by Robin Cook
"Only fourteenth in infant mortality?" asked Jan. Straus had really gotten to her.
"Jan, dear, don't be misled by statistics. You can prove almost anything with statistics if you deal with different sample populations. It can be a kind of mathematical gerrymandering. Straus, being fourteenth or whatever we are in infant mortality probably has more to do with the fact that we keep such accurate records in this country. Lots of countries record only the births in hospitals. All others go unrecorded."
"They're pretty good at record keeping in Sweden," returned Straus with a smile.
"Well, then, there are differences in records according to what time during the pregnancy the kid came out — whether it was a stillbirth, dead in utero, or whether it was a case where the kid died when it was really a viable being. It makes a big difference where a country draws the line in amassing statistics on infant mortality."
Straus put up his hands, palms toward me, and slowly lowered them as he continued. "Again, I won't argue about the technical details of the statistics. But the fact remains that the United States is not at the top. And fourteenth is a pretty low position when you consider where we are in most other technological and service fields. Frankly, Sweden makes us look pretty sick."
"Sweden doesn't have our problems," I said sharply. "They deal with a relatively small, homogeneous population, whereas the United States is a pluralistic society. Do you mean to say you feel that a socialistic welfare state like Sweden is the answer to all social ills, and the solution for us?"
"It seems to be better for infant mortality, and children's dental care, and longevity. But I'm not saying that the United States should adopt the Swedish system of government or health care. All I'm trying to say is that there are places where health care in general is better than here. That, translated, means that better health care is possible, and we have to make it happen."
"Well, you can't create a service industry like medicine out of a vacuum, nor can you abruptly legislate it. Changes in social structure occur only through changes in the attitudes of people. These changes are slow, and related to the educational forces organized to deal with them. People are used to the current doctor-patient relationship. I don't think they want it to change."
"For Christ's sake, Peters, forty million people have never even seen a doctor! How can they develop an attitude? Man, that's a vacuous excuse. Yet it's typical, too. You and your buddies can think of a million little irrelevant reasons why the present system should stand without change. That's why the whole structure has to be scrapped. Otherwise, we'll water down the problem by compromises like Medicare and Medicaid."
"So even Medicare and Medicaid are bad. Straus, you're a real bomb thrower. Everything is black from where you sit. I think Medicare and Medicaid are pretty good laws. The only problem I can see with them is that they screw up the graduate teaching system by making it possible for many of the patients we'd been handling to go to private M.D.'s, who don't let the interns and residents in on the case. As a result, we have effectively lost a large population of patients for learning."
"Well, that’s pretty important," said Straus. "And if s indicative of the Band-Aid solution to gigantic social ills. Yet the biggest problem of Medicare and Medicaid is that they have just thrown more money into the hopper, creating more demand. If the demand goes up and the supply stays the same, prices soar."
"Sure, sure." I was getting a little angry now. "What you want is another monolithic government bureaucracy, with millions of file cabinets and typewriters. But this is going to cost a lot of money. Health-care cost would probably go up, not down, with such a bureaucracy. And I suppose you envision all doctors on government salary. That would be interesting! Society is going to be in for a little shock when it finds out how much money it needs to pay those doctors. Financial return would have to go up, as the doctor rapidly learned to compare himself to someone like a unionized airline pilot, who can get about fifty thousand dollars a year for a sixty-five-hour month. How many doctors would it take to man the healthcare system if each one worked sixty-five hours a month? Plus they'll want retirement benefits—"
"That is a—"
"Just let me finish, Straus. Putting all the doctors on salary would have other, more subtle effects. If you are on salary, no matter what you do, it has an effect on your motivation in marginal situations. Look, Straus, when you drag yourself out of bed at 4:00 a.m., you want something for it, something more than the satisfaction it gives you. Lots of times it doesn't give you any satisfaction at all. Quite the reverse.
