Noble Vision (14 page)

“I’ll try my best.”

The rain quickly became a downpour. The brothers did not seem to notice the liquid needles striking their faces and soaking their shirts. The two figures with the same tall frame and steady eyes still held their firm handshake.

Chapter 8

Payment Due

The sun still hung high in the summer sky when David’s staff quit for the day, leaving him with the familiar mound of paperwork. Two ribbons of light, from windows flanking a bookcase, streamed through the transparent curtains and crossed the earth-toned carpet to flush David’s face. As he sat at his desk, he resisted the temptation to close the blinds, savoring the only contact he would have that day with the outdoors.

He thought of the impending appointment as department head and of his promise to his brother to be a model doctor. His great passion, his career, once inextricably linked to his performance at an operating table, now depended more on how he handled the documents on his desk. He wondered how he could make split-second decisions in the OR, and then have his mind frozen by a pile of papers. He vowed once more to be a model doctor, to handle every document.

The first one involved Bobby Norton, an architect with acute back pain. David had applied for permission to operate on the young man. While awaiting a reply, David was prescribing large doses of narcotics for Bobby. The medication was necessary to relieve the patient’s pain—and sufficient to trigger an official inquiry.

He read a certified letter from the Board of Medical Examiners, the agency that controlled his license, questioning the quantity of narcotics prescribed for Bobby, requesting the patient’s records, and directing David to appear at a meeting. By the way, the letter added, David could bring an attorney. The surgeon stared in bewilderment at the paper. Because of the medication, Bobby could work for the first time in years, and he had landed a job with an architectural firm. The surgeon knew of many cases in which patients in acute pain did not become addicted to the narcotic he was prescribing in the same dosages that normal people did. Bobby showed no signs of being an addict. He kept his appointments, read architectural books in the waiting room, and asked intelligent questions. According to his wife, for the first time in years Bobby was happy. In David’s judgment, his prescriptions were necessary and properly monitored.

Bobby had an appointment the next day. David would need to prescribe more narcotics. If he did, his problem with the Board of Medical Examiners would worsen. If he did not, Bobby would be unable to work. David sighed. The preservation of his license seemed to require that Bobby Norton lose his job and live in pain. Of course, he thought, if he could have operated without waiting for certification, the prescriptions would have been unnecessary! He set the letter aside. He would call his lawyer in the morning.

He reached for the next paper in the stack but could not summon the energy to lift it. His eyes drifted to the photos on his desk of Artur and Bernard, the conjoined twins whom he had separated. Because they were foreign citizens, they had been exempt from the state’s entitlement programs, giving David complete control over their treatment. Their attached brains had shared the same circulatory system. In separating the boys, David had to untangle a complex network of blood vessels flowing through an oblong double brain in the most bizarre pattern that he—or anyone else—had ever seen. David remembered studying the two brains sharing the same blood, trying to decide which vessel to give to Artur, which to Bernard. If he rerouted this artery to Artur’s brain, could Bernard survive? If he gave that vein to Bernard, could Artur survive? The twins seemed to be so intricately linked that separation would kill them.

He remembered the remarkable harmony of movement that the brothers displayed as they played in his office before the surgery, their attached heads pulled to the side, allowing four nimble feet to run along the floor. Their enduring awareness of each other reminded David of the childhood ritual of pricking one’s finger to mingle one’s blood with a friend’s, creating a spiritual bond as well as a blood tie.

Had he ever experienced that kind of intimacy with anyone? He thought of Randy—and felt a rush of guilt. Shouldn’t he have thought of Marie instead? Wasn’t a greater bond possible between husband and wife than between brothers? What stopped his blood from mixing with Marie’s?

He had met her seven years earlier, when she was a medical student and he a young surgeon who taught and conducted research at the university. Just as she was now, Marie was beautiful then, her comely features dominated by arresting brown eyes that flashed with a keen intelligence. At the time, David had a grant to employ a few students as assistants in the lab, among them, Marie. She worked diligently, her efforts extending beyond her meager pay. Because of her parents’ modest means, Marie worked at various jobs to support herself through medical school, a hardship that David, a doctor’s son, never had to endure. She did not complain to him of her struggle. She possessed so strong a love for medicine, he concluded, that it made the years of study and deprivation worthwhile. He thought that in Marie he had found a soul mate.

A year later, they married. Now he wondered about something more puzzling than any physical fibers in the brain: the threads of character in the wife he wanted to understand.

Through adolescence, Marie had a talent and a passion for singing opera. David never understood why she had given it up after years of rigorous study. According to her mother, Marie loved opera but suffered from the jeers of other teenagers. When she practiced at home, her classmates would stand outside her window mocking the sounds so peculiar to their ears. Humiliated, Marie would stop singing. At an annual recital in her high school, Marie performed arias from famous operas. Afterward her classmates nicknamed her “The Warrior,” after a horn-helmeted character that Marie had portrayed from a Wagnerian opera. The next year Marie declined to sing in the recital. Although even the most homely girls in her class had dates for the high school prom, no one asked the Warrior. The intricate musical compositions and grand themes of opera isolated her from other teenagers interested in rock music and video games. The artist in Marie, yearning to sing on the stages of the world, seemed to be at war with the teenager in Marie, seeking acceptance from her peers. On the night of the prom, Marie cried in her room. “I feel like a freak!” she told her mother.

When she entered college, Marie no longer feared being a freak. She gave up opera and with it, the simple joy of singing its haunting melodies. Instead, she focused on her social life—joining a sorority and dating. Her nickname became “Party Girl.” For her college prom, her mother recalled, Marie had her pick of dates.

