Crisis (31 page)

"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 if 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 or 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 that 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, wingtip 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 As?"

"No, they did not."

"Did they all want to get As?"

"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 anti-humanistic 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 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."

"So it is inefficient."

"Yes, you could say that."

"What is the opinion of patients about house calls?"

"Objection!" Tony called out, semi-rising from his chair.

"Hearsay."

Judge Davidson snapped off his reading glasses and glared down at Tony with irritable disbelief.

"Overruled!" he snapped. "As a patient, which we all are at some point, Dr. Brown would be talking from experience. Proceed."

"Would you like me to repeat my question?" Randolph asked.

"No," Dr. Brown said. He hesitated. "Patients generally like house calls."

"How do you think Patience Stanhope felt about house calls?"

"Objection!" Tony said, rising again. "Supposition. There's no way the witness would know how the deceased felt about house calls."

"Sustained," Judge Davidson said with a sigh.

"I assume you read the medical records supplied to the plaintiff."

"Yes, I read them."

"So you are aware that Dr. Bowman made many house calls to tend to Patience Stanhope prior to the evening in question, often in the middle of the night. From reading these records, what was the usual diagnosis on these visits?"

"Anxiety reaction manifesting itself mostly in gastrointestinal complaints."

"And the treatment?"

"Symptomatic and placebo."

"Was pain ever involved?"

"Yes."

"Where was the pain?"

"Mostly low abdominal but occasionally midepigastric."

"Pain in the latter location is occasionally reported as chest pain. Is that correct?"

"Yes, that's correct."

"From your reading of the record, would you say that Patience Stanhope exhibited at least some evidence of hypochondriasis?"

"Objection!" Tony called out but stayed in his chair. "Hypochondriasis is never mentioned in the record."

"Overruled," Judge Davidson said. "The court would like to remind the plaintiff's attorney that the witness is his medical expert."

"From reading the record, I believe it would be a safe assumption that some element of hypochondriasis was involved."

"Does the fact that Dr. Bowman made repeated house calls, which you have said most doctors do not favor, often in the mid-die of the night to a woman with avowed hypochondriasis, say something to you as a physician about Dr. Bowman's attitude and compassion for his patients?"

"No, it does not."

Randolph stiffened with surprise, and his eyebrows rose. "Your response defies rationality. Can you explain?"

"It is my understanding that house calls are one of the perquisites that patients expect when they pay high retainer fees, sometimes as high as twenty thousand dollars a year, to be part of a concierge medical practice. Under such a circumstance, one cannot say Dr. Bowman's making house calls necessarily reflects beneficence or altruism."

"But it might."

"Yes, it might."

"Tell me, Dr. Brown, are you biased against concierge medicine?"

"Of course I'm biased against concierge medicine," Dr. Brown sputtered. Up until that moment, he had maintained a detached coolness, not too dissimilar to Randolph's. It was clear that Randolph's questions had challenged him.

"Can you tell the court why you feel so strongly?"

Dr. Brown took a breath to calm himself. "Concierge medicine flies in the face of one of the three basic principles of medical professionalism."

"Perhaps you could elaborate."

"Of course," Dr. Brown said, lapsing into his familiar professional role. "Besides patient welfare and patient autonomy, the principle of social justice is a key underpinning of twenty-first-century medical professionalism. The practice of concierge medicine is the absolute opposite of trying to eliminate discrimination in health care, which is the key issue of social justice."

"Do you believe that your strong feelings in this regard might compromise your ability to be impartial concerning Dr. Bowman?"

"I do not."

"Perhaps you could tell us why since, to use your words, it 'flies in the face' of rationality."

"As a well-informed internist, Dr. Bowman knows that the symptoms women experience with myocardial infarction do not follow the classic symptoms experienced by men. As soon as an internist thinks about a heart attack in a female, particularly a postmenopausal female, he should act as if it were a heart attack until proven otherwise. There's a parallel in pediatrics: If the thought of meningitis occurs to a physician with a pediatric patient, the physician is obligated to proceed as if it is and do a spinal tap. Same with a female and a possible heart attack. Dr. Bowman suspected a heart attack, and he should have acted accordingly."

"Dr. Brown," Randolph said. "It is often said that medicine is more of an art than a science. Can you tell us what that means?"

"It means that factual information is not enough. A doctor must use his judgment as well, and since this is not an objective arena that can be studied, it is labeled an art."

"So scientific medical knowledge has its limits."

"Exactly. No two humans are exactly the same, even identical twins."

"Would you say that the situation Dr. Bowman faced on the evening of September eighth, 2005, when he was called to see for the second time in the same day a woman whom he knew was hypochondriacal called for a large measure of judgment?"

"All medical situations call for judgment."