"After all, the garbage man, the airline pilot, everybody else gets overtime. Well, the doctor is going to want that, too, or he won't crawl out of bed. Let me put it another way. When you work for a salary, you have specific hours. Come five o'clock, and the salaried doctor washes his hands and goes home. I happen to know that, stripped of a lot of mythology, a doctor is a pretty ordinary human being."
"Can I talk now?" asked Straus.
"Please."
"Several things. Number one: a national health service is not the only answer. You're jumping to conclusions. Private prepaid health plans, for instance, work well, plus improving the productivity of individual doctors for a number of reasons. The government's role could be merely to guarantee that everyone is covered, one way or another, with at least a good-quality, basic health-care package. And number two: I don't agree with your views about the sleeping doctor. At the same time, I do believe the doctor will have to be paid in relation to some rational scale that compares favorably with airline pilots, or plumbers, or anybody else, keeping in mind the duration and investment of his training, as well as the long hours he must work. But, on top of that, I believe that the professional pleasure of practicing medicine will carry the doctor over the bumps in his day — especially if he is relieved of the burden of paper work and other piddling tasks that absorb twenty-five per cent of the solo practitioner's time. Besides—"
"Dr. Peters, Dr. Peters." My name suddenly shot out of the page speakers near the ceiling and echoed around the room. Straus went on talking as I moved toward the phone in the corner.
"Besides, in group practice," continued Straus, "there is more chance for peer review. The doctors can keep a good eye on each other and offer advice and criticism when needed. And records. Patients' records would be far better, because they'd be organized and complete whether the patient saw the G.P. or a specialist." Straus was literally shouting by the time I got to the phone and dialed the operator. Then, thank God, he finally shut up.
The operator connected me to the private surgical floor, and then I had to wait while they looked for a particular nurse.
"Dr. Peters."
"Yes."
"We have a patient of Dr. Moda's who's having some breathing difficulty. He wants the intern to see her. Also, I need an order for a laxative on one of Dr. Henry's patients."
"How bad is the breathing problem?"
"Not too bad. She feels okay when she's sitting up."
"Dr. Straus will be up right away."
"Thank you."
Turning around and retracing my steps, I noticed the whole cafeteria was empty except for us. The sun had disappeared, and the illumination in the room had changed from sharp, contrasting light and shadow to a soft, suffused glow. It was a peaceful scene, made more so by my inner joy at knowing that I could send Straus to see the lady with the breathing problem and to handle the constipation case.
"Peters."
"Yeah?" The voice on the other end of the line was familiar.
'This is Straus."
T couldn't have guessed. You certainly do seem to be busy."
"I can't help it. Everybody's going sour," he said. I glanced at my watch. Ten-thirty.
"Well, what’s the current crisis?" I asked.
"An old lady died. About eighty-five years old. A private patient on Ward F, second floor."
There was a pause. I didn't say anything, expecting to be told more about the problem. Straus's
breathing could be heard on the other end of the line, but he apparently had nothing to add. Eventually I spoke.
"Okay, so an old lady died. What’s the problem?"
"No problem, really. But would you mind coming over and taking a look?"
"Look, Straus, she's dead, right?"
"Right."
"Well, what do you expect me to do? Perform a miracle?"
There was another brief silence. "I just thought you'd want to see her."
"Thanks a million, old boy. But I think I'll pass it up."
"Peters?"
I'm still here."
"What do I do about the family and the paper work?"
"Just ask the nurses. They're old hands at this stuff. All you have to do is sign some papers, notify the family, and get an autopsy."
"An autopsy?" He was genuinely surprised.
"Sure, an autopsy."
"Do you think the private doctor wants an autopsy?"
"Well, he ought to, that's for sure. If he doesn't, he can turn it down. But we should get autopsies on everybody who dies here. It might not be easy, but get the family to agree."
"All right, I'll try, but I'm not guaranteeing anything. I'm not sure I'll be able to communicate much enthusiasm for an autopsy."
"I'm sure you can handle it. Ciao."
