Cell

by Robin Cook

“Please!” Thorn called out after allowing the excited murmuring that had erupted to continue, obviously enjoying the moment. “Let me make one more point before I turn the floor over to Dr. Stonebrenner to provide technical details. With the success of iDoc’s beta test, Amalgamated is about to launch the program nationally. Concurrently, we will also be looking to license the program internationally, particularly in Europe. To that end we’ve been in negotiations with multiple countries, particularly those with extensive, dependable wireless infrastructure. I can confidently report that negotiations are rapidly progressing. The need for iDoc is global. Of course, this underlines how very good an investment in Amalgamated Healthcare is. We are about to conclude deals with several hedge funds, but another round of funding will be required. Our market is global. Our market is massive. Now let me turn the floor over to Dr. Stonebrenner.”

  As Paula stepped forward, George did a rapid Internet search for the meaning of a beta test. He vaguely recalled hearing the term but wouldn’t be able to define it if he was pressed. He quickly found out that it’s a term for the second round of software testing in which it’s used by a limited but sizable audience to ascertain user acceptance while at the same time seeking to identify and fix glitches or problems.

  As Paula began speaking George wasn’t sure how he felt about her taking over his idea without even getting in touch with him. At the same time he realized he hadn’t exactly pursued her.

  “Think of iDoc as the Swiss army knife of health care,” she was saying. “Attachable sensors and independent probes that communicate wirelessly will make the phone a versatile mobile laboratory.” As Paula spoke, a slick video presentation demoed the app’s capabilities. “The property of capacitance is what enables smartphone touchscreens to sense our fingertips. But the screens also have the ability to detect and analyze much smaller things, like DNA or proteins to enable it to identify specific pathogens or particular disease markers. An Amalgamated client could simply place a saliva or blood sample directly onto the touchscreen for an analysis, and treatment would be based on the patient’s past medical history and unique genomic makeup. Recent leaps forward in nanotechnology, wireless technology, and synthetic biology make iDoc possible. With our supercomputer we will constantly monitor, in real time, a host of physiological data on all iDoc users of all vital signs. The sky is the limit. iDoc can even extend into the psychological realm because iDoc has the ability to monitor the client-patient mood, particularly in relation to depression, anxiety, or hyper states, and then communicate with the patient accordingly for on-the-spot counseling or referral to a mental health specialist.”

  Paula then went on to describe how the app is able to monitor many of these functions, in particular those followed routinely only in an intensive-care unit, by the use of a bracelet, ring, or wristband with built-in sensors that communicate with the phone wirelessly. She demoed special eyeglasses that can be worn for additional monitoring of the real-time function of blood vessels and nerves in the retina of the eye, the only true window on the interior of the body. She explained that a continuous recording is made of the EKG and, if needed, the smartphone can function as an ultrasound device for studying cardiac function by merely having the patient press it against his chest.

  Paula paused for a moment and stared out at the audience. From their stunned silence she knew she had their undivided attention. “Okay,” she said soothingly, switching gears, “so the question then becomes, what will iDoc do with this enormous wealth of real-time data? I will tell you. It will do what any good doctor would do and do it better, much better. Thousands of times a second all the data will be correlated via its cloud service by the Amalgamated supercomputer with the client-patient’s full medical history, the client-patient’s known genomic information, and the totality of current medical knowledge that is being updated on a continuous basis.”

  Paula then gave a specific example and talked about the app’s ability to diagnose a heart attack, not only when it is happening, but also well before, so that it would have the ability to alert the patient days before the attack was going to occur. Paula then touched on iDoc’s ability to follow and treat chronic diseases like diabetes. With iDoc and an implanted reservoir of insulin, blood sugar could be tracked in real time and the correct amount of insulin could be released automatically to keep the patient’s blood sugar continually normal. In a very real way, for a diabetic, iDoc is essentially curative.

