Crisis

by Robin Cook

  Berating himself for deliberately provoking the man, Jack thought about finding a hardware store and buying some pepper spray. If there was to be a second confrontation, Jack had no intention of trading blows again. Their difference in size made that an unfair exchange.

  Jack returned to scanning the spectators. Once again, he was taken by the number. He wondered how many were the proverbial courtroom junkies, vicariously thrilled by people receiving their comeuppance, particularly the wealthy and powerful. As a successful doctor, Craig was fair game.

  Finally, Jack found Alexis. She was sitting in the first row over against the wall, close to the jury box. Next to her seemed to be one of the few empty seats. Jack walked down to the bar, and then by excusing himself, he stepped into the aisle. Alexis saw him coming and moved her belongings to make room. Jack gave her shoulder a squeeze before sitting down.

  “Any luck?” Alexis whispered.

  “Progress, I hope, but it’s now out of my hands. What’s been happening here?”

  “More of the same, I’m afraid. It was a slow start, since the judge had to deal with some arcane legal stuff. The first witness was Dr. Noelle Everette.”

  “That couldn’t have been good.”

  “It wasn’t. She came across as a superbly trained, thoughtful, and sensitive professional, with the added benefit that she’s from the community and was involved in the resuscitation attempt. Tony handled it well, I’m sorry to say. The way he questioned her and the way she answered kept the jurors’ attention. I even saw the three homemakers nodding at one point—not a good sign. Her testimony was essentially the same as Dr. William Tardoff’s, but to me more effective. She comes off like the doctor everyone wishes they had.”

  “How was Randolph on cross?”

  “Not as effective as he was with Dr. Tardoff but, personally, I couldn’t see how he could be, considering how well Dr. Everette came across. I had the feeling he just wanted to get her off the stand.”

  “That might have been the best stratagem,” Jack said. “Did the issue of concierge medicine come up?”

  “Oh, yeah. Randolph tried to object, but Judge Davidson is letting it all in.”

  “Did the issue of cyanosis come up?”

  “No. Why do you ask?”

  “It continues to be a nettle in my brain. It will be one of the prime things on my mind when and if I do the autopsy.”

  A sixth sense made Jack turn around and look across the room at Franco. The man was again glaring at Jack with an expression that hovered between a grimace and a cruel smile. On a positive note, from the angle in which Jack was looking, he could see that the left-hand side of Franco’s face was as red as Jack’s. So far, things were apparently equal.

  Settling back on the rock-hard oak pew, Jack directed his attention to the proceedings. Tony was at the podium, while Dr. Herman Brown was in the witness box. In front of the bench, the court reporter’s fingers were playing incessantly on her small machine to create a verbatim record. Tony was having the witness testify to his impressive academic and clinical credentials, and it had been going on for a quarter of an hour. As chief of cardiology at the Boston Memorial Hospital, he also occupied the chair of the Department of Cardiology at Harvard Medical School.

  Randolph had stood on several occasions and offered to stipulate as to the witness’s qualifications as an expert to save the court’s time, but Tony had persisted. He was trying to impress the jury, and it was working. It became increasingly apparent to everyone that it would be hard to find a witness more qualified in cardiology, or even equivalently qualified. The man’s appearance and bearing added to his image. There was a Boston Brahmin aura that was similar to Randolph’s but without the hint of disdain and condescension. Instead of cold and distant, he appeared kind and gentle—the sort of person who would go out of his way to put a baby bird back into its nest. His hair was grandfatherly white and well groomed, his posture straight. His clothes were neat but not overly elegant, and they had a comfortable, lived-in look. He wore a paisley bow tie. There was even a hint of self-deprecation, as Tony had to work to get the man to admit reluctantly to his awards and accomplishments.

