Marker (64 page)

"Now, I know you guys are familiar with Rousseau's head and hands being found in Rakoczi's refrigerator, since they were brought over to the OCME, so I won't go into that."

"Please don't," Laurie said.

"Since David Rosenkrantz was from out of state, the FBI jumped into the ring from day one, and lo and behold, there have been similar deaths in AmeriCare hospitals across the country. And now in each location, there is an ongoing investigation as to the perpetrator."

"Good grief!" Jack blurted. "When I suggested a conspiracy, I was thinking of one or two higher-ups and Rakoczi—certainly nothing on a national scale."

"Well, let me get to the juicy part," Lou said. He pulled his chair closer to the table and leaned forward. "Our saving that dirtbag Rosenkrantz has turned out to be key. He's copped a plea and has cooperated by implicating his immediate boss, Robert Hawthorne.

Hawthorne has turned out to be one interesting dude, and the lynchpin of the whole operation. He's a retired Army Special Forces officer and maintains contact with the military through a network of buddies. He's had an ongoing interest in dissatisfied military medical personnel. Whether he was recruited or had just cleverly created a niche for himself, we don't know. What we do know is that he has been acting like an independent contractor secretly in the employ of a big Saint Louis law firm, which specializes in plaintiff malpractice work. This firm is extremely active, carrying on simultaneous cases all over the country. As near as can be determined, Hawthorne recruited and ran a group of mostly disgruntled nurses, some of whom had been in the military, who were paid to communicate episodes of adverse outcomes from their respective hospitals, and who got bonuses if the case went to trial."

"I've heard about that," Jack said.

"Me, too," Laurie said. "It's mostly OB and anesthesia cases. It's the modern equivalent of the ambulance chasers of old."

"Well, I don't know about those details," Lou said. "But here comes the most interesting part. Over the last few years, there has been movement to make managed-care companies liable for malpractice, which, as an aside, seems reasonable to me."

"What's reasonable and what isn't has little to do with decisions about healthcare in this country," Jack interjected. "Everything is decided according to vested interests."

"By a strange twist of fate," Lou continued, "managed-care companies and malpractice plaintiff attorneys suddenly found themselves in the same bed in their desire to keep any malpractice-reform legislation from happening. I mean, the goals were slightly different in that the managed-care companies didn't want things changed so they could be sued, and the malpractice attorneys didn't want changes that would cap pain-and-suffering awards or eliminate contingency fees, among other things. Both groups employed lobbyists to make sure malpractice law did not change, which brought them together. So, essentially, their waking up in the same bed spawned a weird marriage between the two groups. How it happened is anybody's guess, but someone in AmeriCare must have realized they could use the shady services of Robert Hawthorne, since at least some of his contacts were ... what should we say? Psychopaths or sociopaths capable of murder without pangs of conscience."

"The newest term is 'antisocial disorder,' " Laurie chimed in.

"Okay, whatever," Lou said. "Anyway, some AmeriCare bureaucrat—or bureaucrats, as the case may be—became interested in tapping into the law firm's cast of unsavory medical insiders, which the law firm had formed to drum up business, in order to set up an elimination scheme for high-risk subscribers. These were the subscribers who they knew would be costing them millions of dollars in specialized care and thereby put upward pressure on premium rates. I mean, it makes some sort of sick sense."

"Good grief!" Jack reiterated. "This is close to what I feared, but on a larger scale."

"Let me finish!" Lou said after making sure no one was overhearing. "Whether there was any further cooperation in the works, such that the malpractice lawyers would then take advantage of the deaths by appealing to the next of kin to sue the doctors involved, we don't know. So far, we are only aware of one suit involving a doctor at Saint Francis Hospital."

"But that suit will surely be dropped now that homicide is suspected," Jack said.

"Maybe so," Lou said, "But I wouldn't count on it, since the perpetrator was in the hospital's employ."

"So, what's the state of the investigation at this point?" Laurie asked.

"There's a very active hunt for the Jasmine Rakoczis at these other institutions where a similar pattern of deaths has occurred.

The hope is to nab one and have that individual turn state's evidence. If that happens, maybe the whole house of cards will tumble down."

"Have there been any indictments so far from the hit man's testimony?" Laurie asked.

