The Chairmen

by Robert I. Katz

  Serkin and Castillo were looking over papers. Dunn and Christina Pirelli whispered together in the back of the room, glancing occasionally at Serkin, who ignored them both. Moller walked in a couple of minutes later, accompanied by the latest interviewee, Richard Green, from Barnes, in St. Louis. “Sit down anywhere,” Moller said.

  They went around the room and introduced themselves, after which Moller rubbed his hands together, gave a sunny smile and said, “Why don’t we begin…”

  Richard Green, it quickly became apparent, was not going to get the job. For one thing, he twitched. Every one or two seconds a different part of his body would give a little jerk. Usually it was his eyes, sometimes his shoulders, sometimes his hands. This annoying mannerism might have been written off as an unfortunate neurological condition, but he also tended to wander around a point and not quite answer the question that was asked. It was a short interview. After a mere thirty minutes, Moller smiled brightly and said, “Thank you, Doctor Green. The secretary will conduct you to your first meeting. Have a nice day.”

  Green, seemingly oblivious to the undercurrents that he had created, smiled happily back and rose to his feet. “Let’s hope that this is the start of a something exciting,” he said.

  “That would be nice,” Moller answered.

  Ten seconds later, Green was on his way. As soon as the door closed behind him, Moller smiled around the room. “Well?”

  “He needs his lithium level checked,” Dunn said.

  “Not exactly what the job requires,” said Nash.

  “Anybody else?” Moller waited. Nobody else spoke. Moller shrugged his shoulders and made a note on his pad. “Scratch Richard Green,” he said.

  She had come to dread the daily trip to the mailbox. Gingerly, she opened the box, picked out the small pile of envelopes, walked back inside, hung her jacket on the back of a chair and looked over the stack. Sure enough, another letter had arrived. There was no stamp on the envelope. It was plain and white and unmarked, but she knew what she would find inside. She opened it, her hands trembling, and unfolded the single, white sheet:

  You’ve always been stupid. Hard work alone isn’t going to be enough. You also have to have brains and that’s where you’re lacking. Turner thinks you’re an idiot. Go home before you flunk out. Go home before you waste any more of your father’s money.

  She hated morning rounds. She didn’t like speaking in front of her colleagues. She did know her patients, but when the attending and the residents and the other students were looking at her, the words, somehow, seemed to stick in her throat. Yesterday, she had nervously laughed, and Dr. Turner had made some obnoxious comment about laughing at her own ignorance. Turner was nobody’s favorite attending but he seemed to take particular delight in abusing her.

  She was far away from home and tired and alone. “Why do you want to do this, anyway?” her father had said. He had never tried to forbid her from pursuing a career but his disappointment in her was plain. She was the first generation to be born in this country and the first to go to college. Girls didn’t become doctors back in Kosovo. They got married and had children and raised families.

  Why did she want to do it? She hardly knew anymore. It wasn’t what she had expected. It was hard and endlessly demanding and she was always tired and the hospital smelled bad. Her latest patient was five years old and dying from an undifferentiated sarcoma. He was sedated but there wasn’t enough sedation in the world to overcome the pain he must be feeling. He whimpered constantly in his sleep and there was nothing that any of them could do for him but watch him suffer and wait for him to die.

  Silently, she sat down at the table, put her head in her hands and began to cry.

  Chapter 7

  “Yaaah!” The scream was strictly by the book but Kurtz still felt stupid doing it. The idea was to distract the opponent, except that at this level of competition, everybody was good and nobody was going to be distracted by loud noises. The crowd expected it, though, and so did the judges. Style counted.

  At one time, Kurtz had toyed with the idea of turning pro. He was good, but the idea of getting his head beaten in for a living seemed, in the end, to lack appeal. He had quit fighting for years until a couple of unexpected murders and a recent brush with an organized crime conspiracy (not to mention a few psychopaths) renewed his interest in the sport.

  His opponent, a kid named Brian Marx, barely grinned as Kurtz cartwheeled in. Both of them ignored the noise. Marx abruptly stopped grinning when Kurtz reversed direction and swept his feet out from under him with a well-timed kick.