  “Why is this medical Olympian testifying for the plaintiff in a malpractice trial?” Jack whispered to Alexis, but it was more of a rhetorical question, and he didn’t expect an answer. He began to wonder if the reason had something to do with Noelle Everette’s unexpected comment about concierge medicine when she had said, “Some of us old-fashioned physicians are angry about concierge doctors.” Maybe Dr. Brown was one of that group because the concept of concierge medicine flew in the face of the new professionalism that academia was trying to espouse, and more than anyone else at the trial, Dr. Herman Brown was representing academia.

  “Dr. Brown,” Tony Fasano said, gripping the sides of the lectern with his short, thick fingers. “Before we get to Patience Stanhope’s unfortunate and avoidable death—”

  “Objection,” Randolph said emphatically. “There has been no establishment that Mrs. Stanhope’s death was avoidable.”

  “Sustained!” Judge Davidson declared. “Rephrase!”

  “Before we get to Patience Stanhope’s unfortunate death, I’d like to ask you if you’ve had previous contact with the defendant, Dr. Craig Bowman.”

  “I have.”

  “Can you explain the nature of your contact to the jury?”

  “Objection, Your Honor,” Randolph said with exasperation. “Immaterial. Or if it is material in some unfathomable way, then I object to Dr. Brown as an expert witness for bias.”

  “Counsels approach the bench, please,” Judge Davidson said.

  Tony and Randolph dutifully grouped at the side of the judge’s bench.

  “I’m going to be very upset if we have a repeat of Monday,” Judge Davidson said. “You’re both experienced lawyers. Behave as such! You both know the rules. As to the current line of questioning: Mr. Fasano! Am I to assume you have a relevant rationale for your current line of questioning?”

  “Absolutely, Your Honor! The core of the plaintiff’s case revolves about Dr. Bowman’s attitude toward his patients in general and Patience Stanhope in particular. I call to the court’s attention the deprecatory ‘PP’ classification. Dr. Brown has the ability to provide some insight into the development of these traits during Dr. Bowman’s critical third year in medical school and during his residency training. Subsequent testimony will relate them directly to the case of Patience Stanhope.”

  “Okay, I will allow this line of questioning,” Judge Davidson said. “But I want it related quickly to establish its relevance. Am I clear about that?”

  “Perfectly clear, Your Honor,” Tony said, unable to suppress a slight smile of satisfaction.

  “Don’t look so goddamned pained,” Judge Davidson said to Randolph. “Your objection has been recorded. My judgment, provided Mr. Fasano is being totally honest about relevancy, is that the probative value will outweigh the prejudicial. I admit it is a judgment call, but that’s why I’m here. In return I will grant the defense wide leniency on cross-examination. As for the question of bias, there’s been ample opportunity to determine that during discovery, and it wasn’t. But the issue can be examined on cross.

  “And I want the pace to pick up,” Judge Davidson said. “I’ve allocated this week for this trial, and here it is Wednesday already. For the sake of the jurors and my schedule, I want it to conclude on Friday unless there are some particularly extenuating circumstances.”

  Both lawyers nodded. Randolph repaired to his seat at the defense table while Tony returned to the podium.

  “Objection overruled,” Judge Davidson called out. “Proceed.”

  “Dr. Brown,” Tony said after clearing his throat. “Would you tell the jury the nature of your contact with Dr. Craig Bowman?”

  “My first contact was as his preceptor at Boston Memorial Hospital on his internal-medicine rotation during his third year of medical school.”

  “Could you expl
ain what this means, since no one in this wonderful jury went to medical school?” Tony made a sweeping gesture down the line of jurors, some of whom nodded in agreement. Everyone was paying rapt attention, except for the plumber’s assistant, who was focusing on his nails.

  “Internal medicine is the most important rotation and the most demanding during the third year, and perhaps for the entire four years. It is the first time the students have prolonged contact with the patients from the patient’s admission to their discharge, and they participate in the diagnosis and therapy under strict observation and supervision by the resident house staff and by the preceptor.”

  “Was this preceptor group that included Dr. Bowman a large group or a small group?”

