Philip cut through the clinical labs to the hallway that would take him out to the main lobby, one floor down from which was the NorthBroad Hospital cafeteria, a huge circular expanse where the entire staff, including physicians, found nourishment. A term used loosely, Philip thought, as he looked around at the various food stations. NorthBroad, like almost all hospitals, hadn’t connected the part of the dietary department that made recommendations about healthy foods to patients with the part that was responsible for serving food to employees. In his most cynical moments, Philip would surmise that the deplorably unhealthy foods the staff was forced to eat weren’t chosen through stupidity but instead represented a plot to foster more heart disease among their well-insured staff, as a way of recovering some of the money NorthBroad was forced to invest in employee health benefits. Even Philip had to wonder if his scorn of hospital administration was rational or simply a byproduct of his constant irritation with the people who ran the place but didn’t understand the core business that they had effectively ruined.
It didn’t really matter because Philip almost never visited the cafeteria, except when he was meeting someone, and even then, he would insist on taking whatever they purchased back to his office to consume, while he ate his own food from home. Too much noise and distraction during a busy workday, and too many nosey people to have an intimate conversation. This early morning was an exception. There were only a few people sitting, half awake, bent over their coffee cups, trying to rouse themselves. Among them were Gilbert and Liz Gold, sitting a little too close for Philip’s comfort, having an intense conversation that Philip was pretty sure wasn’t about medicine.
Philip grabbed a cup of black coffee and headed over to their table. When Gilbert and Liz saw Philip, they stopped talking, sat back in their chairs, and welcomed him. Philip stood awkwardly next to their table before finally sitting down.
“This is some place, Philip,” Gilbert started, trying to make conversation. “I’ve never been in this hospital before.”
“Yeah, big place,” Philip answered, obviously distracted and not in the mood for small talk. “Liz, would you mind if I spoke to Ray … alone?”
“Certainly, Dr. Sarkis. Ray, text me when you’re done. I’m going back over to the EP lab area. We’re going to have to figure out how we’re getting back to Allentown.”
“Sure,” Ray said, dreading his now-private conversation with Philip.
Philip waited until Liz was out of earshot. “You hittin’ that, Ray?”
“Huh?”
“C’mon, Ray. I figure something has to be distracting you to make you miss Nolan’s diagnosis. Just thought that maybe Liz was the diversion.”
“Philip, I really respect you, but that isn’t any of your business.”
“Right. So you are doing her. Is she married?”
Gilbert looked down and sighed, trying to decide if he wanted to be interrogated. “Not happily.”
“But you are?”
“I was. My wife, Linda, died suddenly after I got to Allentown. I thought you knew. Most of the people at Gladwyne did.”
“Jeez, I’m sorry, Ray. If I heard it, I forgot. I guess I was a little distracted back then myself. You know about the malpractice case that took me down.”
“Yeah, I heard you were sued and out of medicine for a while. Then you were practicing general cardiology in the Poconos.”
“I was until my significant other and I moved down here. NorthBroad had a full-time faculty job. I’d had enough of private practice, so here I am.”
Philip wondered how much of the backstory of the Hamlin and Romano murders Gilbert actually had heard and whether he knew that it was Dorothy who had left him in the Poconos and had moved to Philly after he narrowly escaped prosecution for the attack on a malpractice lawyer in Boston. He decided to skip the sordid details but to offer a little of the wisdom he had gained through the process.
“Look, Ray, I’m not going to candy-coat this thing. The Perini case was a real bad miss.”
“I still don’t understand. How can you be so sure that he had torsades?”
Torsades de pointes is a rhythm abnormality from the bottom chamber of the heart that can be inherited but in most cases is caused by a drug that has a specific effect on the ECG. Gilbert was blown away that Philip had suspected and then proven the diagnosis.
“All right, let’s deal with the medicines first,” Philip began. “Perini was doing fine until he went to his family doctor for a cold and got a prescription for erythromycin.”
