by Robin Cook
“Give me the slice one centimeter lower!” He studied the requested image and suddenly he was sure. There were two small irregularities present. “Go back to the original image you had up, the one that’s still being formed.”
“Coming up,” the technician responded.
The irregularities were in this image, too. George took a laser pointer from the pocket of his white coat and lit up the irregularities.
“That doesn’t look good,” he said.
Claudine and the technician studied the frame. Out of the various shades of gray they could now see the two lesions.
“My goodness,” Claudine said. “You are right.”
“It’s pretty damn subtle,” Susan said.
George stepped over to a hospital computer monitor and called up Tarkington’s previous MRI, quickly locating slices from the same location in the liver. They had been normal. The lesions were new. George paused a moment to think about what that could mean. On one level, their discovery meant George was doing his job well. But to the anxious man in the adjacent room with his head stuffed into a 3.0-tesla-strength magnet—a magnetic field 60,000 times the strength of the Earth’s—it meant something quite different. The incongruity of such a situation never failed to discomfit George. It also brought up his raw emotions about Kasey’s sudden death. The image of her face in its mask of death—its frozen pallor, the staring eyes, the dilated pupils—confronted him.
“You okay?” Claudine asked, eyeing him.
“Yeah. Fine. Thanks.”
But he wasn’t. Burying a problem only made it fester. The clarity with which Kasey’s death face appeared in his mind’s eye scared him. In the wake of her death he had discovered she’d just been diagnosed with very aggressive stage-four, grade-three ovarian cancer found by a CT scan she’d had at Santa Monica University Hospital. The test had been performed on the Friday before her death, which was early on a Monday morning, so she hadn’t even been told yet. Since the hospital was a sister hospital to George’s, he had used his resident’s access code to view the study. It had been a violation of HIPAA regulations, but at the time he couldn’t help himself. He was lucky he hadn’t been prosecuted, due to the circumstances, yet he had been worried.
“Let’s finish the study,” George said, shaking himself free of his disturbing thoughts.
“There’s only fourteen minutes to go,” Susan said.
Returning to his chair, George forced himself to go back to flipping through the radiology journal, trying not to think. For a time no one talked. No other abnormalities were found besides the two small lesions, which were undoubtedly tumors, but the implications of that finding hung like a miasma over the control room.
“I’m afraid,” Claudine said, breaking the silence and giving voice to what they were all thinking, “that, with the patient’s history, the lesions are most likely metastases of the patient’s original pancreatic tumor.”
George nodded, and said churlishly, mostly to Claudine, “Okay, now, quick reminder: We do not say or indicate in any manner anything to the patient, beyond mentioning that the test went well, which it did. The material will be read by the senior radiology attending, and a report will be sent to the patient’s oncologist and primary-care doctor. Any ‘informing’ will be done by them. Understood?”
Claudine nodded. She certainly understood, but the admonishment and its tone came across harsher than George had intended and created an uncomfortable silence. Susan looked down, busying herself by arranging her paperwork just so.
George realized how he sounded and launched into a little damage control. “I’m sorry. That was uncalled-for. You’re doing a great job, Claudine. Not just today, but in your whole month of rotation.” He meant it, too. Claudine relaxed visibly and even smiled. George sighed as the previous awkwardness dissolved. He needed to get a grip on himself.
“What’s our schedule for the rest of the day?” he asked.
Claudine consulted her iPad. “Two more MRIs. One at eleven, the other at one thirty. Then, of course, whatever comes in from emergency.”
“Any trouble with the two scheduled MRIs, you think?”
“No. Why?”
“I have to step out for two or three hours. I want to go to a conference over in Century City. Amalgamated Healthcare, the insurance giant and our hospital’s new owner, has a presentation planned for would-be investors. It’s something about a new solution they have come up with to end the shortage of primary-care physicians. Can you imagine: a health insurance company solving the primary-care shortage? What a stretch.”
“Oh, sure! An insurance company solution to the lack of primary-care physicians,” Claudine mocked skeptically. “Now, that sounds like a fantasy if I ever heard one, especially with Obamacare adding thirty million previously uninsured into a system that was already functioning poorly.”
“You sure the presentation isn’t being held down at Disneyland?” Susan said as she prepared to go into the imaging room to see to the patient, who at the moment was being slid out of the MRI machine by an attendant.
“Might as well be,” George said. Even though they were making light of the situation, it was a serious issue. “I’m really curious what they are going to say. It would take a decade, at the very least, to train enough doctors to fill the gap, provided they can talk doctors into practicing primary care, which isn’t a given. Anyway, I’d like to go hear what they have to say, if you don’t have any problem.”
“Me?” Claudine asked. She shook her head. “I don’t have a problem. Knock yourself out!”
“Are you sure?”
“Very sure.”
“Okay. Text me if you need me. I can make it back in about fifteen minutes if I’m needed.”
“No prob,” Claudine said. “Gotcha covered.”
“We’ll review them when I get back.” He paused. “You sure you’re okay with this—my leaving?”
“Yes, of course. I’ll be working with Susan again. She doesn’t need either one of us.”
