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Hard Cases Dr. Abigail Zuger on the everyday ethical issues doctors face.

One of my patients died last month, a man I was particularly fond of. I had known him for almost 20 years. I had come to know his wife in person, the children in his frequently exasperated anecdotes and his grandchildren in blurry cellphone photos. His wife left a message with the unexpected news on a Monday morning.

It took me almost two weeks to get back to her.

How typical, right? The doctor shrugs and moves on. The doctor forgets the symbolic value of closure. The doctor doesn’t bother to show up at the funeral. The doctor ignores the obligations that endure after the patient passes.

But hold your judgments. I called Lenny’s wife back promptly, repeatedly, leaving increasingly puzzled messages and never getting a response.

I suppose you could call it all a medical error. But it wasn’t mine.

Medicine has become a team sport — that’s old news. Everyone knows that the team now includes residents, physician assistants, nurse practitioners, therapists, all taking over portions of the role that once belonged to the doctor alone.

These colleagues slice and dice the doctor’s time-honored obligations into fragments that can be difficult to reassemble. Residents routinely use my license number to write prescriptions; if the resident makes a big mistake, who is liable? Nurses inject medications per my orders; if I miscalculate a dose and disaster ensues, who pays?

These days, that’s not the end of it, not by a long shot. Behind the medical team stands an increasingly large backfield, giant in numbers, humble in training. They answer the phones, arrange consultations, organize the billing, deal with the unrelenting demands of dozens of insurers. Say that a secretary, a pleasant, overworked person sitting with her colleagues in an airless back office, each fielding dozens of calls a day — say she forgets to confirm a phone number scrawled into the medical record long ago. Who is responsible?

You won’t find the answer in the ethics textbooks. Experts continue to talk about the “physican-patient relationship,” that storied historic and fiduciary entity, as if it were still composed of mutual trust and obligations between two people. They haven’t noticed that those two people have turned into a crowd.

Lenny was impossible, the best and the worst kind of patient. He never complained, mostly because he minimized half his problems and overlooked the rest. He vastly preferred to ignore his health and discuss his latest computer acquisitions. We spent a lot of office time on Apple vs. Microsoft. Whose fault was that?

In the long run, it hardly matters. He died at 52 in an emergency room from overwhelming staphylococcal sepsis, a treatable bacterial infection undoubtedly worsened by his chronic liver disease and his chronic denial — and by the impressive personal magnetism that endured to the end: Evidently he refused to let anyone call an ambulance till far too late.

Many things can go wrong in health care. These days more and more of them have nothing to do with actual health care. People leave a competent doctor for a marginal one because the first has a receptionist with a nasty disposition and the second has one who smiles. People change medications from good to not so good because their insurer pays for one set and not the other. People get their doctor on the phone right away because a secretary has the nerve to transfer the call to the staff lounge. People never hear from their doctor because a secretary forgets to confirm a phone number.

After 10 days with no word from Lenny’s wife, I was beside myself. I couldn’t leave any more messages. I couldn’t fathom why she wasn’t calling me back. I figured she was angry with me. So, of course, I got a little angry about that. Does everything have to be my fault? Then I remembered that I knew where she got her own medical care, at an office bound to have more contact information.

Sure enough: I had been calling the wrong number the whole time, off by one digit.

Two conversations end this story. The first one, between me and our secretary, was brief. There wasn’t much to say. I am not her supervisor. Mistakes happen. She didn’t know Lenny; she seldom gets out from the back room to see our world — hers as much as mine — in all its dimensions.

Then Lenny’s wife and I talked for a long time. The edge in her voice eventually softened. We agreed that he had been impossible, and would be grievously missed. I told her I would have been at the funeral, if I had only known, and that I would never forget I had missed it.

So who paid? I guess we all did.