Charlatans

by Robin Cook

  “So you really did use the simulation center?” Noah said. It was a statement more than a question.

  “Absolutely,” Ava said. “Like there was no tomorrow. Within months of my arriving at Brazos University Medical Center, I started my quest to become an anesthesiologist by using the simulators almost every night when the medical students and the residents had gone back to their beds. I did it religiously. I even started writing programs and to trouble-shoot the system because initially there were a lot of bugs in it. But it was a fabulous way to learn, so much better than the standard methodology. It is almost a crime that medical teaching hasn’t been altered for a hundred years, still adhering to a paradigm that started back in 1910, for God’s sake. It’s almost unbelievable because everything else about our culture and technology has changed drastically. Don’t you find it embarrassing that medical education is the most backward of all the pedagogies?”

  “I guess I haven’t given it that much thought,” Noah said.

  “Well, I certainly have,” Ava said. “Do people really need four years of college to be a terrific doctor? Hell, no! Maybe they did in 1910, but not now. Maybe they think they have a richer life, but even that is open to question. Do people need four full years of medical school to be a terrific doctor? I don’t think so. Maybe they did in 1910, when most medical schools were for-profit diploma mills and a bad joke. Do people need to do research for a couple of years? Hell, no, again, unless they choose research as a career. Otherwise it’s like treading water. The proof of all this is that I am a damn good anesthesiologist, better than some at the BMH whom I have been able to observe, and I have handled more than three thousand cases and supervised my share of residents and nurse anesthetists.

  “Now, I know you have had some misgivings about the three recent deaths I’ve had. And believe me, they disturbed me more than anyone because they were my first and hopefully my last. But let’s reassure you yet again that it wasn’t my lack of having had a formal anesthesia residency that was responsible. With Bruce Vincent, we both know that it was the pigheaded Dr. Mason, his fellow, and the patient himself who were at fault. With the Gibson case the problem lay with the departmental rule that it was appropriate for me to supervise two concurrent resident anesthesia cases at the same time and that the resident did not wait for me to be in the room before starting, as I was busy elsewhere. It also didn’t help that there was a computer glitch that created two records, one with the information about the patient’s neck problem and one without, which was the one that the anesthesia resident got. And the malignant-hyperthermia case could not have been handled any better than it was, despite the outcome. This was determined when it was reviewed. And I can tell you that the majority of the anesthesiologists at the BMH have never handled an MH case, either real or virtual. I don’t doubt that they could, but if it were my life on the line, I would rather have me there than them because of my experience. As for why the scrub nurse would tell you I didn’t turn the gas off immediately, I have no idea, because for me it was reflex. Maybe she is upset I am an anesthesiologist and she a nurse, or maybe it is that I am younger and more attractive. Who the hell knows . . .”

  Ava suddenly threw up her hands as if she were surrendering and sat back. “That’s it,” she said. “That’s the whole story, and you are the only person who knows it.” Slowly she lowered her hands, watching Noah expectantly.

  “Why have you told me all this?” Noah said. “Why put the burden on me?”

  “Two main reasons,” Ava said. “First, to save your skin, and second, your career. The NSC sees you as a major threat in regard to me and has let ABC Security know how they feel. Use your imagination for what that might mean! The second reason is that I like you, and we are in many ways ‘two peas in a pod.’ That is a compliment. I enjoy your company. If you want to know the truth, initially I saw you only as a way to deal with the Dr. Mason problem without involving ABC Security. But that was before I got to know you.”

  “I enjoy your company as well,” Noah admitted. “But—”

  “There cannot be any ‘buts,’” Ava interjected. “You have to let sleeping dogs lie. I’ve gone out on a limb for you. I know from your perspective I’ve gotten to where I am today following a unique path that you don’t agree with. But understand that I am the future. Medical education is going to change dramatically in the next five or ten years. It has to change. It took me ten years to get where I am, but I had to work to support myself while I was doing it, and if I didn’t, it would have taken half the time. It is inevitable that becoming a specialist like an anesthesiologist will soon take, say, six years or even less from high school to board qualified instead of the current twelve. The costs of healthcare have to go down, and one of them is the cost of training doctors like anesthesiologists. Hell, it’s more like a trade than we like to admit.”

  “I don’t think I can do what you are asking,” Noah said. “As a real doctor, I’m afraid that I will feel an ethical responsibility to expose you as the charlatan you are. I’m sorry. Maybe you are right about medical education. Perhaps it is behind the times as you say, but I don’t think I can be the judge and jury.”

  “I’m sorry to hear you say this,” Ava said. “If you do out me, then I will feel equally obligated to do the same for you.”

  “What do you mean?” Noah asked hesitantly. The fears he’d felt earlier came back in a rush.

  “I mentioned a few minutes ago that Keyon and George, using the investigative powers of ABC Security, came up with a few secrets of yours that are certainly more prejudicial than some temporal data fudging on a Ph.D. thesis. Would you like to hear what they discovered?”

  Noah nodded reluctantly.