Susan grinned at the compliment.
“Okay, great. Let’s all go in and talk with the patient,” George said, motioning them toward the door.
They put on game faces and entered the imaging chamber. Tarkington was sitting on the edge of the bed, smiling nervously. He was obviously eager for some positive feedback.
The doctors were all careful not to divulge the bad news, knowing that it would most likely mean more chemotherapy, despite the man’s tenuous kidney function. Claudine spoke as reassuringly as she could while George and Susan nodded.
Then, as the attendant and Susan got the patient onto his feet, George and Claudine retreated back to the safety of the control room. Talking with a patient destined to receive very bad news underlined the fragility of life. There was no way to be detached about it.
“That sucked,” Claudine said, sinking into a chair. “I hate not being forthright and honest. I didn’t think that was going to be part of being a doctor.”
“You’ll get over it,” George said with a casualness he didn’t feel.
She looked at him, stunned.
“I didn’t mean it like that. But you will get over it.” George didn’t know why he had just said that. He hadn’t gotten over anything of the sort. He hedged a little. “To some degree, anyway. You have to, or you won’t be able to do your job. It’s not the ‘not being honest’ part that bothers me as much as the shitty situation itself. We just had a conversation with a very nice man in the prime of his life, with a family, who will in all likelihood soon die. That will always suck.” George busied himself with the files of the upcoming cases so as to not have to look directly at Claudine. “But you have to compartmentalize your feelings so you can continue to do your job, which will help save the lives of those who can be helped.”
She looked at him.
George sensed her gaze and felt bad. Rep
eated exposure to such cases had not deadened his own feelings. He looked up at her. “Look . . . ,” he said, searching for the right words. “It’s part of why I went into radiology. So there would be a buffer between me and the patient. I figured if I could deal with the images rather than the patient, I would be better equipped to handle my job.” He motioned to the adjacent room, where they had just left Tarkington. “But as you can see, the buffer has holes in it.”
They both sat silent for a moment, then George moved to the door. “Well, I have to get a move on—”
“Me, too,” Claudine said softly.
George looked at her quizzically: Me, too, what?
“It’s why I went into radiology. And thanks . . . for the honesty.”
George gave her a melancholy smile and left the room.
2
CENTURY PLAZA HOTEL
CENTURY CITY, LOS ANGELES, CALIFORNIA
MONDAY, JUNE 30, 2014, 9:51 A.M.
As George walked into the presentation, he felt like a fish out of water. It was obvious to him that the event was primarily for prospective investors in Amalgamated Healthcare. The room was filled with “people of resources.” In other words, people unlike him. George was immediately struck by their custom-tailored business suits, four-hundred-dollar haircuts, and general air of superiority. He was aware that Amalgamated had recently acquired a number of health care companies and hospitals, including the medical center where he worked. The prospect of offering health insurance on a national scale rather than on a state-by-state basis had been part of their acquisition strategy. George assumed the company had thoroughly combed through the 2,700-plus pages of the Affordable Care Act—aka Obamacare—determined to exploit all of the changes mandating health insurance for everyone.
George pushed through the crowd at the back of the room, thankful he had left his white coat back at the hospital. As it was, he wouldn’t have been surprised if someone attempted to order him out, thinking he was crashing the party. As he walked down one of the aisles, someone handed him a fancy prospectus filled with spreadsheets and financial data. He felt a rush of déjà vu. It was as if he were glimpsing an alternative life he had turned his back on. When he first walked into Columbia University as an undergraduate all those years before, he had already narrowed down his career choices to going either into business or to medical school. By the end of his first year he had veered toward medicine, a choice Kasey had made him come to understand. Had he taken the alternative, he would have felt at home here. This could have been his life. He might even have some money in the bank rather than a mountain of debt. He tried to shut off such thinking; that was another life, another world, another dream. He forced himself to focus on the moment.
There was seating for several hundred people in the room. He noticed several IT barons representing Apple, Oracle, Google, and Microsoft, along with a few well-known hedge fund guys in a reserved section at the front. George frequently watched CNBC while on the treadmill, so he recognized some of the players. The gathering here was like the Fortune 500 version of an Oscar party. Attendees were being served refreshments by a flock of extremely tall and gorgeous young women in futuristic white uniforms.
On the dais at the front of the room were four stainless-steel-and-white-Ultrasuede modern club chairs. Expensive-looking, even from a distance, each one probably worth more than George’s car. Directly behind the stage was an enormous LED screen with two other equally sized screens on either side, at forty-five-degree angles. Amalgamated Healthcare was spelled on each in bold black letters. The room itself also was mostly white, with row upon row of padded Ultrasuede seats with folded writing arms. Also white, of course. George was impressed, making him wonder if the presentation had been arranged by the same consultants who handled the iPhone and iPad product releases for Apple.
George took a seat in the very last row and waited. At exactly ten o’clock the room lights dimmed, and four people appeared on the speakers’ platform: three men and one woman. At the same time, a choral group, reminding George of Celtic pop music, could be heard very faintly from hidden speakers, giving the event an ethereal atmosphere.
