Chapter 59: A Very Astute Observation

July 18, 1987, Indian Hill, Ohio

Neil gave me a complete tour, showing me the five bedrooms upstairs, the entire first floor which consisted of the great room, a study, a large dining room, a small sitting room, the kitchen, and the aforementioned guest room. The basement had a full wet bar, a second projection television which had a video game console connected to it, and a pool table. The only thing missing was a sauna, but those weren't very common.

"May I ask what kind of law you practice?" I inquired as we climbed the stairs from the basement.

"Mostly civil litigation."

"Do you work for yourself?"

"No, I'm a partner at Volstead and Braun in Cincinnati."

I nearly groaned because their firm was representing Melissa Bush. That actually might present a problem, so I had to raise it.

"I need to say something," I said. "And it probably should be in private."

He led me to the study and shut the door behind us.

"Go ahead," he said.

"One of your lawyers is representing a medical student, Melissa Bush, in a lawsuit against McKinley Medical School and Moore Memorial Hospital," I said. "I'm likely to be a witness against her."

"I'm not her counsel of record, nor am I involved in that case. Even though I'm a partner, you can think of us as, well, independent contractors. I work my own cases, and it would be highly unlikely I'd be asked to participate in that case. If I were asked to participate, I'd recuse myself because we now have a personal relationship. And to answer what I suspect is your next question, unless I'm specifically asked, which is also highly unlikely, I won't reveal that I even know you. It would be completely unethical for me to reveal anything I learned about you in a personal relationship, or take any action against you, and I'd be disbarred if I did."

"OK," I replied noncommittally.

He frowned, "I can see you don't trust me. I'm not sure there's anything else I can say because what I said is true."

"Given what you said, I'm sure you don't know the complete story, but I do not want anything to do with her, her family, or anyone who has anything to do with her. The short version is, her father murdered my friend, and she made all sorts of false accusations against me and my mentor. I'm also positive that had the medical school known, they would never have placed me here."

"I'm truly sorry about your friend. What are you going to do?"

"Speak with my wife, then my advisor," I replied.

"My wife will kill me," he said, shaking his head. "Let me try this — do you have an attorney? Or know one you trust?"

"I do."

I actually had two — Mr. Winston and Katy's mom.

"Ask him or her for their opinion before you say anything to anyone, please. Well, besides your wife, obviously."

I thought about it, and decided that was probably wise, though I was still uncomfortable with the situation. My options were likely very limited, as there were less than two weeks before my rotation would begin, and that seemed to force my hand. But I decided I would speak to Mrs. Malenkov after Liturgy in the morning, and then call Mr. Winston on Monday.

"I'll do that," I said.

"Thank you."

We left the study and rejoined Doctor Cooper and Elizaveta.

"Is everything OK?" Doctor Cooper asked.

"Yes," Neil replied. "Mike and I were just getting to know one another."

I saw a look in Elizaveta's eyes that I recognized as suspicion, though I doubted either Doctor Cooper or her husband would catch it.

"Mike, do you play pool?" Neil asked.

"I do," I replied.

"Would you like to play some 8-Ball?"

"Sure," I agreed.

It had been some time since I'd played, but I was confident I'd quickly return to my old form. I followed Neil to the basement, where we played five games before dinner was ready, with me winning four of five.

"Pool shark, in addition to being top of your medical school class," Neil said as we left the basement.

"My parents had a pool table, and I played a lot growing up."

"Do you play golf?"

"I'm learning," I replied. "But I don't have nearly enough time to practice."

We went to the dining room, where Elizaveta, Alan, and Annette were seated. I sat down next to Elizaveta while Neil went to the kitchen to help Doctor Cooper bring dinner to the table.

"Do you have to wear those robes all the time?" Alan asked.

"Alan, that's rude," Neil admonished.

"It's OK," I replied. "I'm used to those kinds of questions. Yes. My bishop requires all his clergy to wear a cassock at all times. I have exceptions for when I need to wear scrubs, or if medical practice dictates I wear a tie under my medical coat."

"So, you're like a priest?" he asked.

"A deacon," I replied. "I assist the priest or bishop with anything that needs to be done during church services, I teach Sunday School and catechism, and I'm also responsible for distributing alms."

"That's charity, Alan," Doctor Cooper interjected.

"Do you attend church?" I asked.

"We're Catholic," Doctor Cooper replied. "So not all that different, really."

"Actually, it's quite different," I replied. "I've heard some people say that we're 'Roman Catholic without the Pope' but the theology is actually very different."

"Our priest says that if there is no Roman Catholic church in an area, we can fulfill our Sunday obligation at an Orthodox Church."

"I'm sure he said that, and I'm sure that's true, but you couldn't receive the Eucharist."