"Ciao."
He hung up and so did I, thinking once again about the yellow woman in the autopsy room in medical school. Jan interrupted me.
"Something wrong?" she asked.
"No. Someone died, and Straus wants to know what to do."
"Are you going over to the hospital?"
"Are you kidding?"
Jan was helping me pack. Actually, she was just there. We certainly didn't need any excuse to be together; we'd been spending a lot of time with each other. So much, in fact, that my imminent departure cast a shadow over the evening, although we had stopped discussing it.
The point at issue was whether I loved her enoughs— her wording — to ask her to follow me to my residency. I had implied as much many times, yet something kept me from asking straight out. What I had tried to tell her was that I wanted her to make the decision, without my direct interference. I didn't want the responsibility of forcing her to come with me. That was how I viewed it. I mean what if we didn't make it after we got to my residency? If I had forced her to leave Hawaii, then I'd undoubtedly feel bound by some sort of guarantee, and I just couldn't do that. I wanted her to come, all right, but on her own.
Jan and I had had a ball. It had been a relief to build a significant relationship with her after the debacle with Karen Christie and her screwed-up fiance. Although I had gone over to Karen's a few times after the confrontation with her boyfriend, I eventually realized that I couldn't keep seeing her. So I stopped.
The phone rang again. "City morgue," I answered, in a loud and cheerful voice.
"Peters, is that you?"
"At your cervix, Straus, old boy."
"You really threw me for a second. Don't do that," said Straus.
"All right, I'll try to be more civil. What’s up?"
"I got a call from the ICU, and there's a patient having difficulty breathing. The nurse said it was probably pulmonary edema. Apparently the private doctor is worried about heart failure."
"Pretty good nurses in there, huh, Straus? Diagnosis and all. That’s real service. Do you agree with them?"
"I haven't seen the patient yet. I'm just on my way up there. I wanted to call you in case you care to be in on the action from the start."
"Straus, your courtesy warms my heart. But why don't you hustle up there, check it out, and then give me a buzz, okay?"
"Okay. I'll call you right back."
"Fine."
Jan was absorbed in trying to fit my medical library into several trunks. It was obviously a problem of Gordian complexity requiring an equally drastic solution. I had to decide which books to leave behind — a terrible tragedy to a doctor. A lot of people appreciate books, but doctors worship them and communicate with them almost sensuously. If a doctor is at all realistic, he quickly grasps the fact that he can never match wits with his library. Consequently, he surrounds himself with books, greedily searching for reasons to buy a new text, whether he will ever read it or not. Books are a doctor's security blanket, and they were mine.
The mere thought of discarding any of my texts smacked of sacrilege — even that psychiatry text, or the one on urology. Urology wasn't my favorite specialty, by any means. I frequently wondered how anyone could spend the rest of his life fooling around with the waterworks — although the field couldn't be too bad, because urologists seemed a pretty happy group, on the average. Undoubtedly they had the best repertoire of dirty jokes.
"You're never going to get all these books in here," said Jan.
"Will, let’s take them all out and start over. In fact, let’s try to stand them up rather than lay them flat." I showed her by propping up approximately forty-eight pounds of Comprehensive Textbook of Psychiatry in the corner of the trunk. Then the phone rang again. It was Straus; his voice carried a sense of urgency.
"Peters?"
"What’s wrong now, Straus?"
"You know the patient I told you about before, the one the nurses thought had pulmonary edema?"
"What about him?" "Well, I think he does have pulmonary edema. I can hear bubbling rales with my stethoscope up both lung fields almost to the apices."
"Okay, Straus. Calm down. Did you telephone the resident on call?"
"Yeah."
"What’d he say?"
"He said to call you."
"Oh, fine." I hesitated, collecting my thoughts. "Is it a private patient?"
"Yes, Dr. Narru, or something like that."
"Is it a teaching case?"
"I don't know."
