Crisis

by Robin Cook

  “So it is inefficient.”

  “Yes, you could say that.”

  “What is the opinion of patients about house calls?”

  “Objection!” Tony called out, semi-rising from his chair. “Hearsay.”

  Judge Davidson snapped off his reading glasses and glared down at Tony with irritable disbelief.

  “Overruled!” he snapped. “As a patient, which we all are at some point, Dr. Brown would be talking from experience. Proceed.”

  “Would you like me to repeat my question?” Randolph asked.

  “No,” Dr. Brown said. He hesitated. “Patients generally like house calls.”

  “How do you think Patience Stanhope felt about house calls?”

  “Objection!” Tony said, rising again. “Supposition. There’s no way the witness would know how the deceased felt about house calls.”

  “Sustained,” Judge Davidson said with a sigh.

  “I assume you read the medical records supplied to the plaintiff.”

  “Yes, I read them.”

  “So you are aware that Dr. Bowman made many house calls to tend to Patience Stanhope prior to the evening in question, often in the middle of the night. From reading these records, what was the usual diagnosis on these visits?”

  “Anxiety reaction manifesting itself mostly in gastrointestinal complaints.”

  “And the treatment?”

  “Symptomatic and placebo.”

  “Was pain ever involved?”

  “Yes.”

  “Where was the pain?”

  “Mostly low abdominal but occasionally midepigastric.”

  “Pain in the latter location is occasionally reported as chest pain. Is that correct?”

  “Yes, that’s correct.”

  “From your reading of the record, would you say that Patience Stanhope exhibited at least some evidence of hypochondriasis?”

  “Objection!” Tony called out but stayed in his chair. “Hypochondriasis is never mentioned in the record.”

  “Overruled,” Judge Davidson said. “The court would like to remind the plaintiff’s attorney that the witness is his medical expert.”

  “From reading the record, I believe it would be a safe assumption that some element of hypochondriasis was involved.”

  “Does the fact that Dr. Bowman made repeated house calls, which you have said most doctors do not favor, often in the middle of the night to a woman with avowed hypochondriasis, say something to you as a physician about Dr. Bowman’s attitude and compassion for his patients?”

  “No, it does not.”

  Randolph stiffened with surprise, and his eyebrows rose. “Your response defies rationality. Can you explain?”

  “It is my understanding that house calls are one of the perquisites that patients expect when they pay high retainer fees, sometimes as high as twenty thousand dollars a year, to be part of a concierge medical practice. Under such a circumstance, one cannot say Dr. Bowman’s making house calls necessarily reflects beneficence or altruism.”

  “But it might.”

  “Yes, it might.”

  “Tell me, Dr. Brown, are you biased against concierge medicine?”

  “Of course I’m biased against concierge medicine,” Dr. Brown sputtered. Up until that moment, he had maintained a detached coolness, not too dissimilar to Randolph’s. It was clear that Randolph’s questions had challenged him.

  “Can you tell the court why you feel so strongly?”

  Dr. Brown took a breath to calm himself. “Concierge medicine flies in the face of one of the three basic principles of medical professionalism.”

  “Perhaps you could elaborate.”

  “Of course,” Dr. Brown said, lapsing into his familiar professional role. “Besides patient welfare and patient autonomy, the principle of social justice is a key underpinning of twenty-first-century medical professionalism. The practice of concierge medicine is the absolute opposite of trying to eliminate discrimination in health care, which is the key issue of social justice.”

  “Do you believe that your strong feelings in this regard might compromise your ability to be impartial concerning Dr. Bowman?”

  “I do not.”

  “Perhaps you could tell us why, since, to use your words, it ‘flies in the face’ of rationality.”

  “As a well-informed internist, Dr. Bowman knows that the symptoms women experience with myocardial infarction do not follow the classic symptoms experienced by men. As soon as an internist thinks about a heart attack in a female, particularly a postmenopausal female, he should act as if it were a heart attack until proven otherwise. There’s a parallel in pediatrics: If the thought of meningitis occurs to a physician with a pediatric patient, the physician is obligated to proceed as if it is and do a spinal tap. Same with a female and a possible heart attack. Dr. Bowman suspected a heart attack, and he should have acted accordingly.”

