Reparations

I was honored to be the guest speaker at The Virtual Dialysis Support Group, an organization dedicated to improving life for patients dependent on kidney dialysis. Most of the members are people of color, as 75 percent of dialysis patients in our dialysis network are Black. I was flattered to be recognized, but I believe the honor rests with the patients trusting me, a guy named “Olaf,” with their care. These are very brave people, and I am humbled.

The incidence of kidney disease in persons of color is four times that of Caucasians. But there is reason for hope. Recently, there has been a breakthrough in the diagnosis and potential unique treatment for Black patients stricken with kidney disease. I would like to get the word out. I owe my Black patients a debt. They have saved me and my career on several occasions. 

* * *

The first occasion occurred over thirty-five years ago. I attended a young woman of color, Tamika (not her real name), who developed juvenile diabetes at the age of fourteen. Four years later, she developed lupus. Lupus is another scourge for Black patients; the incidence is 1 in 300, as opposed to 1 in 2,000 for Caucasians. Two diseases attacked her kidneys, and they rapidly failed. She had to start dialysis. Her father planned to donate a kidney, but in the process of preparing her for the transplant it was discovered she had terminal cancer.

She was twenty years old.

No treatment was offered.

Now it was about acceptance, for the patient and me. You want to change it, but you can’t. You just help patients and comfort them as best you can. As a doctor, being helpless was hard to accept. That she was so young was heartbreaking. That was not why patients come to us, and when we have nothing to offer; comfort and compassion were all that remained. Hope was long gone and not discussed.

This was in the mid-1980’s, and hospitals were adapting to the implementation of the DRG—the Diagnostic Related Group. The hospital was being reimbursed based on the disease, not the individual needs of the patient that happened to have the disease. If the hospital could reduce the length of stay, they could keep the unused money the DRG diagnosis provided. Hospitals were financially motivated to get patients out of the hospital quicker and sicker. If they could beat the DRG, they kept the money. Profits were made for a nonprofit hospital if they could get the patient out before the allotted money was exhausted. Tamika was so ill that, try as they might, the hospital could not beat the DRG. This young woman had too many things wrong with her and was a huge money loser for our not-for-profit hospital, and they wanted her out ASAP.

Nurses were enlisted to oversee the doctors and lobby for expeditious discharge. The overseers were called senior supervisors. We called them “The SS.”

The SS started to pester me about getting Tamika out of the hospital. One woman was very nasty and compulsively pestered me to discharge the patient.

“There is no place to send her,” I said.

“You are not telling her the truth,” the senior supervisor said. “You have to tell her that she is going to die.”

Bloodred lipstick stained her teeth.

“She knows,” I said. “Have some compassion.”

“I’m going to call administration. They’ll make you stop her dialysis.”

“That will never happen, unless it is what Tamika wishes.”

“You are keeping her alive for the money.”

The comment stunned me, but I let it go. I’d never treated anybody for money. Hospital administrators treat people for money, that is why they hire and give sanction to senior supervisors.

Tamika remained in the hospital, and despite the harassment, I remained resolute and would not discharge her to a place that was not safe or to her liking. She wanted to live as long as she could. She was so young, and every day was precious to her. She had so few remaining. I respected her wishes and did not stop her dialysis. I would be with her to the end. She was not in pain and wanted to be with her family for as long as possible. Her family wished the same.

I returned to the hospital to make evening rounds. I stopped to see Tamika. She sat up in bed, crying, hyperventilating, gasping.

“Tamika, what’s the matter?”

“I know I’m going to die,” she said. “I know they want my bed. But I want to live as long as I can. That woman told me that since I’m going to die anyway, why don’t I stop dialysis?”

“Who told you that?”

“That awful nurse,” she said. “I told her I want to live as long as I can.”

I went to the bedside and held Tamika. She was cancer-thin. I had to hold her gently because bones filled with cancer can break easily. She was crying and could not talk because of her gagging and gasping. I’ve never seen someone cry like that. The tears welled up and seemed to pulsate from her eyes with each heartbeat. I held her for a long time until she calmed down. The front of my white coat was wet.

She was trapped by four terminal diseases, yet her eyes were still clear and retained an expected future which was never to be. Her bright eyes were the only remaining evidence of youth.

She went to sleep. I hoped she dreamed of her life before the diabetes, the lupus, and the cancer. When her mother was still alive.