  “Point,” the referee said.

  From the corner of his eye, Kurtz could see Lenore sitting in the stands with David Chao, Kurtz’ partner, and Carrie Owens, David’s small, blonde, newly announced fiancée. David, who usually gave the matches his total attention, was tonight gazing sappily into his lady love’s clear blue eyes.

  Marx rose to his feet, frowning. The referee held up his hand. Both men bowed. Marx immediately aimed a punch at Kurtz’ face. Kurtz moved back by half an inch and the punch passed by his nose. Marx must really have been rattled. The back of his neck was wide open. Kurtz hit him with the edge of his hand.

  “Point,” the referee said.

  One more point and Kurtz would have the match. Marx shook his head. He took a deep breath. Again, they bowed. This time, Marx circled warily, his hands open, his face impassive. Kurtz circled with him. Marx spread his arms wide, then took a sidewise step. Interesting, Kurtz thought. The white crane, a Tibetan style that looked good in movies but had one decisive practical weakness. The style emphasized evasive tactics and well-timed counterattacks. Kurtz smiled to himself. With two points to his opponent’ none, Kurtz did not have to attack. Sooner or later, Marx would have to come to him or he would lose the match by default.

  They continued to circle. Marx’ eyes flicked to the side, to the clock hanging on the wall. Suddenly, he screamed and lunged toward Kurtz’ chest. He was fast. Kurtz barely avoided the lunge and had no time left to counter. Marx twisted, turned, aimed a kick at Kurtz’ legs. Kurtz jumped, landed on the balls of his feet and barely managed to block a reverse kick at his abdomen.

  The buzzer sounded. Marx drew a deep breath, sighed, then grinned. The two men bowed, then left the circle.

  Peter Reinhardt was counting the days. Only seventy-three left. Seventy-three days until freedom. Funny, he didn’t used to think of it that way. He was a physician, a surgeon, a heart surgeon. Heart surgeons were at the apex of the physicianly pecking order, the elite of the elite. Funny, how things changed. He had never realized how the responsibility weighed on him until he decided to lay it down. Now, he could hardly wait.

  “Mount Sinai says they can do it for twelve,” Alex Calderon said. Alex Calderon was the CFO of Staunton University Medical Center. He had an MBA from Harvard. His suit was expensive and fit him well. A Phi Beta Kappa key dangled from his vest. His hair was neat, his moustache a perfect black line on his upper lip. Peter Reinhardt couldn’t stand him.

  Twelve meant twelve thousand, as in dollars. Twelve thousand dollars per patient. This was what a chairman’s job had come to. In the old days, a mere decade or so ago, they did a case, they charged for it. Oh, they might not get paid in full, but they got most of it. Today, they had to negotiate with every insurance company for a flat rate. Capitation, they called it. So much per head.

  He sighed.

  “If we want the contract,” Calderon said, “we have to go better than twelve. Can we do that?”

  Nice that they were asking him. Two years ago, the administration had seen fit to bid on a contract with Columbia-HFC for liver transplants. A total disaster. Nobody, including the chairman of surgery, had the faintest idea what their costs were going to be.

  But they knew that they couldn’t let Downstate outbid them. It was a matter of pride. They got the contract, all right. And now they were stuck with it, losing at least three thousand a head on every case that came through the OR.<
br />
  “Once you take out all of the overhead, twelve thousand means that my people would get paid about three hundred per case,” Reinhardt said. “On average.”

  Calderon looked relieved. “You can do it, then,” he said.

  “That depends on what you mean by the word ‘can’. Before you actually get a patient to the OR, you’re talking a minimum of three hours of work, what with seeing the patient, reviewing the records, looking over the labs, talking with the cardiologist and then talking again with the patient and, usually, the patient’s family. The case itself takes about five hours. That’s if everything goes smoothly. The ICU stay averages about twenty hours but thankfully, we’ve got fellows, so the surgeon himself probably spends no more than a couple of hours there. Then you send the patient home and see him again a couple of times, say another two hours in total. Twelve hours of work, minimum, and that’s for a case that has no complications. At three hundred bucks, that comes to twenty-five dollars an hour. Less than half of what a car mechanic would get. A lot less than a plumber.”