  “Dr. Brown,” Randolph said. “It is often said that medicine is more of an art than a science. Can you tell us what that means?”

  “It means that factual information is not enough. A doctor must use his judgment as well, and since this is not an objective arena that can be studied, it is labeled an art.”

  “So scientific medical knowledge has its limits.”

  “Exactly. No two humans are exactly the same, even identical twins.”

  “Would you say that the situation Dr. Bowman faced on the evening of September eighth, 2005, when he was called to see for the second time in the same day a woman whom he knew was hypochondriacal, called for a large measure of judgment?”

  “All medical situations call for judgment.”

  “I’m asking specifically about the evening in question.”

  “Yes. It would have called for a large measure of judgment.”

  “Thank you, doctor,” Randolph said, gathering up his notes. “No more questions.”

  “The witness may be excused,” Judge Davidson said. Then, turning to the jurors, he added, “It is nearing the noon hour, and it looks to me as if you could all use some sustenance. I know I could. Remember not to discuss the case with anyone or among yourselves.” He cracked the gavel. “Court’s adjourned until one thirty.”

  “All rise,” the court officer called out as the judge stepped down from the bench and disappeared into his chambers.

  11

  BOSTON, MASSACHUSETTS

  Wednesday, June 7, 2006

  12:30 p.m.

  Alexis, Craig, and Jack had found a small, noisy sandwich shop that looked out onto the broad Government Center esplanade. Randolph had been invited, but he’d begged off, claiming he had preparation to do. It was a beautiful late-spring day, and the esplanade was full of people escaping from their confining offices for a bit of sunshine and fresh air. Boston struck Jack as an outdoor city much more so than New York.

  Craig had been his usual brooding self at first, but had begun to relax and join the conversation.

  “You haven’t mentioned the autopsy,” Craig said suddenly. “What’s the status?”

  “It’s in the hands of a funeral director at the moment,” Jack said. “He’s got to take the paperwork to the health department and arrange for opening the grave and transporting the coffin.”

  “So it’s still a go?”

  “We are trying,” Jack said. “Earlier I was hoping it might happen this afternoon, but since there’s been no word, I guess we’ll have to aim for tomorrow.”

  “The judge wants the case to go to the jury on Friday,” Craig said discouragingly. “Tomorrow might be too late. I hate to put you through all this effort for nothing.”

  “Maybe it is futile,” Alexis agreed dejectedly. “Maybe it is all for nothing.”

  Jack looked from one to the other. “Hey, come on, you guys. I don’t see it for nothing. It gives me the sense I’m doing something. And besides, I’m interested the more I think about the cyanosis issue.”

  “Why exactly?” Alexis questioned. “Explain it to me again.”
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  “Don’t get him started!” Craig said. “I don’t want to raise any false hopes. Let’s analyze this morning’s proceedings.”

  “I didn’t think you wanted to talk about it,” Alexis said with some surprise.

  “Actually, I’d rather forget about it, but unfortunately, I don’t have that luxury if we’re going to make any changes.”

  Both Craig and Alexis eyed Jack expectantly.

  “What is this?” Jack questioned with a wry smile, looking from one to the other. “An interrogation? Why me?”

  “You can be the most objective of all of us,” Alexis said. “That’s obvious.”

  “How do you feel Randolph is doing, now that you’ve seen more of him in action?” Craig asked. “I’m worried. I don’t want to lose this case, and not just because there was no negligence involved. My reputation will be in the gutter. That last witness had been my preceptor in medical school, as he said, and my attending as a resident. I worshipped that guy, and still do professionally.”

  “I can understand how devastating and humiliating this has to be,” Jack replied. “With that said, I think Randolph is doing a good job. He neutralized most of what Tony established with Dr. Brown. So I suppose I have to say from what I saw this morning it was a wash. The problem is that Tony is more entertaining, but that’s not enough to switch attorneys in midstream.”