Then I made an angry mistake. I went to the nurse’s station and announced, “Whomever told my patient to stop her dialysis treatments because she was going to die anyway, tell that bastard to stay out of her room.”

I knew who did it. The person who said it knew I knew, but I did not single her out. I did not directly confront the person that made the inappropriate comment to my patient.

It remains the cruelest, clumsiest statement I’ve heard someone say to another human being. And in my forty-year career, I’ve heard and seen a lot of cruel things. To say such a thing to a twenty-year-old woman who was terminally ill was beastly.

The next day I met with Tamika’s father and uncle. We talked in a conference room. Her dad tried to tell me what was said to his daughter. He could not talk; he cried. He shook his head and looked away as if he could not understand.

“I know what was said to your daughter. Tamika is not going to be discharged; that I can promise you.”

Her uncle looked like a distinguished figure from the past. He wore a three-piece tweed suit; a Phi Beta Kappa key hung from his vest. His mostly bald head was rimmed with gray hair, and he wore wire-rimmed glasses, French cuffs, and his fingernails were trimmed and lacquered.

He spoke very softly and elegantly. He gestured with small hand movements with fists that pantomimed outrage, compassion, and opened when he asked questions such as where was mercy?

“My niece has been through a lot.”

I learned her uncle was the president of a Black religious coalition. He told me that if Tamika or I had more problems with the administration he would come and speak to the head of the hospital and explain what was said to his niece. He would intervene.

I told him I didn’t think that would be necessary.

“I hope you are correct,” her uncle said. “But I understand people that work for organizations. If you need me, I am at your service.”

I thanked him.

Tamika contracted pneumonia. Her dad made her NO CPR; there would be no resuscitation.

She died gently.

I hoped Tamika realized that there are nice people in the world, and that we did care about her, and that there was grace and mercy. Her life was so difficult and short. I wanted her to leave this world with some nice memories. Something good she could take with her wherever she was going.

After her death I got calls from the administration. A registered letter saying I was a “problem physician” and that I called the nurse “a bastard.”

I said that “bastard” was too nice a word. I didn’t direct the words directly at her. I questioned who it was that said such a thing. In a sense she admitted to those inhumane words. 

Another registered letter came and stated I would have to meet with the CEO of the hospital and then be tried by the Medical Executive Board.

The Medical Executive Board of a hospital is a kangaroo court where the wishes of medical and corporate administration are carried out. It’s like the Salem witch trials. They put you in a leather bag and toss you in the water. If you drown, you’re innocent. Few doctors have survived the inquisition of the Medical Executive Board. The results are predetermined, political, and arbitrary. Going before the Medical Executive Board was just a formality.

I went to the CEO of the hospital. I told him about Tamika’s uncle and his position with the Coalition of African American Christian Ministries. They didn’t think I would pull the trigger, I guessed. So being dragged to the Medical Executive Board was in my future, or lack of one.

The CEO thought I was bluffing.

“I’m not playing,” I said. “What was done to my patient was inhumane. Her uncle is a leader in one of the Black religious organizations who will come to my defense and expose what was done to his niece. He is connected to several media outlets, local and national, newspaper and television. I will make the call if you persist.”

I took out my flip phone. The CEO waved me off.

“I assume we are done here,” I said. “You will leave me alone?”

He nodded.

Hospitals hate outside exposure. Especially when racial issues are in the mix. You have to fight fire with fire and brimstone sometimes. The Coalition of Black Baptist Ministries saved my career.

Tamika has been dead for thirty-five years.

Every year I get a Christmas card from her dad. In his card he thanked me for how I helped his daughter decades ago. The message was always the same and explains how his family had grown. He now has six grandchildren and three great-grandchildren.

He always mentions what I did to help his daughter.

The arrival of his card initiates my Christmas season. Once I get the card, I send him a card with a picture of my wife, children, and five grandchildren. I remind him of how he and his brother saved me.

Tamika’s dad must be close to ninety. There will be a year when the card won’t come, but so far it has arrived like clockwork for decades and brought comfort if not joy.

* * *

A few years later, a patient came to my office with a disease called sarcoidosis. He was Black, and sarcoidosis is another disease more common in people of color. The disease affected his kidneys. With the use of steroids, he came off dialysis.

But there were complications.

