#the times that the gang have called on arthur for missions because he's their 'insurance' makes me so sad for him

[arthursfuckinghat]

Nothing can describe the way my heart shattered when Arthur asked if Dutch was going to go look for him after he was kidnapped by Colm in chapter 3- all he got was a "Oh of course, son" in the most pitiful, unassured tone of voice I'd ever heard from Dutch.

The three of them had set up a meeting point at "the fork in the road" if the O'Driscoll parlay went south, Arthur seemingly disappeared and didn't return for another day or so until he was physically crawling trying to get back to camp, and still nobody questioned where he was?

Yes, it's typical for Arthur to wander and find his own way home after missions, but the key word is AFTER. Arthur disappeared DURING the meeting and didn't regroup at the designated rendezvous point AFTERWARDS.

Especially dealing with the likes of the O'Driscolls, wouldn't that ring some kind of alarm? If not from Dutch or Micah, then wouldn't anybody else at the camp question it?

I imagine an (exaggerated) conversation like this probably happened if anyone at camp asked:

"Hey Dutch how was the meeting with the O'Driscolls?"

"It went fine we talked a bit then they left suddenly so weird"

"Where's Arthur then?"

"Oh I don't know we didn't see him after we split up for the meeting haha probably wandered off again typical Arthur"

God, if you're going to treat Arthur like the gang's workhorse, then act like you care about him at least.

Arthur is strong, but he isn't invincible.

[verai-marcel]

The Light That You Shine (RDR2 Fanfic, John Marston x F!Reader, Chapter 4 of 6, 18+)

Tags, Warnings, & Notes in Chapter 1.  |  Chapter 2  |  Chapter 3

AO3 Link is here.

Chapter 4 - A Dip in the Road

Word Count: 2416

The next couple weeks were a blur as you temporarily moved back to your uncle and aunt’s place, just for safety. When the cops called, asking you to identify two men who had been arrested for attempted extortion, you gladly did, and when they were off the streets, the police assured you that it was safe to return to your apartment.

The whole time, John stayed in touch, letting you know that he was here for you. He even came to visit you a few times, taking you out for dinner, but he always stayed a little away from your aunt & uncle’s house.

“They don’t need to see me,” he always said as he waved goodbye and sped away.

You had a feeling that one day, he would need to meet your family, because the way things were going, he was starting to occupy more and more of your heart.

***

Early in the morning, before the sun really rose in the sky, you headed back to your apartment, ready to move back in. You carried your IKEA tote full of your clothes from your car and around the corner to the shop front. 

At the sight before you, you dropped your tote and rushed forward. 

"John!" 

Laying on the sidewalk, groaning softly, John glanced up to see you and immediately tried getting up. 

"Sweetheart…"

Stepping around the broken glass, you reached for him. He looked like he had taken quite a beating. "We need to take you to a hospital."

"No, no, I'm fine, just need to rest," he grumbled, slowly getting up with your help. When you gave him a disbelieving look, he looked at you, his grey eyes hardening with resolve. "I'm alright. I promise."

You finally nodded and helped him into your shop. Sitting him down at your work table in the back, you ran back out to grab your tote, threw it upstairs and grabbed your first aid kit.

John sat quietly, letting you fuss over his wounds. For as bloody as he looked, they were mostly surface scrapes, minor cuts, nothing that would need stitches. He was bruised to hell, and when he took off his shirt to let you tend to his other cuts, your eyes wandered over his chest briefly. 

"Enjoyin' the view, baby?" he teased, winking at you. 

"Why would you call me out like that," you accused, putting some hydrogen peroxide on one of his cuts and grinning ruthlessly as he flinched from the sting. 

"Sorry, just tellin' it like it is."

You laughed softly. A few moments passed before you finally asked, "What happened?" 

John sighed. "You said you were comin' back in the mornin', so I thought I'd surprise you. But when I got here, there were a couple of guys smashing the windows. I tried to stop them, but they got the better of me and took off."

"You should've called the police! What if they killed you?" 

John shrugged. "Cops wouldn't have gotten here in time anyway."

You cupped his cheek. "That wasn't my point. I meant you. You could've been more hurt."

When he met your eyes, saw the care you had for him and the worry that he had caused you, he leaned into your touch, closed his eyes, and sighed. "You're right. I'm sorry."

You leaned in and kissed his forehead. "As long as you understand. Please take care of yourself."

He shrugged. 

"Please. For me?" 

His eyes softened as he took your hand and kissed it tenderly. "For you? Anythin'."

***

You called the police, filed a report, and called the insurance company, and basically spent most of the day taking care of business. John stayed by your side, helping you clean, despite his injuries, and generally being a good boyfriend. 

Boyfriend. You hadn't really thought about it with everything else going on in your life, but John seemed really devoted to you, making time to see you as much as possible. 

Towards the end of the day, you had appointments for your window to be repaired, and John had helped rebuild some of your display cases, even though you took on most of the heavy lifting this time.

You watched him as he sat down, looking exhausted. Coming over to his side, you ran your fingers through his hair.

“Do you want to rest here tonight?”

He looked up at you, surprised. You were surprised yourself, to be honest. You’d never had a man over before.

After a few moments, while John was clearly debating with himself, he eventually shook his head. “As tempted as I am by the offer, I best be goin’ home. Dutch will chew me out if I’m not there in the morning.”

You tilted your head, curious. He hadn’t mentioned this ‘Dutch’ person before. “Is that your stepdad?”