  “What Randolph didn’t neutralize was Dr. Brown’s powerful analogy about a pediatric patient and meningitis. He’s right, because that is the way you have to respond to a postmenopausal female when you even think she might be having a heart attack. Women don’t have the same symptoms as men in a surprising number of cases. Maybe I screwed up, because a heart attack did pass through my mind.”

  “Second-guessing oneself is a rampant tendency in physicians in every case of adverse outcome,” Jack reminded Craig. “It’s especially so when there’s alleged malpractice. The reality is you bent over backward with this woman, who was actually taking advantage of you. I know it’s not politically correct to say that, but it is true. With all her false alarms, calling you out in the middle of the night, there’s no wonder your index of suspicion of real illness would have been down in the lower basement.”

  “Thank you,” Craig said with his shoulders sagging. “It means a lot to me to hear you say that.”

  “The trouble is, Randolph must make the jury understand that. That’s it in a nutshell. And keep in mind Randolph hasn’t presented his case. You have your own experts who are willing to testify to exactly what I outlined.”

  Craig took a deep breath and let it out noisily. He nodded a few times. “You’re right. I can’t give up, but tomorrow I’ll have to testify.”

  “I would think you would be looking forward to it,” Jack said. “You are the one more than anyone else who knows exactly what happened and when.”

  “I understand that perfectly well,” Craig said. “The problem is I despise Tony Fasano so much, I have trouble keeping my cool. You’ve read the deposition. He got to me. Randolph advised me not to appear arrogant; I appeared arrogant. Randolph advised me not to get into an argument; I got into an argument. Randolph advised me not to get angry; I got angry. Randolph advised me only to answer each question; I flew off on a tangent, trying to justify honest mistakes. I was terrible, and I’m afraid it might happen all over again. I’m not good at this.”

  “Consider your deposition a learning experience,” Jack said. “And remember: The deposition lasted two days. The judge will not allow that. He’s the one who wants this trial brought to an end by Friday.”

  “I suppose it boils down to the fact that I don’t trust myself,” Craig said. “The one good aspect of this whole damn affair is that it has forced me to look at myself in the proverbial mirror. The reason Tony Fasano got me to appear arrogant is because I am arrogant. I know it’s not politically correct to say so, but I am the best doctor I know. I’ve had confirmation in so many different ways. I’ve always been one of the best students, if not the best, throughout my training, and I’ve become addicted to acclaim. I want to hear it, which is why the reverse, like what I’m hearing throughout this malpractice ordeal, is so goddamn distressing and humiliating.”

  Craig fell silent after his outburst. Both Alexis and Jack were dumbfounded and momentarily speechless. The waiter came over and bused away the dirty dishes. Alexis and Jack glanced briefly at each other and went back to staring wide-eyed at Craig.

  “Somebody say something!” Craig demanded.

  Alexis spread her hands palms up and shook her head. “I don’t quite know what to say. I don’t know whether to respond emotionally or professionally.”

  “Try professionally. I think I need the reality check. I’m in free fall here. And you know why? I’ll tell you why. When I went to college and worked my balls off, I thought it sucked but that once I got into medical school, I’d be home free. Well, medical school sucked, too, so I looked forward to residency. You’re probably getting the picture. Well, residency was no picnic, yet around the corner was opening my practice. That’s when reality really set in, thanks to insurance companies and managed care and all the bullshit that has to be endured.”

  Jack looked at Alexis. He could tell she was struggling with what to say to these sudden revelations, but he was hoping she’d come up with something, since he was incapable. He was shocked by Craig’s monologue. Psychology was not his forte by any stretch of the imagination. There’d been a time when it was all he could do to hold himself together.

  “Your insight is dramatic,” Alexis began.

  “Don’t give me any patronizing bullshit,” Craig snapped.