  “A small group: six students, to be exact. The teaching is intense.”

  “So you as the preceptor see the students on a regular basis.”

  “Every day.”

  “So you can observe the overall performance of each student.”

  “Very much so. It is a critical time in the student’s life, and it marks the beginning of the individual’s transformation from a student to a physician.”

  “So that attitudes that are observed or develop are important.”

  “Exceedingly so.”

  “And how do you rate your responsibility as a preceptor vis-à-vis attitudes?”

  “Again, exceedingly important. As a preceptor, we have to balance the explicit attitudes toward patients as promulgated by the medical school versus the implicit attitudes often exhibited by the overworked and -stressed house staff.”

  “There’s a difference?” Tony questioned with exaggerated disbelief. “Can you explain the difference?”

  “The amount of knowledge medical trainees must assimilate and have immediate recall of is staggering and increasing every year. As pressed as residents are, they can sometimes lose sight of the ultimate humanistic aspects of what they are doing and which form the basis of professionalism. There are also defensive coping mechanisms in the face of suffering, dying, and death that are not healthy.”

  Tony shook his head in bewilderment. “Let me ask you if I have this correct. In simplified terms, there can be a tendency on the part of medical trainees to devalue individual people, like losing sight of the trees by paying too much attention to the forest.”

  “I suppose,” Dr. Brown said. “But it is important not to trivialize this issue.”

  “We’ll all try,” Tony said with a short chuckle, which brought a few tentative smiles from the jurors. “Now, let’s get back to the defendant, Dr. Craig Bowman. How did he do during his rotation in third-year internal medicine?”

  “Generally excellent. In the group of six students, he was far and away the most knowledgeable and the most prepared. I was often astonished at his recall. I remember one episode of asking what a patient’s BUN was.”

  “The BUN is a laboratory test?” Tony asked.

  “Yes. I asked it more as a rhetorical question, to emphasize that knowledge of kidney function was key in the treatment of the patient’s condition. Dr. Bowman rattled it off without hesitation, making me wonder if he had made it up, a frequent medical student ploy to cover unpreparedness. Later, I looked it up. It was exactly right.”

  “So Dr. Bowman got a good grade for the course.”

  “He got an A.”

  “Yet you qualified excellent by saying ‘generally excellent.’”

  “I did.”

  “Can you tell us why?”

  “I had a nagging feeling, which I again got while supervising Dr. Bowman when he was a resident at the Boston Memorial Hospital.”

  “And what was this feeling?”

  “I had the impression that his personality—”

  “Objection!” Randolph called out. “Foundation: The witness is neither a psychiatrist nor a psychologist.”

  “Overruled,” Judge Davidson said. “As a physician, the witness has had exposure to those fields, the amount of which can be challenged on cross. The witness may proceed.”

  “It was my impression that Dr. Bowman’s desire to succeed and his lionization of our then chief resident made him view patients as a means to compete. He actively sought out the most difficult patients so his presentations were intellectually the most interesting and achieved the widest acclaim.”

  “In other words, it was your impression Dr. Bowman saw patients as a way to further his career?”

  “Essentially, yes.”

  “And that kind of attitude is not consistent with the current concept of professionalism?”

  “That’s correct.”

  “Thank you, doctor,” Tony said. He paused and looked from one juror to another, making eye contact with each, allowing the testimony to sink in.

  Jack leaned over toward Alexis and whispered, “Now I understand what you said about Tony Fasano; this guy is good. Now he’s putting academic medicine and its inherent competitiveness on trial along with concierge medicine.”

  “What’s bothering me is that he’s changing Craig’s successes into a liability in anticipation of Randolph trying to do the opposite.”

  When Tony recommenced his questioning, he zeroed in on the Patience Stanhope episode with a vengeance. In short order, he got Dr. Brown to testify how important it was to begin treatment for victims of a heart attack absolutely as soon as possible and that, from reviewing the records, Patience’s chances of survival had substantially diminished due to Craig’s delay in confirming the diagnosis.

