“Me, too,” Susan added with more sparkle.
“I didn’t know you were on the symphony board,” Will said.
“I’m planning on being on it someday.”
“All right,” Katz said, “let’s get on with this. Will, it’s a good thing you enjoy your work, because you certainly do a heck of a lot of it.”
Jim Katz had seven patients in the hospital, Susan and Will three apiece, and Gordon Cameron, who had already gone home, two, including the case he and Will had done earlier in the day. The trio of surgeons that included Steve Schwaitzberg had another five. Schwaitzberg had signed his three out over the lunch hour, and the other two would do so by phone. Twenty patients in all-a load by modern standards. Insurance restrictions had seen to it that most of them had received their pre-op evaluations as outpatients, and had been operated on before they had even seen their rooms or met the nurses who were going to be their caregivers. The moment after their surgery was completed, they were being primed for discharge. Actuarial tables compiled by the managed-care and insurance industries had demonstrated that such policies saved money without causing a significant rise in post-op complications. Will’s experience with his own and many other practices had shown that a good number of patients would gladly beg to differ with those statistics.
At Susan’s urging, they saw Jim Katz’s group first. He would never complain about his workload or diminishing physical capabilities, but the three younger members of the group had each seen evidence that layers were peeling off his stamina and abilities in the OR, and they sought to protect him in any way they could. All went well until the last of Katz’s patients, a sixty-three-year-old diabetic man whose gallbladder Katz had removed the morning before.
“So, Mr. Garfield,” Katz said, checking the four small incisions he had made into the man’s abdominal cavity, and nodding approval of the way they looked, “is your wife on her way here to get you?”
“She just called from the parking garage, I shouldn’t worry,” Garfield said.
“Good, good. And the nurses have given you my discharge instructions? Good.”
Will didn’t like anything about what he was seeing and hearing. Stuart Garfield was doing his very best to mask it, and maybe he didn’t even realize it was happening, but he was experiencing some shortness of breath. Susan nodded minutely that she had noticed the same thing. The managed-care companies decreed that a night in the hospital or even less was to be the standard of care for the laparoscopic removal of a gallbladder. Katz did not consider that the man’s diabetes was reason to argue for more, and it wouldn’t have been except for the distension of the veins alongside the man’s neck and the slight bluish cast to his lips-both subtle signs of evolving trouble.
Nonchalantly, Will sidled over to the bedside, slipped his stethoscope into his ears, and listened through the man’s back to the base of his lungs. Rales, the crackling sounds made by fluid filling the small air sacs, were most definitely present. Stuart Garfield was in early heart failure-a potentially serious condition in any patient, but even more so in a diabetic who, with little warning, perhaps by the time he and his wife had reached the highway, could be in full-blown pulmonary edema-a terrifying, life-threatening emergency. Will motioned Katz over to the doorway. There was no easy way to present the findings, and with a physician as forthright and honorable as Katz, it wasn’t smart to try.
“Jim, he’s in some congestive heart failure,” Will whispered. “Neck veins distended, rales at both bases, a little blue around the gills.”
Katz sagged visibly, crossed to the bedside to listen, then returned to the doorway.
“I knew I shouldn’t have been rushing him out,” he said, shaking his head in dismay.
“Listen, don’t be hard on yourself. We’re making rounds together as a team. This sort of thing is why we do it. Thanks to our friendly neighborhood insurance companies, the pressure’s on all of us now all the time. They tell you that the average surgeon gets his gallbladder patients out of the hospital on the first post-op day, or even the day of the procedure. You know darn well that if you keep yours in an extra day or two, you’re going to be right down on the HMOs’ list. They don’t ignore these things.”
“Just the same,” Katz said wearily, “thanks for saving my bacon.” He returned to his patient. “Mr. Garfield, I’m going to wait for your wife to get up here, then we have to talk.”
“I’ve never seen him so glum,” Susan said, as they headed off to see the first of her patients.
As the sole woman in the group, Susan had proclaimed herself the mother hen, dedicated to keeping Gordo’s weight under control, seeing that Will got enough sleep and met someone special, and insisting that Jim Katz cut back on his many obligations.
“We more or less grew up with the problems of managed care,” Will said. “Jim’s had to adapt to them. He gets sort of wistful when he talks about the time when you simply diagnosed a surgical problem in a patient, cut it out, and cared for the person until they were ready to go home.”
“Ah, yes, the good old days before one-size-fits-all medicine. My mom is embroiled in a battle with her HMO right now. She’s got huge fibroids, complete with pain and vaginal bleeding, and her GYN wants to do a hysterectomy.”
“Makes sense to me.”
“Me, too, but the evaluators at her HMO say the procedure is unnecessary. What’s more, they performed their magnificent evaluation of her over the phone. No one from her HMO has ever laid eyes or hands on her, but they’re the ones making the decision.”
Will hoisted himself up haughtily and adopted a dense British accent.
“I’m not a doctor, but I play one on the phone.”
“Exactly. So Mom has pain every time she takes a step, and her doctor says the fibroids would make it impossible for him to feel a malignancy if one were there.”
“Goodness. She still in Idaho?”
“Forever.”
“And you never had any desire to go back there to practice?”
“How can I know I exist if I can’t see myself in store windows when I walk down the street?” Susan’s dark eyes smiled. “Besides, what do I have in common with Demi Moore and all of those other big-name transplants from Hollywood?”
“You should bring your mom’s case up at the Society meeting Thursday night.”
“Um. . the truth is, I hadn’t decided if I was going to go. Will, I appreciate your enthusiasm for the Hippocrates Society, really I do, but after almost a year of going every month, I just haven’t gotten caught up in it. I’m definitely upset with managed-care companies’ policies and regulations and all they’re doing to the way we practice, but I just haven’t been able to get as. . as fired up as the rest of you, even with my mom’s recent problems. You know me. I’m pretty reserved about most things-not shy like some people think, but not that outspoken, either. And excuse me for saying so, but you people are fanatics.”
Will laughed.
“Hey, now, I wouldn’t go that far. How about committed?”
“If that makes you more comfortable.”
“Listen, Suze, we need every body we can get at these meetings. There were over a hundred docs there last time. A hundred! The papers are really starting to take notice.”
“Will, I’m on two committees in the hospital and a couple at church. The people on the desk at my gym don’t know who I am, and I’m afraid my boyfriend may be headed there, too.”
“I understand. Just do your best. I may tell your mom’s story anyway.”
“You have my permission.”
“These companies have ripped the heart out of medicine, Susan. They have to be stopped.”
“You just be careful not to rile them up too much. You wouldn’t be the first doctor they’ve squashed.”
“I’d like to see them try,” Will said.
CHAPTER 2
Ashford was a bedroom community located almost midway between Fredrickston and Worcester. Beeper and cell phone at the ready, Will checked out with the ER and surgical residents and headed west through modest late-afternoon traffic. He knew that he was hardly the only divorced dad forced to drive to the house that had once been his to take his children out for dinner, but that knowledge did nothing to assuage the weirdness he invariably felt in the situation-especially when the doorbell was answered, as it was tonight, by Mark Mueller, once a friend and financial adviser to him and Maxine, and now, for more than a year, her live-in.