Matters of Choice

by Noah Gordon

  “We have to volunteer answers in class. Faculty asks questions, we stick up our hands, right in their sexist faces, and give ’em correct answers. We get noticed because we work our asses off, right? It means we have to study harder than the men, be better prepared than they are, act generally sharper.”

  It meant a crushing workload on top of the medicolegal research R.J. was doing in order to stay in school, but it was the kind of challenge she needed. The three of them studied together, drilled and grilled one another before examinations, and bolstered each other when they detected academic weaknesses.

  The strategy largely worked, despite the fact that they quickly developed a reputation as aggressive women. A couple of times they believed their grades suffered because of an instructor’s resentment, but most of the time they received the high marks they earned. They ignored the occasional sexual remarks made by male students—and even, on rare occasions, by a faculty member. They dated only once in a while, not out of disinclination but because time and energy had become vital commodities that had to be doled out stingily. Whenever they had a free evening, they went together to the anatomy lab, which Samantha had made her real home. From the beginning, everyone in the anatomy department knew that Samantha Potter was hot, a future professor in their specialty. While other students fought for an arm or a leg to dissect, there was somehow always a cadaver reserved for Samantha, and Sam shared with her two friends. Over four years they dissected four dead human beings—an elderly bald Chinese man with the overdeveloped chest that spelled chronic emphysema, an old black woman with gray hair, and two whites, one of them an athletic middle-aged man, the other a pregnant woman about their own age. Samantha guided R.J. and Gwen into the study of anatomy as if it were an exotic and wonderful country. They spent hour after hour dissecting, stripping the bodies down layer by layer, exposing and sketching muscles and organs, joints and blood vessels and nerves in exquisite detail, learning the wonderful intricacies and mysteries of the human anatomical machine.

  Just before the beginning of the second year of medical school, R.J. and Samantha moved from the apartment in the mews off Charles Street. R.J. was glad to leave the converted stable; it was too full of memories of Charlie. Gwen joined them, the three of them renting a shabby railroad flat only a block from the medical school. It was on the fringe of a rough neighborhood, but they wouldn’t waste precious time getting to labs or the hospital, and the evening before classes began, they threw an open-house bash. Characteristically, it was the hostesses who shooed the guests out the door at an early hour so they could be up to form in school the next day.

  When their clinical work in the wards started, R.J. met it as though she had been preparing for it all her life. She saw medicine differently from most of her classmates, very much through her own eyes. Because she had lost Charlie Harris due to an unclean catheter, and because she still was an attorney working constantly on malpractice briefs, she tended to search for dangers to which most of her fellow students were oblivious.

  Researching a law case, she found a report by Dr. Knight Steel of the Boston University Medical Center, who had studied 815 consecutive medical cases (excluding cancer, which carries a large risk of adverse results from chemotherapy). Of the 815 patients, 290—more than one out of every three—developed an iatrogenic illness.

  Seventy-three people, nine percent, had complications that threatened their lives or left them permanently disabled—catastrophes that wouldn’t have happened to them if they had stayed away from their doctors or their hospitals.

  The mishaps involved drugs, diagnostic tests and treatment, diet, nursing, transportation, heart catheterization, intravenous treatment, arteriography and dialysis, urinary catheterization, and a myriad of other procedures that compose a patient’s experience.

  Soon it was clear to R.J. that in every aspect of medical care, patients were at risk from their benefactors. As increasing numbers of new drugs were put on the market, and as increasing numbers of tests and lab studies were ordered by doctors to protect themselves against malpractice suits, the possibilities of iatrogenic damage increased. Dr. Franz Ingelfinger, the very respected professor of medicine at Harvard and editor of the New England Journal of Medicine, wrote:

  Let us assume that 80 percent of patients have either self-limited disorders or conditions not improvable, even by modern medicine. In slightly over 10 percent of the cases, however, medical intervention is dramatically successful…. But alas, in the final 9 percent, give or take a point or two, the doctor may diagnose or treat inadequately, or he may just have bad luck. Whatever the reason, the patient ends up with iatrogenic problems.

  R.J. saw that despite the high costs in human suffering and in money, medical schools weren’t making students aware of the dangers of human mistakes in treating patients, nor were they teaching them how to react to malpractice suits, despite the proliferation of legal action against doctors. In the course of her own ongoing work for Wigoder, Grant and Berlow, R.J. began to accumulate an extensive file of cases and data in both these areas.

  The trio was broken up after graduation. Samantha had always known that she wanted to spend her life teaching anatomy, and she accepted a residency in pathology at Yale-New Haven Medical Center. Gwen hadn’t had the slightest idea about a specialty through most of the four years of medical school, but ultimately her politics influenced her to choose gynecology, and she took a residency at the Mary Hitchcock Hospital in Hanover, New Hampshire. R.J. wanted it all, everything being a physician had to offer. She stayed in Boston, taking a three-year residency in medicine at the Lemuel Grace Hospital. Even during the worst of times—when dirty jobs were piled on her, and during the terrible grind, the sleeplessness and the marathon hours—she didn’t doubt what she was doing. She was the only woman among the thirty internal medicine residents of her program. As in law school and medical school, she had to speak a little louder than the men, work a little harder. The doctors’ lounge was male country, where her fellow residents hung out, spoke obscenely about women (gynecological residents were known as “connoisseurs of the cunt”), and mostly ignored her. But from the start she kept her eyes on her goal, which was to become the best doctor she was able to be, and she was good enough to rise above sexism when she met it, as she had watched Samantha rise above racism.

