The Cole Trilogy: The Physician, Shaman, and Matters of Choice

by Noah Gordon

  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good practitioners, she said, Buchanan hired what was available—an unboarded internist whose hospital privileges had been revoked for shoddy practice in Boise, a sixty-seven-year-old man who never had practiced but had spent his professional life doing research, and a young rent-a-doc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 practitioner 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 assigned “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 damn 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 shit 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 harassed them sexually.

  “One can imagine Buchanan’s pleasure. He sent Dr. Martin B. Murrow a registered letter telling him of the sexual harassment 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 sexually 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 harassed 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 furnishings 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 Massachusetts, and they both agreed he would be just right to fill an opening on the UMass 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 ou
r 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 Massachusetts, 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 participate 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 associations, 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 passed 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….”

  She looked at R.J. moodily. “Doctors may have to change things without much help from the politicians, try to treat some people without charge.”

  “I already do.”

  Gwen nodded. “Hell, you and I are good physicians, R.J. Suppose we started our own medical group? We could begin by practicing together.”

  The thought swept R.J. into momentary excitement, but very quickly reason took over. “You’re my best friend and I love you, Gwen. But my office is too small for two doctors, and I don’t want to move. This has become my town, the people are my people. What I’ve made for myself here … it suits me. How do I explain? I can’t risk ruining it.”

  Gwen nodded and placed her fingers on R.J.’s lips. “I wouldn’t want to do anything to spoil things for you.”

  “Suppose you set up an office of your own nearby? We could still incorporate, and maybe form a cooperative network of good independent physicians. We could buy our supplies together, cover for one another, contract together for lab work, refer patients to one another, share someone to do our billing, and try to figure out how to provide treatment for uninsured people. What do you think?”

  “I think I like it!”

  The following afternoon they began searching for office space for Gwen in nearby towns. Three days later they found the space she wanted, in a two-story red-brick building in Shelburne Falls that already housed two lawyers, a psychotherapist, and a studio that taught ballroom dancing.

  On a Tuesday morning they got up in the dark, had time only for coffee, and drove to the hospital through the predawn chill. They went through the scrubbing process with Dr. Noyes, achieving antisepsis in the prescribed routine that was at the same time necessary practice and a rite of their profession.
At 6:45 they were in an operating theater when Toby was wheeled in.

  “Hey there, kiddo,” R.J. said behind the mask, and winked.

  Toby smiled blearily. She already had been started on an intravenous solution of lactated Ringer’s solution to which a relaxant had been added—Midazolam, R.J. knew from her conversation with Dom Perrone, the anesthesiologist who was overseeing the attachment of EKG, BP, and pulse oximeter. R.J. and Gwen stood with folded arms safely outside the sterile field, watching while Dr. Perrone gave Toby 120 mgs of Propofol.

  Ta-ta, my friend. Sleep well, Tobe, R.J. thought tenderly.

  The anesthesiologist administered a muscle relaxant, inserted the endotrachial tube and began the flow of oxygen, adding nitrous oxide and Isoflurane. Finally he grunted in satisfaction. “She’s all set for you, Dr. Noyes.”

  In a few minutes, Dan Noyes had accomplished the three tiny incisions and inserted the fiber optics eye, and presently they were watching a screen that revealed the interior of Toby’s pelvis.

  “Endometrial growth on the pelvic wall,” Dr. Noyes observed. “That would explain the occasional random pain noted on her chart.” In a moment they were zeroed in on something else, and he and his visitors exchanged nods; the screen showed five small cysts between the ovaries and the fallopian tubes, two on one side, three on the other.