John blinked. “No, not really.” He was silent after that, and you had the distinct feeling that any further questions in that direction would get shut down.

“Oh. Alright then.” You weren’t sure what to say after that. He was clearly hiding his home life. You wondered if it was shame, embarrassment, or something else entirely.

He must have seen the inquisitive look on your face because he took your hand in his. “I’ll tell you everything, some day. Just not right now.” He kissed the back of your hand. “I promise.”

“Awful lot of promises, John. You better keep them.”

He grinned. “I will.”

Standing up, he leaned in and gave you a tender kiss, his lips brushing over yours before he cupped your cheeks and slowly coaxed your lips open, deepening his kiss for a few blissful moments before pulling away. “Good night, sweetheart. Stay safe.”

As he left the shop, he made sure you were right behind him, locking the door before he walked away, waving as he went. You waved back and watched him go, and wondered why your heart felt like it was going with him.

***

“What the hell happened to you?” Dutch nearly yelled, his voice cracking slightly when he took in John’s form as he entered the motorcycle club. He stormed up to him and stared him down, waiting for an answer.

“Glad to see you too, Dutch,” John shot back. He glanced around but didn’t see Arthur.

“Arthur’s off doing a delivery,” Dutch said in response to his unasked question. He stood back and crossed his arms. “Working hard, unlike some people.”

“I was busy.”

“What could be more important than the gang?”

“The ODB are coming north. Ran into them while I was riding, stopped them from smashing some poor girl’s shop.”

Dutch suddenly stood up straighter. “Which town?”

John told him.

“I see.” Dutch paced around for a few moments. John stayed quiet, watching him. Then Dutch turned to John and glared again. “They’re serious business, John. You see them again on your own, you come straight back here. Don’t put yourself in danger just because you see some girl getting her shop trashed.”

John bit back his response; he hadn’t told Dutch about the girl he was seeing, and he wasn’t about to mention her now. He merely nodded.

“Good. Now, get your priorities in order. The gang comes first.” He touched his shoulder. “I just want us to be in a good place, and for that, we need money.” Patting his shoulder as he walked past him, Dutch bid him good night and left the building.

John let out a breath. 

The door opened again. He could hear Arthur telling Dutch the job was done, and that he’d see him tomorrow. Then Arthur came in, took one look at John, and shut the door, walking over to him before speaking in a low voice.

“What happened?”

John told him everything, up to when Dutch had left him alone in the warehouse.

“Well, you’re not wrong.” Arthur scratched his beard. “You really like this girl?”

“Yeah.”

“You serious about her?”

John swallowed. He’d had his share of hookups in the past, but this girl was different. She was something pure, something wonderful. He wanted to be worthy of standing beside her. 

Arthur tilted his head when he didn’t answer. A few moments of silence passed.

“Would you leave the gang for her?” Arthur finally asked.

John’s jaw dropped as he stared at him. But Arthur’s serious stare forced him to think, to really consider his own priorities. He realized with a shock that he would do anything for her. 

“Yeah,” he finally answered. “I would.”

Expecting to be yelled at, John was surprised when Arthur only smiled wryly before looking serious again. “Then get out of this life, John. Get out and don’t look back. If you want to have a real chance with her, you need to get clean.”

Arthur started walking towards his room, leaving John to wonder what would make Arthur, king of loyalists, to give him that kind of advice.

***

“Boys, we have a problem.”

The gang turned to Dutch as he sauntered into the warehouse as they were all tuning their bikes. Standing to face him, the men shared some discreet glances at each other. Of course, they all knew about John and his girl, and had all encouraged him to start cleaning up his life. And without John knowing, the others had secretly agreed to not breathe a word to Dutch.

“John has told me that the O’Driscolls are comin’ north, towards our turf. Now I know I said that we shouldn’t mess with such a large gang. But I have you boys, the fastest, smartest, toughest gang in the city. I have a plan. We’re going to hit them hard, and let them know to stay south of the county line.”

“How’re we goin’ ta do t’at?” Sean asked.

“I hear they’re trying to open up a new chapter of their club nearby. We blow the place, leave a clear message they are not welcome here.”

The men wore varying expressions of wariness. Arthur, keeping his expression neutral, just nodded. “Alright Dutch, let us know the plan.”

***

As Dutch left the building, he realized that Arthur alone had followed him outside, leaving the others to start gearing up for the mission.

“Dutch, remember the last time we did anything like this?”

“We sent a clear message.”

“We lost Davey and Mac!”

“Arthur, now, if I could take their place, I would. But the gang as a whole survived, thanks to their sacrifice. Don’t let their loss be in vain! We must survive. Don’t you have faith in me, son?”

“...Of course I do.”

***

John looked up when Arthur came back in, his back hunched, his face wrinkled in a scowl. He continued to work, making the molotovs with Sean at the workbench.

When Arthur pulled him aside, he followed quietly until they were out of earshot of the others.

“When we go on this mission, you stay in the back.”

“What?” John nearly shouted.

“Shut up,” Arthur growled. “You have someone waiting for you.”

John glared. “I won’t hide like some little kid.”

Arthur glared back. “Just do as I say.”

“Why the hell should I?”

Arthur reached out to grip his shoulder. “Because you’ll make her cry if you get hurt.” He let his words sink in for a moment before continuing. “Just this once, please listen to me. It’d mean a lot to me if you did.”

John looked at Arthur and suddenly felt the age difference between them. When John had joined the gang 5 years ago, he was only 15, a dumb teenager. Arthur was already 25, probably had his own experiences that he never talked about.

