A Tale of Shared Accountability

This is a work of satire and fiction.

The best and most beautiful plants are fertilized with shit.

I. The Window

The waiting room of Quaternary Risk Management had fourteen chairs, a water cooler with no cups, and a television playing the system’s commercial, in which a woman jogged across a bridge at dawn while a voice said together eleven times. A banner read: Quaternary Health. The fourth level of care. Please complete the first three. Under it, smaller: One concern per visit.

Marisol Vega had one concern. It was thirteen years old and sitting next to her.

His name was Dante. He was playing Super Mario on his grandfather’s original Game Boy, the gray brick with the green screen. It was older than Quaternary’s electronic medical record and, unlike the record, had never gone down for maintenance. The volume was all the way up. He had been told about the volume. He had considered the information and declined.

Her complaint was on the form in block letters so there could be no confusion.

In 2013 I called Quaternary for a contraception appointment. The first available new-patient visit was four months out. I took it. By the time it came, it was a prenatal visit. I would like to know who decided four months.

The form had a dropdown for Nature of Concern. None of the options was “conceived.” The closest was Parking, which was at least where it had started.

II. The Wait

Four months was not a decision. That was the first thing she would learn. It was a template.

New-patient slots were made on one side of the four-foot gap in the belt and consumed on the other, and in between they fell. The ones that survived the crossing were released on the first of the month, at midnight, to whoever was holding. Marisol had held for forty minutes, the full length of the hold music, which had been shown in trials to resolve a third of all complaints without intervention. She had not been resolved. She had been given October.

Dr. Anjali Patel saw her. Dr. Patel was told at 7:58 that it was a contraception consult and at 8:04 that it was not. She found the heartbeat. She said, “Well. Okay. Let’s do this.” She wrote the prenatal vitamins and stayed eleven minutes past the slot, which the practice administrator flagged in her quarterly throughput review. It was the only part of the process that worked, and it was the only part anyone would ever be punished for.

III. The Liaison

At 9:15 a door opened and a man in a lanyard said “Vega?” the way you say the name of a dog you are not sure is yours. His badge said Patient Experience Liaison. He led them to a room with a round table, a box of tissues, and the word INTEGRITY framed over a photograph of a canoe.

“First, I want to thank you for sharing your experience.”

“I haven’t shared it yet.”

“And I want to honor that.” He found the date on the form and did the math. You could watch him do it. “So this is outside our standard thirty-day window.”

“By how much?”

“Roughly four thousand seven hundred days.” He said it kindly. “But I’d be happy to open a new case. Our next intake is February.”

Through the wall, Dante reached the underground level. The music changed. The liaison flinched.

IV. The Ecosystem

Here is what Marisol learned over the next three hours. You cannot sue Quaternary Health, because Quaternary Health is not, in the legal sense, a thing.

It is a care ecosystem. It is a family of brands. It is a nonprofit that owns a management company that contracts with a physician group that is an LLC that leases its doctors to a hospital that belongs to a foundation whose board meets in a city none of them live in. You cannot sue an ecosystem. You can only sue a tree.

The tree was Dr. Patel.

Her name was on the chart. It was the only name on anything. She had not set the template; the template was set by a Patient Access Optimization Committee that was disbanded in 2016, in a building sold in 2019 to a company that makes dental implants. She had not built the gap. She had not recorded the hold music. She had done the visit, and done it well, and so when Marisol asked the only question she had come to ask, the liaison slid a piece of paper across the table with one name on it, and the name drove a 2011 Corolla.

This was the arrangement. The system employed the doctor, or did not, depending on which was cheaper that year. The insurer credentialed her, billed under her, and denied in her name. The system built the schedule, set the wait, decided that fourteen minutes was a visit and that a new patient could hold for a season. And when the wait produced a consequence, a missed cancer, a missed stroke, a thirteen-year-old in the lobby, the system turned, slowly and with great institutional warmth, and held the doctor up in front of itself.

She was the only one in the building with a license to lose. That was what made her useful.

Her malpractice carrier was the Policy, from the case on the executive floor: one company, mandatory, its address a post office box in the Caribbean, owned personally by Richard. It had never paid a claim. The box was four inches wide. A letter from a law firm she had never heard of went out to Dr. Patel that morning, encouraging her to contact her carrier, which was owned by the man whose system had built the schedule, which was the thing she was being sued for.

V. The Drill

At 11:20 the drilling began.

Nobody on the fourth floor had anticipated a Game Boy. The Threat Assessment Matrix covered firearms, bodily fluids, and journalists. It had nothing on an eight-bit soundtrack at full volume for three hours in a space designed to absorb grief. By ten the Chief Risk Officer had a tic. By ten-thirty the VP of Patient Experience could no longer hear the word together. By eleven a memo had gone out, and the memo had made a team.

It was called the Rapid Response Response Team, because the Rapid Response Team already existed and did something medical. The acronym was RRRT. Everyone pronounced it as a small burp.