“It wasn’t on his med list on admission. I know. I checked when I worked him up.”
“That’s correct. It wasn’t. Ellen picked up on the fact that the resident didn’t order it after he came in, and she hounded him until he wrote the order. She was afraid to death that Nolan would get pneumonia on top of his heart problem.”
“But he couldn’t take erythromycin. He couldn’t get anything by mouth. He wasn’t awake enough to swallow the capsules.”
“I know, so your idiot resident ordered it intravenously.”
“He did what?”
“He threw gasoline on the fire, Ray. The oral erythromycin was bad enough, but the increased levels he got with the IV really stretched his QT interval.”
“And caused all of those awful arrhythmias.”
“When I went back through his chart, before I came to the lab, I saw that Perini had periods when things were pretty quiet. Turned out it was when his pacemaker was on and his heart rate was not slow. But when the pacemaker was turned down, his QT interval was a yard long, and the arrhythmias would start firing off.”
“And you were able to replicate that sequence in the lab?”
“Exactly.”
“Which means that the IV amiodarone they gave him up there and that I continued was just making things a lot worse?”
“Afraid so,” Philip answered.
“Why didn’t the magnesium work?”
“Too little, too late, I think. That’s where the mexiletine comes in. Once we get enough of it into him, he should quiet down.”
“What did the family have to say when you met with them?”
“Not much. They’re just happy the guy is OK.”
“And you think I blew the diagnosis and almost killed him because I’ve been having an affair with a married woman?” Gilbert asked.
Philip took a sip of his coffee, contemplating how much of his soul he should bare to this suffering young doctor, and decided that telling Gilbert his story wouldn’t help. “Ray, I won’t get into the specifics, but a lot of the troubles I had back at Gladwyne were self-inflicted. Let’s just say I fell off the marriage train. It was a horrible experience, believe me.”
Gilbert looked off into the distance, measuring his response. “I appreciate your concern, Philip, and as a matter of fact, I have been distracted. But it’s not because I’m obsessed with Liz. If anything, the affair is winding down. She tells me that her husband has a temper, and I don’t need the aggravation.”
Philip nodded, not sure he believed Gilbert but willing to listen to his explanation.
“My worry, Philip, is that we’ve had a rash of cases from upstate that I can’t figure out.”
“You mean you don’t know why they have arrhythmia problems?”
“Sort of. Well, actually, it’s simpler than that. I don’t even know why they’re getting devices.”
“They don’t meet guideline criteria? You know that’s not a big deal, Ray. We’re talking about our professional organizations setting arbitrary rules. You know how I feel about that crap.”
Indeed, Philip’s disdain for guidelines was well known among his trainees and the profession in general. He had written several scathing editorials and papers outlining their limitations, his most important point being that over half of what was contained in guideline recommendations for practitioners was based on conjecture and opinion and not on high-grade scientific studies. Furthermore, for fear of conflict of interest, anyone with industry relationships of any kind was excluded from the guidelines-writing committees, which meant that the people who participated were not the most senior or knowledgeable people.
Nevertheless, guidelines were accepted by payers, hospital administrators, and the naïve patient public as the absolute truth upon which all clinical decisions were to be grounded. Most dangerous was their use by lawyers who routinely roasted defendant physicians who dared to stray from the guidelines to treat an individual patient problem differently. What made the situation even more frustrating for doctors was that any given disease state might have dozens of guidelines, published by competing professional organizations trying to sell their own medical journal, and recommendations among these documents were never uniform or consistent.
Gilbert had anticipated Sarkis’s legendary ire. “I know all of that, Philip. And I agree that they’re flawed. But I’m not talking about subtle interpretations of the guidelines. There have been several cases in which I flat out couldn’t figure why the patient had received a pacemaker or a defibrillator in the first place.”
“Give me an example.”
“Well, Nolan is one of the most obvious. You saw his history. His ejection fraction was bad at the beginning, but they waited several months, as they should have, to see if he would get better. And he did, but they went ahead with the defibrillator anyway.”