The sarcoid left him with a horribly scarred face. Oily, wart-like growths emerged on his cheeks and formed a large mass that encased his nose. The growths were getting larger. His nose resembled a gourd.

“Can’t you help me?” he asked.

“I’ve called your HMO,” I said. “They said your policy doesn’t cover cosmetic surgery.”

“This isn’t a nose job I’m asking for. I want my life back. I’m a monster. People stare and stare and stare. The kids laugh at me.”

“I understand,” I said.

“No, you don’t. I won’t go through this much longer. I’m barely hanging on. I can’t go anywhere.”

“If only I could get the HMO doctors to see the problem.”

“Why won’t they examine me?”

“It’s easier to say ‘no’ over the phone,” I said. “I have a stack of denials for the past year. They said your policy does not cover cosmetic surgery.”

“This is not cosmetic,” he said.

He left the office, meeting stares in the waiting room.

A devious thought entered my mind.

I got the phone number of the HMO and got their “we care about you” hotline. It was a recording. “Your call is important to us, please leave a message after the tone.”

“My patient needs help. I have been trying to get lifesaving surgery for him for over a year. This African American man needs surgery, and you have denied it. You have two hours to call me back, or I will call the NAACP and see if they can help.”

The phone rang.

“Hello.”

“Who am I speaking with?” the agitated voice on the other end said.

“To whom am I speaking?” I asked.

“This is the medical director of the HMO.”

“I’m Dr. Kroneman.”

“Did you just call threatening to involve the NAACP?”

“That’s me.”

“I don’t like to be threatened.”

“It’s not a threat. It’s a courtesy call.”

“You’re angry.”

“Damn right I’m angry. I don’t like you jacking my patient around.”

“What you mean, jacking the patient around?”

“It’s an expression for making him fill out forms and making me write letters knowing all along you won’t approve the surgery. I’ve been trying for a year. He is horribly disfigured.”

“I have reviewed his policy. He is not covered for cosmetic procedures.”

“If you saw him, if you had a heart, you would have approved this a year ago.”

“I have a heart.”

“If so, would you examine him?”

“I have reviewed the case. His insurance does not cover this.”

“That’s it. I’m going to drop the dime on you.”

“What you mean, ‘drop the dime’?”

“It’s an expression for calling the NAACP.”

“Look, I’m a brown man, and I know prejudice.”

“I’m a WASP.”

“What WASP?”

“You know, Honkie.”

“Donkey?”

“Look, I’m a Danish white guy, but I can’t determine if you’re prejudiced or not because you denied the patient care without seeing him. You had no idea he was Black until I informed you of my intent to call the NAACP.”

“You’re playing the race card.”

“You forced me.”

“Will they listen to you?”

“Are you willing to take that chance?”

There was silence. I could wait.

“Okay,” he said. “I’ll approve this.”

“I want a date and time and approval number.”

He gave me the number.

“Dr. Kroneman, I just want to say you are a difficult man with no tact and no bedside manner.”

“When my bedside manner gets really bad, I’ll become a director of an HMO, just like you.”

He hung up.

The surgery went really well. They did a great job. He got his face and his life back.

* * *

I learned that a Dr. Dee (not his real name) committed fraud.

“Keep out of it, Dr. Kroneman,” Dee said.

“There is no statute of limitations on Medicare fraud,” I said.

Dee smiled.

I consulted my attorney. He informed me that if I did not report the fraud, I would be complicit. My attorney informed Dr. Dee’s attorney to get him to come clean.

Later, I received a call from my attorney.

“Dr. Dee’s lawyer returned my call. He said you breached the computer and reviewed his client’s personal medical records. It’s a serious HIPAA violation.”

“What?”

It was blackmail.

“Yeah, I called Dee’s attorney and urged him to cease and desist or my client would have to report him. He said I should have you come clean about looking up his private health records. He said we might want to reconsider reporting him for fraud and they would not pursue the HIPAA violation.”

I thought it was absurd.

“That’s extortion, blackmail. I didn’t look up his records. I can’t even spell his name to enter it into the computer. It’s one of those real long foreign names so everyone calls him Dr. Dee. His lawyer knows it’s blackmail, extortion,” I said to my lawyer.

“It’s close to extortion, and I could report his lawyer to the bar, but it’s not quite there. It would be difficult to prove.”

This was getting weird.

“You really can’t spell his name?”