Four physician assistants, three nurse practitioners, and a rotating squadron of Caribbean medical students, who had been issued drones. The drones hovered at a regulatory altitude of four hundred feet, from which nothing could be seen, but the students were very good at being deployed, which was the skill Quaternary had been developing in them all along. Between shifts they flew the drones south to check on the post office box. It was still there. It was still four inches wide.

The PAs and NPs were issued Nerf blasters. The blasters had been through Supply Chain, so each foam dart carried a barcode, a lot number, and a unit cost of $340.

Their mission was to protect Richard.

Richard was the Chief Utilization Officer. He had never met a patient, and it had gone very well for him. Dante was the closest he had ever come, and the formations existed to keep it that way. Whenever a Mario shirt was seen or a Mario theme was heard, the RRRT assembled around Richard in one of six approved formations and escorted him to the safe room, which was a conference room with a better canoe.

There was the Pyramid, NP on top. The Turtle, seven providers crouched with blasters out and Richard in the middle holding a latte. The Chevron, the Lotus, the Phalanx, and one a PA named Brittany invented in the first ten minutes that involved everyone spinning in place and was called, officially, the Brittany.

They were extremely good at it. These were people who intubated, who ran codes, who saw thirty patients a day under someone else’s name. Give them a drill and they would drill. Richard, who wore a velvet blazer on Mondays and favored the word groovy when he thought it would land, walked through a Turtle at 11:40 and shouted “Who IS this boy?” Nobody answered. Nobody on the team had been told. They had been told there was a threat and to form up. They had not been told why.

That was also the arrangement.

Richard was the one person in the building who could not be sued. He was the only one with a guard.

VI. The Glass

Marisol watched through the conference room wall while the liaison explained, for the third time, that the physician group was a separate entity and that concerns about Dr. Patel’s care should go to the state board.

“I don’t have concerns about Dr. Patel’s care. Dr. Patel’s care was the only part that was fine.”

“I’m hearing that.”

“I have concerns about the four months.”

“And I want to validate that the four months was outside Dr. Patel’s control.”

“Yes. That’s my point. Whose control was it in?”

He opened his mouth. In the hallway, seven providers dropped into a Lotus. A drone drifted past the window at four hundred feet, seeing nothing. On the far side of the glass, Dante found the warp zone.

At 1:00 the liaison stood, which meant the meeting was over. Marisol asked for a copy of her complaint.

“Of the complaint?”

“The one I wrote. On the form. An hour ago.”

He explained that once a concern was received, it became part of Quaternary’s quality improvement work product, which was privileged, and could not be released, including to the person who had written it, because releasing it would discourage people from writing it.

She could request her own words through Release of Information. She had not checked the box. Processing took thirty days. What she would receive was not the complaint but a two-page summary describing the complaint, prepared by a person who had not read it.

“I have it memorized,” she said.

“We’d ask that you not,” he said, and gave her a tote bag that said together.

VII. The Cafeteria

She found Dr. Patel by accident at 1:15. Dr. Patel was eating a yogurt standing up, reading the letter. They sat down together. It was not dramatic. There was nowhere else to sit.

“I remember you. You were the contraception visit.”

“I was the contraception visit.”

“How is he?”

“He’s loud.”

They could hear him from there. “They put me on the letter,” Dr. Patel said. Not quite a question.

“I didn’t put you on the letter.”

“Nobody ever does. It just arrives with your name on it. Like the schedule.” She capped the yogurt. “You know what their defense is going to be? That I should have seen you sooner. Me. One body. The physician failed to ensure timely access.“

“Can’t you leave?”

Dr. Patel lifted her ankle an inch. The chain was light. It was thirty miles long. “A fifth of my salary is in a locked box until December. My insurance is in a box in the Caribbean. I’m in this box.” She stood and put the letter in her coat. “I came here to practice medicine. I’m the padding.”

“I came here to sue somebody,” Marisol said. “I don’t think I want to sue you.”

“Nobody ever does. That’s what makes it work.”

VIII. The Survey

At 2:00 Marisol collected Dante from the lobby. The RRRT had gone to lunch, except the drones, which circled the parking structure, logging it. Richard, from inside a Turtle, gave her a thumbs up.

In the car Dante paused the game. The red light was on. Low battery. Six hours on four AAs, longer than anything in the building had gone without a reboot.

“What were you even complaining about?”

She thought about how to say it. “I made an appointment to not have you, and they made me wait so long I had you instead.”

He considered this. He was thirteen, and he was, by any measure, the strongest argument against Quaternary Health that anyone had ever carried into that waiting room, and he knew it.

“So who’s in trouble?”

“Dr. Patel.”

“The nice one?”

“The nice one.”

He turned the Game Boy back on. The music started. It was, she realized, pulling out under the drones, the only thing in the building that had answered to its own name.

Her phone buzzed before she reached the road. Quaternary wanted to know how likely she was, from zero to ten, to recommend Quaternary Health to friends and family.

She gave them a four. One for each month.

FIN