The Society

CHAPTER 5

The Boston chapter of the Hippocrates Society had been meeting on the third Thursday of each month since its inception fourteen years ago. Initially, the three founders of the chapter met at the home of one or another of them. Soon, driven by a steady increase in membership, they moved to a conference room at Harvard Medical School. Now, for nearly four years, meetings had been held in the amphitheater of the Massachusetts Medical Society-a spectacular modern structure located in a Waltham office park, featuring a massive four-story glass atrium at the main entrance, which opened onto terraced gardens and a bamboo forest.

The avowed goal of the Hippocrates Society was to recapture the practice of medicine from the capricious and viselike grip of the managed-care industry. Begun originally in San Francisco, the Society now had chapters in Chicago, Philadelphia, New York, and Houston, as well as its most rapidly expanding member, Boston. It was named for the fourth-century BC Greek physician, who was now widely recognized as the father of medicine. Hippocrates held the then-heretical belief that illness had a physical and rational explanation and did not represent possession of the body by evil spirits. He also preached the natural healing properties of rest, a good diet, fresh air, and cleanliness, and wrote the Oath of Medical Ethics taken today at most medical-school graduations.

Will arrived at the medical society with fifteen minutes to spare before the seven P.M. start. He had spent the last hour with John Doe, who had, over the past forty-eight hours, made the transition from near-hopeless physical disaster to medical miracle. Following his remarkable surgery there had been a rocky period during which his coma remained dense, his temperature once reached 106 degrees, and his systolic blood pressure persisted below 80 despite the most vigorous treatment.

To make matters worse, the shock and hypothermia had caused his kidneys to shut down, producing no urine output at all. Will brought in specialists from cardiology, neurology, and nephrology-the kidney experts. He and his residents delicately monitored dozens of body chemicals, working under the dangling sword of nonfunctioning kidneys, which meant that toxins couldn’t be cleared from John Doe’s body. In addition, without kidneys, the blood level of administered medications was a challenge to control and could, in fact, have easily become a source of lethal complications.

Hour after hour, the man’s life hung by the thinnest of threads. Suddenly, twenty hours after Will had stepped back from the operating table and stripped off his gloves signaling the end of the surgery, a single magnificent drop of urine appeared in John Doe’s catheter. . then, a minute later, there was another. Kidney function was returning, and from a treatment standpoint, anything was now possible. Will, the nurses, the residents, and the nephrologist toasted the event in the nurses’ lounge with coffee and stale doughnuts.

Just three hours ago, nearly two days after he was left for dead in an alley, the man remarkably and progressively regained consciousness. All at once John Doe had a real name-Jack Langley-and a life. He was a salesman from Des Moines, lowa, and father of three, and had been incapacitated by sudden, severe abdominal pain. He was down on one knee when he was attacked by three men. Fortunately, it appeared that Langley wasn’t conscious for most of the ensuing beating. Now, hardly out of the woods but certainly improving, Langley was filling the nurses in on the details of his life even as they were bringing him up to speed on his close brush with mortality.

Will was pleased to find that most of the medical society amphitheater’s 140 state-of-the-art conference seats were occupied. As he stepped into the hall, he was immediately surrounded by colleagues wanting some sort of update on the latest in the managed-care killings. As head of publicity and public relations for the Boston chapter for the past two years, Will had expected to be contacted by the press if not the police, but so far nothing.

An eager OB named Runyon, clearly more interested in what he had to say than in any grisly headlines, captured the conversation.

“So, get this one, Will. Twenty-three-year-old woman develops severe abdominal cramping. It’s the holiday weekend, so she gets called by the HMO on-call doc, who phones in a scrip for indigestion. The office is closed for the weekend, so no arrangements are made for follow-up. She is worse by morning and calls again and gets another doc who calls in a different prescription, insinuating that last night’s doc doesn’t know what in the hell he’s doing.”

“Tubal pregnancy,” Will said, anxious to speak with Tom Lemm, the Society president.

Runyon looked crestfallen at having the tag line of his tale preempted.

“Exactly,” he said, speaking to those nearby, as Will had headed off. “She bled out on the way to an ER-as in died. Can you believe it?”

