on hand. Several years ago, he had tried it himself for knee pain. It had helped. So he did it again, and again. Then he started doing it even when he wasn't in pain. Before long, he had to continue the injections just to stave off withdrawal symptoms. Fudging records to avoid suspicion had been easy.

"I know, I know," he said like a naughty boy handling his father. "I'm a damned fool. Look, I'm going to quit." He'd quit before, he assured me. He could do it again.

Cautiously, I broached the subject of his medical practice. This guy performed surgery at our hospital. He wielded a scalpel, he cut people open, and at least some of that time he was probably high.

"Allen, you know you can't go on like this," I said. "You need help."

"Ah, you worry too much," Van Kirk muttered, trying to put the best face on it. "I've cut down lately. I can quit on my own." He noted my skeptical look. "Really."

We talked a bit more. No one knew that he was an addict, not even his wife. Again, he swore me to secrecy, citing the sanctity of the doctor-patient relationship.

I wasn't sure how to respond. I had never faced this situation before.

His slurred speech began to clear. Swinging off the gurney, he stood up. I worried that he would keel over, but he didn't. When I saw that he could walk unassisted, I did the only thing I could think of at the time: I discharged him.

As Van Kirk rejoined Marge, she shot me a worried glance. "He'll be okay," I lied, forcing a weak smile meant to be reassuring. "There's nothing to worry about." I couldn't bring myself to tell her the truth. I could barely accept it myself. Moreover, he had insisted on secrecy and although, I'd never uttered a word of assent, I hadn't said No, either. Van Kirk had taken my silence for agreement—and I'd let him.

For the next two weeks, I was racked with guilt and tormented by disturbing mental images. When would Van Kirk cripple someone or give himself a lethal overdose? Next week? Next month? It was only a matter of time.

Finally, needing to say something—anything—to someone, I broached my dilemma in abstract terms with the ER director and with my wife: "Suppose a doctor who knew of another doctor . . . " Neither could give me the painless solution I wanted. They sympathized with my predicament, but I was on my own.

Even then, I went back and forth over what "the right thing" was. Van Kirk was my patient. My duty was to do what I deemed best for him. And his patients, indirectly, were now my responsibility as well. On the other hand, doctor-patient confidentiality is a sacred trust. Its sanctity gives patients the freedom to tell me the truth, and me the freedom to do right by them. I was never supposed to betray that, let alone betray a fellow physician.

I knew of only two options: Treat Van Kirk personally, or report him to the state medical board, possibly destroying his career. Treating him personally was out of the question. I lacked the experience, the time, and the office space. I wasn't a primary care physician. Everything I did as an ER doctor was unsuitably public.

After much soul-searching, two realizations forced my decision. If push came to shove, I would rather go to court for breach of confidentiality than be implicated in a malpractice suit brought by a patient whom he'd harmed. And when all was said and done, I was Van Kirk's doctor. When it came to his care, the buck stopped with me.

So I spilled my guts to the hospital's chief of staff. His response was sympathetic. "You did the right thing," he assured me. "I'll take it from here." I felt a huge sense of relief. I was off the hook, sort of. But what would become of Van Kirk?

I didn't have to wonder long. "Dr. Klocke, phone call for you," an ER nurse announced the next evening. I gave her a questioning look. "Dr. Van Kirk," she said.

My palm was moist against the receiver.

Van Kirk didn't beat around the bush. Without preamble, he unleashed a tirade of invective. "You just had to tell them, didn't you?" he snarled. "I asked you to keep this between us on your honor as a physician. You broke our agreement, you no good sonofabitch! You've destroyed me. I might as well get a gun and blow my brains out."

And my brains, too, I now began to fret in the wake of his boiling rage. A shiver of fear shot down my back. Van Kirk's size and strength were intimidating enough. And now this talk of guns. What was a man pushed to the brink capable of? I knew the answer from newspaper headlines: any horror one cared to imagine.

Paranoia set in. I avoided being alone. I shunned shadowy areas of the hospital parking lot. I turned building corners warily. I had visions of Van Kirk, crazed to the point of insanity, leaping out at me, pistol in hand.

After several weeks without incident, I began to relax a bit. In my subsequent encounters with the chief of staff, Van Kirk was never mentioned. From the hospital's perspective, I supposed, the less said about his case, the better. But not knowing what had become of him, I could never let down my guard entirely. And then, two months later, an ER nurse handed me the phone. It was Van Kirk.

"I want to talk to you," said the gruff voice on the other end of the line. "Is it okay if I drop by?"

It wasn't a question. It was a statement of intent. I heard myself mumble, "Okay." As I hung up the phone, I shuddered. I envisioned those powerful hands clamped on my throat. I pictured Van Kirk whipping out a gun at the nurses' station in a homicidal rage.

And then, there he was, striding into the ER, again nattily dressed, towering over everyone, making a beeline for me.

"Can we speak privately?" he asked. Again, it wasn't really a question. Grasping my arm, he began to lead me to a back hallway. Frantically, I tried to think of someplace where we wouldn't be alone. But before I knew it, we were in the on-call room—little more than a large closet with a desk and cot. I felt trapped—and Van Kirk was closing the door.

Turning to me, he cleared his throat. My shirt was plastered to my back. My mouth went dry. "Dave," he began. Inwardly, I cringed, as if to ward off a blow. "I owe you my life. You saved my marriage, my career—all of it," he said quietly, with an unmistakable sincerity. "I was in over my head. I realize that now. Thank you."

As he grasped my hand and shook it with a viselike grip, I gazed up at him, astonished, relieved, and dumbstruck. I managed to stammer, "You're welcome," and murmured something about how I was just doing my job.

For the past six weeks, he'd been enrolled in a drug treatment program, he went on to explain. For the next five years, he would be monitored, submitting to random drug testing to ensure he stayed clean. During that time, his license would be restricted—he wouldn't be permitted to perform surgery without another surgeon present—but at least he could continue to practice. He seemed to have made peace with this.

"Well," he concluded after it was all out. There was an awkward moment. Then, giving my arm a final squeeze, he opened the door and disappeared. Not long after that, for unrelated reasons, I took a job in another city. I never saw him again.

Today, I look back on my actions as one of the good things I've done as a physician. I've since been involved in a few more situations like Van Kirk's, although none was as traumatic for me as his. Partly that's experience, I guess. Partly it's because I now know that I don't have to bear this sort of cross alone. Help through a physician health program is available to doctors in almost every state (see "Why is it so hard to report a problem doctor?" in this issue), and impairment need not mean a ruined career—if it's treated in time.

Of course, whether a problem doctor will accept help and stick with a program is a personal decision. Happily for us both, Van Kirk was able to tough it out. I'm just glad that I helped give him that chance. Had I looked the other way, he might not be a colleague today.

*All names are pseudonyms.

 

David Klocke. Was I doing my duty--or ratting on a colleague?. Medical Economics 2001;7:105.