by Robin Cook
“Well . . . ,” George said, clearing his throat. “I appreciate your candor. Point taken.” He wasn’t offended so much as surprised at her frankness. If iDoc was half as good as they claimed, she was right. He decided to ask how iDoc would affect him if he were sick, thinking of his stint in the ER beginning the next day. “How does it work when someone has to go to the emergency room?”
“It’s simple. If the hospital is owned by Amalgamated Healthcare, which is a distinct possibility, since we’ve bought up a number of hospital chains, we’ll soon have an integrated and automatic wireless hookup. iDoc will know when a client-patient enters one of our hospitals, and it will alert the staff because iDoc will have sent the patient to the hospital in the first place. Theoretically, client-patients will not even have to approach anyone on staff; they can just take a seat. The appropriate personnel will be alerted to their presence and can locate them by both GPS and facial recognition. Staff will know why that individual is there, if not by iDoc vital sign readings and known medical history, then by having been told why the patient asked to go to the ER. iDoc will forward that information through the appropriate channels. Basically, you will be triaged immediately upon entering the facility. If it is not an Amalgamated hospital, the iDoc physician will consult directly with the emergency room physician, explaining why the patient needed emergency care, or the patient’s medical history and vital stats can be downloaded by a licensed handheld device provided to the ER by Amalgamated. The information can then be uploaded into the hospital’s computer system and accessed by the ER staff. Handheld downloads are how our beta testers are operating now.”
George tried to think of other reasons why he thought iDoc wouldn’t work as well as Paula believed, but he couldn’t come up with any. He wasn’t sure exactly why he hoped the system would fail, although he guessed it had something to do with his viewing it as competition. He changed the subject: “Are you really an iDoc user or was that story you told about strep for effect?”
“I absolutely am an iDoc user, and I love it like everyone else.”
“Let me see it?”
“Not concerned about HIPAA, huh?” Paula teased as she pulled out her phone and opened the app. She held the phone up a foot away with the screen facing her and asked: “How are my vital signs today?”
A crisp but caring woman’s voice responded in a slight English accent. “Hello, Paula. Your phone is on speaker. May I proceed?”
“Yes. Speakerphone is fine.” She glanced at George and turned the phone so that he could see the screen. On it was an animated image of an attractive woman in a white doctor’s coat. Speaking to George, Paula whispered: “I always loved English accents. They seem so authoritative and reassuring.”
“Excellent,” Paula’s iDoc doctor responded to Paula’s giving permission to proceed. “Your vital signs are entirely normal, but about an hour earlier, there was the suggestion of anxiety, not enough to warn you about but enough to alert me that something out of the ordinary was happening. I also noticed that your sleep was interrupted last night. Your periods of deep sleep were shorter than usual. How are you feeling?”
“Much better. I was anxious about a big presentation I had to give this morning. I should have given you warning.”
“I do appreciate as much information as possible in advance.”
“Okay. Bye.” Paula closed the app.
George grinned, impressed. The short interaction was uniquely personable. “Nice. Much better than I imagined.”
“The program is heuristic, too, like you heard at the presentation. So much so that my iDoc avatar has been learning to relate to me in the manner I like to be talked to. I can’t say that any of my primary-care doctors ever bothered to.”
“You have a point there.” George checked his watch. “I have to get back to the hospital.”
“I’ll go out with you. I have to get back to the potential investors.”
She accompanied George to the elevator. After the doors closed Paula said softly, “I wish your mother had had iDoc.”
The comment startled him. “Thanks! Me, too.” George realized his mother might still be alive today if she had had such a device.
“During the development process, I included a test that I named ‘Harriet.’ For your mom.”
George turned and studied Paula’s face. He didn’t know what to say in response, as it was truly a generous gesture. Paula was full of surprises today.
“Also, I insisted that an anti-addiction program be included for specific drugs, alcohol, and particularly cigarettes, such that iDoc knows immediately when any are ingested. iDoc will interrupt and initiate a conversation with the patient. Not like after one glass of wine or anything, but if certain levels are reached or heavy habits established, it will take action.”
While George was touched by her thinking of his mother, he couldn’t shake an underlying resistance to the app. “Won’t that be just plain irritating? Sounds like it could be viewed as Big Brother.”
“I’m sure it is irritating to some people, and they can decline the conversation. If they do that, it won’t continue to hector them. But that is not what has happened in the beta test. In fact a number of our smokers have been able to quit. Immediate intervention with every episode seems to help a lot of people. Patients can’t hide their habit from iDoc because it constantly searches for offending agents.”
“I guess that might be helpful,” he said, wondering if it might have gotten his mother to stop smoking, but he doubted it. She would have just turned the app off.
“Well, thanks for the tour,” George said as they walked across the lobby. “And for inviting me to the presentation.” He thought briefly about bringing up the fact that Kasey had been part of the iDoc beta study and had died possibly because her phone had been charging, but he couldn’t do it. He didn’t want to think about Kasey, much less talk about her with Paula.
