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Looking at Rodney, Thomas allowed an ironic smile to steal across his face. He wondered just how selfconfident Rodney would feel if he held a man’s heart in his hand. That was a time for decision, not discussion. As far as Thomas was concerned, Rodney’s presence at the meeting was one more indication of the bureaucratic soup in which medicine was drowning.

“Before we start,” said Dr. Ballantine, extending his arms with hands spread out as if to quiet a crowd, “I want to be sure that everyone has seen the article in this week’s Time magazine rating the Boston Memorial as the center for cardiac bypass surgery. I think we deserve it, and I want to thank each and every one of you for helping us reach this position.” Ballantine clapped, followed by George and a smattering of others.

Thomas, who’d sat near the door in case he was called to the recovery room, glowered. Ballantine and the other doctors were taking credit for something that was due largely to Thomas and to a lesser extent to two other private surgeons who happened to be absent. When he had gone into surgery, Thomas thought he would avoid the bullshit that surrounded most other professions. It was going to be him and the patient against disease! But as Thomas looked around the room, he realized that almost everyone at the meeting could interfere with his work because of one aggravating problem—the limited number of cardiac surgical beds and associated OR time. The Memorial had become so famous that it seemed as if everyone wanted to have their bypass there. People literally had to wait in line. Especially in Thomas’s practice. He had been limited to nineteen OR slots a week and he had a backlog of more than a month.

“While George passes out the schedule for next week,” said Dr. Ballantine, extending a stack of stapled papers to George, “I’d like to recap this week.”

He droned on as Thomas turned his attention to the schedule. His own patients were scheduled by his nurse, who collated the necessary information and got it over to Ballantine’s secretary, who typed it up. It contained a capsule medical history of each patient, a listing of significant diagnostic data, and an explanation of the need for surgery. The idea was that everyone at the conference would go over each patient and make sure that the operation was needed or advisable. But in reality it rarely happened, except if you missed the meeting.

Once when Thomas had been absent, the anesthesiology department had canceled several of his cases, resulting in a row no one was likely to forget. Thomas continued reviewing the sheets until Ballantine mentioned something about deaths. Thomas looked up.

“Unfortunately there were two surgical deaths this week,” said Dr. Ballantine. “The first was a case on the teaching service, Albert Bigelow, an eighty-two-year-old gentleman who could not be weaned from the pump after a double-valve replacement. He’d been scheduled as an emergency. Is there word on the autopsy yet, George?”

“Not yet,” said George. “I must point out that Mr. Bigelow was a very sick cookie. His alcoholism had seriously affected his liver. We knew we were taking a risk going to surgery. You win some and you lose some.”

There was a silence. Thomas commented sarcastically to himself that Mr. Bigelow’s untimely demise had prompted a stimulating discussion. The galling part was that it was this kind of patient that was keeping Thomas’s patients waiting.

Ballantine glanced around, and when no one spoke he continued: “The second death was a patient of mine, Mr. Wilkinson. He died last night. He was autopsied this morning.”

Thomas saw Ballantine look over at George, who shook his head almost imperceptibly.

Ballantine cleared his throat and said that both cases would be discussed at the next death conference.

Thomas wondered at the silent communication. It brought to mind the weird comment George had made up in the lounge. Thomas shook his head.

Something was going on between Ballantine and George, and Thomas felt a twinge of uneasiness. Ballantine had a unique position in the medical center.

As chief of cardiac surgery, he held an endowed chair with the university and was paid a salary. But Ballantine also had a private practice. Ballantine was a holdover from the past, bridging as he did the full-time salaried men like George and the private staff, like Thomas. Of late Thomas had begun to think that Ballantine, whose skills were obviously on the decline, was beginning to favor the prestige of being a professor over the rewards of private practice. If that were true, it could cause trouble by upsetting the balance between the full-time staff and the private physicians, which in the past had always tilted toward the latter.

“Now, if everyone will turn to the last page of the handout,” said Dr. Ballantine, “I’d like to point out that there has been a major scheduling change.”