  “But you can do it,” Calderon said. He was smiling.

  “For twelve thousand? You said that Mount Sinai was bidding twelve thousand. What are we supposed to bid?”

  Calderon looked at him carefully, weighing his words. “We were considering a bid of ten.”

  “Ten thousand.”

  Calderon gave a crisp nod.

  “Do I have any choice?” Reinhardt asked.

  “Of course, you have a choice,” Calderon said. “You can say ‘no.’”

  “And if I say no, what happens then?”

  “Then Mount Sinai gets the bid.”

  Reinhardt stared at him. “Don’t offer ten,” he said. “Offer eleven five. We might break even. Who knows? Maybe they’ll go for it.”

  Calderon sniffed. “We have it on excellent authority that Mount Sinai is willing to go down to eleven.”

  “Eleven,” Reinhardt said. “Right.” His head was pounding. He looked at Calderon’s blandly blank face. When did these guys come to own us? How did that happen?

  “I will not accept responsibility for ten thousand,” Reinhardt said. “Not even for eleven.”

  Calderon frowned. “Your department might take a loss, but we feel that the institution as a whole would do better than break even, and we would be willing to supplement your budget from the general revenue.”

  Clearly, this guy was delusional. It always cost more than you expected. That was a law of the Universe. Reinhardt closed his eyes and swallowed. “As I said, I will not accept responsibility for that bid.”

  “But you won’t say no.”

  Reinhardt smiled. He felt like his face was cracking. “No,” he said, “I won’t say no.”

  Seventy-three days, and counting.

  Henry Tolliver was forty-six years old, a little on the young side to be applying for chairmanships, but he had eighty-seven peer-reviewed papers to his credit, nearly three million in NIH grants, and a full professorship at Hopkins. He had a round, ruddy face, a dignified pot-belly and prematurely gray, curling hair. He looked around the table and beamed, as if there were no place on earth that he would rather be at that instant. Moller had already introduced the committee and they had spent a few minutes on casual chit-chat when Christina Pirelli asked the first significant question. “Tell me, Doctor Tolliver, what is your vision of the sort of department you would like to run?”

  The chairmen on the committee tended to use the word ‘vision.’ ‘Vision’ meant that they saw things that the ordinary mortal did not. It was very important that a chairman have vision.

  Tolliver nodded wisely. “Patient care must come first and foremost. The second priority is that the residents and fellows be properly trained, but make no mistake, I want to run an academic department, which means an environment where scholarly work is not only encouraged but rewarded.”

  Encouragement could mean so many things, Kurtz thought: a raise, a bonus…a flogging.

  Serkin, however, nodded. So did Nash and Castillo. Moller looked doubtful. “How do you plan on accomplishing this?”

  “By aligning the incentives properly. Reward people for their productivity. I would give salary increases for research productivity but reserve a bonus for those who are most clinically productive. That way, everybody has something to work for.”

  “How much experience do you have with managing a budget?” Moller asked.

  Tolliver gave a minute frown. “My father was a businessman, and I’ve taken two management courses at Harvard. I’m aware of the principle that the money coming in has to equal the money going out.”

  In other words, none. Tolliver was Associate Chief of Thoracic Surgery, which sounded good but which meant almost nothing. Tolliver had no budgetary experience whatsoever, but this did not necessarily disqualify him for the position. Obviously, Tolliver was a smart man, which might be enough to carry him through if he was also a hard-headed and practical man. You didn’t need an MBA to be a chairman, though these days, a lot of people who were aiming for chairmanships decided to get one. Nevertheless, a little experience would have been reassuring, to Kurtz at least, and presumably to Moller as well.