“You okay? With all of this?” Paula sensed George was a little overwhelmed.
“Would it matter if I wasn’t?”
“It would matter to me. As I admitted, our talk those few years ago was my initial inspiration to pursue it.”
“Thanks. I appreciate that, but to be honest, I’m not sure how I feel. It’s a lot to get my head around. You guys—an insurance company—are assuming a lot of responsibility.” He put his hand out to shake. “It’s been an interesting morning. Thanks.”
“Thanks for coming. It meant a lot to me.”
George smiled and turned to leave. Paula called after him.
“Why radiology?”
George turned back. “What?”
“Why radiology? I always meant to ask you. After all the grief you gave me in medical school about the MD-MBA program and taking up space in medical school while never intending to practice medicine on real human beings—and here you end up in a residency program that, for the most part, avoids patient contact. It’s ironic. iDoc uses avatar doctors and you apparently prefer patient avatars in the image form of X-ray, MRI, and PET scans.”
It was her second reference to his chosen specialty. Was she picking on him? Her tone didn’t sound like it, but he wasn’t sure. “There is definitely some truth in what you say.”
“I always had you pegged for a GP or an internist. I never suspected radiology. What motivated you?”
“I don’t think anything really happened,” George said. Suddenly he could hear Kasey’s voice in his head. She had helped him understand his career motivations, namely that he had gone into medicine in order to feel worthy of people’s respect. The issue stemmed from a vain attempt to gain his stepfather’s respect. He wasn’t sure he was up to sharing that now with Paula.
“Well, it is a big difference from the way you talked in our second year.”
“To be truthful, the farther along in medicine I went, the less tolerance I had for direct patient contact. It was
a surprise. Actually, at first I wondered if I was really that shallow. Maybe it was because I got the feeling I was coming down with every disease I encountered.”
“That happened to all of us, even if we didn’t talk about it.”
“It happened to you, too?”
“Absolutely. It’s human. Your interest in radiology had to come from something else. When we were first introduced to it, I was intimidated,” Paula said. “Were you?”
“I liked it from the word ‘go’!” George said. “I was intrigued by its definitiveness. It could make a real diagnosis that could lead to definitive treatment, especially with radiology becoming more interventional.”
“Well, there you go,” Paula said. “That makes sense.”
“To be completely honest, someone told me that I have too much empathy and that I needed a specialty that distanced me a little from my patients so I could be objective. Like, I don’t know how people can become oncologists. All the more power to them. I couldn’t do it. No way.”
“That I can relate to as well, even more than the hypochondriasis. Thanks for being honest.”
“You’re welcome,” George said. He checked his watch and winced. “Well, thanks again for inviting me to this presentation. Now I have to get back to the hospital for sure.”
She gave him a brief hug good-bye before he headed for the door.
“Keep the idea open of your coming over to my house on Saturday, Dr. Honesty,” she called after him.
7
CENTURY PLAZA HOTEL
CENTURY CITY, LOS ANGELES, CALIFORNIA
MONDAY, JUNE 30, 2014, 11:42 A.M.
Lewis Langley terminated the call and pocketed his phone. He was troubled. He scanned the room, looking for Bradley Thorn. He spotted him holding court with two hedge fund managers whose faces he recognized from their frequent appearances on financial shows. He knew Thorn would be pissed but Langley didn’t want to waste any time. He pushed his way through the crowd until he reached the CEO’s side. Thorn reluctantly turned to him, irritated at the interruption.
“I need a moment,” Langley whispered in Thorn’s ear.
“Now? In case you haven’t noticed, I’m busy.”
Langley just stared at him, raising a single eyebrow.
Thorn hesitated. The last thing he wanted to do was step away from the potential investors standing in front of him, but Langley looked upset. In private Thorn joked that his dealings with Langley were similar to Pope Julius II’s dealings with Michelangelo. Langley was a genius but could be a pain in the ass.
“Excuse me, gentlemen, I’ll be right back,” Thorn said, following his tech manager.
“It better be good,” Thorn said quietly. “They were eating out of my hand.”
“I just became aware of something. I don’t want to rain on our parade, but my IT head just reported that a bug seems to have appeared in the iDoc application. Reappeared, actually.”
Thorn’s face turned hostile. Langley could tell that this was the last thing his boss wanted to hear, especially in the present company. But Langley didn’t care. Diplomacy was not his concern, nor was Thorn’s reaction. But the success of iDoc was. “This newest incident happened at Santa Monica University Hospital, same place as the first. We thought it had been a fluke at the time but apparently not.”
“What kind of a bug are we talking about?” Thorn asked, though he wasn’t sure he wanted to hear. “Something serious?”
“I would qualify it as serious. Especially if the media or the FDA became aware of it. Two patients involved in the beta test have died.”
Thorn swallowed hard. “How many people know about it?”
“Just the IT supervisor. Me. And now you.”
