by LaGreca, Gen
Dr. Marie Lang sat at one of the tables with the partners of Reliant Care, the large group practice that employed her. She looked poised in her black silk gown but for the persistent nervous tapping of slim tanned feet under it. Her sleek auburn hair brushed alluringly against her naked shoulders, while eyes of the same burnished brown darted anxiously around the room. Almost everyone found thirty-four-year-old Marie charming. The occasional more perceptive observer, however, found her puzzling, for when she smiled, her eyes did not follow suit.
She turned toward the entrance as if searching for someone, then frowned when she didn’t find the person there. Her eyes fell irritably on the only empty seat at the table, the one next to her that was costing her group practice two thousand dollars.
“I know you don’t support the governor, but I’m asking you to come to this dinner to support me,” she had said earlier to the person supposed to occupy that seat. “I’m the only staff physician the partners invited. I’m probably going to get an award for being their best doctor.”
“That’s what concerns me” was the reply.
With a sweep of her hair, Marie shook off the troubling recollection. Turning to the officers of her group practice and their spouses at the table, she smiled broadly.
“Before the politicians give their speeches, let me make a statement of my own: I’m delighted—and honored—to be here tonight. Thank you for inviting me!”
“We’re glad you could make it,” said Dr. Paul Eastman, the stocky president of the fifty-doctor practice.
His youthful tan clashed with his sagging jowls to make him appear both robust and rotund. His perpetually racing eyes seemed to scan the world in search of the next task to tackle. He had entered medicine when it was easy to make a mid-six-figure income and left it for business administration when doctors’ compensation became more regulated and took a sharp turn south.
“We didn’t invite you just to toot a horn for Governor Burrow,” Eastman continued. “We have our own drum-roll for the GP who’s done so much to help Reliant Care reach its goals. Don’t we?”
The partners nodded.
“Now whatever do you mean?” Marie asked gaily.
“You’ll see.”
Her innocent eyes belied the fact that she knew a bonus check had been cut for her that day. Her friendship with Eastman’s secretary had paid off.
With one raised finger, Eastman signaled a waiter. With a circular motion of that finger he ordered a round of cocktails. “By the way, where’s David?” he asked, as the waiter took the drink orders.
Marie’s smile vanished. “Unfortunately, something came up. He was very disappointed he couldn’t come. He said to thank you for your invitation and to send his regrets.”
Everyone nodded sympathetically. Marie was married to a neurosurgeon.
“That downright ruins the aesthetics,” said sixty-year-old Edna Eastman about the absence of Marie’s very attractive thirty-seven-year-old husband, provoking a chuckle from the other women.
“Paul, I know you didn’t invite me here so Edna could stare at my husband.”
“Actually, we want you to be the center of attention.”
“My goodness! Why?”
“Is this gal amazing?” said the head of the clinical staff. “She works her magic so naturally, she doesn’t even know she’s doing it!”
Marie knew that the second-quarter figures were in and that she had surpassed the goals set by the company for its physicians. Nevertheless, she was enjoying her little game with her employers.
“These are changing times for medicine,” said Eastman. “Instead of pining for the old days, Marie is one doctor who adapts to change. Reliant needs MDs like you, my dear. CareFree needs them.”
CareFree was the state’s most celebrated public assistance program. Created by the governor two years earlier, the agency provided free health care to all New Yorkers. Subsidized by an approving federal government, CareFree took under its massive wing all patients formerly covered by national programs. This giant single payer of medical bills provided tax relief and other incentives to doctors for giving up solo practice to join groups, which the state thought were more economical and easier to monitor.
Recognizing the new trends, Paul Eastman had formed Reliant Care. The firm paid its doctors a salary as employees and collected a fee for their work from CareFree. Eastman spared his practitioners the necessity of dealing with the regulators, and the doctors in turn made a profit for the firm by working within the parameters set by CareFree. In the two years of its existence, his fledgling firm had grown to fifty doctors.
