"I wish I could have," Marjorie said. "But we're not allowed. I did go once the winter before last, but CMV refused to pay because it turned out to be the flu. Unless my problem is life-threatening, I have to come here to the office. I can't go to the emergency room without prior approval from a CMV physician. If I do, they won't pay."
"But that's absurd," David said. "How can you know in advance if your problem is life-threatening?"
Marjorie shrugged. "That's the same question I asked, but they didn't have an answer. They just reiterated the rule. Anyway, I'm glad you're here. If I have a problem I'll call you."
"Please do," David said. "Now let's start talking about your health. Who is following you in regard to your cancer?"
"You are," Marjorie said.
"You don't have an oncologist?" David asked.
"CMV doesn't have an oncologist," Marjorie said. "I'm to see you routinely and Dr. Mieslich, the oncologist, when you think it is necessary. Dr. Mieslich is not a CMV physician. I can't see him unless you order it."
David nodded, recognizing that there were realities about his new practice that would take time to learn. He also knew he'd have to spend considerable time going over Marjorie's chart in detail.
For the next fifteen minutes, David applied himself to the process of "working up" Marjorie's chest pain. While listening to her chest and in between her deep breathing, he asked her what she did at the school.
"I'm a teacher," Marjorie said.
"What grade?" he asked. He took his stethoscope from his ears and began preparations to run an EKG.
"Third grade," she said proudly. "I taught second grade for a number of years, but I much prefer third. The children are really blossoming then."
"My daughter is to start the third grade in the fall," David said.
"How wonderful," Marjorie said. "Then she'll be in my class."
"Do you have a family?" David asked.
"My word, yes!" Marjorie said. "My husband, Lloyd, works at the computer software company. He's a programmer. We have two children: a boy in high school and a girl in the sixth grade."
Half an hour later David felt confident enough to reassure Marjorie that her chest pain was not at all serious and that it had nothing to do with either her heart or her cancer, Marjorie's two chief concerns. She thanked him profusely once again for coming to Bartlet before he stepped out of the room.
David ducked into his private office with a sense of exuberance. If all his patients were as warm and appreciative as Marjorie, he could count on a rewarding career in Bartlet. He put her chart on his desk for further study.
Taking the file from its holder on the second examining room door, David perused his next patient's chart. The diagnostic summary read: leukemia treated with massive chemotherapy. David inwardly groaned; it was another difficult case that would require more "homework." The patient's name was John Tarlow. He was a forty-eight-year-old man who'd been under treatment for three and a half years.
Stepping into the room, David introduced himself. John Tarlow was a handsome, friendly man whose face reflected intelligence and warmth equal to Marjorie's. Despite his complicated history, John's complaint of insomnia was both easier and quicker to deal with than Marjorie's chest pain. After a short conversation it was clear to David that the problem was an understandable psychological reaction to a death in the family. David gave him a prescription for some sleeping medication that he was certain would help John get back to his usual routine.
After he was through with John, David added his chart to Marjorie's for further review. Then he searched for Susan. He found her in the tiny lab used for simple, routine tests.
"Are there a lot of oncology patients in the practice?" David asked hesitantly.
David very much admired the sort of people who chose to go into oncology. He knew himself well enough to know that he was not suited for the specialty. So it was with some trepidation that he discovered his first two CMV patients were both dealing with cancer.
Susan assured him that there were only a few such patients. David wanted to believe her. When he went back to get the chart out of the box on examining room one, he felt reassured. It wasn't an oncological problem; the case concerned diabetes.
David's morning passed quickly and happily. The patients had been a delight. They'd all been affable, attentive to what David had to say, and, in contrast to the non-compliant patients he'd dealt with during his residency, eager to follow his recommendations. All of them had also expressed appreciation for David's arrival, not as fervently as Marjorie, but enough to make David feel good about his reception.
For lunch, David met Angela at the coffee shop run by the volunteers. Over sandwiches, they discussed their morning.
"Dr. Wadley is terrific," Angela said. "He's very helpful and interested in teaching. The more I see him, the less he reminds me of my father. He's far more demonstrative than my father ever would be-far more enthusiastic and affectionate. He even gave me a hug when I arrived this morning. My father would die before he'd do that."
David told Angela about the patients he'd seen. She was particularly touched to hear about Marjorie Kleber's reaction to David's arrival.
"She's a teacher," David added. "In fact she teaches the third grade so she'll be Nikki's teacher."
"What a coincidence," Angela said. "What's she like?"
"She seems warm, giving, and intelligent," David said. "I'd guess she's a marvelous teacher. The problem is she's had metastatic breast cancer."
"Oh, dear," Angela said.
"But she's been doing fine," David said. "I don't think she's had any recurrence yet, but I haven't gone over her chart in detail."
"It's a bad disease," Angela said, thinking how many times she'd worried about it herself.
"The only complaint I have so far about the practice is that I've seen too many oncology patients," David said.
"I know that's not your cup of tea," Angela said.
"The nurse says it was just a coincidence that I started with two in a row," David said. "I'll have to keep my fingers crossed."
"Now don't get depressed," Angela said. "I'm sure your nurse was right." Angela remembered all too well David's response to the deaths of several oncology patients when he'd been a junior resident.
"Talk about depression," David said. He leaned closer and whispered. "Did you hear about Dr. Portland?"
Angela shook her head.
"He committed suicide," David said. "He shot himself in the office that I'm now using."
"That's terrible," Angela said. "Do you have to stay there? Maybe you can move to a different suite."
"Don't be ridiculous," David said. "What am I going to say to Kelley? I'm superstitious about death and suicide? I can't do that. Besides, they repainted the walls and recarpeted the floor." David shrugged. "It'll be okay."
"Why did he do it?" Angela asked.
"Depression," David said.
"I knew it," Angela said. "I knew he was depressed. I even said it. Remember?"
"I didn't say he wasn't depressed," David said. "I said he looked ill. Anyway, he must have killed himself soon after we met him because Charles Kelley said he'd done it in May."
"The poor man," Angela said. "Did he have a family?"
"A wife and two young boys."
Angela shook her head. Suicide among doctors was an issue of which she was well aware. One of her resident colleagues had killed herself.
"On a lighter note," David said, "Charles Kelley told me that there's a bonus plan to reward me for keeping hospitalization at a minimum. The less I hospitalize the more I get paid. I can even win a trip to the Bahamas. Can you believe it?"
"I've heard of that kind of incentive plan," Angela said. "It's a ploy health maintenance organizations use to reduce costs."
David shook his head in disbelief. "Some of the realities of this 'managed care' and 'managed competition' stuff are really mind-boggling. I personally find it insulting."