Will spotted Lemm, a family practitioner in his fifties, on the far side of the hall. By the time he reached the man, he had been regaled by a surgeon, whose name he didn’t know, with the story of a woman whose HMO told her to wait awhile to have her thyroid biopsy repeated because the evidence of cancer from the first set of seven painful needle biopsies was inconclusive. Three months later, her husband was transferred to another state and assigned coverage with a different HMO. When the woman’s cancer suddenly began rapidly growing, the new HMO refused to pay for treatment, claiming it was a preexisting condition.

“Hey, Will,” Lemm called out as he approached, “this may be our largest gathering yet.”

He motioned to the crowd, and Will noticed as he followed the gesture that his partner, Susan Hollister, had just entered and was casting about for a seat.

Thanks for showing up, Suze. I owe you one.

“I’ve got a couple of cases, Tom. Do you think they’re appropriate given this latest murder?”

“Are they funny?”

“That depends.”

“On what?”

“On whether you mean funny, ha ha, or funny, all of a sudden I can’t see out of my right eye.”

“Which are these?”

“A little of both.”

“Well, you’re on the agenda. There’s more tension than usual from what’s going on, but I don’t see any reason to withhold an anecdote or two. Tonight it’ll be right after we finish discussing the status of the class-action suit. After your report, we’ll decide what we’re going to do about the big debate against Boyd Halliday next week.”

“What do you mean?”

“I spoke to him an hour ago. He says it would send the wrong message to the public and the killer if he called off the debate.”

The debate, billed as a forum, had been organized by the Wellness Project, a respected independent consumer health-care coalition, and was scheduled for venerable Faneuil Hall in downtown Boston. Halliday, the powerful and dynamic CEO of Excelsius Health, was to be matched up against Jeremy Purcell, a world-renowned surgeon, Harvard professor, philosopher, and former president of the Hippocrates Society. Thanks in large measure to Will’s efforts, publicity for the forum, which was titled Managed Care: Boon or Boondoggle, had been extensive, and a sellout was anticipated. Of course, the managed-care murders had only heightened interest in the event.

“How does Jeremy feel about it?” Will asked.

“I’m surprised you haven’t heard,” Lemm said. “Jeremy’s had a fairly large coronary. He had emergency bypass surgery at White Memorial.”

“And?”

“He’s reasonably stable now, but he won’t be ready for next week. We have to decide what we’re going to do.”

“Halliday’s a force,” Will said, in what he knew was something of an understatement.

“He is that. Listen, I’ve got to get this show on the road. Don’t worry about your stories. If people want to laugh they’ll laugh. I think one of the big reasons we’re getting more members at every meeting is you and your stories.”

“I don’t make them up, I just read them.”

“That’s the point. They’re real.”

“Okay, I’ll do my best.”

“Will, you’re doing great things for this organization, and don’t think we don’t appreciate it.”

“Well, garsh, thanks, Mickey,” Will said in his highly tuned Goofy imitation-the only one in his repertoire.

Lemm, a lean six-footer, shambled up to the podium and silenced the crowd with a few taps on the microphone.

“Three nurses die in an accident and are spirited up to the pearly gates,” he began, without any introductory remarks. “Saint Peter is there and asks each one, ‘Who are you, and why should you be allowed to walk through these gates?’ ‘I was a nurse in a private doctor’s office for forty-five years,’ the first responds. ‘I instructed patients on how to take their medicines; I gave out lollipops to the children-sugar-free, of course.’ ‘Go right in,’ Saint Pete says.

“The second nurse walks up. Same question from Saint Pete. ‘I was a nurse in a hospice,’ she says, ‘and for many years I soothed dying people’s fears of crossing over to the other side, and made the transition a peaceful and enlightening one.’ ‘Please go right in,’ Pete says again. ‘Milk and cookies are on the right.’ The third nurse comes forward. Again, Pete asks about her qualifications for admission. ‘I did case reviews for a managed-care company,’ she says. Pete checks his massive golden book. ‘Ah yes,’ he says, ‘I have you right here.’ He swings open the gate, and as she starts in, he adds, ‘But we’ve only got you scheduled for a three-day stay.’ ”

Laughter from the assembled was enthusiastic, even though Will suspected that most had heard the joke before. Lemm was right. These men and women needed to laugh. Their profession, in many cases their dream, was under constant attack, and the AMA, the organization they had counted on to man the battlements, had mounted a feeble defense. The well-oiled machine of the managed-care industry had cut through the various medical specialties like a thresher.

