Noble Vision (11 page)

“Now get away from me, and don’t come into my OR again,” he said quietly.

Inspector Norwood’s clipboard shook. With the coldness of his attacker more frightening than any rage, the official slowly stepped back, and then found the trembling snarl that had become his voice.

“You’ll hear about this, Doctor! You’ll see which of us will be cut down to size!”

As the incredulous surgical team watched the incident through the windows on the OR doors, the inspector stormed down the hall. David scrubbed again and donned a new gown and gloves. The technician took the image. The OR team resumed its positions. And the surgery proceeded—all in silence, as if this incident, too, were now to be taken in stride.

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When David’s staff left the office that day, he yearned to do the same. Since dawn, he had energetically handled his surgeries, hospital rounds, and office appointments. Now, facing a desk full of papers, he suddenly felt drained. Medicine had always been the seductress in his life, one to whom he had been untiringly faithful. Why had he lately found it difficult to clear his desk?

He sat in an office that was a library. Mahogany bookcases filled with musty medical volumes lined the walls. The worn arms of a leather chair testified to thousands of patients seen, scores of papers written, and years of study by the chair’s owner. A plastic replica of the human brain rested on a shelf. From the wall, a portrait of history’s first neurosurgeon smiled approvingly.

A photo on the desk displayed a rare medical anomaly: twin boys, aged two, joined at the head. A more recent picture showed the boys as normal four-year-olds, two years after David had separated them in a landmark surgery. Before coming to David, the children’s parents had traveled from their home in Europe to consult with neurosurgeons around the world, all of whom had agreed that separating their sons was impossible. A glance at the photo of the healthy, smiling four-year-olds, who had become his adopted nephews, brought David a moment’s pleasure. It vanished when his eyes dropped to the small mountain of documents that his staff had left for him.

He grabbed the first form, regarding permission for early admission, which was attached to the chart folder of Carla Adams, a patient scheduled for surgery. Because of her medical history, David wanted her admitted to the hospital the day before, instead of the morning of, her operation, as a precaution. The early admission fell outside of CareFree’s range of norms, so David had to write a report justifying the action. He glanced at his watch. To provide the information would take thirty minutes. Should he forget the precaution or write the report? What were his chances of getting approval? He did not know. He set the form aside; he would return to it later.

Next in the stack was a letter from the Quality Assurance Review Board of Riverview Hospital, a consulting group hired by CareFree to evaluate how attending physicians used the hospital’s services. The letter asked David to explain why he had kept a Mr. Muldoon, who had developed a postoperative complication, in the hospital four days longer than was customary after the patient’s surgery. David paused again. Another half hour to write this reply. If he ignored the letter, he would be fined. If he replied and the review board overruled his judgment, he would be fined anyway. If he challenged the fine, he would have to present his case at a hearing, costing him more in lost time than the fine itself. David sighed. He set this form aside also; he would return to it later.

He glanced at the remaining papers. There was an authorization to perform additional testing for an upcoming case similar to the one he had just encountered, a tumor at the base of the brain that could be evacuated via the sinus route, if use of the mobile scanner was permitted. To use the device, he had to request permission by completing the form. After the morning’s incident in the OR, he could guess the response. He crushed the document into a ball and slammed it into the wastebasket. To save the agency the cost of the test, he would do the craniotomy, which would be more expensive—and riskier for the patient!

Next was a claim that David had filed concerning a Mr. Harrington. CareFree returned the claim because David had failed to enter a diagnosis. He could make no diagnosis without performing more tests. However, CareFree required a diagnosis before it would allow more tests on Mr. Harrington. David sighed again. The man who made split-second decisions in surgery could not determine what to do now. He set this form aside also.

At the bottom of the stack, he spotted a large envelope that he had been eagerly awaiting. It contained brain scans that he had ordered for a patient. David permitted himself to peek at the scans, just glimpse, promising himself that he would return to the paperwork at once. He guiltily clipped the crisp films to a view box behind his desk and gazed at a colorful web of blood vessels from the patient’s brain. His fatigue vanished as the swirling vessels cast a red net over his face, trapping him in their mysteries. In a moment there were no authorizations, no forms, no letters, only an unusual vascular pattern in a brain that intrigued him. Could he find a solution? For the next thirty minutes he studied the films for the answer.

He did not hear the footsteps advancing to the opened door of his office or the first knock.

“Dr. Lang, I need to speak to you. . . . Dr. Lang?”

Pulling his eyes from a galaxy away, he looked up at a pale pink suit containing the dark-haired, bespectacled Pamela Varner, a CareFree administrator.

“Now’s not a good time. Please make an appointment through my secretary.” He turned back to the view box.

“But Doctor, if I have to wait, then the payment we owe you will be delayed. I can’t authorize it until we discuss some things.”

He swiveled his chair around to face her. “What is it?” he asked tiredly.

She pulled a chair close to the desk and sat, crossing her legs comfortably as if preparing for a lengthy visit. Looking at him above glasses resting low on her nose, she opened a folder from her briefcase and began: “Blake Otis had a simple case of back discomfort.”

“You mean the Blake Otis who couldn’t get out of bed without searing pain?”

“His general physician didn’t think a visit to the neurosurgeon was necessary, only physical therapy. But Mr. Otis walks into your office—without authorization from his general doc—and next thing we know, he’s in the OR.”

“I thought everyone was entitled to treatment.”

