The Cole Trilogy: The Physician, Shaman, and Matters of Choice (212 page)

She went back into the brook and tried to lift the bridge on the low end but it was impossible for her to move it, and she surveyed the slanting structure bitterly. It would be possible to cross it gingerly, if it didn’t drop any more. But it would be folly to try to get across it while carrying a heavy load, or while pushing a laden wheelbarrow.

She collected her tools and made her slow way home, bone weary and terribly disappointed. It would no longer be easy or pleasurable to boast to herself that she could do anything, if she had to add a qualifier:

“… almost.”

38

T
HE
R
EUNION

George Palmer came to R.J.’s office one day when every seat was taken in the waiting room and Nordahl Peterson was sitting outside on the front steps. Still, when she had finished talking with George Palmer about his bursitis, explaining why she wasn’t going to give him any more cortisone, he nodded and thanked her but showed no sign of leaving.

“My youngest child is Harold. My baby,” he said sardonically. “Now forty-two years old. Harold Wellington Palmer.”

R.J. smiled and nodded.

“Accountant. Lives in Boston. That is, he
has
been living there, past twelve years. Now he’s going to be living with me again. He’s coming back to Woodfield.”

“Oh? That should be nice for you, George,” she said cautiously, having no way to know whether or not it would be nice until he came to the point.

It turned out that it might not be at all nice for George.

“Harold is what they call HIV positive. He’s coming here with his friend Eugene. They’ve been living together for nine years….” He seemed to lose his train of thought and then found it again with a start. “Well, he’s going to need a doctor’s care.”

R.J. put her hand on George’s hand. “I’ll look forward to meeting him and being his doctor,” she said, and squeezed his hand. George Palmer smiled at her and thanked her and left her office.

* * *

There wasn’t a great deal of forest between the end of the trail and her house, but the sadly sagged bridge had dampened her enthusiasm for trail building, and she turned to her vegetable garden with relief. It was too early for tender vegetables. The gardening books said she should have planted peas several weeks earlier instead of working in the woods, but the cool mountain climate gave her leeway, and she spread peat moss, compost, and two bags of purchased greensand on the raised beds that she and David had made, and dug everything in. She planted edible pod peas, of which she was especially fond, and spinach, knowing that neither would be bothered by the heavy frosts that still fell at night with regularity.

She watered carefully—not too much, to avoid damping off; not too little, to avoid aridness—and was rewarded by a row of seedlings that lasted scarcely a week. At the end of that time they had vanished, and the clue to where they had gone was a single perfect print in the velvet earth.

A small deer.

That night she went for coffee and dessert to the Smiths’ house and told them what had happened. “What do I do now? Replant?”

“You can,” Toby said. “You might still have time to get a crop.”

“But there are a whole lot of deer out in the woods,” Jan said. “You’d better take steps to keep the wild animals away from your garden.”

“You’re the fish and game expert,” R.J. said. “So how do I do that?”

“Well, some folks collect human hair from barbershops and spread it around. I’ve tried that myself. Sometimes it works, sometimes it doesn’t.”

“How do you protect your own garden?”

“We pee all around it,” Toby said calmly. “Well,
I
don’t.” She jerked her thumb at her husband.
“He
does.”

Jan nodded. “Best thing. One whiff of human piss, the critters find an excuse to make a business trip elsewhere. That’s what you should use.”

“Easy for you to say. There is a certain physiological dissimilarity
that makes my situation more difficult than your own when it comes to spraying. Would you consider coming over to my place, and …?”

“Nope,” Toby said firmly. “His supply is limited, and spoken for.”

Jan grinned and offered a final word of advice. “Use a paper cup.”

That was what she did, after replanting her peas. The problem was, she had a very limited supply too, even when she forced herself to drink more fluids than her thirst demanded. But she anointed the area next to the portion of the raised bed where she had replanted her peas, and this time when the seedlings came up, they weren’t eaten.

One day R.J. heard a sound like multiple motors in her backyard, and when she left the house she saw that a buzzing host was lifting from one of the hives. Thousands of bees rose in twisting, dancing ropes that coalesced and merged at roof height into a thick column that looked almost solid at times, so closely packed and multitudinous were the small black bodies. The column became a cloud that contracted and expanded, shifted and grew, and eventually it lifted and moved darkly over the trees and into the woods.

Two days later, another hive swarmed. David had worked hard on his bees, and R.J. had ignored them, but their loss gave her no feelings of guilt. She was busy with her own work and interests, and she had decided that she had her own life to live.

The afternoon of the second swarm she received a telephone call at the office. Gwen Gabler was coming from Idaho to visit her. “I need to be in western Massachusetts for a couple of weeks. I’ll explain when I see you,” Gwen said.

Marital problems? But no, it didn’t sound like that at all: “Phil and the boys send their love,” Gwen said.

“Give my love to them. And hurry from there to here. Hurry,” R.J. told her.

* * *

R.J. wanted to pick her up, but Gwen knew what a doctor’s schedule was like, and she arrived by cab from the Hartford airport, the same wiseass, warm, wonderful Gwen!

She came in the afternoon accompanied by a spring rainstorm, and they hugged damply and kissed and stared at one another and hooted and laughed. R.J. showed her the guest room.

“Never mind that. Where’s the toilet? I’ve held it in since Springfield.”

“First door on the left,” R.J. said. “Ooh, wait.” She ran into her own room, grabbed four paper cups from the bureau top, and hurried after Gwen. “Here. Would you use these, please? I’d appreciate it greatly.”

Gwen stared. “You want a specimen?”

“As much as you can give. It’s for the garden.”

