by Robin Cook
Thomas still did not say anything, although he nodded at the truth of the comment. As he pulled on his own shirt, he thought of Norman Ballantine, that white-haired, friendly old doc whom everyone loved and applauded. The fact of the matter was that Ballantine probably shouldn’t still be operating, although no one had the nerve to tell him. It was common knowledge in the department that one of the chief thoracic resident’s jobs was to assign himself to all of Ballantine’s cases so that he could help the chief when he blundered. So much for academic medicine, thought Thomas. Ballantine, thanks to the residents, got reasonable results, and his patients and their families worshipped him despite what went on when the patient was anesthetized.
Thomas had to agree with Larry’s comment. He also thought that it would be infinitely more appropriate if he, Dr. Thomas Kingsley, was chief. After all, he did most of the surgery, for God’s sake. It was he, more than any other single person, who had made Boston Memorial the place to have any cardiac surgery. Even Time magazine had said as much.
Yet Thomas did not know if he wanted to be chief any longer. At one time it was all he could think about. It had been one of his driving forces, pushing him on to greater efforts and more personal sacrifice. It had seemed part of a natural progression, and colleagues had started talking about it while he was still a fellow. But that was quite a few years ago, before all the administrative bullshit had reared its ugly head and showed just how much it could interfere in his practice.
Thomas stopped dressing and stared ahead into the distance. He felt an emptiness inside of him. Comprehending that one of his long sought-after goals was potentially no longer attractive was depressing, especially when the goal was finally within his grasp. Maybe there was no place to go… maybe he’d reached his apogee. God, what an awful thought!
“I’m awfully sorry to hear about your wife,” said Larry as he sat down to put on his shoes. “It really is a shame.”
“What do you mean?” asked Thomas, pronouncing each word with deliberate precision. He took immediate offense that a subordinate like Larry would presume to be so familiar.
Larry, oblivious to Thomas’s response, bent to tie his shoes. “I mean about her diabetes and her eye problem. I heard she’s got to have a vitrectomy. That’s terrible.”
“The surgery is not definite,” snapped Thomas.
Hearing the anger in Thomas’s voice, Larry looked up. “I didn’t mean it was necessarily definite,” he managed. “I’m sorry I brought it up. It must be difficult for you. I just hoped that she was okay.”
“My wife is perfectly fine,” said Thomas angrily. “Furthermore, I don’t think that her health is any of your business.”
“I’m sorry.”
There was an uncomfortable silence as Larry quickly finished with his shoes. Thomas tied his tie and splashed on Yves St. Laurent cologne with rapid, irritated motions.
“Where did you hear this rumor?” asked Thomas.
“From a pathology resident,” said Larry. “Robert Seibert.”
Larry closed his locker and told Thomas he’d be in the recovery room if he was needed.
Thomas ran a comb through his hair, trying to calm down. It just wasn’t his day. Everyone seemed intent on upsetting him. The idea that his wife’s ill health was a topic of idle conversation among the resident staff seemed inexplicably galling. It was also humiliating.
Placing the comb back in his locker, Thomas noticed a small plastic container. Feeling a rising inner tension and the stirrings of a headache, he flipped open the lid of the bottle. Snapping one of the scored yellow tablets in two, he popped the half into his mouth. Hesitant, he then popped in the other half as well. After all, he deserved it.
The tablets tasted bitter, and he needed a drink from the fountain to wash them down. But almost immediately he felt relief from his growing anxiety.
The Friday afternoon cardiac surgery conference was held in the Turner surgical teaching room diagonally across the hall from the surgical intensive care unit. It had been donated by the wife of a Mr. J. P. Turner, who’d died in the late nineteen-thirties, and the decor had an Art Deco flavor. The room provided seating for sixty, half the medical school class size in 1939. In the front there was a raised podium, a dusty blackboard, an overhead rack of ancient anatomy charts, and a standing skeleton.