  “First and foremost, it was determined that your father did not die of a heart attack but rather is in prison and will be there for a long, long time, possibly for life for drug trafficking, attempted murder, money laundering, and a few other odds and ends amounting to an impressive felonious résumé. His name is Peter Forrester, and your name was Peter Forrester Jr. until it was legally changed to Noah Rothauser, with Rothauser being your mother’s maiden name. I like the choice of Noah, with its biblical connection. Should I go on?”

  Noah didn’t move, nor did he even blink, yet perspiration appeared on his forehead as evidence of his inner turmoil.

  “I’ll take your silence as a yes,” Ava said. “It was confirmed that you, too, were arrested with your father when you were fourteen for abetting some of your father’s activities, and you too went to prison in South Carolina for a time, but as a juvenile offender, since it had been judged that there had been an element of coercion involved. It was also confirmed that you were released at age eighteen and your felony record was sealed. Unfortunately for you but fortunately for us, nothing disappears in the digital age. In the old days, a page was literally torn out of a court log and thrown away. Today, there is no way to make a record such as yours vanish, and the ABC Security investigators, mostly Keyon and George, found all of it. Now, there were some commendable aspects to your backstory, such as you getting your high school diploma with some AP credits while in prison as evidence to your rehabilitation, to the delight of the prison officials. It is also impressive that the warden, hearing of your desire to become a doctor, made great efforts to get you accepted into Columbia University.”

  “My record is officially sealed,” Noah said, finding his voice. “It can’t be used against me.”

  “That is correct, to an extent,” Ava said, as the corners of her mouth turned up in a slight but knowing smile. “However, there is the sticky point about the expectation of being truthful. When you filled out the form for your DEA license and there was a place for you to respond to the question of whether you had been convicted of any felonies, you should have marked the box for yes and then on the back of the form in the space provided, you should have explained about having been a juvenile offender and the record sealed. It will be
interesting to talk with the DEA about this issue, and see what they say, particularly because your felony involved drug trafficking. The legal opinion is that you will lose your DEA license and thereby make practicing as a doctor all but impossible. It is also interesting to consider how the Residency Advisory Board, which will be ruling on your suspension, will react when they learn that you had lied on your DEA application, which is far more serious than temporarily fudging data on a Ph.D. thesis.”

  “They cannot use a sealed record against me,” Noah repeated, but his voice lacked conviction.

  “The Residency Advisory Board is tasked with making a value judgment about ethics,” Ava said. “But let’s not get into an argument about details, because there is more to your story. It was confirmed that your mother is in an Alzheimer’s facility. It was also discovered you have a sister with a chromosomal abnormality who is also institutionalized. It was also confirmed that you were forced to spread your medical school career over six years because of financial difficulties involving supporting your mother, your sister, and yourself, which was all very noble. But since you worked for the medical school administration, it was obvious to me that you would have had special access to the medical school’s computer similar to my access to the Brazos University computer. And since we share computer proficiency as part of being ‘two peas in a pod,’ I recommended that Keyon and George use some IT forensics to look at your record. What was found was not pathognomonic but suggestive there had been some alterations. What I am saying is that at this stage it is not known for certain if you had made any changes to your record to help your application to your BMH residency, and further study would be needed to ascertain it. But here is yet another major area where you are vulnerable.”

  Ava paused and took a deep breath, watching Noah. She was hoping for more of a reaction, but he just stared back at her, breathing shallowly.

  “I can see you are distressed, and for good reason,” Ava continued. “So let’s talk about a resolution. You want to be one of the world’s premier surgeons and have worked stupendously hard to that end. I want to do the same in anesthesia and have worked equally as hard but on a different trajectory. The reason I had you brought back here and have made you privy to all these secrets that no one else knows is that I see our similarities more than our differences, and I like you. I told you all this because there is a solution. What I have intentionally created is a true Mexican standoff, meaning there are three entities pointing guns at each other: you, me, and the NSC. The only way for this to be resolved and we all win is for all of us to agree to the status quo and lay down our weapons. If not, we all lose.”

  “Every time you say something, it is another surprise,” Noah said. “Why do you think the NSC is holding a gun on you? You are their darling.”

  “If you make an issue about me being a charlatan, I will no longer be their darling but their enemy.”

  “So the NSC has no idea you are a charlatan?” Noah said, shocked yet again.

  “Absolutely not,” Ava said.

  “And how are you holding a gun against the NSC?”

  “That’s easy,” Ava said. “I could disrupt what I have already accomplished about keeping the 1994 DSHEA from being amended. Also, over the years I have learned enough about the supplement industry to seriously discredit it.”

  Another silence ensued as Noah struggled to put everything he’d learned over the last half-hour into context. Finally, he said in a subdued voice: “What would you have me do?”

  “Nothing,” Ava said with a smile. It was clear to her she was making progress. “It is key that you do nothing, but you have to be convincing you are going to do nothing. The NSC has to be absolutely certain that you are not going to try to discredit me in any way at all. As you’ve guessed, they are enamored of me, which is obvious when you consider this house, my Mercedes, my computer, and all my toys and lifestyle I enjoy. Of course, it would be even better and more convincing if you were willing to help the cause.”