“Nope. The case against me is nonsense.”

“Well,” he said. “Dr. Dee has to protect himself or be deported. He’s clever. He thinks he bought your silence.”

“He didn’t buy shit.”

“I used to have a lot of faith in doctors, before I had to deal with them,” my lawyer said.

I left his office. I hoped it would all blow over, go away. But I had to report the fraud or I’d be in jeopardy for the rest of my career.

Before I could report the fraud to the medical board, an FBI letter arrived. The hospital was initiating proceedings against me for a HIPAA violation.

I had a hard time believing that the hospital really thought me guilty. I’d been on staff for thirty years. At first, I did not take this seriously. I came to view it as ridiculous and an obvious hoax which would be dismissed by common sense. Dee should have gone to the hospital rather than blackmail me through his attorney. The hospital trusted me to take care of human life. I’m trusted with a narcotic license. Do they really believe I would look at other doctors’ records?

I learned it was difficult to prove a negative.

* * *

I returned to seeing patients.

“Dr. Kroneman, what’s wrong?” a longtime patient asked.

“Why? Nothing.”

“You’re not you.”

I could no longer keep my feelings below the surface. She saw the tip of the iceberg.

I explained to her that the hospital was coming after me for something I didn’t do. They were hell-bent on ending my career.

“So you’re being framed?”

“Yep.”

“My husband works homicide; he can help you.”

“But there’s no murder here.”

“In a way they are trying to destroy you and your family and hurt us, your patients. We need you.”

“A homicide detective can help me?” I asked.

“Call him. He knows everybody. He’ll find somebody that can help you. You cure patients like me, and they solve crimes and catch criminals.”

“This is a sophisticated white-collar crime.”

“Done by white guys, I bet.”

“Not many Black guys in hospital administration,” I said.

She smiled. “My husband would like to get a crack at them. It would be a pleasant change for him.”

I met with her husband at inner-city police headquarters. I saw the sign, “Homicide.” My stomach turned.

The detective was Black, about sixty years old, wiry, and always had a toothpick in his mouth, which he would move from side to side while speaking. He oozed tough street cred with a Glock tucked in his waistband. I’d taken care of his wife for years; now he was coming to my aid. I repeated my story.

“A blackmailer’s worse than a murderer. They’re crazy and cold-blooded sociopaths. I can help you. I’ll take you to the high-tech crimes division. My friend works there.”

The detective arranged a meeting with an agent that worked in the cybercrimes division of the state’s Attorney General. My wife and I drove to the inner city and entered the Attorney General’s headquarters. 

We were ushered into the office of Special Agent Henry Hayes (not his real name). Agent Hayes stood six feet tall and was well over three hundred pounds. He was Black, with a shaved head and a soul patch under his lip. He had a very large gun on his very large waist.

He smiled. “You got computer trouble?”

“Yep.” I explained the situation.

I handed him the computer log-in. He looked at it and laughed.

“This is not the original,” he said.

“We tried to get the original.” 

“You don’t need anything. A log-in proves nothing. It doesn’t prove who was at that computer. They need a timed photo of you at the computer at the time of the breach.”

“I swear I didn’t do this. I left a computer logged on.”

“What’s the log-off time?”

“Ten minutes.”

“Then there’s no security, you were tailgated.”

“Tailgated?”

“It’s a term we have for people that are exploited for not logging off of a computer. Criminals hang around looking for a vulnerable computer. The person who reports the breach in a tailgating frame-up is the perp. We all know that. After we talk with them, the accuser, they come clean. If you need us to, we’ll talk to Dr. Dee. He’ll cave once he understands it’s prison for computer fraud, identity theft, and extortion. If your hospital knew anything about computer crimes, they’d go after Dr. Dee. We could probably get his attorney also.”

“They have fired over one hundred people based on a tailgated log-in.”

“They’ve got trouble if the right lawyer finds out.”

“Can you write the hospital and tell them what you think?”

“Sure. Any computer with a ten-minute log-off interval is not safe,” he said. “Doctor, you’ve been blackmailed.”

We thanked Agent Hayes and left his office.

“They must carry guns in case they get attacked by a computer mouse,” my wife said.

“Funny,” I said.

* * *

“If we could prove Dee did this, he’d be guilty of eight felony counts, federal crimes with prison terms of five to ten years per count,” I told my lawyer. “That’s what the agent from the Attorney General told me.”