It probably wasn’t totally fair to draw the analogy between the way managed care overwhelmed the practice of medicine one specialty at a time (giving concessions to the ophthalmologists at the expense of the GPs, then suddenly regulating the ophthalmologists) and the way Hitler swept through Europe a country at a time, but Will was hardly the first physician to see it that way. There was a remarkable, intensely moving Holocaust memorial near Quincy Market in Boston. At the entrance was a quote from a Lutheran pastor named Martin Niemoller.

In Germany they came first for the Communists, and I didn’t speak up-because I wasn’t a Communist.

Then they came for the Jews, and I didn’t speak up-because I wasn’t a Jew.

Then they came for the trade unionists, and I didn’t speak up-because I wasn’t a trade unionist.

Then they came for the Catholics, and I didn’t speak up-because I was a Protestant.

Then they came for me-and by this time there was no one left to speak up.

“Let’s begin this meeting as we do all our meetings with a reading of the roll-physicians who have notified us they are leaving patient care or retiring from medicine prematurely. Their specific reasons vary, but the themes behind them do not. These physicians can no longer handle the paperwork, frustration, and inconvenience to their patients, if not actual danger, of corporate medicine.”

The reading of the roll, consisting of as many as twenty names each month, was, as always, painful. Along with most of the names was a short statement of the reasons this fifty-one-year-old family practitioner or that forty-eight-year-old obstetrician decided to look elsewhere for the emotionally fulfilling, economically rewarding life that they at one time felt was worth the years of sacrifice, exhaustion, and escalating financial outlay demanded by medical school and residency.

This month, three of the nine names on the roll were well known to Will. One of them had been a clinical instructor of his in med school. Half of all physicians recently polled, he was thinking glumly and angrily, had said that given the chance, they would not do it over. .

After the reading of the roll, Lemm called on the Society’s legal committee, which reviewed in detail the status of a class-action suit being brought against several of the largest HMOs by the Hippocrates Society in conjunction with a number of state medical associations and some individual physicians. The case, which had been plodding forward for almost five years but was now gaining some momentum, charged the HMOs with extortion and with violating the federal Racketeer Influenced and Corrupt Organizations Act.

Other legal actions from around the country were also reviewed, including a lawsuit in California accusing the health plans of interfering with physicians’ ability to make independent medical decisions. The plans threatened physicians with economic loss, the suit was charging, in an effort to deter them from fulfilling their duty owed their patients and encourage them to place unreasonable and often unsafe restrictions on the level of medical services that might be delivered to their patients.

The legal team’s presentation was interrupted a number of times by applause. In the analogies to the Nazi takeover of Europe, the lawyers and physicians of the legal team were the resistance-sniping at the enemy, disrupting them wherever possible. When they had finished their presentation, there was an almost palpable drop in energy throughout the hall.

“So,” Lemm announced, perhaps sensing the same thing, “before we do new business, let’s hear from our illustrious publicity and public relations chairman, Will Grant. What do you have for us tonight, Will?”

There was a smattering of applause as Will took over the microphone. He had been painfully shy as a child, and as an adult had never been that comfortable speaking in public. But over time he had managed to convince himself that looking or sounding like a fool wasn’t that big a deal. After two years, reporting to the Society each month held no great stress-especially when he had material such as he did tonight.

“Before I present a couple of cases,” he began, “I want to say that advance ticket sales for our forum with Boyd Halliday of Excelsius Health are brisk, and we already may have sold out Faneuil Hall. When I’m finished, Tom has some announcements to make regarding that event, which is going to be held despite the recent managed-care murders.

“As many of you know, my writing is about as dynamic as a snail derby. Thankfully, our committee has Randy Harrington, who continues regularly to submit wonderful letters to the editor and op-ed pieces to both papers as well as some suburban publications. This past month two of them have been published, one in the Globe. I hope you’ve had the chance to read them. If not, they are on our web site. Randy, could you take a bow?”

Harrington, a slightly built pediatrician with a pediatrician’s penchant for colorful bow ties, did as he was asked.

“Will Grant is a much better writer than he would have any of us believe,” Harrington said after the applause had quieted, “especially for a surgeon.”