“My biggest migraine,” Eastman complained, “comes from doctors who fight the system. The whiners want the old way back, but it’s not to be. The whiners are stubborn. They don’t want to take advice. They resist collaborating with the regulators and want to make all the treatment decisions themselves. But you, Marie, have a real knack for getting along with the administrators.”
“I think other people have opinions, too. It’s good to get their views,” said Marie to the approving nods of the others. “I’m not always right, so I don’t mind cooperating.”
“Instead of getting lost in the weeds, we need to make our garden grow. And Marie has a remarkable green thumb.” Eastman picked up her hand and held her thumb up.
“Oh, Paul, really—the new system isn’t so bad. I don’t like to complain. I’d rather get the job done.”
“And so you do! We have our semiannual bonus for the doctor we select as Distinguished Caregiver,” Eastman explained. “The numbers are in, and your record was unmatched, Marie. Of all the primary doctors in our group, you had the largest roster of patients, and you demonstrated the most prudent use of medical resources, with well-controlled hospital admissions, consults with specialists, and outside testing. Because of this record, you had no skirmishes with the folks at CareFree, which means no headaches for me.”
Marie, who tallied her numbers the way a monk counts his prayers, tried to look surprised.
“If we could clone you, we would, kiddo,” said the head of marketing. “I want to feature you in our advertising campaign to recruit new doctors.”
“Oh, really, now!” exclaimed Marie.
“She’s a natural healer!” added Eastman. “Some people are born with the gift.” He threw an arm around Marie, his jowls shaking as he laughed.
The tension vanished from Marie’s face. This time her smile did reach her eyes. The empty seat no longer seemed to matter; she rested her purse on it.
Eastman removed an envelope and jewelry box from his vest pocket, his midsection spilling over his cummerbund. He raised his voice, commanding the attention of everyone at the table. “Our selection for Distinguished Caregiver was unanimous—Dr. Marie Lang!” To the applause of the others, Eastman handed her the gifts.
Marie planted a kiss on his fleshy cheek and opened her presents. The envelope contained a check for ten thousand dollars, and the box held a gold pin engraved with the company logo and the words Dr. Marie Lang, Distinguished Caregiver.
“Thank you very much!” Marie placed a hand over her heart and bowed her head appreciatively.
“At a time when many of our colleagues are struggling, with independent practitioners becoming dinosaurs, Reliant Care is thriving,” said Eastman. “Doctors like Marie prove we can expand our comfort zone and work under the new system.”
“You did a great job, Marie,” said the company’s financial officer.
“And here’s the booze. Perfect timing!” said another partner, as the waiter arrived. “A toast to Marie.”
“And to the governor’s reelection,” someone added.
“To Reliant Care,” said Marie, raising her wineglass.
Eastman grabbed his martini off the tray before the waiter could serve it. “To the future, which looks rosier every day.”
* * * * *
Eight miles across the East River in Oak Hills, Queens, a man returned home from work, an unknotted tie
across his chest and a suit jacket dangling from his shoulder. The soft silk coat crushed as he dropped it on a chair. He removed a note that his secretary had slipped into the pocket when he was leaving the office. He grabbed a beer, and as he entered the living room and lay across a couch, he drank eagerly without the benefit of a glass.
His legs, which he had never felt during twelve hours in surgery, now throbbed from the knees down. His neck cracked with the tension of craning over a microscope all day. His green eyes, which had spent hours locked on a section of protoplasm inside a human brain, now ached. His exquisitely sensitive fingers, which had controlled countless minute tools, were stiffening. Even his forehead, under his boyish sweep of black hair, burned where the rim of the surgical cap had scraped. He felt as if his body were going on strike.
He lay with his head on a throw pillow, content in knowing he could finally relax. There was no longer a life at stake. Or was there? He glanced at the note from his secretary: “You have an appointment to present your project to the BOM research committee at 4 tomorrow afternoon.”
