Content warning: references to medical procedures and suicide
Adapted with permission from a social media post by Dr Anthony Youn
Stop.
Rewind.
Last year, on an ordinary day in July, at exactly 3:43pm, Dr Antonia Franklin made the worst decision of her life.
Dr Franklin was performing breast reduction surgery. Her patient was a local St Paul school teacher, just shy of 30 years old.
Violet Sweet – the patient – had a bubbly personality. Always smiling, genial to her students and fellow teachers. She lived in a split-level apartment in the Como neighbourhood with a Pomeranian called Paul, whom she loved taking for walks along the banks of the Mississippi. On weekends, she volunteered at the Good Neighbor Center.
But in private, she was crushed by a dark secret. She spent most evenings staring at her naked torso in the mirror, chastising herself for her ugliness. She would say to herself, “Your chest looks like two sacks of potatoes.” She would repeat it again and again. Sacksapotatoes. Sacksapotatoes. She would scrape at the rashes under her breasts until she bled.
Her friends became concerned for her, and persuaded her to apply for Medicaid. Throughout the long and stressful process, Violet maintained her cheery exterior, though her insides roiled with angst. Eventually, she was pre-approved by the insurance company for breast reduction surgery, on the condition that at least 800 grams of breast tissue was removed from each breast.
In the prep room, Violet asked Dr Franklin about the condition the insurance company had imposed.
“That’s normal,” explained Dr Franklin reassuringly. “It’s just a way for the insurance company to make sure the operation is ‘medically necessary’.”
“But don’t you be taking off too much,” said Violet. “I don’t want them small, I just want them pretty.”
The early stages of the operation went well. Dr Franklin made an incision around the areolae and down each breast. She removed the excess tissue from the lateral and inferior, and lifted the nipple into place. But just as she prepared to start suturing, the surgical resident pointed out that only a total of 1,200 grams of breast tissue had been removed – 600 grams from each breast. Not enough to meet the insurance company’s condition for pre-approval.
Dr Franklin considered her options. For one stretched second, none of the members of the surgical team moved, and the room seemed eerily silent – as if they had momentarily reached a fulcrum around which time and space turned.
It was exactly 3:43pm.
Dr Franklin remembered Violet’s comment just before the surgery. “I don’t want them small, I just want them pretty.” Given Violet’s size, removing another 200 grams of tissue from each breast would make them look small. Dr Franklin decided to proceed with the suturing, and the 1,200 grams of breast tissue was sent over to pathology.
Violet’s recovery was smooth. A week after the operation, the tubes that drained the excess fluid from her wounds were removed, she came off the pain meds, and she was finally allowed to have a long and luxurious shower. She looked at herself in the mirror and cried with happiness. The scars were thin. There was no pain. She was beautiful.
She blossomed with a new-found confidence. Her friends complimented her new look, her new energy. She felt fantastic – until she got a call from the insurance company. The surgery, she learned, would not be covered by insurance, because the pre-approval condition had not been met. The bill was over ten thousand dollars, and she would have to pay in full.
It was in Violet’s nature not to make a fuss, so she swallowed her rising panic and applied for a new credit card. She tried not to think of how much she had been struggling to meet the payments on her other maxed-out credit cards. How she would pay next month’s bill.
She negotiated with her landlord to delay her next rent payment until after payday. She declined her friends’ invitations to eat out. She turned off the air conditioning unit in her home. Saving a few dollars here and there would be enough to get her through.
But it wasn’t. The bills kept coming, and she was out of her depth vertiginously quickly. Three months after her operation, she received a 14-day notice of eviction from her landlord. She vowed to find the money, sue for justice, beg for forgiveness; but before she could get her thoughts in order, she was spending nights in her Kia Forte.
The next time Dr Franklin saw her former patient, Violet was panhandling on St Peter Street outside the back of the old cinema.
Stop.
Rewind.
Back to the start.
Last year, on an ordinary day in July, at exactly 3:43pm, Dr Antonia Franklin made the worst decision of her life.
Dr Franklin was performing breast reduction surgery. Her patient was schoolteacher Violet Sweet, nearly 30 years old.
The early stages of the operation had gone well. But just as she prepared to start suturing, the surgical resident pointed out that only a total of 1,200 grams of breast tissue had been removed. Not enough to meet the insurance company’s condition for pre-approval.
Dr Franklin considered her options. Her senses became heightened. She could feel it: this moment… had moment.
It was exactly 3:43pm.
She concluded that the surgery had to continue. She knew this patient – Violet Sweet – had qualified for Medicaid, and she couldn’t risk casting Violet further into financial hardship by voiding the insurance.
Dr Franklin carefully removed another 200 grams of tissue from each breast, and the 1,600 grams of breast tissue was sent over to pathology.
Violet’s recovery was smooth. A week after the operation, the tubes that drained the excess fluid from her wounds were removed, she came off the pain meds, and she was finally allowed to have a long and luxurious shower.
Violet looked at her naked torso in the mirror, and cried.
Her breasts were so small. They didn’t feel natural. Her chest looked freakish; her nipples stood out like…
“Bee stings,” she said aloud. She repeated it again and again and again. Beestings beestings beestings beestings.
When Violet returned to work, every single person she passed commented on her chest. How could they help but notice such a dramatic transformation? Their words were gentle, but they hit like mallets. She had always felt self-conscious about her breasts, but now it was her own fault.
She tried stuffing her bra, mocking herself out loud for doing it, feeling like an idiot twelve-year-old. She tried wearing baggy sweaters. Eventually, she avoided people altogether.
Violet spiralled into an oil-black depression, and started entertaining thoughts of suicide.
The next time Dr Franklin saw her former patient was in the open casket at her funeral.