  “Believe me, I’m not,” Alexis said. “I’m impressed. Truly! What you are trying to communicate is that your romantic nature has been constantly suffering disillusionment as reality has failed to meet your idealized expectations. Every time you get to a goal, it was not what you thought it would be. That’s tragic.”

  Craig rolled his eyes. “That sounds like bullshit to me.”

  “It’s not,” Alexis insisted. “Think about it.”

  Craig pressed his lips together and knitted his brows for a long moment. “Okay,” he said finally. “It does make sense. Yet it seems like a damn convoluted way of saying, ‘Things just haven’t quite worked out.’ But then again, I’ve never been up on psychologyspeak.”

  “You have been struggling with some conflicts,” Alexis continued. “It’s not been easy for you.”

  “Oh, really,” Craig said with a touch of superciliousness.

  “Now, don’t get defensive,” Alexis urged. “You specifically asked for my professional response.”

  “You’re right! Sorry! Let me hear the conflicts.”

  “The easiest one is your conflict between clinical medicine and research medicine. That has caused you some anxiety in the past because of your need to apply yourself one hundred percent in any pursuit, but in this case, you’ve been able to strike a balance. A more problematic conflict is between devoting yourself to your practice or devoting yourself to your family. This has caused a lot of anxiety.”

  Craig stared back at Alexis but remained silent.

  “For obvious reasons, I cannot be objective,” Alexis continued. “What I’d like to do is encourage you to explore these insights of yours with a professional individual.”

  “I don’t like to ask for help,” Craig said.

  “I know, but even that attitude says something that might be valuable for you to explore.” Alexis turned to Jack. “Do you want to add anything?”

  Jack raised his hands. “Nope. This is an arena I’m not good at.” Actually, what he was thinking was that he’d been struggling with his own conflicts—namely, whether to start a new family with Laurie, as he was scheduled to do come Friday. For many years he’d said no, he didn’t deserve to be happy, and that another family would demean his first. But then as the years had gone by, it had changed to a fear of putting Laurie at risk. Jack had struggled with the adm
ittedly irrational fear that his loving someone put them in jeopardy.

  The conversation took a lighter turn, and Jack seized the moment to excuse himself to use his phone. Walking out onto the bricked esplanade, he dialed the OCME. He had meant to leave a message with Calvin’s secretary. His hope was that Calvin would be out of the office at lunch. Unfortunately, that wasn’t the case. It was the secretary who was out to lunch. Calvin answered the phone.

  “When the hell are you getting yourself back here?” Calvin demanded when he heard Jack’s voice.

  “It’s looking bad,” Jack said. He then had to hold the phone away from his ear while Calvin cursed and carried on about Jack’s irresponsibility. After Jack heard, “What the hell are you doing, anyway?” he put the phone back to his ear and explained the proposed autopsy. He told Calvin about being introduced to the Boston chief medical examiner, Dr. Kevin Carson.

  “Really! How is that old southern boy?” Calvin questioned.

  “Seemed fine to me. He was in the middle of a case when I met him, so we chatted only briefly.”

  “Did he ask for me?”

  “Oh, yeah!” Jack lied. “He said to say hello.”

  “Well, tell him hello from me if you see him again. And then get back here. I don’t have to tell you that you’ve got Laurie all up in arms with the big day just around the corner. You’re not going to try to rush down here at the last minute, are you?”

  “Of course not,” Jack said. He knew that Calvin was one of the people from the office she’d insisted on inviting. If it had been up to him, he wouldn’t have invited anyone other than Chet, his office mate. The office already knew too much about their private life.

  After finding Craig and Alexis, whom Jack joined for a short stroll in the sunshine, they returned to the courthouse. When they arrived outside the courtroom, other people were just filing in. It was quarter after one. They followed suit.

  Craig went through the bar with Randolph and his assistant. Jordan Stanhope was already at the plaintiff’s table with Tony Fasano and Renee Relf. Jack guessed that Tony was giving Jordan last-minute advice before his testimony. Although the sound of his voice was lost in the general babble of the room, his lips were moving rapidly, and he was gesticulating with both hands.