The Magic Bullet

by Harry Stein

  He paused, nodding in the direction of Kratsas. “Some of you are familiar with Dr. Kratsas. He will give you a brief overview of the trials currently in progress. Everything you will hear is privileged information. Divulging any of it without authorization shall be regarded as grounds for immediate dismissal.”

  The threat was of course unnecessary, a pointless insult to the professionalism of the highly skilled young doctors present; yet Logan felt certain the man’s loutishness was not even intentional. His style reflected his essence.

  “Dr. Kratsas,” he said, surrendering the floor.

  Kratsas’s sudden smile was ingratiating, a conscious effect to dispel the chill that had settled over the room.

  “First,” he began, “I want to extend a personal welcome. I’m sure I speak for the entire senior staff in saying that we are always available as colleagues and friends.”

  Logan glanced at Larsen, who stared straight ahead, showing nothing. Sure, he thought, that guy’ll be my friend, all right—the day jelly beans cure cancer.

  “Now, then,” continued Kratsas, “some of you may know I’m an avid fan of the film director Alfred Hitchcock. I bring this up for a reason—because I believe Hitchcock would have made a magnificent cancer researcher. Why? He was canny, he was precise, he was resourceful and—a quality we must all nurture—he understood desperation and fear. Not only understood them, but knew how to work with them.” As he scanned the table meaningfully, there was not a doubt in Logan’s mind that he’d delivered these lines a dozen times before.

  Kratsas smiled again and patted a notebook on the table before him. “Now, then, as I’m sure you know, our courses of experimental treatment fall into three categories. A Phase One trial is by definition a new and highly innovative form of treatment. Subjects’ malignancies are highly advanced and we obviously recognize going in that the chances of meaningful success are remote.” He paused and took a sip from the glass of water before him. “Indeed, in such trials our very definition of success changes. Usually, what most interests us is measuring toxicity—gauging the maximum dose of this new drug the human body will tolerate. Its impact on the malignancy is often of only secondary concern.”

  He held up a notebook. “As you read through your material, you will note that we are currently conducting only two Phase One protocols here at the ACF. Which is to say, no one will be dealing with more than two or three patients who are participating in such research. Still, given such patients’ highly advanced levels of disease, they are likely to require a considerable amount of attention.” He paused, glancing at Larsen. “Obviously, we do not lie to patients. Ethics is a serious concern here at the ACF. But neither, when a patient’s situation is desperate, is it necessarily always the best policy to volunteer every scintilla of truth. Think of Hitchcock: patients who are led to feel there is no hope have precious little incentive to remain with the program.”

  He cleared his throat and took another sip of water. “Now, then, only a small number of the drugs that go through a Phase One test, perhaps ten percent, move on to a Phase Two trial—a more comprehensive test aimed at determining a compound’s effectiveness against malignancy in a specific organ. In turn, no more than about ten percent of those drugs—one percent of the total—are sufficiently promising to warrant Phase Three trials, which test the new treatment against the best existing therapy. When a patient signs on, he does not know whether he will receive an established or an experimental treatment. I can tell you, however, that it is our policy to never give any cancer patient a placebo. That would constitute deception of the cruelest kind.”

  He paused. “We all know that lay people—and that includes our patients and their families—tend to have a wildly optimistic view of what can be achieved. They don’t come here merely because everything’s free; they’re hoping to be cured. We, however, are scientists. Our hopes may be great, but our expectations are realistic: a successful Phase Three trial is defined as one that produces a response rate only slightly better than the standard treatment, or one that meaningfully improves quality of life.

  “Now, then, that doesn’t mean breakthroughs don’t occur. I presume you are all familiar with the drug cisplatin …?” He paused, surveying the serious faces around the table, seeming to wait for a response.

  “Active against testicular cancer,” spoke up Reston.

  “Yes, but that’s hardly the full story. I suppose you’re all too young to remember a movie called Brian’s Song, but it was a great success when I was your age. It was based on the story of a football player who died of testicular cancer as a very young man.”

  “Brian Piccolo,” said Logan softly, from his seat beside Larsen’s secretary.

  Larsen looked at him sharply. “This is not a free-for-all, Doctor. Or a television quiz program.”

  “Now, then,” continued Kratsas, “in those years, the early seventies, the cure rate for metastatic testicular cancer was on the order of thirty percent. Today it is what?”

  Silence.

  It was Sabrina Como, the Italian, who finally spoke up. “I believe it is seventy-five percent,” she said.

  Kratsas nodded. “Actually, with cisplatin, it’s closer to eighty.”

  He picked up one of the spiral notebooks and let it fall to the table with a bang. Several of the young associates started. “Heavy, huh? It contains, among other things, a rundown of all current protocols—thirty-six in all. You shall be expected to have familiarized yourself with them all by Wednesday. Because that is the day you assume charge of your full complement of patients.”

  Even during their long years as interns and residents, none of the younger doctors had ever heard anyone suggest such a workload: in two days each would be handed over one hundred patients desperately ill with cancer—patients whose course of treatment, whose very medicines, at this moment they knew nothing about.