“Did you call the doctor up there and ask why they did that?”
Gilbert dropped his head. “No, but I should have.”
“And you have a lot of other examples?”
“I do. Some aren’t as blatant, and most of the patients weren’t harmed.”
“Then how did you discover them?”
“Calls from primary care doctors up in that area who were concerned and weren’t getting straight answers. Some of them even sent the patients down to me for a second-opinion consultation, so I had a chance to go through the records.”
“Were there cases that were guideline-adherent but your clinical judgment was different?”
“Yes.”
“For example?”
“In a couple of cases, the patients were pretty old. I would’ve left them alone.”
“That’s a tough one, Ray. You know it’s not about chronological age. Biology is the most important thing.”
“I know that, Philip, and I always try to take that into account. But we’re talking about demented people in their nineties getting defibrillators. That’s just not right.”
“Ray, unless you get a lot more specific information about what’s going on up there in the boonies, I’m not sure there’s much you’ll be able to do about it.”
“I know, and what makes it even worse is that our hospital has built a strong relationship with the doctors in that area. They send a lot of their cardiac surgery and tough coronary artery cases to us. If we start making noise and accusing them of inappropriate things, they’ll send their patients elsewhere, like Penn State Hershey or Geisinger.”
“I understand, Ray. It puts you in a tough spot. Have you been able to focus on any particular hospital or doctor? Maybe you could get a little glimpse behind the scenes.”
“I haven’t been able to identify an individual, but most of the problems seem to come from the farthest northern areas. And there’s one other thing I noticed. I hesitate to bring it up because it sounds pretty stupid, but a number of questionable implants have been Sterling devices.”
“You mean the new device company that just came online?”
“Have you had a chance to see their stuff?”
Philip winced. He almost never entertained device representatives in his office. But every once in a while, his young and inexperienced NorthBroad secretary would put one on his calendar. Since he had left his treasured Rhonda at Gladwyne, Philip had gone through several secretaries and had been told by his chief to lighten up on them. So when appointments he disliked were scheduled, he usually held his tongue and gave the people a few minutes to explain what they had for sale.
The visits were pleasant enough. After all, most of the representatives had been selected because of their outgoing personalities and good looks, and they were eager to impress. Unfortunately, what they had to offer to the medical profession—and to Philip’s patients, in particular—usually fell short. Most of the new things that pharma or device reps were given to “promote” in doctors’ offices were me-too products that added marginally to what was already out there and frequently did so with no real economic advantage.
Such had been the case with Sterling, who descended on his office several weeks earlier and had a chance to tell Philip about their products. In preparation for their meeting, Philip had learned that a number of executives and engineers had become unhappy and frustrated with the market leaders and eventually colluded to leave and form their own device company. They had been careful to use technology that was no longer patent-protected by the three companies that shared the cardiology rhythm-control device market and to change the hardware and software to be able to skirt allegations of patent infringement. They jazzed up the devices just enough to make them look good and did whatever they could to provide better prices and service.
“I remember meeting with a couple of their people a few months ago. Their devices seemed OK but nothing special.”
“Agreed. That was my take. They were pretty aggressive with the people in my group, getting in our faces. When they didn’t make much headway with us, they went to the hospital bean counters and made a case for a lower price point. Next thing we knew, the devices were on our shelves, and our department managers kept asking us if we wanted to give them a try.”
“Did you?”
“I put in a couple of them in low-risk cases, just to shut them up.”
“How’d they work out?”
“Fine, as I recollect. Their implant equipment is not quite as refined as the stuff we usually use, but it was passable. The programmers were nothing like anything we’ve been used to, so it took a while to become familiar with them. And of course, we had to send some of the nurses away to Saint Paul for a few days so they could get educated on how to use them.”
“When are these companies going to get together and make a universal programmer so we don’t have to waste so much time?” Philip muttered.