  “Just a few more questions, Dr. Brown,” Tony said. “Are you acquainted with Dr. William Tardoff?”

  “Yes, I am.”

  “Are you aware he trained at Boston University?”

  “I am.”

  “And likewise are you acquainted with Dr. Noelle Everette, and are you aware that she trained at Tufts?”

  “I am, on both accounts.”

  “Does it surprise you that three cardiology experts from our area’s three prestigious medical schools all concur that Dr. Craig Bowman did not meet the standard of care in relation to Patience Stanhope?”

  “It does not. It merely shows unanimity on the issue of the need for rapid treatment of heart attack victims.”

  “Thank you, doctor. No more questions.” Tony picked up his papers from the lectern and walked back to the plaintiff’s table. Both his assistant and Jordan acknowledged his performance with pats on the arm.

  Randolph slowly stood to his commanding height and approached the podium. He adjusted his jacket and put one of his heavy, thick-soled, wing-tip lawyer shoes on the rail.

  “Dr. Brown,” Randolph began, “I agree that there is unanimity on the need of treating heart attack victims as soon as possible in an appropriately equipped facility. However, that is not the issue before the court. The issue involves whether or not Dr. Bowman met the standard of care.”

  “Insisting on going to the Stanhope residence rather than meeting the victim at the hospital caused a delay.”

  “But prior to Dr. Bowman’s arrival at the Stanhope residence, there was not a definitive diagnosis.”

  “According to the plaintiff’s testimony at deposition, Dr. Bowman told him his wife was having a heart attack.”

  “That was the plaintiff’s testimony,” Randolph said, “but it was the defendant’s testimony that he specifically said a heart attack must be ruled out. He did not categorically say Patience Stanhope was having what you doctors call a myocardial infarction, or MI. If there had not been a heart attack, there would not have been a delay. Is that not true?”

  “That is true, but she had a heart attack. That’s been documented. It was also in the record she had a questionable stress test.”

  “But my point is that Dr. Bowman did not know for certain Patience had had an MI,” Randolph said. “And he will testify to that in this court. But let us turn our attention to your earlier testimony about medical school. Let me ask you if you got an A in your third-year rotation on internal medicine?”

  �
��I did.”

  “Did all your fellow students in your preceptor group get A’s?”

  “No, they did not.”

  “Did they all want to get A’s?”

  “I suppose.”

  “How do you get into medical school? Must you routinely get A’s in your premedical curriculum?”

  “Of course.”

  “And how do you get the most coveted residencies, like at the Boston Memorial Hospital?”

  “By getting A’s.”

  “Is it not hypocritical for academicians to decry competition as antihumanistic and yet base the whole system upon it?”

  “They do not have to be mutually exclusive.”

  “Perhaps in the best of worlds, but reality is something different. Competition does not breed compassion in any field. As you eloquently testified, medical students must absorb a staggering amount of information, which is what they are graded on. And one further question in this regard. In your experience both as a student and as a preceptor, is there competition for the, quote, ‘most interesting patients’ rather than the routine degenerative afflictions?”

  “I guess there is.”

  “And that’s because their presentations gather the most acclaim.”

  “I suppose.”

  “Which suggests that all of the students, but particularly the top students, to a degree use the patients both to learn from and to advance their careers.”

  “Perhaps.”

  “Thank you, doctor,” Randolph said. “Now, let’s turn to the issue of medical house calls. What is your professional impression of house calls?”

  “They are of limited value. One doesn’t have access to the tools that are necessary to practice twenty-first-century medicine.”

  “So doctors generally are not in favor of house calls. Would you agree?”

  “I would. Besides the lack of equipment, it represents an inappropriate utilization of resources, since there is too much downtime traveling to and from the home. In the same time frame, many more patients could be seen.”