He had waited months for an appointment with the state’s Bureau of Medicine, or BOM, but wished he didn’t have to go. The massive agency ran CareFree, the state’s health care program, and also regulated hospitals, medical schools, and research. Nervously tapping the note against his fingers, he wondered how to get the committee’s permission to complete his research. If his seven-year quest had led only to blind alleys, he could give up. But he couldn’t cut the journey short just when he could see his dream, almost touch it, in the distance.
What if his proposal were rejected? Was there another way? He had exhausted every avenue. Should he move to another state? Conditions were becoming the same everywhere. Should he go abroad? The medical climate was no better there. What arguments could he prepare for the most important meeting of his life?
It seemed so much easier to fight the battle he had waged earlier that day against a benign brain tumor, a meningioma. He thought it misleading to call a meningioma benign when it could burgeon to the size of a grapefruit and kill as surely as its undisguised sibling, cancer. A meningioma forces the brain’s blood vessels to service its cause. It feeds off human protein, growing larger and larger. To make room for its girth, it squeezes out the good brain tissue until its unwilling host can no longer function. Finally, the pressure of the intruder becomes so great that the brain one day quits. The “benign” meningioma murders its life source and therefore destroys itself. Such is its perverted aim.
There is only one cure: The unwelcome guest has to be thrown out. However, a meningioma is vindictive. It punishes its host for trying to expel it. If any minuscule part of it remains, the vengeful alien can grow back faster and more deadly than before. The only way to stop it is to remove every last morsel.
His patient that day was a man of fifty-seven, twenty years his senior. The meningioma was easy to spot. There was the healthy yellow brain tissue with its pulsating web of blood vessels and nerves. Then there was the tumor, a dull gray mass resembling a tennis ball. He gently pecked at it, removing a piece at a time, careful not to disturb the delicate nerves and vessels adhering to it. Hours later, after he had removed most of the meningioma, he discovered something disturbing. He pulled his instruments out to rest his hands and decide what to do. The last bit of the tumor was attached to the command center that regulates respiration, blood pressure, and heartbeat, controlling life itself: the brainstem. The area where the meningioma had lodged seemed inoperable because the result of just one touch on the brainstem could . . . could not be very good at all. If he quit now, he thought, he would have given the patient ten years before the meningioma regrew to kill him. But if he could get the last recalcitrant bit of the tumor out, the patient could live thirty years, the full course of his life.
He sipped soda through a straw that the nurse slid inside his mask as he considered the options. The last remains of the meningioma stuck to the brainstem like chewing gum on the trigger of a bomb. Could he remove it without touching it? Coax it out? Wish it out? If he quit now, he had already bargained ten years from the invader. If he continued, the patient could live thirty years or die on the table. Ten years or thirty? Life or death? A nurse ran a dry cloth across his wet forehead. Finally, he stepped up to the brain, stared at the meningioma, and silently forewarned it: One of us is going to get tired first, and it’s not going to be me.
Six hours later, he’d completed the operation. He had rid the brain of every vestige of the trespasser. The patient would fully recover and lead a normal life. That was easy. Meeting the BOM’s research committee, however, was another matter. It was a foreign substance in the fabric of his life. It, too, pretended to be benign—but was it? How could he keep it from arresting his vital functions?
He glanced at his watch. It was eight o’clock, time for dinner. He wondered where his wife was, and then remembered she was attending a banquet. The prospect of spending the evening alone pleased him, but being pleased with her absence evoked guilt. He thought he should attend the banquet as she had so urgently requested, yet he couldn’t bring himself to go.
He had not eaten since before entering the OR that morning. Was he too tired to eat or too hungry to sleep? His eyes decided for him. They closed.
Minutes later, his pager awakened him. A number he knew well flashed on the device. He reached for his pocket phone and dialed.
“Riverview Hospital Emergency Room.”
“This is David Lang. I was just beeped.”
“Yes, Doctor—hold on.”
The next voice was that of a neurosurgery resident.
“Dr. Lang, this is Tom Bentley. I’m calling about my patient, a thirty-eight-year-old woman who was hit in the back of the head with a baseball five days ago.”