  George found himself nodding. It was apparent to him immediately that iDoc had handled Kasey’s diabetes and why she didn’t talk about it. Kasey’s word was her bond, and she had obviously signed a nondisclosure agreement. He remembered how pleased she was at the time, being free of her usual burdensome monitoring. George even knew she had had some sort of implanted device. Now he knew what it had been. It had been a reservoir just as Paula was describing.

  Paula concluded by saying that embedded reservoirs have been and would be used for various ailments, and not just for chronic diseases, noting that it would be the answer to the problem of poor compliance that a number of patients demonstrate when it comes to taking medications as instructed.

  Despite his irritation at having been, in his words, ripped off on the concept, George became progressively impressed by what he was hearing. He could tell everyone else in the room felt the same. Paula was offering understandable specifics, and everyone was listening with rapt attention. George could easily see why iDoc would make a superb primary-care doctor, especially when the doctor was available 24/7 to answer a patient’s questions without the inconvenience of having to make an appointment, travel to an office, and wait to be seen by someone who might be rushed, distracted, or not able to find the appropriate patient records, and, worse yet, might have forgotten half of what he or she learned in medical school.

  “From the outset,” Paula continued after another astutely planned pause, “we wanted to make iDoc extremely personable. The client-patient can choose the gender of his doctor avatar as well as his or her attitude in relation to being paternal or maternal in tone. So far there is also a choice between forty-four languages and several accents. There are also choices available regarding how the patient would like to be notified when his iDoc doctor wants to have a chat when stimulated by a change in the client-patient’s constant physiological or mental monitoring.

  “I want to emphasize that iDoc never has a memory lapse, never gets tired, never gets angry, is never on vacation, and never has a drink, pain reliever, or sedative. And lastly, client-patients can select a name for their avatar doctor, either made up or from a preset list. If they don’t want to be bothered, a name will be selected for them with a choice of ethnicities. For privacy concerns, if a client-patient’s speakerphone is activated, iDoc will ask patients if they are alone and if it’s okay to have an open audio conversation. iDoc will strictly guard patient confidentiality, using the full gamut of biometric identifiers.

  “What I have just given is a rapid, superficial overview of iDoc. It uses an extraordinarily versatile algorithm. As Mr. Thorn mentioned, the reception by our client-patients throughout the beta test has been exceptionally positive far beyond our expectations and hopes. People love iDoc and already are telling us they don’t want to give it up at the conclusion of the test period and are eager to share their experience with family and friends, which they have been strictly forbidden to do. iDoc has already saved lives as well as time and inconvenience for the patients that have it, and it has saved money, too.” Paula paused on that note, letting the audience absorb the information. When everyone realized she was done, applause erupted. Paula waited a few beats, acknowledging the audience’s response, then said a quick thank-you.

  George marveled at why other people had not come up with the iDoc idea. After Paula’s presentation it seemed intuitive, given current technology. He watched Paula return to her seat as the third speaker approached the front of the stage. George hoped he might catch her eye, but sh
e didn’t look in his direction.

  Lewis Langley addressed the audience for only a couple of minutes. Even from where George was sitting he could see his cowboy-style fitted shirt had snaps instead of buttons. With his hair that was cut long, giving Langley a rather wild, artsy look, George got the impression he was the right-brain, creative type in contrast to his left-brain colleagues.

  “I’m not going to take much of your time,” Langley said with a discordant New York accent. “There are only three things I want to convey above and beyond what you have already heard from Mr. Thorn and Dr. Stonebrenner. First off, and most important, the iDoc algorithm was written to be heuristic so that it would improve itself by learning on its own over the course of time. This has already proven to be the case to a marked degree during the beta test. As a backup to iDoc, Amalgamated has employed a large group of internists, surgeons, and other specialists who rotate through a twenty-four-seven state-of-the-art call center. At any given time there are at least fifty of them on hand.