George’s eyes were drawn to the woman. He recognized her immediately. Her name was Paula Stonebrenner, and it was because of her that he’d been invited to this presentation. Paula was dressed in a smart business suit, with just enough white ruffles around her neck to broadcast her femininity. She was attractive in a classic, Ivy League fashion.
Paula had been George’s classmate at Columbia Medical School, and he had gotten to know her reasonably well back then. “Reasonably well,” as in they hooked up once or twice. They had been attracted to each other in the first weeks of medical school and ended up going out for drinks with some other new friends, and one thing led to another. “Another” being the roof of Bard Hall, the medical school dorm at Columbia. George still considered it the most risqué sexual episode of his life.
After the initial sparks George’s interest abruptly waned when he discovered another Columbia classmate, Pia Grazdani. Pia was dark, exotic, and an off-the-charts gorgeous mix of Italian and Albanian heritage. Her mere presence swept him off his feet. Her aloof manner captivated him. And her callousness stomped on his heart. She resisted any and all attempts at friendship, let alone romance. Throughout high school and college George had never had trouble getting women to go out with him. He had an outgoing personality and was a starter on all the right sports teams. He was used to being the one to call the shots. Not so with Pia.
Prior to Pia, George had been one to avoid commitment. He would rationalize his quick departure from relationships as his version of “compassion,” likening his exit to a girl getting stung by a bee. It hurt briefly but was quickly forgotten. And it wasn’t like he was being selfish—all through high school and college his desire to succeed, whether as a doctor or businessman, had taken precedence over social attachment, which for him had been more about entertainment than an opportunity for self-learning.
George understood all this now, even though he hadn’t in the past. And again, it was all because of Kasey and her unique understanding of interpersonal relationships. She had a natural intuition about people that had drawn George to her like a hungry mouse to cheese. Kasey was the first woman who had become a best friend and confidante to George before becoming a lover. It had been a revelation for George, a kind of rebirth that made him understand what he had been missing.
Today George had to admit that Paula looked fantastic. He also had to admit that he really didn’t know anything about her other than she was smart as a whip, fun to be with, and what he used to call a “live wire.” After being essentially dumped for Pia, Paula had acted the part of spurned lover. She wouldn’t even talk to George for the rest of that year. But by the second year, she didn’t seem to care. They happened to live in adjacent dorm rooms and had a hard time ignoring each other anyway. By their final year they were friends, or at least friendly acquaintances.
For a moment George entertained the idea of walking down to the dais and saying hello to Paula, but then chickened out. Instead he watched with growing fascination as she interacted comfortably with the three men on the stage and with some of the financial VIPs in the reserved section at the front. She took a seat in one of the club chairs with two of the accompanying men. The third man stepped forward to speak. From George’s perspective he was extremely impressive. He was meticulously dressed, standing ramrod straight with a commanding, almost military presence. His graying hair literally sparkled in the glare of the halogen spotlights. On the huge LED screen behind him appeared his name: Bradley Thorn, Amalgamated’s president and CEO.
“Welcome!” Thorn boomed with a broad smile. Without a visible microphone, his voice filled the large room. George wasn’t surprised. Everything was wireless these days.
Conversation hushed. People who had not yet found a place now rushed for a chair. George glanced back at Pau
la as well as the other two men seated beside her. With sudden shock George recognized one of them, and scrunched down in his seat, as if that would keep him from being seen. His pulse picked up.
“Oh, shit,” he murmured.
3
CENTURY PLAZA HOTEL
CENTURY CITY, LOS ANGELES, CALIFORNIA
MONDAY, JUNE 30, 2014, 10:02 A.M.
Sitting on the stage was the internationally known radiologist Dr. Clayton Hanson. He was also the chair of the residency training program at L.A. University Medical Center, someone George happened to know quite well, better than any of the other professors and attendings. He was essentially George’s boss, and George was currently playing hooky. The reason they knew each other well was because, besides being George’s superior, Clayton considered himself to be a lothario (the man was not without ego), and he had hit on Kasey even when he knew she and George were an item, although that was before the engagement.
The year before George arrived on the scene, Clayton had divorced a fading actress after twelve years of a dysfunctional marriage and was intent on making up for lost time. George had heard rumors that Clayton’s frequent transgressions had been a significant factor in his former wife’s decision to seek the divorce.
As George was one of the few unmarried residents, Clayton had initially sought him out for hints on how to meet some of the young fillies (Clayton’s word) that he assumed George would be privy to. That had never come to pass, but over time Clayton and George had established a friendship of sorts that for the most part had evolved into Clayton’s trying to fix George up with the women so that he, Clayton, could meet their friends.
George’s immediate problem was that before coming to the presentation he hadn’t bothered to get permission to leave the hospital, so he was AWOL with one of the radiology bigwigs onstage in front of him. Even though it was his last day of an easy rotation, and he had covered himself, he felt uncomfortable. He considered getting up and walking out but decided doing so would call more attention to him than just remaining in his seat. Luckily he was a good distance from the dais, and Clayton showed no sign of having spotted his resident.