Gilbert could only shake his head, acknowledging the Tower of Babel that device technology had become. Each manufacturer had its own equipment to activate and inactivate and to program implanted devices. Since so many different parameters could be interrogated and then changed, learning how to use the devices had become a full-time job for the staff who supported the electrophysiology program. The worst nightmare was the patient who appeared in the emergency department with frequent shocks that sent the ER team scurrying to find someone who could help them take care of the patient. Philip and other senior arrhythmia physicians had lobbied for a “universal programmer” that could be used with any pacemaker or defibrillator to perform the most basic functions, most importantly just turning the damn thing off. But as had become typical in the wonderful world of capitalism, companies dug in, refusing to cooperate for fear that any technology advantage would be unearthed and copied by their competition. With no statute to compel the few manufacturers to collaborate, nothing had been done.
“But you don’t suspect that Sterling has done anything to divert cases or to encourage doctors to do inappropriate things, do you?”
“Not really. It could all just be a coincidence.”
“My thought, exactly.” Philip paused and looked at his former student, realizing that Gilbert was truly unhappy, and figured he was in need of some brotherly advice. “Ray, I suggest you try to put this Sterling stuff aside, and get back to work. Exercise regularly again, and for Christ’s sake, get yourself a girlfriend. I’m sure there are a lot of good-looking, single women in your hospital looking for a stud like you. Stop playing the field, and settle into a real relationship.”
“I think that’s good advice, Philip, and I appreciate your candor.”
“Candor has never been a problem for me, Ray, as you know well. Tell you what—if you can put aside some time, we should look into doing some joint research projects. I don’t have a ton of stuff going on like I used to, but we do participate in some cool multicenter trials. They’re always looking for high-volume centers to help recruitment, and if you do a good job with that, we can get you on some of the manuscripts and steering committees. That should help you kick your career into a higher gear. What do you think?”
“That sounds wonderful, Philip. I feel intellectually isolated up there, and it would be great to do something exciting at work for a change.”
“Exactly. Diversification helps quell the boredom. And I guarantee that everything will go better once you get your private life straightened out too. It really makes a big difference when you have a good relationship. I know it did for me.”
There had been plenty of rumors about how Philip and Dorothy had begun their relationship, and Philip thought about sharing more of the details but thought better of it. Better to stay upbeat than to conjure up unpleasant memories.
“Thanks for spending some time with me, Philip. I promise to keep in touch, and I’ll definitely take you up on that offer to collaborate.”
“Good, Ray,” Philip said, rising from his chair. The last thing he wanted was to make small talk. Now that his message had been delivered, he was anxious to get on with his day and, if he planned things right, make an early departure to spend some quality after-school time with his girls.
After they discarded their empty cups and ascended the circular stairway to the main lobby, Philip put his arm around Gilbert. “I meant what I said, Ray. I think you have a good mind and a bright future. I regret that I haven’t been very good at keeping up with the people who trained with me, and I want to make it up to you, as best I can. Call me if I can ever be of help.”
“Thanks, Philip. I appreciate that. I have a lot of things to work on myself, but your mentorship would be terrific.”
They found Liz in the lobby area, waiting impatiently. “I don’t know how to get us back to Allentown, Ray,” she said, sounding too much like a scolding wife for Philip’s taste.
“I can help,” Philip said. It took him only a few moments to call his secretary and have her arrange a Lyft driver to meet Gilbert and Liz at the ER entrance. He shook hands with both of them, said his goodbyes, and walked briskly toward his office.
“Quite a doctor,” Liz remarked, as Philip retreated.
“Yes. Actually, quite a guy. He offered to help me get back into doing some clinical research. He thinks it will be helpful to my psyche. He had a lot of good ideas.”
“He did, did he? Care to share any specifics?”
“Nothing special, Liz,” Gilbert answered, quite sure that she wouldn’t be at all happy with the most important thing Philip Sarkis had recommended he do to improve his life.