The Cole Trilogy: The Physician, Shaman And Matters Of Choice Part 142

It turned out that it might not be at all nice for George.

"Harold is what they call HIV positive. He's coming here with his friend Eugene. They've been living together for nine years...." He seemed to lose his train of thought and then found it again with a start. "Well, he's going to need a doctor's care."

R.J. put her hand on George's hand. "I'll look forward to meeting him and being his doctor," she said, and squeezed his hand. George Palmer smiled at her and thanked her and left her office.

There wasn't a great deal of forest between the end of the trail and her house, but the sadly sagged bridge had dampened her enthusiasm for trail building, and she turned to her vegetable garden with relief. It was too early for tender vegetables. The gardening books said she should have planted peas several weeks earlier instead of working in the woods, but the cool mountain climate gave her leeway, and she spread peat moss, compost, and two bags of purchased greensand on the raised beds that she and David had made, and dug everything in. She planted edible pod peas, of which she was especially fond, and spinach, knowing that neither would be bothered by the heavy frosts that still fell at night with regularity.

She watered carefully-not too much, to avoid damping off; not too little, to avoid aridness-and was rewarded by a row of seedlings that lasted scarcely a week. At the end of that time they had vanished, and the clue to where they had gone was a single perfect print in the velvet earth.

A small deer.

That night she went for coffee and dessert to the Smiths' house and told them what had happened. "What do I do now? Replant?"

"You can," Toby said. "You might still have time to get a crop."

"But there are a whole lot of deer out in the woods," Jan said. "You'd better take steps to keep the wild animals away from your garden."

"You're the fish and game expert," R.J. said. "So how do I do that?"

"Well, some folks collect human hair from barbershops and spread it around. I've tried that myself. Sometimes it works, sometimes it doesn't."

"How do you protect your own garden?"

"We pee all around it," Toby said calmly. "Well, I don't." She jerked her thumb at her husband. "He does."

Jan nodded. "Best thing. One whiff of human p.i.s.s, the critters find an excuse to make a business trip elsewhere. That's what you should use."

"Easy for you to say. There is a certain physiological dissimilarity that makes my situation more difficult than your own when it comes to spraying. Would you consider coming over to my place, and ...?"

"Nope," Toby said firmly. "His supply is limited, and spoken for."

Jan grinned and offered a final word of advice. "Use a paper cup."

That was what she did, after replanting her peas. The problem was, she had a very limited supply too, even when she forced herself to drink more fluids than her thirst demanded. But she anointed the area next to the portion of the raised bed where she had replanted her peas, and this time when the seedlings came up, they weren't eaten.

One day R.J. heard a sound like multiple motors in her backyard, and when she left the house she saw that a buzzing host was lifting from one of the hives. Thousands of bees rose in twisting, dancing ropes that coalesced and merged at roof height into a thick column that looked almost solid at times, so closely packed and mult.i.tudinous were the small black bodies. The column became a cloud that contracted and expanded, s.h.i.+fted and grew, and eventually it lifted and moved darkly over the trees and into the woods.

Two days later, another hive swarmed. David had worked hard on his bees, and R.J. had ignored them, but their loss gave her no feelings of guilt. She was busy with her own work and interests, and she had decided that she had her own life to live.

The afternoon of the second swarm she received a telephone call at the office. Gwen Gabler was coming from Idaho to visit her. "I need to be in western Ma.s.sachusetts for a couple of weeks. I'll explain when I see you," Gwen said.

Marital problems? But no, it didn't sound like that at all: "Phil and the boys send their love," Gwen said.

"Give my love to them. And hurry from there to here. Hurry," R.J. told her.

R.J. wanted to pick her up, but Gwen knew what a doctor's schedule was like, and she arrived by cab from the Hartford airport, the same wisea.s.s, warm, wonderful Gwen!

She came in the afternoon accompanied by a spring rainstorm, and they hugged damply and kissed and stared at one another and hooted and laughed. R.J. showed her the guest room.

"Never mind that. Where's the toilet? I've held it in since Springfield."

"First door on the left," R.J. said. "Ooh, wait." She ran into her own room, grabbed four paper cups from the bureau top, and hurried after Gwen. "Here. Would you use these, please? I'd appreciate it greatly."

Gwen stared. "You want a specimen?"

"As much as you can give. It's for the garden."

"Oh, for the garden." Gwen turned away, but her shoulders were already shaking, and in a moment she was roaring, leaning against the wall helplessly. "You haven't changed, not one marvelous cell. G.o.d, how I have missed you, R.J. Cole," she said, wiping her eyes. "For the garden?"

"Well, let me explain."

"Don't you dare. I don't ever want to hear it. Don't spoil a thing," Gwen said, and clutching the four cups, ran into the bathroom.