  “I hope you don’t mean me supporting the nutritional-supplement industry,” Noah said.

  “That’s exactly what I mean,” Ava said with a chuckle. “Get down off your high horse, Dr. Rothauser! The industry is trying in some ways to clean up its act. Not all companies are bad; it’s like everything else, including hospitals and doctors, there’s good and bad. The bad ones are really bad, especially the ones who get all their products from China and India, go overboard on their health claims, and really don’t give a damn. But with your participation you could be an effective positive force on the inside, trying to get the bad companies to mend their ways by toning down their absurd claims and making them feel responsible for the poisonous crap that’s in the bottles they advertise and sell. I can tell you that the good companies, the ones which care about their products and are selling legitimate vitamins and such, are very aware of those companies responsible for all the harm and bad publicity. The reality is that you could do a lot more good on the inside than tilting at windmills from the outside.”

  Ava paused, aware she was getting carried away. “So what are your thoughts?” she said finally, in a calmer voice.

  “I have to think about being supportive,” Noah said.

  “Okay, you do that,” Ava said. “But if you feel as strongly as you say about the nutritional-supplement industry, this could be an opportunity for you to do something positive. The industry is not going to change on its own. The problem is, just like the rest of healthcare, there is too much money involved and the industry has a lot of politicians in their pocket. And as a final note, I imagine the potential remuneration you would receive with your Ivy League credentials from the NSC could easily take care of your educational debt and your mother’s and sister’s ongoing care. How bad is that?”

  EPILOGUE

  THURSDAY, AUGUST 24, 1:53 P.M.

  Dressed in his only jacket and tie, Noah pushed through the revolving door at the entrance to the Stanhope Building. Finally, after several weeks of torment, worrying that his surgical residency was going to be prematurely ended, he felt confident he was going to be reinstated. The day before had been the feared Surgical Residency Advisory Board meeting, but it had gone as well as could be expected. There had been eight members present, which included the program director, Dr. Cantor, and the two assistant program directors, Dr. Mason and Dr. Hiroshi, as well as five surgical residents who had been elected to represent each of the five years of the program. Noah’s seat had been empty for obvious reasons. He had served on the board every year he’d been a resident.

  Although Noah had been nervous at the outset, it soon became clear to him by the questions asked that his lawyer, John Cavendish, had made it abundantly clear Noah had not fabricated data on his thesis but rather had conservatively estimated results of the final concluding experiment and then replaced them with the real data as soon as it was available, with the motivation being to have his Ph.D. be considered as part of his medical school application. At the end of the meeting, Noah had been told that the board would vote on his case and that he should return in twenty-four hours for the result.

  The only surprise for Noah had been Dr. Mason’s total silence during the hour-long proceedings. Although Noah had been told by Keyon and George that they had uncovered some potentially compromising information about Dr. Mason, which had been communicated to him, Noah had suspected the worst from his long-time antagonist. He hadn’t known why it hadn’t happened until last night at Ava’s.

  As they had eaten their dinner overlooking her garden, she’d explained that Keyon and George had discovered that Dr. Mason had made it a habit over the years to insist that Arab sheiks from the Emirates and Saudi Arabia provide progressively extravagant gifts for the privilege of being seen in a timely fashion, which was important for pancreatic cancer patients. At first these gifts had been mainly in the form of large contributions to his research efforts or to hospital building projects, but the
n about seven years previously, they became more personal, including his beloved, flamboyant red Ferrari.

  After consulting with several knowledgeable tax attorneys, Keyon and George had ascertained that from the IRS’s point of view, these gifts had to be considered income, since they were required to secure an appointment and were therefore fee-for-service and not voluntary. Since the amount of money involved was more than 25 percent of Dr. Mason’s academic salary, there was the specter of statutory fraud, meaning possible prison time. This information had been provided to Dr. Mason with the advice that it would be best for him to curtail his ongoing harassment of Dr. Noah Rothauser.

  Noah took the Stanhope’s elevators up to the third floor. Once there, he walked across the sumptuous carpeting toward the double mahogany doors leading into the hospital boardroom where the Advisory Board meeting had been held the day before. He told the hospital president’s secretary whose desk was nearby that he was there and then took a seat in the administrative waiting area. It was 1:58 P.M. He had wanted to be exactly on time, not too early and certainly not late, and he could congratulate himself on his timing. Although he’d been optimistic about the upcoming meeting, now that he was waiting to be seen, he felt the old anxiety he’d always felt when forced to confront authority figures. There was always the chance his life could once again be upended. Nervously, he flipped through a magazine that he’d picked up from the low table in front of him.

  After the previous night’s dinner and following the revelations about Dr. Mason’s tax fraud, Noah and Ava had retreated up to her study. He’d been staying with her the whole week, and each night they had gone to the study to continue their conversations. Last night, just when they were ready to call it a night, Noah had said he had a condition he wanted to run by her that involved her babysitters. After explaining what he had in mind, Ava’s response had been she’d think about it although a half-hour later she’d reluctantly agreed.