“Yes?”
“After the injury, she developed headaches, sought medical attention, and was treated for migraines. As the week progressed, her headaches worsened. She recently gave birth and has been taking an anticoagulant for a blood clot in her leg. Her husband brought her in tonight because she was becoming harder and harder to arouse. Brain scans show a large subdural bleed in the posterior fossa. She’s falling into a coma.”
“Is her airway clear?” David Lang sat up.
“Yes.”
“Is she intubated?”
“No. She’s been breathing on her own, but her respiration is becoming shallow—”
David heard someone in the background yell, “Arrest!”
“My patient just stopped breathing,” Bentley reported.
“Ventilate her, and give her K-35 in an IV drip to counteract the anticoagulant and restore normal clotting. Take her to the OR. I’m on my way.”
The headpiece on the wall phone in the ER bobbed up and down after Bentley dropped it. David Lang’s beer spilled across the carpet as he rushed to the door.
Bentley joined a wall of uniforms surrounding the almost lifeless woman. A gasping pump forced oxygen into her lungs. Monitors beeped, drawers slammed, voices sounded, wires trembled, and white jackets flew around her bed.
Chapter 3
. . . And the OR
The clatter of conversation in the grand ballroom of the Rutledge Hotel faded when the man on the dais beside Governor Burrow took the podium. Sixty-five years had taken the color but not the thickness from the speaker’s hair. He possessed the intelligent face of a scientist and the expensive clothes of a diplomat. His regal manner suggested a noble purpose, but his eyes seemed to be counting the number of television cameras following him. He was a former surgeon who had become the secretary of the Bureau of Medicine. Because the BOM’s universal health care program, CareFree, was under constant attack by political opponents, the state’s medicine czar was essential to the governor’s bid for reelection. The secretary’s job in the campaign was to defend CareFree. With his crest of white hair and tuxedo-clad trim form, he resembled a tall radio beacon emitting a message.
“Ladies and gentlemen, there
are two things in the world that I cherish. One, which I made my former career, is medicine. I studied the glorious human body, discovered its mysteries, and defended it against attack. A doctor is a thinker, an explorer, and a crusader, a testament to the power of science in enriching our lives.
“But medicine is not an end in itself. We must use it to achieve a higher purpose. A proper health care system does just that. It frees medicine from the selfish concerns of business to serve the public. It guarantees care to every person as a right, the way our Founding Fathers guaranteed life and liberty. The other thing I cherish, which embodies this noble ideal, is our new system of medicine, CareFree.”
Waiters watched from the sidelines, ready to serve the first course when the speaker finished.
“Contrary to our opponents’ denials, private medicine has failed. Oh, it gave us dazzling technological advances and a standard of care unmatched in the world. But it failed on moral grounds. Patients had to pay for their care while doctors profited from the sick. The poor suffered the indignity of having to say ‘please’ and ‘thank you’ for someone’s charity. Under CareFree, no one needs to rely on a doctor’s alms, because care is guaranteed to all by law.
“At first the state did not want to manage doctors’ business but merely to pay the bills for special groups like the older folks and the needy. But when the government picked up the tab, patients acted like sweepstakes winners on a shopping spree and providers behaved like retailers whose customers held the key to Fort Knox. The demand for care soared as people sought costly tests for every headache and fancy drugs for every stomachache. And the providers welcomed the increased business with expanded offices, new wings, elaborate equipment, and expensive tests. So there was a problem: People spent more when someone gave them a blank check. The solution was to keep giving the check—no caring person would dispute that—but to fill in the blanks.
“This is why the government had to step in to manage medicine. But did our providers accept the limits placed on them for the public interest? Regrettably, many fought us. To compensate for the lower fees they received for their public patients, the providers hiked the billings to their private patients. This squeezed the private insurance companies that were paying those bills. The insurers reacted by raising their premiums. This continued until the prices got so high that nobody could afford a policy. The problem was worsening. The solution was more management by the state.”