That night they were more serious. They stayed up and talked late, late, while outside the rain drummed against the windowpanes. Gwen listened as R.J. spoke about David and told her about Sarah. She asked a question or two and held R.J.'s hand.

"And what of you? How is life in the HMO?"

"Well, Idaho's beautiful and the people are really nice. But the Highland Family Health Center is a Health Maintenance Organization from h.e.l.l."

"Ah, Gwen, d.a.m.n. Your hopes were so high."

Gwen shrugged. She said that in the beginning it had appeared ideal. She believed in the HMO system, and she had received a bonus for signing her contract. She was guaranteed four weeks of paid vacation time and three weeks to attend professional meetings. There were a couple of doctors who seemed to her to be less than geniuses, but she saw at once that four of the staff physicians were first-rate, three men and a woman.

But almost immediately one of the good male doctors, an internist, had left the Highland Center and gone to work at a nearby Veterans Administration hospital. Then another man-the HMO's only other ob-gyn-had moved to Chicago. By the time the woman doc, a pediatrician, had bailed out, Gwen had a good idea what the exodus was about.

The management was very bad. The company owned nine HMOs throughout the western states and advertised that its driving goal was quality care, but the bottom line clearly was profit. Its regional manager, a former internist named Ralph Buchanan, now did time-and-motion studies instead of practicing medicine. Buchanan reviewed all the case reports to determine where money was "wasted" by the employee-physicians. It didn't matter whether a doctor sensed something in a patient that made him or her want to investigate further. Unless there were citable "book reasons" for ordering a test, the physician was brought to account. The company had something it called the Algorithmic Decision Tree. "If A occurs, go to B. If B happens, go to C," Gwen said. "It's truly medical practice by the numbers. The science is standardized and spelled out for you, with no allowance for individual variations and needs. Management insists that the nonclinical details of a patient's life-the background that sometimes points us to the real causes of trouble-must be ignored as a waste of time. There's absolutely no room for a doctor to practice the art of medicine."

It wasn't the HMO system that failed, Gwen insisted. "I still believe managed health care can work. I think medical science has progressed sufficiently so we can work under time and test restrictions established for each ailment, so long as the physicians have the right and ability to depart from 'the book' without having to spend time and energy defending themselves to management. But this particular HMO is owned and run by bozos." Gwen smiled. "Wait. It gets worse."

To fill in for the loss of the three good pract.i.tioners, she said, Buchanan hired what was available-an unboarded internist whose hospital privileges had been revoked for shoddy practice in Boise, a sixty-seven-year-old man who never had practiced but had spent his professional life doing research, and a young rent-a-doc general pract.i.tioner from a medical temp agency, who would work until the company was able to find another physician.

"The one remaining good physician, besides yours truly, was a bushy-tailed New Age doc in his thirties. Marty Murrow. He wore blue jeans to the office, had long hair. Actually went to medical conventions to learn new things. Tried to read everything in sight. He was a terrific young internist in love with medicine. Remember?

"Anyway, the two of us got into immediate trouble."

It began for her, she said, when the company a.s.signed "the klutz from Boise" to cover for her on her days off. Many calls ensued from her to Buchanan, at first polite and friendly, rapidly becoming acerbic. She told him that she was a boarded obstetrician-gynecologist and she wasn't going to allow an unqualified person to share responsibility for her patients. That she had inherited a lot of cases from the departed ob-gyn. That she was far beyond the case load limit specified in her contract, the limit at which she could continue to function as a physician at a quality level, and that they d.a.m.n well better find another ob-gyn to share the burden.

"Buchanan reminded me that this was a team operation, that I had to be a team player. I told him he could stuff that up his flexura sacralis recti unless he hired another qualified obstetrician. So I became an honored name on his s.h.i.+t list.

"Meanwhile, Marty Murrow was getting into far worse trouble. His contract called for him to treat sixteen hundred patients, and he was handling more than twenty-two hundred people. The lousy new doctors each were 'caring for' from four hundred to six hundred patients. The researcher just didn't know very much about internal medicine. Whenever he was in the ICU, he had to ask the nurses to write his orders for him. He lasted less than two months.

"The patients soon caught on that there were some lousy doctors at the Highland Family Health Center. When Highland got the contract to provide health care for a small factory with fifty workers, forty-eight requested Marty Murrow as their doctor. He and I began to freak out. We didn't recognize a lot of the names on the charts. Often we were asked to sign prescription forms for other doctors' patients, to order drugs for people we didn't know and whose illnesses we weren't familiar with. And because doctors were just employees, we had no control over the general lack of quality in the place."