"Well, check, Straus." I played with the bell of my stethoscope while Straus left the line. Jan was making good headway with the books; it began to appear that she would get them all in.
"Yeah, if s a teaching case, Peters," said Straus.
"Did you call Dr. Narru?"
"Sure. I did that first."
"What’d he say?"
"He said to go ahead and do whatever was necessary, that he'd stop by later and check on things when he made his evening rounds."
With my index finger, I tipped my watch over so I could see the dial. Five after eleven. Either Narru was putting Straus on or he really did make late-evening rounds — very late. Somehow I couldn't imagine that.
"Jan, why don't you put Christopher's surgical text in before those little books? Just a minute, Straus. Christopher's is that big red one. That’s it." It was going to be close. "All right, Straus, what kind of surgery did this fellow have?"
"I'm not sure. Some sort of abdominal surgery. He has an abdominal dressing."
"Does he have a fever?"
"A fever? I don't know."
"Is he on digitalis?"
"I don't know. Look, all I've done is listen to his chest."
"Did you listen to his heart?"
"Sort of."
"Was there a gallop rhythm?"
I'm not sure," he said evasively.
Good God, this guy is really eager, I thought sarcastically. "Straus," I said, "I want you to examine the patient, keeping in mind three possible diagnoses — pulmonary edema, which he probably has, pulmonary embolism, and pneumonia. Read the chart and find out about his cardiac history. Meanwhile, get a chest film, a complete blood count, a urinalysis, an EKG, and anything else you think you want. Is he very stuporous?"
"No, he's quite alert."
"Okay, then give him 10 mg. of morphine and put him on oxygen with a mask. But be sure to watch him carefully when you first give the oxygen. Then, when you get everything organized, call me back."
I was about to hang up when I thought of something else. "One other thing. If he's never had digitalis — at least, not during the last two weeks— give him 1 mg. of digitoxin IV. But do it slowly. Str
aus, are you still there?"
"I'm here," he said.
"We probably should give him some diuretic as well, to get rid of some of his excess fluid. Try about 25 mg. of ethacrynic acid." I knew that stuff was so powerful it would wring pee from a stone. Powerful — my inner fear of diuretics made me think twice, and I changed my mind.
"On second thought, hold the diuretic until we're sure of the diagnosis of pulmonary edema. If he has pneumonia, it wouldn't help too much." The old lady with cancer whom I had killed with the diuretic haunted me for a moment; she had died of pneumonia. Finally I hung up the phone.
"Hey, Jan, that’s great." She'd been able to squeeze in all but one small book. The remaining volume was what we called a throwaway — one given out by a drug firm hoping to convince somebody that one of its drugs was the answer to all pathological evil. I'd never read it, nor did I intend to. Nevertheless, I jammed it into one of my already full suitcases.
Except for my shaving equipment and other toilet articles, the clothes I was going to wear in the morning, and the dirty set of whites I was now wearing, all my junk was packed. The shippers were scheduled to take my trunks in the morning; the suitcases were going with me, along with an array of hand luggage that included a large piece of coral. Finally all was ready. I could relax and enjoy what remained of my year in Hawaii.
Jan chose that moment to drop her bomb by abruptly informing me she was going home. Just when we could forget all the packing and be together, she decided she was leaving. Obviously, it came as a complete surprise, since I had blithely assumed we would sleep together, as usual.
"Jan, why in heaven's name do you have to leave? Please stay. If s my last night."
"You need a good night's sleep before your trip," she said evasively.
"Well, how about that!" I gazed into her tanned face. She looked at me with her head tilted slightly forward and to one side, flirting expertly and suggesting that her sudden coyness was based on complicated female reasons. Yet I wasn't sure. I could understand her desire to leave if it sprang from a disdain for the artificial last-night routine, from not wanting to reduce our love-making to a sort of ritual to celebrate a passing era. The closeness we normally enjoyed probably wouldn't have been there, anyhow, since we were both preoccupied with other thoughts.