"Only Robert Hawthorne, who isn't talking and is in fact out on sizable bail," Lou said. "Unfortunately, the hit man was not really apprised of the whole operation. All he knew was that his boss, Robert, was a frequent visitor to the law firm. He didn't know whom he saw or what was ever talked about."

"Nobody in the AmeriCare hierarchy has been indicted?" Jack asked plaintively.

"Not yet," Lou admitted. "But we have our fingers crossed."

"What a nightmare," Laurie said with a shudder, remembering something of her ordeal in the hospital.

"Hey!" Lou said, eyeing the bubbles rising in the flute next to his water glass as if it were the first time he'd seen them. "This is champagne." He reached out and lifted the bottle from the ice bucket. "I don't know why I'm looking at this. I wouldn't know one brand from the next." He nestled the bottle back into the ice. "What is this, some kind of celebration?"

"Sort of," Laurie said with a smile. She looked at Jack, who raised his eyebrows as if there was a secret.

"Okay, out with it!" Lou commanded. He looked from one to the other.

"Well, it's not that big a deal," Laurie said. "I had a medical test today, which wasn't very pleasant I must say, but the result was reassuring. Apparently, the reason I had an ectopic pregnancy was because I had an abnormal or damaged oviduct. The test I had today showed my remaining oviduct is perfectly normal."

"That's great!" Lou said. He nodded a few times. He again looked back and forth between his two friends, both of whom were avoiding eye contact by looking down and swirling their drinks. "Well," Lou added. "Does this favorable result mean you two are planning to put this oviduct to the real test?"

Laurie looked up at Jack and said, "Unfortunately, at the moment, it just means it could be put to the real test."

"Too bad," Lou commented. "Well, if you need any volunteers to test that duct, I'm available."

Jack laughed and looked up at Lou and then Laurie. "Why do I have the feeling you two are ganging up on me?"

"Hey, I'm just trying to be a good friend," Lou said while raising both hands to profess his innocence.

"Well, good friend," Jack said, putting his arm around Laurie. "In the oviduct-testing business, I think Laurie and I can manage just fine."

"I'll drink to that," Lou said, raising his glass.

"Me, too," Laurie said.

AUTHOR'S NOTE

The announcement of the completion of the first draft of the human genome's 3.2

billion base pairs was made with great fanfare in June of 2000, and included the participation of two heads of state, President Bill Clinton and Prime Minister Tony Blair.

Although the media's excitement could be measured by coverage on both the network evening news as well as prominent front-page space in all the major newspapers on the following day, the public greeted the event with vague interest, a touch of bewilderment, and varying degrees of ennui, then quickly forgot about it. Despite glowing promises of future benefits, the subject apparently was too esoteric. Perhaps because of the public's reaction, the mass media soon forgot about it as well, except for a few follow-up articles on the colorful personalities of the leading scientists of the two competing organizations that carried out the painstaking work and the almost soap opera-like race to the finish.

The public's disregard for this landmark achievement has continued, even though the involved science and technology have been charging ahead, and reporting startling discoveries, such as the surprising fact that we humans have only about twenty-five thousand or so genes—a far cry from the hundred thousand experts had predicted not too long ago—and not that many more than an organism as comparatively simple as a roundworm! (This discovery is a blow to humanity's hubris equivalent to the Copernican revelation that the earth revolved around the sun, instead of vice versa.) In short, the decipherment of the human genome and the avalanche of research cascading from it has disappeared from most everyone's radar except for those working in the two new and related endeavors of Genomics and Bioinformatics. Genomics, in simple terms, is the study of the flow of information in a cell, while Bioinformatics is the application of computers to make sense of the enormous amount of data coming from Genomics.

In my mind, this lack of interest or apathy or whatever it might be called is startling; I believe the decipherment of the human genome might be the most important milestone in the history of medical science to date. After all, it gives us all the letters of the "book of life" in the right order, despite our having, as of yet, imperfect understanding of the language or the punctuation. In other words, in a cryptic form that is now being decoded with gathering speed, we have access to all the information nature has amassed to make and run a human being! As a consequence, the knowledge of the human genome will change just about everything we know about medicine, and some of the changes are going to happen sooner rather than later.