“No, I don’t know about it. Just you and your IT man do. This is your responsibility. Deal with it, and do it quietly and effectively! That’s your job.” Thorn looked around, making sure no one was within earshot. “And if we need to have a conversation this sensitive, this would not be the time or place for it. Don’t be such a goddamn cowboy, even though you look the part. Furthermore, fix your errors, Langley! Or I’ll get someone who can.” He turned to head back to his guests.
“You don’t understand,” Langley snapped, grabbing Thorn’s arm. Thorn stared at Langley’s hand until it was dropped. “My take is that it’s not an error. At least technically speaking. Rather, the program is working too well. We might not want to fix it. In fact, this kind of bug may appeal to certain parties we’re currently negotiating with, namely Centers for Medicare and Medicaid Services. It might be just what will get CMS to take iDoc for all its beneficiaries.”
“Explain yourself!”
“My sense is that the IPAB set up by the ACA might find this bug entirely to their liking. If they do, and force CMS’s hand, that’s eighty-seven million potential client-patients in the plus column.” Langley had the habit of lapsing into geek-speak punctuated with acronyms, but it didn’t trouble Thorn. He knew Langley was referring to the Independent Payment Advisory Board and the Affordable Care Act, but he was still confused. “All right! All right! You are going to have to explain in more detail. But not now, for Chrissake!” He straightened his tie and plastered a broad smile on his face before walking off to rejoin the waiting hedge fund managers.
8
L.A. UNIVERSITY MEDICAL CENTER
WESTWOOD, LOS ANGELES, CALIFORNIA
MONDAY, JUNE 30, 2014, 11:45 A.M.
Greg Tarkington entered the office of his oncologist, Dr. Peter White. Greg was nervous. He had noticed that the MRI technician had been reluctant to make eye contact at the conclusion of the procedure earlier that morning. The resident, Dr. Boucher, did the same. Greg sensed it meant bad news. After everything that Greg had been through, he knew the ground rules regarding ancillary personnel: divulge nothing. But Dr. White couldn’t hide behind that dictum, and finally he spilled the beans.
“I’m afraid the MRI showed several questionable lesions in your liver. We aren’t sure they’re cancer metastases, so we will have to biopsy them, and we want to do it sooner rather than later.”
The doctor spoke calmly, as if discussing an ingrown toenail that needed treatment. At least that’s how it sounded to Greg. He was tired of being patronized. He was tired of the whole experience since he had first noticed that the whites of his eyes had turned yellow. That had been the very first symptom that started the nightmare. Then came the tests, the surgery, and the chemotherapy, which had been a torture.
“So the pancreatic cancer is back?” Greg’s voice was accusatory.
“Well . . .”
“Straight up, Doc! I don’t have time for equivocation.” Greg’s worst fears were materializing. He wanted it all out. Now. No more false hopes.
Dr. White sighed. “As we have discussed, it’s a very difficult cancer to treat. Its location and anatomy are . . . problematic. We have done the best we can. If the biopsy confirms that these new lesions are the same cancer, then we will have to be aggressive.”
“Will that mean more chemo?”
“I’m afraid it does.”
“But the chemo is killing me! It already compromised my kidneys, I’m still undergoing dialysis. On a less frequent basis than before but . . .”
“There are a lot of arrows left in our quiver, Greg. If more chemo is needed, we will choose agents that don’t have kidney toxicity.”
“Like what?” Greg wanted specifics. His goddamn life was on the line.
“I can’t say exactly what that might be. Not yet. Let’s wait and see what we are up against.”
“How much time do I have?” Greg pressed.
“The biopsy has yet to be done—”
“How much time if the biopsy is positive?”
“I can’t say.”
“Guess!” he demanded. Dr. White was not going to get away with hemming and hawing. N
ot today.
“I’ve never been right when forced to give a guess in such a situation, but let’s just say that it would be a good time to get your affairs in order. I’m sorry, Greg, but you are just going to have to buck up.”
The comment hung in the air.
“Buck up?” Greg repeated mockingly. “After all I have been through and you’re telling me to ‘buck up.’ Worse, you’re being evasive. But it’s okay. I’ll contact iDoc when I get home and get what I need.” Greg knew he was being confrontational, something he had not done up until that moment, but now he didn’t care. He was sitting on the business end of a death sentence.
“I am not being evasive. The answers to your questions are unknowns,” Dr. White replied. He was aware that Greg was part of the first cohort to use iDoc. He had been impressed with the app since the number of off-hour phone calls had dropped significantly. Emergency room visits and requests for office visits from others in the program had plummeted, too. “But let me remind you that iDoc hasn’t gotten the results of the MRI yet. I received the preliminary report by calling the radiology resident. When iDoc does receive the results, please let me know if it offers any new perspective. As I understand it, its algorithm has significant resources of knowledge available. So in the event that I’m missing anything, I would welcome hearing about it.”
He started making notes on a digital tablet. “But most important, we have to ascertain what these liver lesions are. We need to schedule a biopsy and a series of pre-biopsy clotting studies.”
“iDoc can do the clotting studies the morning of the biopsy,” Greg said.