There was a simultaneous rustle as everyone flipped the pages. Thomas did the same, placing the papers on the arm of his chair. He did not like the sound of a major scheduling change.

The last page was divided vertically into four columns, representing the four rooms used for open-heart surgery. Horizontally the page was divided into the five days of the work week. Within each box were the names of the surgeons scheduled for that day. OR No. 18 was Thomas’s room. As the fastest and busiest surgeon, he was assigned four cases on each day except Friday when he had three because of the conference. The first thing Thomas checked when he looked at the page was OR No. 18. His eyes widened in disbelief. The schedule suggested that he’d been cut to three cases a day, Monday through Thursday. He’d lost four slots!

“The university has authorized us to hire another full-time attending for the teaching service,” Dr. Ballantine was saying proudly, “and we have started a search for a pediatric cardiac surgeon. This, of course, is a major advance for the department. In preparation for this new situation, we are expanding the teaching service by an additional four cases per week.”

“Dr. Ballantine,” began Thomas, carefully controlling himself. “It appears from the schedule that all four additional teaching slots are being taken from my allotted time. Am I to assume that is just for next week?”

“No,” said Dr. Ballantine. “The schedule you see will hold until further notice.”

Thomas breathed out slowly before speaking. “I must object. I hardly think it’s fair that I should be the sole person to give up OR time.”

“The fact of the matter is that you have been controlling about forty percent of the OR time,” said George. “And this is a teaching hospital.”

“I participate in teaching,” snapped Thomas.

“We understand that,” said Ballantine. “You’re not to take this personally. It is plainly a matter of more equitable distribution of OR time,”

“I’m already over a month behind on my patient schedule,” said Thomas. “There isn’t that kind of demand for teaching cases. There aren’t enough patients to fill the current teaching slots.”

“Don’t worry,” said George. “We’ll find the cases.”

Thomas knew what the real issue was. George, and most of the others, were jealous of the number of cases Thomas did and how much money Thomas earned. He felt like getting up and punching George right in the face.

Glancing around the room, Thomas noticed that the rest of the doctors were suddenly busy with their notes, papers, or other belongings. He could not count on any of the people present to back him up.

“What we all have to understand,” said Dr. Ballantine, “is that we are all part of the university system. And teaching is a major goal. If you feel pressure from some of your private patients, you could take them to other institutions.”

Thomas’s anger and frustration made it hard for him to think clearly. He knew, in fact everybody knew, that he could not just pick up and go to another hospital. Cardiac surgery required a trained and experienced team. Thomas had helped build the system at the Memorial, and he depended on the structure.

Priscilla Grenier spoke up, saying they might be able to add an additional OR room if they got an appropriation for another heart-lung machine and perfusionist to run it.

“That’s a thought,” responded Dr. Ballantine. “Thomas, perhaps you’d be willing to chair an ad hoc committee to look into the advisability of such expansion.”

Thomas thanked Dr. Ballantine, struggling to keep his sarcasm to a minimum. He said that with his current workload it was not possible to accept Ballantine’s offer immediately, but that he’d think about it. At the moment he had to worry about putting off patients who might die before they had OR time. Patients with a ninety-nine-percent chance of living long, productive lives if they did not find their OR time sacrificed to some sclerotic wino whom the teaching service wished to experiment on!

On that note the meeting was adjourned.

Struggling to keep his temper under control, Thomas went up to Ballantine. George had, of course, beat Thomas to the podium, but Thomas interrupted.

“Could I speak to you for a moment?” asked Thomas.

“Of course,” said Dr. Ballantine.

“Alone,” said Thomas succinctly.

“I was heading over to the ICU anyway,” said George amiably. “I’ll be in my office if you need me.” George gave Thomas a pat on the shoulder before leaving.

To Thomas, Ballantine was the Hollywood image of the physician, with his soft white hair combed back from a deeply lined but tanned and handsome face. The only feature that somewhat marred the overall effect were the ears. By anyone’s standards they were large. Right now Thomas felt like grabbing and shaking them.