Now, looking at Arthur, a 30 year old man trying to run around as if he was still in his early twenties, John felt his tiredness. He felt the world on Arthur’s shoulders. 

So he nodded, if only to help alleviate even a little bit of that weight. “Alright, Arthur.”

“Thank you.”

***

It was easy enough to find out where the O’Driscoll Boys were starting their new chapter. The building was shiny and new, freshly painted and almost ready to open. So the VDL Riders did what they did best: snuck in, did their damage, and slunk off into the night with no one the wiser.

Except tonight their luck had run out.

As John tossed the last molotov into the smoking building, a bullet broke his left rear view mirror. He immediately ducked and started weaving out of the way, looking in the other mirror to see three bikers chasing after him.

“Shit!”

He twisted and turned his way through town, trying to lose his pursuers, but to no avail. He finally reached for the S&W M&P 9mm in his belt and shot at their tires. He didn’t want to use a gun; attracted too much attention, but if he needed to use it, he would.

8 bullets later, the three men had stopped chasing him, their tires flat. He had some bullet grazes because he had to aim and shoot, but it was worth it. He sped up, seeing Lenny and Sean’s bikes go down, only to see Arthur and Charles turn back around and pick them up, pulling them onto their bikes as they quickly raced away, taking a hard left turn.

From the right, John could see five more bikers barrelling down the hill, coming after them.

He didn’t even think.

John threw his empty gun at the biker at the head of the pack, and swerved into the path of the other four, causing them all to scatter around him. Three of them slowed. One didn’t.

It almost was like slow motion, as the last biker careened into John’s rear tire, sending his bike spinning and John rolling and skidding down the road until he finally came to a stop on the sidewalk. He tasted blood, smelled blood, heard blood pumping through his veins and out of his multiple wounds. 

He bitterly thought about his favorite leather jacket and how it was probably torn up beyond repair. He felt like his limbs had become lead weights, too heavy to move, too numb to feel pain. 

The last thing John saw was blue and red flashing lights coming into his vision, the last thing he heard was the very last thing he wanted to hear.

Sirens. 

And somewhere in the background, he could hear the sound of a Harley come and go. Perhaps he imagined it.

Then darkness and blissful silence.

----------------

Chapter 5

[headquartersforlievmuses]

► Stephanie Brown

Stephanie Brown was born the daughter of the Cluemaster, one of Gotham City's third-rate villains. Stephanie's father spent most of her childhood in prison or away from the family. Though he claimed to be "rehabilitated" upon his return to Gotham, Stephanie was furious to discover that he was actually returning to crime without his need to leave clues behind. She decided something needed to be done. Stephanie tailored a costume for herself, and called herself the Spoiler. She knew where her father was hiding out, found out his plans, and left clues so that the police and Batman could stop him. Robin (Tim Drake) tracked her down, and she joined in on the capturing of Cluemaster. She also became attracted to Robin, and it annoyed her that he knew her identity but she did not know his.

During the events of "Knightquest", Cluemaster broke out of prison, along with Czonk and the Electrocutioner. Stephanie learned of the breakout on the news. Her mother, suffering from depression, was struggling with an addiction to painkillers. Steph decided to don her Spoiler outfit and go after her dad. She ran into Robin, and he let her work with him, although they got separated. Spoiler helped Robin out and he gave her a kiss in thanks. Before she could find out if she would see him again, the police arrived and they had to part ways.

Stephanie was kidnapped shortly thereafter by the Gully Carson gang, working with Cluemaster, who was still behind bars. Cluemaster got the idea to use her as insurance, but when the Carson gang withheld his part of the cut, he contacted Batman and Robin and told them that he had been forced to orchestrate their schemes because they were holding his daughter. Batman located the Carson's lair and Robin freed Stephanie. She insisted on getting her costume and going with him to bring down the rest of the gang--against Batman's objection. They were successful, and Stephanie decided to pay her dad a little visit in prison. She also made her attraction to the Boy Wonder very clear.

Spoiler next bumped into Robin when he was teamed up with the Green Arrow (Connor Hawke) to take down a street gang selling guns. She told him that she did not think it was fair that he got to have all the fun, so she was going to become the Spoiler more often. She insisted on coming with the two of them as they took down the gang, flirting with Robin as usual. There was no time for that, however, when they went after the real leaders of the gang the following night, as Robin was enraged over the death of a fellow student, Karl Ranck. Steph went to the funeral, unaware that Robin was there (with his girlfriend) in his civilian identity. That night, Spoiler met up with Robin, telling him that she was going to be Spoiler more often, and would help him go against the boy who shot Ranck. They were in over their heads however, but thankfully Batman turned up, saved their necks and ordered Stephanie to go home.

During a point in which Tim and his then-girlfriend Ariana were unable to see each other, he and Stephanie grew even closer. He soon came to realize that his feelings for Stephanie had grown into something more, and after breaking up with Ariana, began dating Stephanie. Unfortunately, because he needed to maintain the Batman Family secrecy, Robin was unable to reveal his true identity to Spoiler. At first, she seemed more than happy with this arrangement.

Unfortunately for Stephanie, she found out she was pregnant by her ex-boyfriend Dean, who had left Gotham City during the Cataclysm. Tim, in his cover identity Alvin Draper, took Stephanie to Lamaze classes, and the two became even closer. Unfortunately Robin was moved temporarily to Keystone City during the last few months of her pregnancy. He however returned to her when she was giving birth. With Tim's help, she was able to deal with giving her child up for adoption. Although a painful experience, she felt it best to give her daughter a chance at a better life.