It had been at Dr. Norman Ballantine’s insistence that the Friday meeting be held in the Turner teaching room because it was close to the ward, and, as Dr. Ballantine put it, “It is the patients that it’s all about.” But the small group of a dozen or so looked lost among the sea of empty seats and distinctly uncomfortable behind the spartanly designed desks.
“I think we should get the meeting under way,” called Dr. Ballantine over the hum of conversation. The people took their seats. Present at the meeting were six of the eight cardiac surgeons on staff, including Ballantine, Sherman, and Kingsley, as well as various other doctors and administrators, and a relatively new addition, Rodney Stoddard, philosopher.
Thomas watched Rodney Stoddard sit down. He looked like he was in his late twenties despite the fact that he was mostly bald and his remaining hair was such a light color that it was difficult to see it. He wore thin wire-rimmed glasses and an expression of constant self-satisfaction. To Thomas it seemed as if the man were saying, “Ask me about your problem because I know the answer.”
Stoddard had been hired at the university’s insistence. Until recently doctors were committed to trying to save all their patients. But now, with the advent of such expensive and complicated procedures as open-heart surgery, transplants, and artificial organs, hospitals had to pick and choose to whom to give these life-saving operations. For the time being, these techniques were limited by extraordinary costs and by the space available in the sophisticated units needed for aftercare. In general the teaching staff tended to favor patients with multisystemic disease, who did not always do well, while private physicians such as Thomas leaned toward otherwise healthy, productive members of society.
Looking at Rodney, Thomas allowed an ironic smile to steal across his face. He wondered just how self-confident Rodney would feel if he held a man’s heart in his hand. That was a time for decision, not discussion. As far as Thomas was concerned, Rodney’s presence at the meeting was one more indication of the bureaucratic soup in which medicine was drowning.
“Before we start,” said Dr. Ballantine, extending his arms with hands spread out as if to quiet a crowd, “I want to be sure that everyone has seen the article in this week’s Time magazine rating the Boston Memorial as the center for cardiac bypass surgery. I think we deserve it, and I want to thank each and every one of you for helping us reach this position.” Ballantine clapped, followed by George and a smattering of others.
Thomas, who’d sat near the door in case he was called to the recovery room, glowered. Ballantine and the other doctors were taking credit for something that was due largely to Thomas and to a lesser extent to two other private surgeons who happened to be absent. When he had gone into surgery, Thomas thought he would avoid the bullshit that surrounded most other professions. It was going to be him and the patient against disease! But as Thomas looked around the room, he realized that almost everyone at the meeting could interfere with his work because of one aggravating problem-the limited number of cardiac surgical beds and associated OR time. The Memorial had become so famous that it seemed as if everyone wanted to have their bypass there. People literally had to wait in line. Especially in Thomas’s practice. He had been limited to nineteen OR slots a week and he had a backlog of more than a month.
“While George passes out the schedule for next week,” said Dr. Ballantine, extending a stack of stapled papers to George, “I’d like to recap this week.”
He droned on as Thomas turned his attention to the schedule. His own patients were scheduled by his nurse, who collated the necessary information and got it over to Ballantine’s secretary, who typed it up. It contained a capsule medical history of each pa
tient, a listing of significant diagnostic data, and an explanation of the need for surgery. The idea was that everyone at the conference would go over each patient and make sure that the operation was needed or advisable. But in reality it rarely happened, except if you missed the meeting. Once when Thomas had been absent, the anesthesiology department had canceled several of his cases, resulting in a row no one was likely to forget. Thomas continued reviewing the sheets until Ballantine mentioned something about deaths. Thomas looked up.
“Unfortunately there were two surgical deaths this week,” said Dr. Ballantine. “The first was a case on the teaching service, Albert Bigelow, an eighty-two-year-old gentleman who could not be weaned from the pump after a double-valve replacement. He’d been scheduled as an emergency. Is there word on the autopsy yet, George?”
“Not yet,” said George. “I must point out that Mr. Bigelow was a very sick cookie. His alcoholism had seriously affected his liver. We knew we were taking a risk going to surgery. You win some and you lose some.”