“Roughly translated,” Will replied, “that means I know several words with more than one syllable and own at least five books that don’t require crayons.”

Tom Lemm laughed loudest of all.

“So,” Will went on, “as you know, your crack publicity and public relations committee members are constantly casting about for stories we might submit to the papers or at least present to you all. Tonight I have two of them in which our friendly neighborhood HMOs combine medicine and mathematics to give the best possible care to their constituents.

“A Newton psychiatrist writes: I admitted a twelve-year-old boy from orthopedics to our inpatient adolescent unit. He had bilateral ankle fractures sustained after jumping off the peak of the roof of his family’s garage. It was no challenge to diagnose the boy with major depressive illness and to conclude that his leap was a bona fide suicide attempt. I contacted the medical director of his HMO and requested a two-week hospitalization to do intensive family work in an attempt to provide him with a safer home environment, to initiate antidepressant medication, and to monitor his pain meds since one fracture needed to be repaired with an open reduction. I presented the case, including the mental-status exam, which was positive for a profoundly depressed mood, constricted affect, suicidal ideation, substance abuse, feelings of hopelessness and worthlessness, and sleep and appetite disturbances.

“Now, tell me again, the HMO medical gatekeeper asked, how high was the building he jumped off?

“What has that got to do with anything? This kid is hell-bent on killing himself. He needs at least fourteen days in the hospital.

“I’ll ask you again-how high was the garage?

“Two stories, I said. What difference does it make?

“If it really was two stories, he said, I’ll give you two days of initial authorization.

“Two days?!! So if it was three stories I’d get three days?

“Two days is what I can give you. You can call back after that and request approval for more, but I can’t guarantee you’ll get them.

“If this were your son, I’m sure your response would be different, I said. But, then again, he’d probably be dead by now, you Janus-faced bastard.

“The gatekeeper hung up on me. Eventually I got a total of six days for the kid. In the lobby the day he was discharged, I heard his father call him a little jerk. The next day I submitted my resignation from the hospital and started looking for a nonclinical job. Thank you, managed care.”

The ending, tragic though it was, brought sustained applause. The members’ exuberance was born purely of frustration. Every one of them had encountered similar, logic-defying bureaucratic stonewalling of the way they wished to practice medicine.

“You had to have made this up,” someone cried out.

Will shook his head.

“I don’t have that kind of imagination,” he said. “These are real stories from real people. Okay, one more math-and-medicine case, this one a quickie from a surgeon in Worcester. Patient comes to see her with bleeding, horribly painful hemorrhoids. The guy’s done everything his family doc asked him to-soaks, suppositories, stool softeners, rubber donut. Finally, sleepless, in constant pain, bleeding through a pad, and unable to sit at work, he comes in for surgery. The surgeon dutifully calls for the HMO’s preapproval and is stunned to have the young voice on the phone ask how large the hemorrhoids are. Clearly the lad is parroting questions off a computer screen, the surgeon writes. What difference does it make how large or small they are, she asks, THEY’RE KILLING HIM!!! Just say you’ll pay for this man’s care and let me fix him up. Ma’am, I’m afraid I can’t do that, the kid says. I need to know the size of the hemorrhoids before I can approve payment for the surgery. Okay, okay, okay, says the surgeon-on the faculty at the medical school, incidentally-the guy’s hemorrhoids are roughly the size of Nebraska. The lad making medical decisions for his HMO over the phone thinks for a few seconds, fills in the blank on his screen, then approves the procedure.”

The laughter this time was heartfelt, but also a bit edgy. Having medicine practiced over the telephone by HMO MDs or, even worse, non-MDs was a constant sore point for most of the Hippocrates Society members.

“That’s it until next month,” Will said. “Back to you, Tom.”

Lemm returned to the podium and silenced those who were still buzzing over Will’s cases.

“One last piece of business,” he said. “As many of you know, Jeremy Purcell, who was to champion our cause at next week’s forum, has had emergency bypass surgery. He’s reasonably stable at White Memorial but has been absolutely forbidden to participate in the debate. We can’t back out of the deal, so we need to select someone who can face up to Boyd Halliday. Jeremy has promised to make his notes and slides available and to spend time coaching whomever we choose. As a last resort, I will do this, but you all know as well as I do that I am a plodder-a behind-the-scene type of guy. I’ll help, and even sit beside our champion, but we really need someone with more panache than I have, someone with just the right balance of intellect, passion, and humor.”