  “These doctors assist iDoc’s automated decision making as a default mechanism whenever there is the slightest problem. At first, at the outset of the beta test, there were quite a few calls, maybe as often as twenty percent of the episodes. But that changed rapidly, and during the course of the three-month beta-test period, the number of calls coming into the center dropped by eleven percent, meaning the iDoc logarithm is indeed learning.

  “The second issue I want to explain is that important subjective issues have been meticulously researched and included in the iDoc algorithm, such as pain and suffering associated with treatment options and possible outcomes, something traditional medicine has always had great difficulty considering. Cost was another issue taken into consideration in the iDoc algorithm. For example, generic drugs are prescribed, provided the efficacy between the generic and the brand-name drug is equal. If the brand-name drug is superior, it is prescribed.

  “The third and last issue I want to mention is that it is my firm belief that iDoc will bring about a miraculous democratization of medicine, somewhat akin to what the Gutenberg Bible did for religion. iDoc will free the general public from the clutches of doctors and the medical profession just as the Bible freed the public from the clutches of priests and organized religion. iDoc will be making the paradigm of the practice of medicine personal, meaning that if a drug is prescribed, it will be prescribed because iDoc knows that it will benefit the specific patient rather than knowing it will benefit five percent of patients with the hope that the specific patient will be part of that five percent. Because of this democratization of medicine, I believe the introduction of iDoc will prove to be on par with or more important than other major technological milestones, such as the development of the computer, the Internet, the mobile phone, and DNA sequencing.”

  Dr. Clayton Hanson was the final speaker to address the audience. Despite acknowledging to himself that he was acting ridiculous, George flattened himself down in his chair throughout Hanson’s brief talk. His remarks, in contrast to those of the other speakers, were pedestrian. He talked briefly about the medical imaging capabilities of iDoc, particularly ultrasound in conjunction with a wireless handheld transducer. He listed as an example the cardiac function tests that could be performed from the privacy of the patient’s home. Until now these tests required multiple hospital visits and thousands of dollars. His point was that not only was iDoc a better primary-care physician than a flesh-and-blood individual, it was also going to save society a significant amount of money immediately and over the long haul.

  Thorn stepped forward again as soon as Clayton finished and took his seat. “Thank you all for attending. And before I open the floor to questions, I want to remind you that we’ll be having a reception and buffet lunch in the restaurant on the first floor of this tower immediately following our presentation, so we all have a chance to speak personally. Okay, who’s first?” A number of hands shot up. The excitement in the room was palpable.

  6

  CENTURY PLAZA HOTEL

  CENTURY CITY, LOS ANGELES, CALIFORNIA

  MONDAY, JUNE 30, 2014, 11:00 A.M.

  George took the elevator down to the first floor and walked toward the restaurant’s entrance with a number of the other attendees. He was deep in thought, debating what to do next. He knew he should head back to the hospital but couldn’t let the opportunity to confront Paula pass, even if he risked being seen by Clayton. He rationalized that he wouldn’t be long, and he hadn’t received any texts or calls from Claudine Boucher, so things were undoubtedly fine in the MRI unit. George wasn’t surprised, since Claudine was one of the more accomplished residents on her last day on an MRI rotation; she knew the ropes in spades.

  He walked into the restaurant, which was reserved for Amalgamated, leaned on the bar, and ordered a Diet Coke. Again, the caffeine was a slight risk, considering he had already had coffee, but, hey, he was rolling the dice today. With his drink in hand he moved to a corner of the room, waiting for Paula to appear. He wanted to avoid any conversations with strangers, if possible. The truth was George couldn’t shake the feeling of inferiority to these successful market warriors. They were a part of the real world, an arena outside the hospital in which he had limited experience.

  He spotted her as she strolled in with the other speakers. There was a smattering of applause. It was apparent that the presentation had elicited a very positive reaction. Luckily for George, Clayton immediately veered off, zeroing in on an attractive female in an expensive business suit. George gathered up his courage and walked over toward Paula. Eyeing the situation, looking for an opportunity to present himself, he saw she looked even better up close and was obviously totally at ease in what was to George an alien environment. He wondered what might have happened between them during their first year of medical school if he hadn’t been such an immature ass. Just then she looked up and caught sight of George and smiled broadly. Encouraged by her grin, he headed straight for her.