There was a silence. Thomas commented sarcastically to himself that Mr. Bigelow’s untimely demise had prompted a stimulating discussion. The galling part was that it was this kind of patient that was keeping Thomas’s patients waiting.
Ballantine glanced around, and when no one spoke he continued: “The second death was a patient of mine, Mr. Wilkinson. He died last night. He was autopsied this morning.”
Thomas saw Ballantine look over at George, who shook his head almost imperceptibly.
Ballantine cleared his throat and said that both cases would be discussed at the next death conference.
Thomas wondered at the silent communication. It brought to mind the weird comment George had made up in the lounge. Thomas shook his head.
Something was going on between Ballantine and George, and Thomas felt a twinge of uneasiness. Ballantine had a unique position in the medical center. As chief of cardiac surgery, he held an endowed chair with the university and was paid a salary. But Ballantine also had a private practice. Ballantine was a holdover from the past, bridging as he did the full-time salaried men like George and the private staff, like Thomas. Of late Thomas had begun to think that Ballantine, whose skills were obviously on the decline, was beginning to favor the prestige of being a professor over the rewards of private practice. If that were true, it could cause trouble by upsetting the balance between the full-time staff and the private physicians, which in the past had always tilted toward the latter.
“Now, if everyone will turn to the last page of the handout,” said Dr. Ballantine, “I’d like to point out that there has been a major scheduling change.”
There was a simultaneous rustle as everyone flipped the pages. Thomas did the same, placing the papers on the arm of his chair. He did not like the sound of a major scheduling change.
The last page was divided vertically into four columns, representing the four rooms used for open-heart surgery. Horizontally the page was divided into the five days of the work week. Within each box were the names of the surgeons scheduled for that day. OR No. 18 was Thomas’s room. As the fastest and busiest surgeon, he was assigned four cases on each day except Friday when he had three because of the conference. The first thing Thomas checked when he looked at the page was OR No. 18. His eyes widened in disbelief. The schedule suggested that he’d been cut to three cases a day, Monday through Thursday. He’d lost four slots!
“The university has authorized us to hire another full-time attending for the teaching service,” Dr. Ballantine was saying proudly, “and we have started a search for a pediatric cardiac surgeon. This, of course, is a major advance for the department. In preparation for this new situation, we are expanding the teaching service by an additional four cases per week.”
“Dr. Ballantine,” began Thomas, carefully controlling himself. “It appears from the schedule that all four additional teaching slots are being taken from my allotted time. Am I to assume that is just for next week?”
“No,” said Dr. Ballantine. “The schedule you see will hold until further notice.”
Thomas breathed out slowly before speaking. “I must object. I hardly think it’s fair that I should be the sole person to give up OR time.”
“The fact of the matter is that you have been controlling about forty percent of the OR time,” said George. “And this is a teaching hospital.”
“I participate in teaching,” snapped Thomas.
“We understand that,” said Ballantine. “You’re not to take this personally. It is plainly a matter of more equitable distribution of OR time.”
“I’m already over a month behind on my patient schedule,” said Thomas. “There isn’t that kind of demand for teaching cases. There aren’t enough patients to fill the current teaching slots.”
“Don’t worry,” said George. “We’ll find the cases.”
Thomas knew what the real issue was. George, and most of the others, were jealous of the number of cases Thomas did and how much money Thomas earned. He felt like getting up and punching George right in the face. Glancing around the room, Thomas noticed that the rest of the doctors were suddenly busy with their notes, papers, or other belongings. He could not count on any of the people present to back him up.
“What we all have to understand,” said Dr. Ballantine, “is that we are all part of the university system. And teaching is a major goal. If you feel pressure from some of your private patients, you could take them to other institutions.”
Thomas’s anger and frustration made it hard for him to think clearly. He knew, in fact everybody knew, that he could not just pick up and go to another hospital. Cardiac surgery required a trained and experienced team. Thomas had helped build the system at the Memorial, and he depended on the structure.
Priscilla Grenier spoke up, saying they might be able to add an additional OR room if they got an appropriation for another heart-lung machine and perfusionist to run it.
