Summer, 1998
Three Rivers Stadium
Pittsburgh, Pennsylvania

It was a typical Saturday morning on call. We’d finished rounds and I’d taken the sign-out from the resident who’d worked the night before. I headed to the library, planning to do some board prep before the inevitable beeper call to the ER or ICU. I was a PGY-4 neurosurgery resident, with many previous weekends on duty to my credit. No reason to think this one would be any different.

When the pager beeped I read the message and was very surprised.

The operator connected me to my chairman, Dr. Joe Maroon. He wasn’t the attending physician that day, so when I saw his name on my pager I swallowed hard.

Am I in some kind of trouble?

“Good morning Lee,” he said, “You like baseball, right?”

Dr. Maroon was the team doctor for the Pittsburgh Pirates, and he’d been asked to see a player from the visiting team whose neck was hurting. In a moment of great kindness (one of dozens he’s extended to me over the years), Dr. Maroon thought I might want to go with him to the stadium and meet the players.

What Dr. Maroon didn’t know was that the other team’s manager was my all-time baseball hero, a former World Series MVP. I had every one of his baseball cards, and even his jersey when I was a kid. We entered the locker room in Three Rivers and there stood my boyhood idol, wearing only his jock strap.

It wasn’t the way I’d envisioned meeting him, but hey, dreams and reality seldom match up, right?

Then we met him, the Reds’ general manager, several trainers, and the injured outfielder. Dr. Maroon examined the young man, and began to discuss the problem with the manger and the others.

The player turned to me and asked if I wanted him to show me around the locker room. I said, “Don’t you want to discuss your injury with Dr. Maroon?”

“Nah,” he said, “I’ve got no say in whether I play or not. I just do what they tell me.”

Over the next half hour, I listened as my chairman and my baseball hero argued about the player’s future.

The conversation went something like this.

Dr. M: “He shouldn’t play until his pain is better.”

Team personnel: “We could rest him tonight, but we have to have him for Atlanta.”

And so forth.

It became clear to me that the team’s concerns were not chiefly, or even significantly related to the player’s long-term health. It was a business discussion, a team decision, a money problem. They needed to win, and the player’s health was only one small variable in their equation.

Fast-forward almost twenty years to my office. My patient waits in an exam room while I discuss her neck pain with her insurer. I’m trying to get her approved for an MRI scan, and I’m doing a so-called peer-to-peer review on the phone. Except my, uhm, peer is not a neurosurgeon. Not an orthopedic spine surgeon. In fact, he’s not any kind of surgeon. He’s a nuclear medicine specialist, retired.

We battle for a while, and ultimately he denies my request. He ignores all the reasons why I, a board-certified neurosurgeon, think that this particular patient should not have to go through eight weeks of physical therapy before the MRI. She’s weak, she’s dropping things, she’s got muscle atrophy.

He says the evidence-based guidelines do not support early imaging here. I can appeal it if I want; a decision would take sixty to ninety days.

Meanwhile, the patient waits, rubbing her neck and wondering if she gets to play her normal life again, or if she has to sit out, getting weaker, waiting for a test that may never be approved or an operation that could restore her to normal health.

She thinks to herself, “I’ve got no say in whether I play or not. I just do what they tell me.”

W. Lee Warren is a neurosurgeon who blogs at his self-titled site, W. Lee Warren, MD.  He is the author of A Peek Under the Hood: A Brain Surgeon Looks at Life, Called Out: A Brain Surgeon Goes to War, and the upcoming book, No Place to Hide: A Brain Surgeon’s Long Journey Home from the Iraq War.