  Early in her training she had revealed evident talent as a diagnostician, and she enjoyed looking at each patient as a puzzle to be worked out by using her brain and her training. One night, joking with an elderly male cardiac patient named Bruce Weiler, R.J. took both his hands in hers and squeezed them.

  She couldn’t let go.

  It was as if they were linked by … what? She felt faint with certain knowledge she hadn’t possessed a few moments before. She wanted to scream out a warning to Mr. Weiler. Instead, she muttered a dazed pleasantry and spent the next forty minutes poring over his records and taking his pulse and blood pressure again and again and listening to his heart. She told herself she was having a mental breakdown; nothing in Bruce Weiler’s chart or vital signs indicated that his mending heart was anything but strong and getting healthier by the moment.

  In spite of that, she was positive he was dying.

  She said nothing to Fritzie Baldwin, the chief resident. She was able to tell him nothing that made any sense, and he would have ridiculed her savagely.

  But in the small hours of the morning, Mr. Weiler’s heart blew out like a faulty inner tube, and he was gone.

  A few weeks later, she had a similar experience. Troubled and intrigued, she spoke about the incidents to her father. Professor Cole nodded, a gleam of interest in his eyes.

  “Sometimes doctors seem to have a sixth sense about the way a patient will respond.”

  “I experienced this thing long before I became a doctor. I knew that Charlie Harris was going to die. I knew it with absolute certainty.”

  “There’s a legend in our family,” he said tentatively, and R.J. groaned to herself, not being in the
mood to hear family legends.

  “It was said that some of the Cole physicians down through the ages have been able to foretell death by holding the hands of their patients.”

  R.J. snorted.

  “No, I’m serious. They called it the Gift.”

  “Come on, Dad. Talk about superstition! That’s straight from the days when they prescribed eye of newt and toe of frog. Could they really have believed it?”

  He shrugged. “Supposedly my grandfather, Dr. Robert Jefferson Cole, and my great-grandfather, Dr. Robert Judson Cole, both had it when they were country doctors in Illinois,” he said mildly. “It can skip generations. Reportedly, several of my cousins had it. I was left the family’s prize antiques, Rob J.’s scalpel that I keep on my desk, and my great-grandfather’s viola da gamba, but I would have preferred the Gift.”

  “Then … you’ve never experienced anything like that?”

  “Certainly I’ve known whether particular patients were going to live or die. But, no, I’ve never had the sure knowledge of approaching death without signs or symptoms. Of course,” he said blandly, “the family legend also says the Gift is dulled or ruined by the use of stimulants.”

  “That leaves you out, then,” R.J. said. For years, until his generation of doctors had learned better, Professor Cole had enjoyed the frequent comfort of good cigars, and he continued to relish his regular evening reward of a good single-malt liquor.

  R.J. had tried marijuana briefly in high school but never had taken to either kind of smoking. Like her father, she enjoyed alcohol. She hadn’t allowed it to interfere with her work, but during times of stress she found a drink a distinct comfort, of which sometimes she availed herself greedily.

  By the time she finished the third year of her medical residency, R.J. knew she wanted to treat entire families, people of all ages and of both sexes. But to do so adequately, she wanted to know more about the medical problems of women. She sought and received permission to take three rotation periods in obstetrics and gynecology instead of one. When she completed her medical residency she took a one-year externship in ob-gyn at Lemuel Grace, at the same time taking advantage of an opportunity to do the medical examinations for a large research program dealing with the hormonal problems of women. That year she took and passed the examination to become a fellow of the American Academy of Internal Medicine.

  By that time, she was an old hand at the hospital. It was generally known that she had done a great deal of legal work for malpractice suits that often won large sums from insurance companies. Malpractice insurance rates were soaring. Some doctors said in open anger that there was no excuse for a physician to do work that would harm a fellow doctor, and throughout her years of training there were unpleasant moments when someone didn’t bother to hide the animosity they felt toward her. But she worked on a number of court cases in which her legal briefs for the defendant had saved the doctor who was being sued, and that became widely known as well.

  R.J. had a quiet reply for anyone who attacked her: “The answer isn’t to eliminate malpractice suits. The answer is to eliminate habitual malpractice, to teach the public to do away with frivolous claims and awards, and to teach doctors how to protect themselves during those times when they make the mistakes that happen to every human being.

  “We feel free to criticize otherwise-honest police officers who protect crooked cops because of their Blue Code. But we have our White Code. It allows some doctors to get away with clinical shoddiness and bad medicine, and I say to hell with it.”