“That’s a thought,” responded Dr. Ballantine. “Thomas, perhaps you’d be willing to chair an ad hoc committee to look into the advisability of such expansion.”
Thomas thanked Dr. Ballantine, struggling to keep his sarcasm to a minimum. He said that with his current workload it was not possible to accept Ballantine’s offer immediately, but that he’d think about it. At the moment he had to worry about putting off patients who might die before they had OR time. Patients with a ninety-nine-percent chance of living long, productive lives if they did not find their OR time sacrificed to some sclerotic wino whom the teaching service wished to experiment on!
On that note the meeting was adjourned.
Struggling to keep his temper under control, Thomas went up to Ballantine. George had, of course, beat Thomas to the podium, but Thomas interrupted.
“Could I speak to you for a moment?” asked Thomas.
“Of course,” said Dr. Ballantine.
“Alone,” said Thomas succinctly.
“I was heading over to the ICU anyway,” said George amiably. “I’ll be in my office if you need me.” George gave Thomas a pat on the shoulder before leaving.
To Thomas, Ballantine was the Hollywood image of the physician, with his soft white hair combed back from a deeply lined but tanned and handsome face. The only feature that somewhat marred the overall effect were the ears. By anyone’s standards they were large. Right now Thomas felt like grabbing and shaking them.
“Now, Thomas,” said Dr. Ballantine quickly. “I don’t want you getting paranoid about all this. You have to understand that the university has been putting pressure on me to delegate more OR time to teaching, especially with the Time article. That kind of publicity is doing wonders for the endowment program. And as George pointed out, you have been controlling a disproportionate amount of hours. I’m sorry you had to learn about it like this, but…”
“But what?” asked Thomas.
“You are in private practice,” said Dr. Ballantine. “Now if you’d agree to come full-time, I can guarantee a full prof
essorship and…”
“My title as Assistant Clinical Professor is fine with me,” said Thomas. Suddenly he understood. The new schedule was another attempt at pressuring him into giving up his private practice.
“Thomas, you do know that the chief of cardiac surgery who follows me will have to be full-time.”
“So I’m to look at this cut in my OR time as a fait accompli,” said Thomas, ignoring Ballantine’s implications.
“I’m afraid so, Thomas. Unless we get another OR, but, as you know, that takes time.”
Abruptly Thomas turned to go.
“You’ll think about coming aboard full-time, won’t you?” called Dr. Ballantine.
“I’ll consider it,” said Thomas, knowing he was lying.
Thomas left the teaching room and started down the stairs. At the first landing he stopped. Gripping the handrail and closing his eyes as tightly as possible, he let his body shake with sheer anger. It was only for a moment. Then he straightened up. He was back in control. After all, he was a rational individual, and he’d been up against bureaucratic nonsense long enough to deal with it. He’d suspected that Ballantine and George were up to something. Now he knew. But Thomas wondered if that were all. Maybe it was something more than the OR schedule change because he still had the anxious feeling something else was going on that he should know about.
Three
Cassi always experienced a degree of apprehension when she dipped the test tape into her urine. There was always the chance that the color of the tape would change and indicate she was losing sugar. Not that a little sugar in her urine was all that big a deal, especially if it occurred only once in a while. It was more an emotional thing; if she was spilling sugar, then she was not in control. It was the psychological aspect that was disturbing.
The light in the toilet was poor, forcing Cassi to unlatch the stall door in order to get a good look at the tape. It had not changed its color. Having gotten so little sleep the night before and having cheated that afternoon with a fruit yogurt snack, she wouldn’t have been too surprised to see a little sugar. Cassi was pleased that the amount of insulin she was giving herself and her diet were in balance. Her internist, Dr. Malcolm McInery, talked occasionally of switching her to a constant insulin-infusion device, but Cassi had demurred. She was reluctant to alter a system that seemed to be working. She did not mind giving herself two injections a day, one before breakfast and one before dinner. It had become so routine as to be effortless.