Will, focused approvingly on Lemm’s words more than on the man himself, suddenly realized that the Society’s president was staring directly over at him. Before he could react, an internist from Springfield had waved his hand and shouted out, “I nominate Will Grant!”

“Second!” a dozen voices rang out.

“Third!” someone yelled.

“Fourth!”

Lemm waved the members to quiet down.

“Will,” he said earnestly, “I know you must be feeling like you’ve been set up. Well, I am here to assure you that you have.” Laughter. “Calm down! Hush up, please, all of you. I’m sorry, Will. I apologize for making light of this. And seriously, it was Jeremy who suggested you as his replacement just yesterday, and the executive committee agreed. I know there’s not much time for preparation, but we will help you in any way we can, and if you want me, I’ll be right up there on the stage beside you as your aide-de-camp.”

There was absolute silence throughout the auditorium.

Will sighed. He knew he desperately did not want to publicly debate the flamboyant president of Excelsius Health. He also knew that he couldn’t say no to the Society.

“I’ve been humiliated and utterly degraded before,” he said without leaving his seat. “I suppose that means I’m well prepared for an encounter with Boyd Halliday.”

“Will. . Will. . Will. . Will,” someone began chanting, as if they were ringside at a prizefight. One hundred and forty joined in.

“Will. . Will. . Will. . Will.”

“There being no further business,” Lemm shouted out over the din, “I’ll see you all at Faneuil Hall. Nice job, all. Meeting adjourned.”

Of all the dumb things, Will thought, as he drove out through the largely deserted parking lot. You are no more equipped to match up with Boyd Halliday than you are to bat against Pedro Martinez. He pulled off to the side of the road, set his palm pilot on the wheel, and called up Tom Lemm’s cell phone number. Lemm would just have to do it. Before he could dial, his own cell began ringing.

“Dr. Grant?” a woman’s voice asked.

“Yes.”

“This is Ellie Newell. I work in the comptroller’s office at the hospital. Mr. Davidson is my boss. I called him about this, and he called Mr. Brodsky. Apparently, Mr. Brodsky told him you would want to hear what’s just happened.”

Seth Brodsky was the longtime CFO of Fredrickston General.

“What’s this about?” Will asked.

“It’s about your patient, John Doe, in the ICU.”

“He’s not John Doe anymore. He just woke up and told us his name. It’s Langley, Jack Langley from Des Moines, Iowa.”

“Yes, I know,” Ellie said. “I just spoke to his wife.”

“You did?” Will had called Marybeth Langley just a few hours before.

“I also spoke with an officer at Midwest Industrial Care, the HMO that covers the Langley family.”

“And?”

“Dr. Grant, correct me if I’m wrong, but it seems Mr. Langley is still facing a long hospitalization.”

“If there are no serious setbacks, he is. The man was essentially dead when he was brought in. It’s a miracle he’s alive at all. I would guess ten more days. Maybe even two weeks.”

“His bill already-counting, among other factors, the cost of the ER, the OR, the surgical team, the recovery room, the ICU, and a number of consultants-is in excess of forty-five thousand dollars.”

“I’m not surprised.”

“Well, Midwest Industrial has flatly refused to pay anything and will not pay for any subsequent care.”

“That’s ridiculous. What reason did they give?”

Ellie Newell hesitated.

“Well,” she said, “the insurance company has a strict policy regarding all surgery. No coverage unless the procedure is preapproved by them or approved within twenty-four hours.”

“But the man was in a coma!”

“I know.”

“How can they do this?”

“Mr. Davidson told me that you of all doctors wouldn’t even bother asking that question-that you’d already know the answer.”

Will felt himself deflate.

“You know, Mr. Davidson is absolutely right,” he said. “He’s absolutely right. Thanks for calling me.”

Will ended the call, then called Tom Lemm.

“Tom, it’s Will.”

“Hey, I hope you’re not upset with me for the way I railroaded you back there. Desperate situations call for desperate measures.”

“No problem,” Will replied. “I was just calling to see if we could get together tomorrow. We’ve got a lot to do before next week.”