Soon afterwards, Tim was sent away to boarding school by his father, and the two were forced into a long distance relationship, made even more complicated by the fact she still did not know his real name. During his time away, Robin became friends with a girl named Star. One night, after seeing her go into an alley with some suspicious-looking people, Robin decided to follow her in costume. He ran into Stephanie, also on patrol, and she followed him as he tracked down Star to a gang meeting that erupted in a violent shootout. He managed to save Star, but Stephanie became convinced that he was cheating on her, and refused to see him for a time.

Shortly after this, Robin disappeared from Gotham for several days (he was off in Tibet on a secret mission), and in his absence Spoiler realized that she still wanted to be with him. Batman approached Spoiler and offered to train her. He also told her Tim's real name, and this betrayal drove a wedge in between him and Robin for awhile, as well as causing trouble for Stephanie and Tim. Spoiler began to train with Batman, and also the Birds of Prey (although they were a bit more reluctant). Stephanie also began a friendship with Batgirl Cassandra Cain who helped train her in-exchange for reading lessons.

Stephanie and Tim, as she now knew him, reconciled. Even after Batman - having decided that she was not really hero material - told her to hang up her costume and the Birds stopped mentoring her, she still patrolled with Robin, as well as went on regular dates. When the US Government came to Stephanie and her mother, and told her that the Cluemaster had died in service of his country in the Suicide Squad, Stephanie was shocked. She cut off ties with Tim and went on a crime-fighting rampage, hunting down the Riddler, her father's former associate, to try to get a better idea of who he had been in life. Eventually, she made peace with his memory, and she and Tim rekindled their relationship (It was later revealed after Stephanie's "death" that Arthur Brown had indeed survived, though it remains unknown if she knows that he is alive, or he her).

When his father discovered his secret identity, Tim was told to hang up his cape, and he did. He was forced to live a normal life for a time. During one day after school, Stephanie attempted to surprise Tim with a visit. Unfortunately as she arrived, she caught a female classmate of Tim's attempting to put the moves on him. Assuming yet again that Tim was being unfaithful, Stephanie broke off ties with Tim and angrily decided to put her attention elsewhere. Creating a homemade Robin costume, Stephanie snuck into the Batcave and demanded that Batman train her as the new Robin. Despite his past belief that Stephanie was an inept crime fighter, Batman accepted her, put her through several months of intensive training and made her a costume with the same modifications as Tim's. As Robin she patrolled with Batman, and for a time seemed like a capable replacement for Tim. She was eventually captured by Mr. Zsasz and she used lethal violence against him. Batman did not like that. After Stephanie disobeyed Batman's orders (in order to save his life), Batman later fired her and told her that she was done being a hero because he could not trust her in the field.

In an effort to prove her worth to Batman, Stephanie stole one of his long-range plans for dealing with the entirety of Gotham's criminal underworld. Since this plan was predicated on the involvement of "Matches Malone" (who she did not know was actually one of Batman's alter egos), it quickly spun out of control. The result was a citywide gang war, in which Stephanie was captured by Black Mask, who tortured her to get information about Batman. Although she escaped and made her way to Leslie Thompkins' clinic, she had been severely injured by the villain, and died in a hospital bed as Batman sat beside her.

About a year later, a Spoiler appeared in Gotham once more. Although her identity had yet to be revealed, it was been shown that she had blonde hair and knew Tim Drake's secret identity, leading to confusion and anger on his part. When Robin confronted this new spoiler, it was revealed Stephanie Brown did not die in the above mentioned adventure, but was severely wounded to the point of near-death. Seeing this as a chance for a new life, Stephanie asked Dr. Tompkins to help her fake her death. The two went to Africa, where Stephanie worked as a missionary during her recovery. After recovering, Stephanie returned to the United States and took up her former identity as Spoiler and has resumed her friendship with Drake after announcing her return to her mother. Stephanie also enrolled in the same school with Drake under an assumed name to prevent those criminals who think her already dead to prevent them from resuming their attacks on her in her real name.

Shortly after, Batman disappeared without a trace and Robin summoned Spoiler to talk about the situation. She helped Robin on his quest to find the truth about Batman and together they stopped the Sprang Bridge Soldiers. However, when they found evidence of Batman's activities, she prevented Robin from seeing them. After tearing the city apart, Robin finally learned that Spoiler had sabotaged his efforts and she revealed that she did so under Batman's request.

Spoiler infiltrated Intergang's headquarters to learn if they knew anything about Batman's location. However, her plan failed when Vigilante attacked the place with the intention of killing Johnny Stitches and Spoiler had to stop him. They took the fight outside and were stopped by Batgirl, who made them both an offer to join a new team she was gathering.

After her attempt to sabotage Robin's mission, Stephanie decided to give up her crime fighting career and live a normal life, until she was forced to stop Nocturna from fleeing a crime scene. Then, she realized that she could not give up. Stephanie started working as Spoiler again and this time she captured Nocturna for good. After this, she talked to Tim, who told her that he was leaving Gotham and she finally admitted that she would not stop working as a crime-fighter.