“Of course everyone’s entitled to treatment.”

“Well?”

“Treatment according to the guidelines, Doctor.”

“But not according to the patient’s problem and wishes?”

“His general physician prescribed physical therapy.”

“His spinal cord images showed a ruptured disk. After my surgery to remove it, Mr. Otis could tie his shoelaces for the first time in years.”

“But, Doctor, you have a moral and legal obligation to the general physician.”

“But not to the patient?”

“We were willing to hear your side on this one. I sent my case manager to see you, but you refused to talk to him.” She sighed. “It’s his job to determine if treatment is necessary. Surely you can’t object to us wanting to spend the taxpayers’ money wisely.”

“By sending a clerk with no medical degree to second-guess me? How is that wise?”

“Wise or not, that one cost you four thousand dollars.”

He said nothing. She read the next document.

“Then there’s the case of Sammy Sullivan. Here’s someone who
was
sent to you by his general physician. He was entitled to your services, but you threw him out of your office, didn’t you, Doctor?”

“If he had gone into cardiac arrest, I’m not sure I could have forced myself to save him.”

“But this patient was
entitled
to your services.”

“Even though he was rude to me and my receptionist? Even though I’d bet you never found anything wrong with him because he had a history of hypochondriacal behavior?”

He smiled at the momentary flush reddening her face, an admission that he was right.

“Even though he’s filing a discrimination suit against you, Doctor?”

David’s smile vanished. Pamela Varner’s eyes widened subtly in victory.

“Whether you like him or not, Sammy Sullivan is still entitled to treatment.”

“But Blake Otis isn’t?”

“Two thousand for refusing treatment.”

She selected another document from her stack. “You expect us to pay extra for twelve hours of surgery to remove a meningioma from John Rittenhouse’s brain?”

“So?”

“So our statistical studies brought the cost for those surgeries
down
, not
up
.”

“What does a statistical study have to do with John Rittenhouse?”

“You know we pay on the
average
cost, Dr. Lang. I can reimburse you for six hours of surgery, not twelve.”

“But after six hours, the tumor wasn’t completely removed. It would have grown back.”

“That’s not the point.”

“It’s not the point whether the patient lives ten years or thirty?”

“Your fellow surgeons are cooperating with us on
reducing
their time in surgery. There are courses on how to do that. Maybe you should take one.”

His eyes flashed in anger, but he reminded himself that Pamela Varner was not the appropriate object for a strong feeling of any kind.

“If that’s it, Ms. Varner, you will excuse me.”

“There’s also the case of Denton Moore. When you operated on his herniated disk, you also removed a tumor near the surgical site.”

“So?”

“So we can’t pay for two different surgical procedures during one operation. You know we stopped doing that after the scandal with surgeons padding their bills with extra procedures they never performed.”

“You mean the scandal that began after you cut the surgeons’ pay?”

“Compensation models are established by another department, so I can’t help you there. Regarding Denton Moore, I need to know if you want to be paid for the tumor or the disk.”

“And how do I get paid for both?”

“That’s explained in the practice guidelines, Dr. Lang. You’d have to perform separate operations on different days.”

“But I thought I needed to
reduce
the time I spent in surgery.”

She had no retort. He smiled bitterly.

He rose, walked to the door, and held it for her. “Now, you will excuse me.”

She gathered her papers and walked toward him, her face somber, her voice low. “And don’t think the whole agency hasn’t heard about the incident with Inspector Norwood this morning in the OR. We know about that one, all right!”

“You should also know that I’m not above treating a woman the same way.”

“You hand-picked the right case to terrorize an inspector. You were clever, I’ll give you that.”

“What do you mean?” he asked blankly.

“I mean your patient with the pituitary tumor being the niece of Senator Wayne Carlton.”

“What?”

“I called you about that case last week and told you her connections.”

“That’s right! You did, didn’t you?” The relief in his voice confessed how much the incident had worried him.

“Could you really have forgotten the only thing that saved your skin?” she blurted out involuntarily. “I’ve seen licenses pulled for much less.”

For an unguarded moment, she saw his face tighten in fear.

“Dr. Lang, for your own sake, you’d better change your ways. You’re going too far. With all due respect, you’re uncivilized, you’re dangerous, you’re a menace to society.”

“Funny, I was thinking the same thing about you.”

Chapter 7

The Last Chance

The ball pounded the racquetball court with the blast of a shotgun. Two heads—one with black hair, one with blond—followed it. Two lean bodies cornered it, and then two tanned arms raised racquets to slam it. The players reveled in a violent release of energy that seemed more like a need than a pleasure. The game, a Sunday-morning ritual, ended that particular day with the dark-haired man scoring the winning point.

“Since when do you smile when I beat you?” David Lang asked his brother as the two ran dry towels over sweat-drenched heads and arms.

“On a day when nothing could go wrong in the world,” replied Randall Lang, the president of Riverview Hospital.

Their faces still held the boyish good looks of their childhood, except for the loss of innocence in the eyes. David’s had grown more cautious; his brother’s, more suspicious. However, that day Randall Lang’s face beamed with an exuberance that David had not seen in years.

“You’re unusually happy today, Randy.” David’s voice held surprise and pleasure at the change in the man two years his junior.

“Actually, I have some pretty exciting news to tell you,” Randy said with a grin, as he followed David through the clear plastic door of the court.