  “For your benefit,” picked up Kratsas, “the senior associates have dictated a full history of each case. Later this afternoon, you will learn from the communications people how to do proper ACF evaluation dictation. Such an evaluation will be expected whenever a patient is discharged, or otherwise passes from the program.” Logan could scarcely suppress a smile; passes from the program—the euphemism was a new one to him, even after Claremont. “These evaluations must be letter perfect,” Kratsas droned on. “Master the form! By Wednesday, you will also be expected to have full command of the computer system.”

  Logan paused in his note taking to chance a quick smile in Reston’s direction: this was so overwhelming, there seemed no other possible response.

  “As for hospital duty, at least one of you must be on the patient floor at all times, day and night. It is expected that you will divide up the night coverage equitably among yourselves. If you want some sleep, I suggest you find an empty patient room.”

  He turned back to Larsen. “Now, then, I think that about covers it.”

  Larsen nodded crisply. “One thing I wish to emphasize. Every doctor here of course has a responsibility to his patients. But his primary responsibility—his overriding priority—must always be this institution. Is that understood?”

  Larsen’s fearsome gaze swept the table. Then, tentatively, a hand rose into the air. Barbara Lukas.

  “What is it?” snapped Larsen.

  Clearly, this was not easy, and her voice quavered slightly. “It’s just a small thing. In referring to a doctor, you keep saying his responsibility and his priority. I was just wondering, since there are also quite a few of us women here, if you might be a bit more inclusive.”

  There was total, stupefied silence. Larsen’s face visibly reddened, and Logan thought he could see a vein in his temple start to twitch. In an effort to distance themselves from this kamikaze mission, most of the other women present stared down at the table.

  But, incredibly, Larsen seemed to keep his cool. “What,” he said, tight-lipped, “would you suggest?”

  Lukas seemed to gain in confidence. “Perhaps he
or she, something like that. Just a little more sensitivity.”

  He drummed his fingers on the table, appearing to consider this. “No, Dr. Lukas, NO!” With a sudden crack, his hand came crashing down on the polished wood. “Maybe young people get away with bullying their elders at Duke these days, but it will not happen here!”

  He paused, then resumed his former tone. “After your patient-care year, you will in turn pass on your patient roster to next year’s incoming fellows. And, assuming we are pleased with you”—here, stopping for a millisecond, he shot Lukas daggers—“you will then be attached to a laboratory in which to pursue your specific area of interest.”

  Abruptly, a bell sounded in the corridor outside the conference room, followed immediately by a commanding female voice on the loudspeaker. “Code blue. Twelfth floor. Room thirty-eight.”

  “Never mind that,” snapped Larsen. “Let’s continue.”

  “Dr. Larsen …” The words, the first his secretary had spoken, were barely above a whisper, but Logan picked them up.

  Larsen leaned toward her.

  “That’s Mrs. Conrad.”

  He hesitated an instant, frowned, then rose to his feet. “Dr. Kratsas,” he said, moving briskly toward the door, “take over, will you?”

  “Who’s Mrs. Conrad?” ventured Logan, several hours later.

  Rich Levitt, the senior associate whose patient roster Dan was about to inherit, stared at him across his tidy desk. “She’s an ovarian patient.”

  “That’s it?”

  “The wife of Senator Conrad …?” He raised an eyebrow, waiting for it to sink in. “… North Carolina? The Senate Appropriations Committee?”

  “Ahhhh.”

  “Why?”

  Logan recounted the episode from the meeting.

  “Don’t tell me that’s your first visit to the real world. How do you think this place gets most of its funding?”

  Dan nodded. Of course, it made perfect sense. Every medical facility he knew of, no matter how supposedly democratic, provided treatment a bit more equal for the select few. What took him aback was the other’s straightforwardness. Entry into an ACF program was widely believed to be solely on the basis of suitability for a treatment protocol.

  “I guess I kind of thought the ACF was above that kind of politics,” Dan admitted.

  “Look, it’s not like she wasn’t a legitimate candidate. Let’s say she just got more consideration than other legitimate candidates. The important thing for you to know is that it’s not your problem: Mrs. Conrad’s not on our patient roster.” He smiled and shook his head. “Above politics? Some of these guys spend half their lives up on the Hill trying to shake money loose for their pet projects.”

  “Any big shots on our patient roster?”

  Levitt held out a hand and ticked them off. “Two congressmen. The administrative aide for the number-two man on the Senate Armed Services Committee. One Labor Department spouse, one Defense Department staff spouse.” He tapped his head and smiled. “It’s all right here in case of emergency. But none of them are as important as Mrs. Conrad. You saw it, she makes even Larsen jump.”

  Logan didn’t know quite what to make of Levitt. Rarely had he encountered so improbable a mix of selflessness and utter cynicism; then again, increasingly that seemed simply a reflection of the ACF itself.

  “So Mrs. Conrad’s the top VIP here now?”

  “Absolutely.” He paused. “As far as I know.”

  “What does that mean?”

  Levitt exhaled deeply. Though he had no objection to answering the newcomer’s wide-eyed questions, his real concern was handing over his patients so he could move on to better things.