“Oh, for the garden.” Gwen turned away, but her shoulders were already shaking, and in a moment she was roaring, leaning against the wall helplessly. “You haven’t changed, not one marvelous cell. God, how I have missed you, R.J. Cole,” she said, wiping her eyes. “For the garden?”

“Well, let me explain.”

“Don’t you dare. I don’t ever want to hear it. Don’t spoil a thing,” Gwen said, and clutching the four cups, ran into the bathroom.

That night they were more serious. They stayed up and talked late, late, while outside the rain drummed against the windowpanes. Gwen listened as R.J. spoke about David and told her about Sarah. She asked a question or two and held R.J.’s hand.

“And what of you? How is life in the HMO?”

“Well, Idaho’s beautiful and the people are really nice. But the Highland Family Health Center is a Health Maintenance Organization from hell.”

“Ah, Gwen, damn. Your hopes were so high.”

Gwen shrugged. She said that in the beginning it had appeared ideal. She believed in the HMO system, and she had received a bonus for signing her contract. She was guaranteed four weeks of paid vacation time and three weeks to attend professional meetings.
There were a couple of doctors who seemed to her to be less than geniuses, but she saw at once that four of the staff physicians were first-rate, three men and a woman.

But almost immediately one of the good male doctors, an internist, had left the Highland Center and gone to work at a nearby Veterans Administration hospital. Then another man—the HMO’s only other ob-gyn—had moved to Chicago. By the time the woman doc, a pediatrician, had bailed out, Gwen had a good idea what the exodus was about.

The management was very bad. The company owned nine HMOs throughout the western states and advertised that its driving goal was quality care, but the bottom line clearly was profit. Its regional manager, a former internist named Ralph Buchanan, now did time-and-motion studies instead of practicing medicine. Buchanan reviewed all the case reports to determine where money was “wasted” by the employee-physicians. It didn’t matter whether a doctor sensed something in a patient that made him or her want to investigate further. Unless there were citable “book reasons” for ordering a test, the physician was brought to account. The company had something it called the Algorithmic Decision Tree. “If A occurs, go to B. If B happens, go to C,” Gwen said. “It’s truly medical practice by the numbers. The science is standardized and spelled out for you, with no allowance for individual variations and needs. Management insists that the nonclinical details of a patient’s life—the background that sometimes points us to the real causes of trouble—must be ignored as a waste of time. There’s absolutely no room for a doctor to practice the art of medicine.”

It wasn’t the HMO system that failed, Gwen insisted. “I still believe managed health care can work. I think medical science has progressed sufficiently so we can work under time and test restrictions established for each ailment, so long as the physicians have the right and ability to depart from ‘the book’ without having to spend time and energy defending themselves to management. But this particular HMO is owned and run by bozos.” Gwen smiled. “Wait. It gets worse.”

To fill in for the loss of the three good practitioners, she said,
Buchanan hired what was available—an unboarded internist whose hospital privileges had been revoked for shoddy practice in Boise, a sixty-seven-year-old man who never had practiced but had spent his professional life doing research, and a young rent-a-doc general practitioner from a medical temp agency, who would work until the company was able to find another physician.

“The one remaining good physician, besides yours truly, was a bushy-tailed New Age doc in his thirties. Marty Murrow. He wore blue jeans to the office, had long hair. Actually went to medical conventions to learn new things. Tried to read everything in sight. He was a terrific young internist in love with medicine. Remember?

“Anyway, the two of us got into immediate trouble.”

It began for her, she said, when the company assigned “the klutz from Boise” to cover for her on her days off. Many calls ensued from her to Buchanan, at first polite and friendly, rapidly becoming acerbic. She told him that she was a boarded obstetrician-gynecologist and she wasn’t going to allow an unqualified person to share responsibility for her patients. That she had inherited a lot of cases from the departed ob-gyn. That she was far beyond the case load limit specified in her contract, the limit at which she could continue to function as a physician at a quality level, and that they damn well better find another ob-gyn to share the burden.

“Buchanan reminded me that this was a team operation, that I had to be a team player. I told him he could stuff that up his flexura sacralis recti unless he hired another qualified obstetrician. So I became an honored name on his shit list.

“Meanwhile, Marty Murrow was getting into far worse trouble. His contract called for him to treat sixteen hundred patients, and he was handling more than twenty-two hundred people. The lousy new doctors each were ‘caring for’ from four hundred to six hundred patients. The researcher just didn’t know very much about internal medicine. Whenever he was in the ICU, he had to ask the nurses to write his orders for him. He lasted less than two months.

“The patients soon caught on that there were some lousy doctors
at the Highland Family Health Center. When Highland got the contract to provide health care for a small factory with fifty workers, forty-eight requested Marty Murrow as their doctor. He and I began to freak out. We didn’t recognize a lot of the names on the charts. Often we were asked to sign prescription forms for other doctors’ patients, to order drugs for people we didn’t know and whose illnesses we weren’t familiar with. And because doctors were just employees, we had no control over the general lack of quality in the place.”

One of the nurses, Gwen told R.J., was particularly bad. Marty Murrow caught her in repeated mistakes when she brought prescription refills for his signature—“ordering the patient to take Zantax instead of Xanax, things like that. We had to watch her.” It bothered Gwen that the receptionist was rude and sarcastic in the office and over the telephone and often neglected to deliver patients’ messages and questions to the doctors.

“Marty Murrow and I screamed and called them names,” Gwen said. “We both telephoned Buchanan regularly to complain, which he liked because it gave him an opportunity to put us in our places by ignoring us. So Marty Murrow sat down and wrote to the president of the company, a retired urologist who lives in Los Angeles. Marty complained about the nurse, the receptionist, and Buchanan, and he asked the president to replace all three of them.