  “Tell me,” Serkin said, “do you plan on continuing your research once you’re a chairman?” It was a question with no good answer. There had been considerable turnover among the cardiac surgeons in the past few years. One of the reasons cited had been the lack of opportunity to do research. A chairman was expected to give his people a reason to stay, an opportunity to develop a career. On the other hand, a chairman who did research himself might not have the time for the numerous other tasks required of a chairman.

  Tolliver looked faintly surprised at the question. “Of course,” he said.

  Serkin, to Kurtz’ surprise, frowned at this. “Chairman,” he said, “is, in essence, an administrative position. If the demands of the position turn out to be such that you have no time available for research, would you then be willing to give up your research?” Or not too surprisingly, now that Kurtz thought about it. Serkin, he recalled, had abandoned his own research as soon as he arrived at Staunton, and apparently without a qualm. No research, no clinical work. Serkin spent his days in a business suit. Very nice suits, Kurtz noted. They looked like Armani.

  “I will do whatever turns out to be necessary to be successful in the position.” Tolliver looked like he meant it. Serkin nodded his head and sat back in his chair.

  “However,” Tolliver went on, “I do have funding. I would expect to bring along my research assistant, who is quite capable of carrying on the work without my direct participation. I am certain that I could find some time to give guidance.” The work, according to Tolliver’s CV, was on the exact mechanisms of cellular damage in association with brain injury after cardiopulmonary bypass, a very hot topic these days.

  Christina Pirelli grunted. Castillo and Nash exchanged glances. Funding was an important asset. Funding bought equipment and space and personnel, and in an emergency, might be used to surreptitiously hire another surgeon or two on a ‘research line.’ Nobody gave up funding unless they had to.

  Christina Pirelli looked at Moller and gave a tiny nod. Moller smiled at Tolliver and asked, “What can we tell you about Staunton?”

  Tolliver leaned forward, his face intent. “First of all, what is the size of your support staff?”

  And so it went. Fifteen minutes later, Henry Tolliver was on his way to see Peter Reinhardt. After that, he would talk to the Dean, then somebody in hospital administration, then the head nurse in cardiac and at least two of the cardiac surgeons. He would spend a full day, by the end of which, Henry Tolliver would presumably have a good working knowledge of the ins and outs of the institution and the institution would have a good working knowledge of Henry Tolliver.

  On the whole, Kurtz approved. He liked the way Moller was running the committee. He even liked the people they were bringing in for interviews, most of them. He smiled to himself at the thought. Th
e process was seductive. He had developed an appreciation for research—if not for the research clowns—that he hadn’t had in the beginning. Research was the glue that held an academic department—and an academic institution—together. The trick was to have balance. You couldn’t let yourself be blinded by the number of papers. You had to insist that the guy also be rational. God knows, a number of the applicants obviously were not. One former chairman who had had the gall to send in a CV—an otherwise amazingly impressive CV—was known to have been asked to resign because he had been having an affair with one of his junior residents. This would not usually have resulted in a firing, but the affair was a homosexual one and the resident had felt ‘pressured’ to go along. Also, the resident’s wife had made quite a stink.

  But Tolliver, at least, seemed normal. Not bad, Kurtz thought, not bad at all.

  “I’ve seen you naked. You’re really ugly when you’re naked. Your tits hang down to your waist and the fat on your ass jiggles when you walk. Did anybody ever tell you that?” The voice on the phone held a pleasant, lilting tone.

  Christina Pirelli ground her teeth together. Christina had had a long day, first surgery, then a joint practice meeting with pediatrics to discuss complications in the neonatal ICU, then a meeting with the obstetrical nursing staff. The nurses were upset. Gee. Wonder why.

  “I know all about you,” the voice said. “I’ve watched you when you’re naked. I’ve watched you masturbate in the shower. I’ve watched you sucking off your boyfriends. Would you like to do it right now? Would you like to suck me off? Does my voice turn you on?”

  Not really, she thought. Mostly, it grossed her out, which, she supposed, was the point. The voice was obviously filtered through some sort of device, with a deep mechanical vibration. It sounded inhuman. This wasn’t about sex, or even sexual titillation, it was about power, the power to make her react. The voice annoyed her, and also frightened her, just a little, but still…