One of the nurses, Gwen told R.J., was particularly bad. Marty Murrow caught her in repeated mistakes when she brought prescription refills for his signature-"ordering the patient to take Zantax instead of Xanax, things like that. We had to watch her." It bothered Gwen that the receptionist was rude and sarcastic in the office and over the telephone and often neglected to deliver patients' messages and questions to the doctors.

"Marty Murrow and I screamed and called them names," Gwen said. "We both telephoned Buchanan regularly to complain, which he liked because it gave him an opportunity to put us in our places by ignoring us. So Marty Murrow sat down and wrote to the president of the company, a retired urologist who lives in Los Angeles. Marty complained about the nurse, the receptionist, and Buchanan, and he asked the president to replace all three of them.

"Buchanan got a telephone call from the president and sent letters to the nurse and the receptionist informing them of Dr. Murrow's charges. When he met them subsequently, they both told him the same story: Dr. Martin B. Murrow had hara.s.sed them s.e.xually.

"One can imagine Buchanan's pleasure. He sent Dr. Martin B. Murrow a registered letter telling him of the s.e.xual hara.s.sment charges and informing him that he was suspended for two weeks while an investigation would be held. Marty has a very attractive wife he talks about all the time and two small daughters who take every moment he can spare from medicine. He told his wife what was happening. It was the beginning of a terrible experience for both of them. Buchanan confided to several people that he had suspended Marty, and why. Almost at once, some of the Murrows' friends began to hear the rumors.

"Marty telephoned his big brother, Daniel J. Murrow, a partner in the Wall Street law firm of Golding, Griffey, and Moore. And Daniel J. Murrow telephoned Buchanan and told him that indeed there should be an investigation as announced, and that his client, Dr. Martin Boyden Murrow, insisted that every single person in the office should be interviewed."

R.J. sat up a little straighter. Although she had turned her back on the law, part of her would always respond to the right kind of case. "Are you certain Marty Murrow didn't ..."

Gwen smiled and nodded. "The nurse in question is in her late fifties and quite heavy. As somebody who is getting older and fatter all the time, I don't denigrate the aging or the obese, but I don't imagine they're more s.e.xually alluring than young women who have never had to deal with cellulite. As for the receptionist, she is nineteen, but she's scrawny and nasty. There are eleven females who work with Marty regularly, and three or four of them are knockouts. Every one of them said Dr. Murrow never had hara.s.sed her. One nurse did recall a Monday morning when she told Marty she had a test for him. 'If you're such a hot diagnostician, look into Josie's and Francine's eyes, and tell us which one got laid this weekend.' He said it must have been Francine, because she was the one with the smile on her face."

"Not very incriminating," R.J. said dryly.

"That was the worst thing they were able to get on him. Neither of the two complainants could come up with specifics, and it was obvious they had colluded to bring the charge after he had complained about them. Others in the office had the same complaints about their work performance, and following the investigation the nurse and the receptionist were terminated."

"And Buchanan?"

"Dr. Buchanan still has his job. The offices he supervises turn in a very healthy profit. He sent Marty a letter informing him that the investigation had not resulted in conclusive evidence to substantiate the charges that had been made against him, therefore he was reinstated to practice medicine for the Highland Family Health Center.

"Marty replied at once that he planned to sue Buchanan and the two discharged employees for defamation of character and the HMO for breach of contract.

"The president of the company flew in from California. He met with Marty and asked him about his future plans. When Marty said he intended to go into private practice, the president said the company wanted to help him do that, to avert the negative publicity of litigation. He offered to pay for the unexpired portion of Marty's contract, fifty-two thousand in cash. In addition, Marty could take all the furnis.h.i.+ngs in his office and in his two examining rooms, as well as an EKG machine and sigmoidoscopy equipment that none of the other doctors had bothered to learn how to use. Marty agreed at once."

At that point, Gwen said, she knew she didn't want to stay at the HMO either. "But I was in a quandary. My husband had discovered that he loved to teach, and I hesitated to interfere with his career. Then, at a national meeting of business school educators in New Orleans, Phil met the dean of the business school at the University of Ma.s.sachusetts, and they both agreed he would be just right to fill an opening on the UMa.s.s business faculty.

"So I promptly threatened Buchanan with a suit of my own, for breach of contract, and after a little horse-trading, he agreed to pay our expenses when we move east. We're coming back here in September, and Phil will be teaching in Amherst."

Gwen stopped and grinned at the sight of her friend, capering like an excited and very happy child.

39.

A NAMING.

"So? What will you do when you get here?" R.J. asked.

Gwen shrugged. "I still believe managed care is America's only chance to get health coverage for everybody. I'll look for another HMO to hire me, I guess. And make certain it's a good one this time."