Stephanie Brown not only worked beside Cassandra Cain, but also succeeded her as Batgirl. One night, after Bruce Wayne's apparent death, they were fighting a group of thugs; when the fighting ended, Cain simply took off her outfit saying that since Batman was gone she saw no reason to continue wearing the costume. Stephanie took it and began to wear it, saving people as Batgirl. However, everyone noticed that something was a little off about Batgirl. Barbara tried to reason with Stephanie to get her stop being a vigilante, as she still saw Stephanie as an impetuous youth and remembered her role in causing a city-wide gang war and her near-death experience at Black Mask's hands. However, a new type of recreational drug is hitting the streets of Gotham known as "Thrill," which they discover was manufactured by the Scarecrow and Black Mask. Both women find themselves needing each other to stop this drug trade. Stephanie eventually confronts and defeats Scarecrow, which impresses Barbara and shows that she now has the maturity for the responsibility and is capable of facing her fear and failures,and allows her to continue on as Batgirl. Barbara later takes a job as an assistant professor at Stephanie's school in order to continue to keep in contact with her. Barbara also designs Stephanie a costume for her to replace Cassandra's tattered costume.

As Stephanie is taking steps to balance her double-life as a college student and a vigilante, Barbara makes a test run on Stephanie's Batsuit, which includes monitoring Stephanie's vital signs along with allowing both women to communicate with each other through their comm-links. After battles some of the criminal elements in the city, Stephanie finds herself against Livewire, who causes a blackout on the city while draining its power. Fortunately, Stephanie's costume is insulated, which she is able to easily overpower the villainess. Stephanie also develops an attraction to Gotham PD's newest young recruit Detective Nick Gage, whom also attracted to her as Batgirl and Commissioner Gordon is trying to set as a blind date for Barbara. The elder Gordon finds their mutual attraction unsettling, even though he is not yet awares of the current Batgirl's identity, but knows that she is still a teenager. Her activities also have led her and Barbara to a blow with the new Dynamic Duo: Batman (Dick Grayson) and Robin (Damian Wayne). However, even though Stephanie and Damian Wayne initially do not get along, there is a hint that he harbors a crush on her. While meeting a classmate, Francisco, Stephanie is left unconscious after being shot while trying to protect him from a bunch of kidnappers. Stephanie survives the gunshot wound. It is later revealed that Francisco's real name is Fernando Garcia, a son of a real estate mongul whose father's unethical business practices led him to become a target. Because of Garcia's abduction, Stephanie and Barbara join forces with Batman and Robin, as some of the Gotham's rogues are involved of the crime, including Roulette.

Batgirl and Supergirl team up for the first time. Batgirl has been captured and Oracle sends Supergirl to save them. Batgirl and Supergirl become fast friends and go to stop the Toyboy. Supergirl takes down Toyboy while Batgirl stops Mr.Freeze. They are captured by a giant Superman/Batman robot being powered by the Kryptonite Man. Batgirl manages to send out a distress call to Oracle before disconnecting. Oracle calls Superman and the new Batman (Dick Grayson). Superman, Batman, and Robin save them and in the end Supergirl is seen scolding Robin for calling Batgirl "Fatgirl".

Shortly after these events, Stephanie was "tested" by Bruce Wayne, who was disguised as the Insider at the time, and the two reconciled their differences in a poignant moment, ending with Bruce giving her his full approval. Shortly after this, Batgirl fought against Shellcase of the Seven Men of Death in order to stop them from getting to Vicki Vale.

Stephanie then (as Batgirl) came into conflict with a mysterious group known only as "the Order of the Scythe," whose ranks included a speedster. They plotted to frame her for murdering a student on the campus of Gotham University, and stole a high tech suit of armor designed by the same student. Her clash with the Order was permeated by team-ups with Damian Wayne and Klarion the Witchboy.

Powers

Acrobatics: She was trained by Batman and through her own experience in acrobatic tactics.

Computer Hacking: She was trained by Oracle to hack computers and computerized security systems.

Escapology: She was trained by Batman and through her own experience in the art of escaping.

Investigation: Stephanie's investigative nature has allowed her to uncover even Batman's secrets.

Martial Arts: Stephanie was trained by Batman and Oracle in hand-to-hand combat. Using her skills she has not only taken on Batman's villains but Superboy too.

Stealth: She was trained by Batman and Robin in stealthy maneuvers. She was able to sneak into the Batcave and Tim Drake's international hideout, and she has sneaked through Gotham City by its sewers.

Tactical Analysis: Seeking Batman's approval and to solidify her role as his sidekick she stole one of his most dangerous ultimatum plans and enacted it. Though she did not create this plan she was instrumental in its execution.

Throwing: She is skilled enough in throwing that she is able to contend with Batgirl (Cassandra Cain), Robin (Tim Drake) and many other sidekicks. She was trained by Batman and Oracle.

Verses

Stephanie Brown v.

tba

Stephanie Brown v. College Years

tba

[titheguerrero]

Mission-Hostile Hospital Management: Quieter, but Still Pernicious After All These Years

Hospitals exist to take care of sick people, with the goal of making them better.  Hospitals employ and work with health care professionals, again who are sworn to put taking care of patients ahead of all other concerns. However, since we founded Health Care Renewal, we have noted striking examples of hospital leaders threatening their hospitals' fundamental mission and/or health care professionals' core values, which we dubbed mission-hostile management.  We also saw mission-hostile management affecting the broader health care industry, particularly pharmaceutical and device companies.  Most recently, the most striking examples of mission-hostile health care related management appearing in the press have come from the Trump administration. While journalists attention is focused on Trump et al, and coverage of other topics fades, bad management of hospitals has received less attention.  However, the problem has not vanished, nor become less important.  So here is my round-up of cases of mission-hostile hospital management from the recent past. Hospitals Offering Better Care to Wealthier Patients Hospitlas generally proclaim that they endeavor to care for all patients, regardless of their personal characteristics, or worthiness for care  Yet we have seen non-profit hospitals offering better care to those who can pay more.   Preferential Treatment for Wealthy Foreign Nationals Seeking Organ Transplants  A story from November, 2017 in ProPublica documented how some US hospitals seem to give preferential treatment to wealthy people coming from overseas specifically for organ transplants.  