Like every major discovery/milestone in science, this one will have both good and bad consequences. Consider the consequences stemming from research into the inner structure and workings of the atom. We didn't do so well in that instance, as evidenced by current events, and we have to do better with the decipherment of the human genome, since it behooves society to consider all consequences of major leaps in science and technology and deal with them in a proactive manner rather than on a reactive, ad hoc basis.

Marker
deals with one of the negative consequences—i.e., the negative impact of the ability to predict illness when confidentiality is breached and the information is obtained by or otherwise falls into the wrong hands. Unfortunately, the chances of this occurring will be high, since microarrays as described in
Marker
already exist, with the ability to test with ease for literally thousands of markers linked to deleterious genes with a single drop of blood. (A marker is a point alteration in the sequence of nucleotide bases forming the rungs of the ladder of the DNA molecule. Markers have been mapped throughout the human genome.) The microarray slides are read automatically by laser scanners, and the results, thanks to Bioinformatics, are fed directly into computers armed with appropriate software such that risk and hence cost can be predicted with rapidly advancing speed and accuracy. The end result will be that the concept of health insurance, which is based on pooling risk within specified groups, will become obsolete. In other words, risk cannot be pooled if it can be determined.

From my perspective, the implications of this developing state of affairs are prodigious. As a physician, I have always been against health insurance except for catastrophic care and for those financially unable to pay. The doctor-patient relationship is the most personal and rewarding for both the patient and the physician when a clear, direct fiduciary relationship exists. In such a circumstance, in my experience, both individuals value the encounter more, which invariably leads to more time, more attention to potentially important detail, and a higher level of compliance—all of which invariably results in a better outcome and a more rewarding experience.

With the power of Genomics and Bioinformatics obviating the pooling of risk within defined groups, I have had to revamp my position, which has resulted in my switching from one extreme to the other. I now feel that there is only one solution to the problem of paying for healthcare in the United States, indeed for all developed countries in this global economy: to pool risk for the entire nation. (Under the rubric of healthcare I mean preventive care, acute care, and catastrophic care.) Although I never thought I'd be advocating this, I now believe that the sooner we as a nation move to a government-sponsored, obviously nonprofit, tax-supported single-payer plan, the better off we will be. Only then will we be able to pool risk for the en- tire country, as well as decide rationally how much we should spend on healthcare in general. One of the other effects of Genomics on healthcare will be the opportunity to individualize care. The entire pharmacological basis of therapeutics will be changing, thanks to another new field: Pharmacogenics, which will tailor-make drugs for individual patients according to their unique genomic makeup. The benefits of such care will be enormous, but so will the costs. Since we already spend over 15 percent of our GDP on healthcare, this has to be an important consideration.

There are other compelling arguments for a national, single-payer plan for healthcare, but to my mind none of them is nearly as persuasive as the developing power of Genomics. But change will not come easily. As Jack Stapleton comments in
Marker:

"What's reasonable and what isn't has little to do with decisions about healthcare in this country.... Everything is decided according to vested interests." Difficulties aside, it is my fervent belief that the sooner we move to such a plan, the better off the country will be. Luckily, we have the experiences of a number of other industrialized countries that have already enacted single-payer systems to learn from.

I would like to add just a few words about how a nurse as antisocial as Jasmine Rakoczi could get—and keep—a nursing job. Quite simply, there is a severe nursing shortage in the United States, and our hospitals, even our premier academic centers, are forced to continuously recruit nurses. As mentioned in
Marker,
this recruitment extends to other countries, including undeveloped nations. The combination of low compensation and the pressure to increase productivity (translated into forcing individual nurses to take on more patients than they can reasonably handle) has created enough of an adverse working environment that experienced nurses seek alternate employment, and young men and women are reluctant to begin the long, arduous, and expensive training. What makes this particularly unfortunate is that we all know (at least those who have experienced hospitalization) that the onus of care is not on the doctors who write the orders and leave to go back to their busy offices or cozy homes but on the nurses who stay and carry them out. And for those people who have suffered a major problem in the hospital, it's more likely than not that it was a nurse who recognized it, called the physicians, and instituted lifesaving care. In my opinion and experience we need less high-priced administration, and better pay and optimum working conditions for our beleaguered nurses, who are, as Jasmine Rakoczi herself said, in the trenches, actually taking care of people.