  “Sometimes—rarely, but sometimes—there are people who get seen only by the top guys. They might even check in under phony names.”

  “You’re kidding me.”

  “Not that the rest of us don’t usually know there’s something going on.”

  He glanced at his watch and sighed. “Look,” he said, rising to his feet, “I think it’s about time you met some of my—soon to be your—patients.”

  “Well,” said Logan, following suit, “at least this part will be familiar.”

  “Maybe. Although the patients you’ll be dealing with here may not be what you’re used to.”

  Logan was baffled. “Actually, I had a lot of experience at Claremont dealing with terminal cancer pat—”

  “No,” interrupted Levitt. “There are big differences. First, you were treating those patients individually, improvising as circumstances changed, right?”

  “Of course.”

  “Well—I can’t emphasize this strongly enough, Logan—here you have zero treatment options. None. Your job is to enforce the protocol. Period. Which means that sometimes you’ll actually have to go against your better judgment.”

  Logan was silent as this hit home.

  “It can be a huge psychological adjustment.”

  “What happens if a patient starts questioning the terms of the protocol?”

  “Happens all the time. Your problem is just making sure the patient doesn’t leave the protocol. Because then you’re messing with the entire study: there’ll be no way to know if that patient’s responding to therapy or for how long. When patients start dropping out, people start saying the work was sloppy or the treatment was too toxic.” He paused. “Trust me, if a protocol patient drops out on your watch, the senior guy running that study will have your ass. Some of those guys are killers.”

  “I get that impression.”

  Levitt nodded. “Yeah, I heard about that thing at Shein’s the other day. Welcome to the ACF.”

  In fact, Logan had been thinking of Lukas’s gruesome face-off with Larsen, but no matter. “Some of these guys …” he ventured, “… you get the impression they’re liable to blow any minute.”

  “You learn to take it in stride.”

  “I mean, getting on the junior people is one thing. But they hate each other.”

  “Absolutely.” He smiled. “When I first got here, another guy showed me a chart he’d done of the relationships between the big hitters. Each senior staffer was represented by a circle with lines representing normal interactions in black ink and lines representing hate interactions in red.” He paused for effect. “I’m telling you, the thing looked like a wiring diagram for the phone company.”

  “But it doesn’t make sense. Even at Claremont, there were—”

  “You have any idea how fierce the competition is for funding? It’s a zero-sum game: every time someone wins, someone else loses.”

  Levitt explained that in the case of Shein and Stillman, for instance, the animosity dated to Shein’s long-ago support of a young ACF researcher who had come up with a novel approach to breast cancer: using a syringe to shoot monoclonal antibodies directly into the bloodstream in a kind of biochemical search-and-destroy mission. Stillman vigorously resisted (and won) on the ground that the data on which the conclusions were based were incomplete—though soon afterward he wrote a protocol himself based on the same idea. Quite simply, Stillman regarded breast cancer as his turf; in mucking around with his cancer Shein had earned an enemy for life. More than one enemy, in fact—for Stillman numbered among his allies a half dozen key figures at the ACF.

  “That’s par for the course. None of these guys can stand each other. Larsen—he probably hates Shein even more.”

  “What’s the story there?”

  He shrugged. “Nothing in particular. Just oil and water. To Larsen, Shein represents everything most loathsome not only about science but life. And vice versa.”

  Logan had already sensed as much. “Do Larsen and Stillman get along?”

  “Get along?” he asked, surprised. “You mean, like friends?” He stopped, began again. “Look, I’ll try and simplify things. The way it works is all the top guys have their own little fiefdoms and their own loyalists. The ultimate aim of each is to defeat all the others. But sometimes, for strategic reasons, they�
��ll forge alliances against a common enemy. Get it?”

  “You make it sound medieval.”

  He smiled. “Well, I’ve never actually heard of anyone using maces and boiling oil.”

  Logan nodded soberly. “So what you’re saying is I’d better stay on everyone’s good side. Consider me warned.”

  “And you’d better also be ready for some of what you’re going to be running into from patients—”

  “That I’m familiar with. I’ve dealt with some pretty bad attitudes.”

  “You think so? Because the ones at the ACF are a whole different breed. A lot of them have moved heaven and earth to get here; they’ve told their local doctors, ‘I no longer want this shit you’re giving me,’ and traveled thousands of miles to undergo a course of treatment that might end up doing nothing. The ACF is a roll of the dice and not many shrinking violets take it.”

  “They’re fighters. Nothing wrong with that.”

  Levitt nodded. “The truth is, if you’ve got cancer, there’s no better place to be treated. It’s just that full cooperation is their part of the bargain—and sometimes they make you pay for it.” He started from the room, Logan trailing after. “What I’m trying to tell you is that conflicts are inevitable because we and the patients basically have different agendas. We’re interested in finding ways to cure cancer. They want their cancer cured. No one ever uses the term guinea pig, but some patients eventually get the idea that’s what they’ve signed up for.”

  “I see,” said Logan soberly.

  “No, but you’re about to.” Rounding a corner, they came to a bank of gleaming elevators. “Let’s go see Rochelle Boudin.”