In the morning she went to the village with R.J. They walked the length of Main Street, and she watched wistfully as people called out a greeting to the doctor or gave R.J. a smile. In the office she went from room to room, observing everything, stopping now and again to ask a question.

While R.J. saw patients, Gwen sat in the waiting room and read gynecology journals. They ordered sandwiches at the general store for lunch.

"How many ob-gyns are there in the hilltowns?"

"None. The women have to travel to Greenfield or Amherst or Northampton. There are a couple of midwives based in Greenfield who come up into the hills. All the hilltowns are growing, Gwen, and there are enough women here now to provide a gynecologist with patients." It would be too much for her to hope that Gwen would practice in the hills, and she wasn't surprised when Gwen merely nodded and went on to talk of something else.

That evening Toby and Jan had them to dinner. During the meal the phone rang and someone reported to the fish and game officer that a hunter had wounded a bald eagle in Colrain, so as soon as he had eaten, Jan asked their forgiveness and went to see what that was all about. It was just as well. Left to their own devices, the three women settled down in the living room and talked comfortably.

R.J. had sometimes found it dangerous to meet the close friend of a close friend. The experience could go either way-jealousy and rivalry could sour the meeting, or the two newly introduced people could see in each other what their mutual friend saw in each of them. Happily, Toby and Gwen responded to one another warmly. Toby learned all about Gwen's family, and she was frank in describing her yearning for a child and the weariness she and Jan had come to feel as a result of their unsuccessful efforts.

"This woman is the best ob-gyn I have ever met," R.J. told Toby. "I'd feel so much better if she were to examine you at the office in the morning."

Toby hesitated, and then she nodded. "If it's not too great an imposition?"

"Nonsense. It's not an imposition at all," Gwen said.

Next morning, the three of them met in the inner office after the examination. "You have random abdominal pain?" Gwen said.

Toby nodded. "Sometimes."

"I wasn't able to find any overt problems," Gwen told her slowly. "But I think you should have a laparoscope, an exploratory procedure that would tell us exactly what is going on internally."

Toby made a face. "That's what R.J. has been trying to get me to do."

Gwen nodded. "That's because R.J. is a good doctor."

"Do you do laparoscopies?"

"I do pelviscopies all the time."

"Would you do mine?"

"I wish I could, Toby. I'm still licensed in Ma.s.sachusetts, but I'm not on a hospital staff. If it could be arranged before I have to go back to Idaho, I'd be happy to scrub up and partic.i.p.ate as an observer, and consult with the surgeon of record."

And that's how the arrangements were made. Dan Noyes's secretary was able to book the operating room for three days before Gwen was scheduled to go home. When R.J. talked with Dr. Noyes, he was amiably willing to have Gwen stand at his elbow as an observer.

"Why don't you come, too?" he said to R.J. "I have two elbows."

Gwen spent the next five days visiting HMOs and physicians in a number of communities located within commuting distance of Amherst. On the evening of the fifth day, she and R.J. sat and watched a televised debate about national health care in America.

It was a frustrating experience. Everyone acknowledged that the health care system in the United States was inefficient, exclusive, and too expensive. The simplest and most cost-effective plan was the "single-payer" system used by other leading nations, in which the government collected taxes and paid for the health care of all its citizens. But while American capitalism provides the best aspects of democracy, it also provides the worst, as represented by paid lobbyists applying enormous pressures on Congress to protect the rich profits of the health care industry. The enormous army of lobbyists represented private insurance companies, nursing homes, hospitals, the pharmaceutical industry, doctors' groups, labor unions, business a.s.sociations, pro-choice groups who wanted abortion paid for, anti-abortion groups who wanted abortion excluded, welfare groups, the aged ...

The fight for dollars was mean and dirty, not pretty to watch. Some Republicans admitted they wanted the health care bill killed because if it were pa.s.sed it would help the president's chances for re-election. Other Republicans declared themselves for universal health care but said they would fight to the death against either a raise in taxes or funding of health insurance by employers. Some Democrats who faced re-election campaigns and were dependent on the lobbyists for funds talked exactly like the Republicans.

The business suits on the television screens were agreeing that any plan must be phased in gently, over many years, and that they should be satisfied to cover 90 percent of the United States population eventually. Gwen got up suddenly and switched off the television in anger.

"Idiots. They talk as if ninety percent coverage would be a wonderful achievement. Don't they realize that would leave more than twenty-five million people without care? They'll end up creating a new caste of untouchables in America, millions of people who are poor enough to be allowed to sicken and die."

"What's going to happen, Gwen?"

"Oh, they'll blunder through to a workable system, after years and years of wasted time, wasted health, wasted lives. But just the fact that Bill Clinton had the courage to make them face the problem is making a difference. Superfluous hospitals are closing, others are merging. Doctors aren't ordering unnecessary procedures...."