Years later, when David offered to buy season tickets to the opera, he could not understand why Marie refused. Then one of Marie’s high school friends, a fellow opera student who had become a famous tenor, sent her tickets to his performance. However, Marie unexpectedly contracted a headache and could not attend. She did not play opera music around the house, which also puzzled David. The opera seemed to be a reminder of something painful that Marie wanted to forget.

With her keen intelligence, Marie acquired another interest during college. She enjoyed science and subsequently entered medical school. There she was drawn to cardiology. Dates with David were punctuated with her exuberant descriptions of the remarkable organ that was the center of the circulatory system and, judging by her exciting narratives, the center of the universe itself. One semester she was troubled by a course she took on future trends in medicine. She learned that the climate in medicine was changing, and the shift disturbed her. In one class, a prominent guest speaker declared: “Our health care system has been controlled for too long by high-powered specialists, using expensive technology and commanding exorbitant salaries. Society is now crying uncle, demanding a return to the simpler times when feeling under the weather meant seeing the reliable family doctor, who was also a neighbor and advisor.” Other speakers concurred, warning the young healers: “Specialists, who are financially draining the system, will play a diminished role in the future.” Marie began to lose sleep; her anxiety increased; she became tired and irritable. A new injury seemed to aggravate an old wound. Would she again be an outsider in a world made by others?

Tormented, she asked David for advice on what field of medicine she should enter. “Do what you love. Cardiology, of course,” he said simply. Marie chose family medicine. She apparently did not want to lose favor again. Afterward, she complained about school and procrastinated. Her grades dropped to the minimum required to graduate. She no longer spoke of her career with the same enthusiasm. David felt as if a spark had been extinguished.

Then came the malpractice suit. Marie had vaccinated hundreds of children without incident. The inoculations protected the children from disease and were a requirement for attending school. As with most drugs, vaccines can cause side effects in the rare individual. The parents of such an individual sued Marie for millions, charging that her injection caused convulsions in their child. They won the case.

In a bitter battle taking months of preparation and days of court appearances, Marie was vilified beyond her ability to comprehend. She insisted, and David agreed, that she had given an acceptable standard of care, but the verdict did not seem to rest on that. According to the judge, “the risk of erroneous decision is tolerable when compared with the state’s powerful interest in protecting the patient’s safety.” Who was an erroneous decision tolerable to? David wondered, as Marie cried inconsolably in his arms after the verdict.

From then on, Marie became hesitant about her work. She seemed to agonize over cases, fearful of making decisions. To help bolster her confidence, David bought her the
Taft Encyclopedia of Family Medicine
, an authoritative work in her field. However, when she was unsure of herself, Marie did not open the volumes. Instead, she called other doctors to seek reassurance. She seemed to take comfort in building personal relationships with politically savvy colleagues. She served on the governmental affairs council of the local medical association, and she attended influential parties. She abandoned her fledgling solo office to join a group. And she developed a fondness for committee work.

Doctors have formed groups since the beginning of medicine. David, too, attended meetings to share information and to collaborate. However, he wondered about the committees Marie joined, for they were not created by doctors but were forced on them by the outside. Marie’s cost-containment committee challenged doctors’ billings; her physicians’ review group contested doctors’ decisions; her laboratory committee imposed fines on scientists. By what standard did Marie’s committees operate? When Marie had a questionable case, she would call a friend from one of her committees for advice. As a result of her contacts, Marie never was called to task for lengthy hospitals stays, excessive testing, or immoderate use of specialists. With a warm place reserved at the insiders’ hearth, she was never turned away in the cold as David so frequently was.

When CareFree was established by Governor Burrow, Marie complained, just as the other doctors did. But after reading the practice guidelines, which prescribed to doctors the approved treatment for every disorder, Marie declared that the restrictions were “not so bad.” Rather than taking away something sacred, David thought, the new system apparently gave Marie something comforting.

Stop it!
David ordered himself. General practitioners were under enormous pressure. Weren’t he and Randy also forced to do things they loathed? Why criticize Marie? Was her behavior questionable or merely a practical necessity?

Thoughts of Marie persisted as he gazed absently at the photos of Artur and Bernard. He could not untangle the threads of Marie’s character; the winding vessels in the brains of the twins had been easier to unravel.

Then he heard footsteps approaching his half-opened door.

“Hello, Dr. Lang,” said Pamela Varner.

“Kindly talk to my secretary tomorrow.”

“I’ll have no choice but to delay your payments until we talk.”

He put aside his papers, wondering why she always insisted on seeing him personally and why she grinned coyly when she succeeded in forcing his attention.

“If you’re here about Amy Washington’s surgery, I wrote a composition for your certifications officer, who gave me a passing grade,” David said, referring to a case they had discussed previously.

“That one flies. I’m here about another matter.”

She paused, as if wishing to be prodded, but David waited quietly. He wondered why his dealings with Pamela Varner seemed to be some kind of contest.

“Eileen Miller,” she said finally.

His eyes widened as if the case held a special interest to him. “What about Eileen Miller?”

“I can’t pay you for her surgery.”

“What?”

“Are you aware that your treatment wasn’t warranted by the general physician’s diagnosis?”

“I’m aware that the patient would have died without my treatment.”

“I’m not disputing that. I’m talking about our new rule.”

“And I’m talking about Eileen Miller’s life.”

“Doctor, we agree that the patient should receive the best care. The new rule was made to ensure that. It’s designed to prevent people from flooding the ER to see specialists when their general practitioners haven’t authorize a referral. You know the drill. A guy gets an earache, and the general doctor gives him eardrops. But the patient’s not satisfied with that. He wants to see a
specialist
. So he goes to the ER, where he has all of the specialists and their tests at his disposal. Unfortunately, people abuse the system,” she complained. “How can we give them their right to medical care when they do things they have no right to do?”