“Now, Thomas,” said Dr. Ballantine quickly. “I don’t want you getting paranoid about all this. You have to understand that the university has been putting pressure on me to delegate more OR time to teaching, especially with the Time article, That kind of publicity is doing wonders for the endowment program. And as George pointed out, you have been controlling a disproportionate amount of hours. I’m sorry you had to learn about it like this, but ...”

“But what?” asked Thomas.

“You are in private practice,” said Dr. Ballantine. “Now if you’d agree to come full-time, I can guarantee a full professorship and ...”

“My title as Assistant Clinical Professor is fine with me,” said Thomas. Suddenly he understood. The new schedule was another attempt at pressuring him into giving up his private practice.

“Thomas, you do know that the chief of cardiac surgery who follows me will have to be full-time.”

“So I’m to look at this cut in my OR time as a fait accompli,” said Thomas, ignoring Ballantine’s implications.

“I’m afraid so, Thomas. Unless we get another OR, but, as you know, that takes time.”

Abruptly Thomas turned to go.

“You’ll think about coming aboard full-time, won’t you?” called Dr. Ballantine.

“I’ll consider it,” said Thomas, knowing he was lying.

Thomas left the teaching room and started down the stairs. At the first landing he stopped. Gripping the handrail and closing his eyes as tightly as possible, he let his body shake with sheer anger. It was only for a moment. Then he straightened up. He was back in control. After all, he was a rational individual, and he’d been up against bureaucratic nonsense long enough to deal with it. He’d suspected that Ballantine and George were up to something. Now he knew.

But Thomas wondered if that were all. Maybe it was something more than the OR schedule change because he still had the anxious feeling something else was going on that he should know about.

CHAPTER 3

CASSI ALWAYS EXPERIENCED a degree of apprehension when she dipped the test tape into her urine. There was always the chance that the color of the tape would change and indicate she was losing sugar. Not that a little sugar in her urine was all that big a deal, especially if it occurred only once in a while. It was more an emotional thing; if she was spilling sugar, then she was not in control. It was the psychological aspect that was disturbing.

The light in the toilet was poor, forcing Cassi to unlatch the stall door in order to get a good look at the tape. It had not changed its color. Having gotten so little sleep the night before and having cheated that afternoon with a fruit yogurt snack, she wouldn’t have been too surprised to see a little sugar. Cassi was pleased that the amount of insulin she was giving herself and her diet were in balance. Her internist, Dr. Malcolm McInery, talked occasionally of switching her to a constant insulin-infusion device, but Cassi had demurred. She was reluctant to alter a system that seemed to be working. She did not mind giving herself two injections a day, one before breakfast and one before dinner. It had become so routine as to be effortless.

Closing her right eye, Cassi looked at the test tape. There was just a vague sensation of light as if she were looking through a wall of ground glass. She wished that she didn’t have the problem with her eye because the idea of blindness terrified her more, in some ways, than the idea of death. The possibility of death she could deny, just like everyone else. But denying the possibility of blindness was difficult with the condition of her left eye there to remind her each and every day. The problem had happened suddenly. She’d been told that a blood vessel had broken, causing blood to enter into the vitreous cavity.

As she washed her hands, Cassi examined herself in the mirror. The single overhead light was kind, she decided, giving her skin more color than she knew it possessed. She looked at her nose. It was too small for her face. And her eyes: they curved unnaturally upwards at the outer corners as if she had her hair pulled back too tightly. Cassi tried to look at herself without concentrating on any single feature. Was she really as attractive as people said? She’d never felt pretty. She had always thought that diabetes was indelibly stamped in bold letters across her forehead. She was convinced that her disease was a major flaw that everyone could see. It hadn’t always been that way. In high school Cassi had tried to reduce it to a small aspect of her life. Something she could compartmentalize. And although she was conscientious about her medicine and diet, she did not want to dwell on it. Yet this approach made her parents, mostly her mother, understandably concerned. They felt that the only way she would be able to maintain the discipline the disease required was to make it her major focus. At least that was the way Mrs. Cassidy had dealt with the problem.