“You went to the Attorney General? Why didn’t you tell me?”

“You’d have charged me.”

“Damn right,” he said. “Will he help us?”

“Yes, he’ll send a letter stating that computer crimes should be handled by professionals, and a professional would never prosecute something like this.”

* * *

We had yet to receive the original computer printout. We were desperate, so my wife called Agent Hayes, and he gave her the name of a forensic computer specialist. We drove to his office. He was tall and thin and very expensive. His skin looked like it had never seen the sun. Blue veins snaked around the side of his head.

He looked at the computer printout and said, “It’s incomplete, you need the original.”

“I’m to go before the hospital’s Medical Executive Board in a week.”

“We need an accurate computer record.”

Three days later, my lawyer called. We got the original log-in—thanks to a court order.

We met with the forensic computer specialist again.

“It’s a good thing we got the log-in,” he said. “It shows that after you discharged your patient there was a seven-minute dead time, ample time to be tailgated. There is enough here to clear you. The gap in time should be all you need. I’ll send a letter to your hospital.”

We thanked him.

When we got home, my lawyer called.

“Dr. Kroneman, you need to take a lie detector test.”

“What?”

“A lie detector test.”

“Come on, I’m a doctor, not a criminal. We have evidence that there was sufficient time for someone to tailgate me on a computer: Seven minutes are not accounted for. The computer specialist said that’s all we need.”

“Take the polygraph. The hospital wants to destroy you, and we have to prove your innocence beyond the shadow of a doubt, in case we have to appeal or sue.”

“Should I wear an orange jumpsuit?”

I took the polygraph. I passed. 

I had the polygraph, the seven-minute gap, an inner-city homicide detective, the Attorney General high tech crimes agent, and the truth.

My lawyer said, “The truth will help, a little.”

* * *

My trial date arrived. The proceedings of the kangaroo court were to be held in the hospital’s board room.

I stood at the podium. I spoke.

“I’ve been accused of looking at the medical records of Dr. Dee. I did not do this. I will show you that on the day of the breach, my computer was not secure. There is a ten-minute interval from the last use of a computer to when it recognizes inactivity and finally shuts off. I will admit that I failed to log off, but that was my only crime. If that is a crime.”

Two people folded their arms. I heard the comment “ten minutes” whispered several times.

“I’ve met with a computer specialist and with Agent Hayes of the Attorney General’s high-tech crimes division, who agreed that a ten-minute log-off time is a major security risk. Doctors and nurses are very busy and often forget to log off. We are vulnerable to unscrupulous attacks. I had no motive to look up the medical records of Dr. Dee. I realized any activity under my log-in can be traced directly to me.”

I felt the audience started to comprehend the obvious frame-up.

“If I were interested in his medical records for a nefarious purpose, I would use a computer already opened and logged in under another physician’s or nurse’s name. I would commit a felony but leave no trace. The lack of security on the hospital’s computer system and the HIPAA laws have set the stage for the perfect crime. It’s a perfect way to settle scores, and there are lots of scores to settle in a hospital.”

I heard whispers in the audience.

Everyone knew I had won, even before it was official. It soon became official. I was exonerated.

Once again, my patients of color saved my career. I was saved by a Black homicide detective and a Black agent from the Attorney General’s office.

Ironically, our computer system has been hacked recently, and one million hospital records were breached.

* * *

My Black patients came to my aid not for profit but out of concern and our mutual respect and dependence. It is tragic for me to round in the dialysis unit and see that the majority of the patients are people of color. Recently, it has been discovered that several Black patients carry a gene called APOL1 which, if received from both parents, results in a 20 percent chance of contracting kidney disease. It is thought to be the main reason for the high incidence of kidney disease in Black patients. Eighty percent of Black patients on dialysis carry the gene. The affected can be readily identified by genetic testing.

Recently, a drug has been developed which blocks the expression of the gene, and it might bring a cure. It is promising and mandates further investigation and development of a possible treatment.

There is reason for government involvement at “Warp Speed.”

Imagine if 75 percent of the patients in our city could be spared from the ravages of kidney failure and dialysis.

I am working with The Virtual Dialysis Support Group to spread the word and lobby for the development of a cure and remove my patients from the Big Dialysis corporations.

And I am dedicated to repaying a debt.