  Someone was listening. Toward the end of her ob-gyn externship, Dr. Sidney Ringgold, the chairman of the department of medicine, asked if she would be interested in teaching two courses, The Prevention of and Defense Against Malpractice Suits for fourth-year students and The Elimination of Iatrogenic Incidents for students in their third year. Along with the instructorship in the medical school came an appointment to the medical staff of the hospital. R.J. accepted at once. The appointment created grumbling and several complaints in the department, but Dr. Ringgold weathered them calmly, and it had all worked out well.

  After residency, Samantha Potter had gone straight into the teaching of anatomy at the state university’s medical school in Worcester. Gwen Bennett had joined the established practice of a gynecologist in Framingham and already had begun working part-time in the Family Planning abortion clinic. The three of them remained close friends and political allies. Gwen and Samantha, as well as a number of other women and several forward-thinking male doctors, had backed R.J. resolutely when she proposed the establishment of the Premenstrual Syndrome Clinic at the hospital, and after a period of infighting with a few physicians who thought it a waste of budgetary funds, the PMS clinic had become an established service and part of the teaching curriculum.

  All the controversy had been particularly hard on Professor Cole. He was very much a member of the medical establishment, and the harsh criticism of his daughter, particularly the implication that she was sometimes a traitor to her fellow physicians, had been hard for him to bear. But R.J. knew he was proud of her. He had stood by her repeatedly despite their earlier difficulties. Their relationship was strong, and now she didn’t hesitate to turn to her father again.

  14

  THE LAST COWGIRL

  They met for dinner at Pinerola’s, a restaurant in the North End. When she had first gone there with Charlie Harris she had to walk down a narrow alley between tenement buildings, then up a tall flight of stairs into what was essentially a kitchen with three small tables. Carla Pinerola was the cook, assisted by her elderly mother, who shouted and grumbled at her a lot. Carla was middleaged, sexy, a character. She had had a husband who beat her; sometimes when R.J. and Charlie came into the restaurant there was a bruise on Carla’s arm or she had a black eye. Now the old mother was dead, and Carla was never visible; she had bought one of the tenement buildings and gutted the first and second floors, turning them into a large and comfortable eating place. Now there was always a long line of patrons waiting for tables, businesspeople, college kids. R.J. still liked it; the food was almost as good as in the old days, and she had learned never to go there without a reservation.

  She sat and watched her father hurrying toward her, slightly late. His hair had become almost completely gray. Seeing him reminded her that she was getting older, too.

  They ordered antipasto, veal marsala, and the house wine, and talked of the Red Sox and what was happening to theater in Boston and the fact that the arthritis in his hands was becoming quite painful.

  Sipping her wine, she told him she was preparing to go into private practice in Woodfield.

  “Why private practice?” He was clearly astonished, clearly troubled. “And why in such a place?”

  “It’s time for me to get away from Boston. Not as a doctor, as a person.”

  Professor Cole nodded. “I accept that. But why not go to another medical center? Or work for … I don’t know, a medical-legal institute?”

  She had received a letter from Roger Carleton at Hopkins saying that at present no money was budgeted for a position that would suit her, but he could arrange to have her working in Baltimore in six months. She had received a fax from Irving Simpson saying they would like to put her to work at Penn, and would she come to Philadelphia to talk about money?

  “I don’t want to do those things. I want to become a real doctor.”

  “For God’s sake, R.J.! What are you now?”

  “I want to be a private practitioner in a small town.” She smiled. “I think I’m a throwback to your grandfather.”

  Professor Cole struggled for control, studying his poor child who had chosen to swim against the current all her life. “There’s a reason why seventy-two percent of American doctors are specialists, R.J. Specialists make big money, two or three times more than primary care physicians, and they get to sleep through the night. If you become a country doctor, you’ll make a harder, tougher living. You know what I would do if I were your age, in
your position, no dependents? I’d go back for all the training I could force myself to accept. I’d become a superspecialist.”

  R.J. groaned. “No more externships, my Poppy, and certainly no more residencies. I want to look beyond the technology, beyond all those machines, and see the human beings. I’m going to become a rural physician. I’m prepared to earn less. I want the life.”

  “The life?” He shook his head. “R.J., you’re like that last cowboy fella they keep writing books and songs about, who saddles up his bronc and goes riding through endless traffic jams and housing tracts, searching for the vanished prairie.”

  She smiled and took his hand. “The prairie may be gone, Pop, but the hills are right out there on the other side of the state, full of people who need a doctor. Family practice is the purest kind of medicine. I’m going to give it to myself as a gift.”

  They took a long time over the meal, talking. She listened carefully, aware that her father knew a great deal about medicine.

  “A few years from now, you won’t be able to recognize the American health care system. It’s going to change drastically,” he said. “The presidential race is waxing hotter and hotter, and Bill Clinton has been promising the American people that everybody is going to have health insurance if he is elected.”

  “Do you think he can deliver?”

  “I really think he’s going to try. He seems to be the first politician to give a damn that there are poor people without care, to confess he’s ashamed of what we have now. Universal medical insurance would make things better for you primary care physicians, while lowering the incomes of specialists. We’ll have to wait and see what happens.”