Little known to the public, or to sick patients and their families, organs donated domestically are sometimes given to patients flying in from other countries, who often pay a premium. Some hospitals even seek out foreign patients in need of a transplant. A Saudi Arabian company, Ansaq Medical Co., whose stated aim is to 'facilitate the procedures and mechanisms of ‘medical tourism,’' said it signed an agreement with Ochsner Medical Center in New Orleans in 2015.

In particular,

Foreign patients generally are not entitled to the same discounts as those with private insurance or Medicare, the federal insurance program for seniors and the disabled. In 2015, for instance, the average sticker price for a liver transplant at NewYork-Presbyterian was $371,203, but the average payment for patients in Medicare was less than one-third of that, $112,469, according to data from the Centers for Medicare and Medicaid Services, which runs Medicare. In the case of Saudi Arabia, its embassy in Washington often guarantees payment for patients.

This is actually not a new pheonomenon. 

There have been scandals in the past about foreigners and organ transplants. In 2005, a liver transplant center in Los Angeles shut its doors after disclosing that its team had taken a liver that should have gone to a patient at another hospital and instead had implanted it in a Saudi national. The hospital said its staff members falsified documents to cover up the incident. The University of California, Los Angeles, came under fire in 2008 for performing liver transplants on a powerful Japanese gang boss and other men linked to Japanese gangs, and then receiving donations afterward from at least two of the men. The hospital and its surgeon said they do not make moral judgments about patients.

We discussed the case of the Yakuza transplants most recently here. Note that while foreign nationals seem to end up on the same waiting lists that US citizens may be on, the operation of these medical tourism programs implies that they are virtually guaranteed an organ, while US citizens are not. The preferential treatment of the medical tourists does not seem to stem from compassion, but rather from the larger fees they are willing to pay.  Discouraging Organ Transplants for Patients Unable to Afford Expensive Anti-Rejection Drugs and Other After Care A story from December, 2018 from Kaiser Health News published in the New York Times, suggested that most organ transplant centers will not take care of patients until they can show their ability to pay, usually to pay the "sticker prices." One case made public in November, 2018, brought this issue to light

Hedda Martin, 60, of Grand Rapids, was informed that she was not a candidate for a heart transplant because of her finances. It recommended 'a fund-raising effort of $10,000.'

The Times reporters found that this was not unusual.

Two years ago, Mr. Mannion, of Oxford, Conn., learned he needed a double-lung transplant after contracting idiopathic pulmonary fibrosis, a progressive, fatal disease. From the start, hospital officials told him to set aside $30,000 in a separate bank account to cover the costs. Mr. Mannion, 59, who received his new lungs in May 2017, reflected: 'Here you are, you need a heart — that’s a tough road for any person,' he said. 'And then for that person to have to be a fund-raiser?' Ms. Martin’s case incited outrage over a transplant system that links access to a lifesaving treatment to finances. But requiring proof of payment for organ transplants and postoperative care is common, transplant experts say. 'It happens every day,' said Arthur Caplan, a bioethicist at the New York University Langone Medical Center. 'You get what I call a ‘wallet biopsy.’' Virtually all of the nation’s more than 250 transplant centers, which refer patients to a single national registry, require patients to verify how they will cover bills that can total $400,000 for a kidney transplant or $1.3 million for a heart, plus monthly costs that average $2,500 for anti-rejection drugs that must be taken for life, Dr. Caplan said.

Note again that the 'sticker prices' quoted above are much higher than those paid by US government health insurance programs, so this insistence on having enough money or coverage available to pay the sticker prices appears to discriminate against poorer patients who may not have the most deluxe insurance coverage.  Futhermore, it is likely that the actual costs to do the transplant and provide follow-up care are lower than the discounted prices, suggesting that the hospital are putting their revenue ahead of the mission to provide care to patients according to the patients' needs. Expensive Concierge Care at Non-Profit Academic Medical Centers We have previously discussed cases of non-profit academic hospitals offering deluxe services to patients able to pay hefty fees, despite their idealistic mission statements about serving the whole coummunity.  In March, 2018, the Michigan Daily discussed the latest version of such care offered by Michigan Medicine,

Michigan Medicine at the University of Michigan is currently launching Victors Care, a concierge medical care model aiming to deliver tailored health care access to a limited number of patients. These patients will receive specialized, convenient and optimized care with purchase of an annual membership fee to cover primary care services without copays or deductibles.

A number of faculty members took exception to this program in a letter addressed to top Michigan Medicine executives,

grievances listed in the faculty letter include: being unaware in the content of the Victors Care program invitation letter, video and website; discriminating against the underserved; promotional materials suggesting Victors Care patients will 'receive preferential treatment at Michigan Medicine based on ability to pay'; implication that if receiving Victors Care is quality care, receiving care from traditional primary care physicians is not quality; and a concern that Victors Care promotional materials and website recommend care that is not evidence based. 'We ask that the institution stop recruiting our patients to this program and advertising it as providing much better care than all the rest of our primary care clinics, the letter reads. 'Victors Care purports to offer ‘better’ health care to those with enough money to pay a large access fee. The University of Michigan is a public institution and our commitment is to serve the public, not a private few.' The letter also includes direct quotations from Michigan Medicine faculty, one of which notes: 'This reinforces UM as an elitist institution catering to the wealthy.'