Yikes. Let’s try again. From the top.
Stop.
Rewind.
Last year, in July, at 3:43pm, Dr Antonia Franklin made the worst decision of her life.
The operation had gone well, but the surgical resident pointed out that only a total of 1,200 grams of breast tissue had been removed. 400 grams short of the insurance company’s condition for pre-approval.
Dr Franklin considered her options. Time seemed to slow.
It was exactly 3:43pm.
Removing more tissue wasn’t an option, Dr Franklin decided, nor was stopping now and voiding the insurance. The patient – Violet Sweet – was a large woman, so Dr Franklin requested the emulsification and suctioning tools, and performed a quick liposuction. She removed 400 grams of fat from the patient’s flank. Not enough to be noticeable, but enough to supplement the breast tissue so the insurance company would pay out.
Violet’s recovery was smooth. A week after the operation, she looked at herself in the mirror and cried with happiness. The scars were thin. There was no pain. She was beautiful.
Dr Franklin thought nothing more of the incident, and went on with her everyday life. Until…
Two weeks later, Dr Franklin was summoned to the office of the Medical Director. She instantly felt nervous – there was never a good reason to be summoned to the office of the Medical Director. She racked her brains to think of what she might have done wrong. Racked and rinsed and wrung her brains.
The Medical Director, a hoary-haired man with round-rimmed glasses, told her of a “disturbing report” he had received. “Do you remember performing a breast reduction, two weeks ago, on a patient called Violet Sweet?” he asked.
Yes.
“Did you also perform liposuction on Violet Sweet?” he asked.
Yes.
“Did Violet Sweet request liposuction? Did you have Violet Sweet’s consent to perform liposuction? Was liposuction medically necessary?”
No. But –
“You admit it?” He looked horrified. “You performed unnecessary surgery on a patient without her consent?”
Um…
From that point on, events cascaded like a runaway train – slowly at first, but inevitably, unstoppably, until her entire career was off the rails. Despite her denial, despite her protests, she was powerless to stop it. She had thought the consequences would be… well, she hadn’t thought of consequences at all. It was a minor transgression, was it not? Yet somehow an example had to be made. The hospital’s reputation had to be protected. Ethical standards had to be upheld. After a humiliating series of hearings, Dr Franklin’s licence to practice medicine was revoked.
Shit.
One more time.
Stop.
Rewind.
Last year, July, Dr Antonia Franklin made the worst decision of her life.
The operation on Violet Sweet had gone well, but the breast tissue removed was 400 grams short of the insurance company’s requirement.
Dr Franklin considered her options. The instant touched eternity.
It was exactly 3:43pm.
She reasoned that, prior to the surgery, she had injected a combination of saline and lidocaine to reduce oozing and pain. So, she just bulked up the cast-off breast tissue with saline. You could barely tell. 1,600 grams were sent off to pathology, and the operation was declared a success.
A month later, Dr Franklin was arrested.
The penalties for insurance fraud in the state of Minnesota are surprisingly harsh. A fraudulent claim of just $5,000 merits up to 10 years in jail – and this claim was worth twice that.
But when the prosecutor asked Dr Franklin whether she had prioritised patient health over total transparency with the insurance company, she had to say yes. And, therefore, she had intended to mislead the insurance company? Despite her justifications, the only honest answer was: yes.
No further questions, Your Honor.
Dr Franklin couldn’t believe what she was hearing when the judge handed down her sentence. She spent the next 400 days in the Minnesota Correctional Facility in Shakopee – a day for every gram of fraudulently injected saline.
Stopstopstopstopstop.
Rewind.
Last year, on an ordinary day in July, at exactly 3:43pm, Dr Antonia Franklin made the worst decision of her life.
Except, maybe it wasn’t a decision. Making a decision implies some kind of power over your situation. But fate – and the perverse incentives of the US medical system – had already condemned her.
How did this happen?
Rewind. Further this time.
A month before Violet Sweet’s breast reduction surgery, Joseph Miller opened up Violet’s medical file on his computer. Joseph was a medical insurance clerk, assessing Violet’s Medicaid application. It was nearly the end of the day, though, and he wanted to get home and binge-watch a few more episodes of Grey’s Anatomy. So, instead of studying Violet’s case, he found another breast reduction patient of a similar weight, and copied all the info across. Including the pre-approval condition: at least 800 grams per breast. He approved the case, and hit send.
Stop.
Rewind.
Charlie Fish is founder and editor of www.fictionontheweb.co.uk, the Internet’s longest-running short stories website. His own short stories have been published internationally, including by the British Library, East of the Web, and Mechanics Institute Review. He is also screenwriter of award-winning short films such as The Man Who Married Himself. He can be contacted on charlie@fictionontheweb.co.uk or on Twitter @fishcharlie
A fascinating story that hits close to home. I know two women who had this surgery and I wonder if they thought about such alternative consequences for them or for their their doctors. It’s a shame (what an understatement that is!) we have such advances in medicine and their applications are thwarted, overcomplicated, overcharged, by insurance players. What does the term insurance even mean anymore? Profits for a few, problems for the rest of us.
Thank you for this wonderful chilling piece.
In the modern U.S. healthcare system, there is typically no winning, just different ways of losing.
As a retired physician, over the course of my career, I was demoted by the health insurance companies from “doctor” to “health care provider” and then my autonomy was ex-sanguinated by the thousand cuts of ever-expanding insurance company rules, regulations, limitations, prior authorizations, and other self-contradictory requirements.
U.S. Health insurance companies are in this strange position in that they maximize their profits by delaying or denying access to the care purchased by their customer, as opposed to providing value to their customer.
It is a Kafkaesque nightmare – well represented in this haunting piece!