  “George!” Paula exclaimed. “You made it!”

  “Hello, Paula.” George put out his hand to shake but she disarmed him by pulling him toward her and kissing him on the cheek. She seemed genuinely happy to see him.

  She looked around, still holding on to his hand, and spotted Bradley Thorn shaking hands just behind her. “Bradley, excuse me, this is a dear friend of mine from Columbia Medical School, George Wilson.”

  Thorn peered at George over his half glasses. He was holding one of Amalgamated’s spreadsheets.

  “George, this is Bradley Thorn, my boss. George is a radiology resident over at L.A. University Medical Center. Which makes him one of our new employees!”

  “My pleasure,” Thorn replied. “Excuse me.” He turned from George, his sights set on a big-name CNBC host standing nearby.

  Paula smiled at George and shrugged. “Sorry. He’s in ‘biz’ mode.” She aimed another beaming smile at George; she was obviously still on a high after the excitement of the presentation.

  “Hey, no problem. I get it.” George didn’t want her to feel defensive.

  “I really am glad you came,” she said. “Thanks!”

  “Me, too. It was lucky that I could get away,” George said, feeling a bit nervous and less confrontational now that he was actually talking with Paula. “It’s the last day of this month’s rotation, so the resident I’m supervising is entirely comfortable working alone. Tomorrow will be a different story. July first. I’ll be shepherding one or more first-year residents. You know what that means.”

  She gave him a blank look.

  “July first. The first day of residency, nationwide, for freshly minted medical school grads?” He was trying to help her remember all the requirements to becoming a full-fledged specialist.

  “Oh, right. Aka, the deadliest month of the year for patients.” She chuckled, although there was truth in the statement. Both knew that hospital deaths spiked in July, when thousa
nds of new residents began attending patients.

  “I’ll be in the ER next month . . . well, tomorrow, actually,” George said. “Supervising a few first-years there. It’s my last year as a resident. Finally I will make some real money.” He had meant to say it in jest, but it didn’t come out that way. The look on Paula’s face was confirmation.

  Paula regarded him for a beat, sensing his nervousness. “Thanks again for coming, George. I really wanted you to be here. So . . . what do you think of iDoc?”

  “I think the app is amazing. A real paradigm shifter, just as it’s being billed. Wish I had thought of it.” His eyes stayed close on her.

  “And, of course, you did. Don’t think I’ve forgotten. It’s why I wanted you to be here for our announcement, so you would see it was becoming a reality, not just an idea no one acted upon. It’s actually happening!”

  George was taken aback. He had not expected such honesty.

  “It was a huge amount of work,” she continued. “Tens of thousands of man-hours. Millions upon millions of dollars. But we did it. And it works. It works better than we ever imagined. It’s the answer, George. Better care. Lower costs. That’s something the ACA will never do on its own.”

  George didn’t quite know what to say. He had been so sure that he was going to have to argue to get the credit for giving her the idea.

  “Do you have any free cash?” Paula inquired.

  “Pardon me?” George was thrown by the question.

  “Sorry. I didn’t mean it like that. What I meant to say was that whatever you have, invest it in Amalgamated stock. It’s going to go through the roof. And that’s not insider trading advice. Maybe if I had told you yesterday, but not after today’s presentation to the investor community at large. I’m leveraged to the hilt with stock options and—”

  “I’m a medical resident, Paula,” George replied in an even tone. “I make a bit less than fifty-five thousand dollars a year putting in eighty-hour workweeks and trying to pay down my med school debt while subsidizing my grandmother’s assisted-living expenses. Stock options are not an option for me. I’m sure they are fine for you with what I’m sure is a significantly higher salary, but not for me.”