Note that Michigan Medicine is a creature of the University of Michigan, a non-profit, state-supported institution, although I cannot determine whether legally Michigan Medicine is a government entity, a non-profit corporation, or something else.  The mission statement on the organizational website is:

We advance health to serve Michigan and the world

It says nothing about providing better service to wealthier patients  Hospital Spending Priorities Put Patients and Health Profesionals Last Increasing Market Dominance Rather than Improving Affordability of Health Care The problem was described in a February, 2018, NBC News article, entitled with the question:"Hospitals made $21B on Wall Street last year, but are patients seeing those profits?"

Some medical economists say that nonprofit hospitals are using lucrative Wall Street portfolios to fatten their bottom lines rather than lower what patients pay for health care. 'The tenor and the responsibility of hospital CEOs has now changed over time,' said Gerard Anderson, a professor of health policy, management and international health at the Johns Hopkins University Bloomberg School of Public Health. 'They focus on the bottom line and … they get performance ratings based on profitability,' he said.

In particular, the article suggested rather than using investment earnings to lower costs to patients,

Hospitals have an incentive to reinvest Wall Street income into growing their networks in order to compete. 'To acquire hospitals you need to have money. If you want to be the biggest hospital system in your community you have to have a lot of money,' Anderson said. But bigger hospital networks don’t necessarily mean better, or cheaper, health care for patients.

Luxury Hotel Like Accoutrements Rather than Direct Patient Care Services Furthermore, while the patients may literally see the results of lavish hospital spending, much of that spending has scant relationship to patient care. An  article in the Spectator, March, 2018, described the lavish ways many big non-profit academic medical centers spend their money.

The Emperor Nero would have felt at home in our hospitals. At St. Vincent’s Hospital in Worcester, Massachusetts, visitors immediately encounter a waterfall, trees, massive rocks, and a pathway for hospital-goers interested in a stroll all located underneath a glass atrium. The massive indoor nature preserve of sorts appears about half the size of a football field. It provides peace and tranquility in a place in need of such comforts.

Also,

IU Health in Indianapolis boasts a monorail-like People Mover that shuttles patients, families, employees, and anybody else who cares to ride between hospitals for free. Cedars-Sinai in Los Angeles offers deluxe maternity suites featuring such perks as access to a 'personal doula,' 'soft colors and recessed lighting to offer a soothing environment for laboring women,' and an 'in-room refrigerator stocked with complimentary chilled juices and bottled water.' Even hospitals labeled 'struggling' struggle to avoid lavish spending. The New York Post reported in 2016 that Brooklyn’s SUNY Downstate Medical Center paid consultants $83,000 for such frills as 'pricey rooms at the Carlyle Hotel on the Upper East Side, a booze-infused ‘team dinner’ at the Docks Oyster Bar in Midtown, and sticker-shock limo bills.'

True to the publication's ideology, the article blamed the spending on the government.  Obviously, though, it was hospital managers who made the spending decisions. Hospital Board Members Meet in Cayman Islands While Budget for Employee Benefits Threatened Hospital managers, even in hospitals meant to serve the poor, like to use the hospital budget for lavish perks.  For example, according to a report from Newsday from March, 2018, Nassau University Medical Center, is a "safety net" hospital which

treats low-income people, receives state aid even though Nassau County ended its subsidy several years ago. However, the county is liable for more than $242 million in hospital long-term debt if NHCC defaults.

Its finances have been challenged:

hospital finances continue to be tight as NuHealth faces tens of millions of dollars in liabilities for accrued employee time, health care and pensions. 'This is a cash cow without the cash,' [Chairman of the Board George] Tsunis said. 'We have a very perilous position here.'

Yet until then, hospital management continued

the practice of sending three hospital officials to the Cayman Islands for a week during Thanksgiving and a week in February to discuss the health care corporation’s offshore self-insurance facility, Tsunis said. Like other hospitals, NuHealth set up a limited liability company called NHCC LTD in the Cayman Islands for tax purposes to self-insure for malpractice and general liability claims. The hospital’s chief executive officer, chief financial officer and chief operating officer are the company board members. To maintain the Cayman location, company officials must meet at least once a year outside the United States. The hospital usually sent all three board members to the Cayman Islands twice a year, Tsunis said.

Now the hospital will send two people once a year to a meeting at an airport hotel ... in Canada. So even when the bottom line was threatened, Caribbean jaunts for board members continued, apparently until they were caught  Eliminating Faculty Retention Bonuses to Pay for Legal Liability Due to Alleged Mismanagement While hospital managers may get lavish perks, when expenses go up they do not shrink from cutting the pay of their employees, even their most well-trained medical professionals.  For example, in January, 2018, McClatchey reported (here via the Charlotte Observer) that the University of New Mexico suspended its retention bonuses for anesthesia faculty because of the settlement it had to pay for a suit brought by 'a former dismissed problem resident.' However,

The woman said in the wrongful termination lawsuit filed in 2011 that she was raped in June 2009 by a post-doctoral fellow and anesthesiologist at the university. Afraid she’d face repercussions, she waited until September to report it to department higher-ups, the lawsuit said. The lawsuit said officials 'discouraged' her from reporting the alleged assault to law enforcement officials to avoid damaging the school’s reputation. The suit accused the university of failing to conduct an investigation into the allegations and of eventually terminating the resident, violating state laws, in 2011. The case was thrown out in 2013 but reinstated on appeal in 2015. UNM’s attorneys agreed to settle for an undisclosed amount in November, according to the NM Political Report.

So the suit alleged considerable bad management, as well as bad behavior by one anesthesia trainee,  but the money to settle it had to come out of senior physicians' compensation, not management's pockets. Hospitals Threatening Health Care Professionals who Call for Patient Care Improvements that Might Cost Money Hospitals depend on health care professionals to actually take care of patients. Health professionals swear to put patients and patient care first, while hospital managers have no such professional values, unless they are also health professionals.  Yet hospital managers have been known to threaten health professionals who dare differ with them on matters pertaining to patient care, particularly professionals who call for changes that would cost more money. In Medscape, from October, 2017, Dr John Mandrola described the plight of employed physicians who dare protest actions by their hospitals' managers:

The need to keep one's job decreases a worker's candor. Seniority offers little protection. Look at what happened to an esteemed surgeon who spoke out on double-booking in the OR. Hospital leaders fired him. The irony of the employed-clinician model is that many embraced it for job security but have ended up feeling more vulnerable than before. And feeling vulnerable means making less noise. The danger is obvious: Clinicians become clock-punching workers rather than leaders; bad policies persist; outlier doctors continue working unabated, and low morale becomes the new normal.

In November, 2018, the New York Daily News reported a graphic example of a hospital CEO threatening to fire a nurse who complained about staffing levels:

Brooklyn Hospital CEO Gary Terrinoni, along with several other executives and department heads, were updating the nursing staff about the hospital's future a month ago when Terrinoni launched into what sources described as a nasty screed. 'Are you all tired?' Terrinoni mockingly asked the nurses, according to a letter distributed by the New York State Nurses Association. When no one offered a response, Terrinoni singled out one veteran RN, who at first politely tried to deflect his question. After more prodding, she answered that the biggest problem they faced was understaffed shifts. 'That's what I'm talking about! Look at your attitude!' Terrinoni allegedly erupted. 'Then you don't need to be here. Go find another job! When the 13-year Brooklyn Hospital vet noted she had more than a decade on the job, Terrinoni only grew more agitated, the union said. 'I don't care if you've been here ten years or 30 years,' he allegedly said. 'You can leave if you don't like it here.'

Summary Recently we have seen many examples of mission-hostile management by political appointees to health care related leadership positions in the Trump administration. However, while the political conflagration in Washington, DC has pulled journalists away from the health care beat, we continue to see examples of bad, and particularly mission-hostile management of non-profit hospitals that threatens care of vulnerable patients. Such management tends to prioritize hospital revenues, and the financial self-interest of management over patient care. Some recent examples of related posts included one from 2017 in which we discussed a New York hospital CEO who seemed to put revenue generation in support of his own very generous paycheck ahead of quality of care and patient safety (look here).  Also, the revered Mayo Clinic seemed to let patients with more remunerative commercial insurance coverage get attention before poor patients who have only government insurance, despite its stated mission "providing the best care to every patient" (look here). Mission-hostile management in hospitals, pharmaceutical companies, or government agencies seems to have been enabled by several factors.  Managerialism is the belief that trained managers are better leaders of health care, and every other sort of organization, than are than people familiar with the particulars of the organizations' work.  Managerialism has become an ascendant value in health care over the last 30 years.  The majority of hospital CEOs are now management trained, but lacking in experience and training inmedicine, direct health care, biomedical science, or public health.  And managerialism is now ascendant in the US government.  Our president, and many of his top-level appointees, are former business managers without political experience or government experience.   The rise of the manager-leader occurred at a time when management schools increasingly preach the dogma that maximizing shareholder value, usually equivalent to maximizing short-term revenue, should be the first, if not the only goal of all managers (look here).  A recent article on the miseducation of Sheryl Sandberg, Facebook's chief operating officer, asserted that

Harvard Business School, like much of the M.B.A. universe in which Sandberg was reared, has always cared less about moral leadership than career advancement and financial performance.

The article recounted a recollection of a case discussion which included Jeff Skilling, the now disgraced former CEO of Enron

in which the students were debating what the C.E.O. should do if he discovered that his company was producing a product that could be potentially fatal to consumers. 'I’d keep making and selling the product,' he recalled Skilling saying. 'My job as a businessman is to be a profit center and to maximize return to the shareholders. It’s the government’s job to step in if a product is dangerous.' Several students nodded in agreement, recalled LeBoutillier. 'Neither Jeff nor the others seemed to care about the potential effects of their cavalier attitude. . . . At H.B.S. . . . you were then, and still are, considered soft or a wuss if you dwell on morality or scruples.'

Boards of directors or trustees, which are now often dominated by managers, are inclined to financially reward organizational managers for increasing revenue.  Hospital boards rarely are so interested in improving patient care or public health.  So the result is mission-hostile management, which is very bad for patients' and the public's health As I have said before,  true health care reform would put in place leadership that understands the health care context, upholds health care professionals' values, and puts patients' and the public's health ahead of extraneous, particularly short-term financial concerns. We need health care governance that holds health care leaders accountable, and ensures their transparency, integrity and honesty. But this sort of reform would challenge the interests of managers who are getting very rich off the current system.  And these days, such reform would also challenge the interests of many people in top positions in the US government.  So I am afraid the US may end up going far down this final common pathway before enough people manifest enough strength to make real changes. Article source:Health Care Renewal