"Perhaps we'll save this conversation for later," Neil suggested.

I felt that was a good idea, as I could see Doctor Cooper had some very skewed ideas about the Orthodox Church which actually weren't that uncommon. I now had two amber warning lights flashing and wondered if I should speak to Viktor about some kind of alternative arrangement. The problem was that with less than two weeks before my rotation was set to begin, there was basically no time to find a different place to live.

"Are you a Reds fan, Mike?" Alan asked.

"I am."

"We usually go to a few games in August and September," Neil said. "You're welcome to join us. We'll just need to know before we buy the tickets."

It was obvious Neil was trying to overcome what I was positive he knew was my reluctance to stay with them.

"Thanks," I said. "Just let me know which days and I'll let you know."

"How long have you been married, Elizaveta?" Annette asked.

"Just over two years," Elizaveta replied.

"So, basically right after you graduated?"

"No. Because the bishop wanted to ordain Mike a deacon, we married right after my Sophomore year."

"Whoa!" Annette gasped. "You were sixteen?"

"Yes. I knew Mike needed a wife, so I approached him and proposed."

"That can't possibly be legal!" Doctor Cooper protested.

"It is," Neil quickly interjected. "So long as her parents signed the necessary consent form, she could legally marry at sixteen."

If I needed a third strike, it was Doctor Cooper's reaction to Elizaveta marrying at sixteen. Those three flashing amber lights threatened to turn red. And despite what I'd said to Neil before, I felt I had to speak to Doctor Mertens lest I end up in a terrible situation for two months. A larger problem loomed, and that was that I would be working with Doctor Cooper, and there was basically nothing I could do about that.

But it wasn't just me. I could see that Elizaveta was uncomfortable as well. We did our best to be polite and make conversation, and the food was very good. When we finished dinner and dessert, we excused ourselves because we had to get up early on Sunday for Matins, and Elizaveta needed her sleep. Doctor Cooper easily accepted that, and after thanking them for the meal, we left the house, got into the car, and headed for home.

"You're unhappy," Elizaveta observed.

"Neil works for the firm that represents Melissa Bush."

"No!" Elizaveta gasped.

"He claims he isn't involved, and that he couldn't be involved now that we have a personal relationship, but it just seems risky. Doctor Cooper's discomfort with you marrying at sixteen concerns me, and if you add in the mischaracterization of our faith, there are too many warning signs. Neil suggested I speak with an attorney to confirm what he told me, but I honestly think I need to speak with Doctor Mertens on Monday."

"I think you do, too; what options do you have?"

"I have no idea what the contingency plans are. I'm sure they have something in case someone gets sick, or the house burns down, or whatever. I'm just not sure they'd implement them because of interpersonal relations difficulties. One of the things we're evaluated for is our ability to get along with anyone."

"Sure, but they can't force you to live with an attorney for a girl who made false accusations against you and who should have been kicked out of medical school!"

"That's just it," I replied. "Technically, he's not her attorney. I'm sure what he said is true, but I still think it's a risk. I can ask Mrs. Malenkov and Mr. Winston for their opinions, but I think I'll speak with Doctor Mertens either way, because Doctor Cooper is the one who will be doing my evaluation. And I suspect that would be true whether I live there or not."

"Wait!" Elizaveta protested. "She could fail you because she doesn't think you should have married me?!"

"Not for that reason, but it might make her overly critical and lead to a poor grade. That's the reason why our study group doesn't rock the boat — becoming doctors depends on following the system and that means holding our tongues until we're Attendings. Then we can push hard for change. Before then, saying the wrong thing to the wrong person could create all kinds of problems. What happened with Melissa can happen to anyone, for any number of reasons. What it comes down to is that if we want to join the club, we have to prove to the other members of the club that we're worthy to be members."

"But you're the top student in your class!"

"In book learning and test-taking," I replied. "But medicine is far more than book learning and test taking! So, by the objective measurements available, I'm the best. But that's meaningless if I'm a poor diagnostician, a poor surgeon, fold under pressure, or fail in some other way. Think about how Melissa's medical career unraveled — she had a negative reaction to a patient with AIDS. That exposed a defect in her personality, and led to her being rejected by every Residency program to which she tried to apply, either via the Match or the Scramble."

"What could possibly trip you up?" Elizaveta inquired.

"I have no idea, which is why I work so hard at everything, and do everything I'm told the way I'm told to do it. I prepare for every surgery by reading the procedures, as well as about the ailment that is being treated, I pay very close attention to everything, and try to ask intelligent questions. But, in the end, it's the fact that medicine is at least part art, along with the science, that could trip me up."

"How so?"

"Doctors know that patients don't always tell them what they need to know, sometimes intentionally, sometimes unintentionally. Doctors also know that patients often do not follow treatment protocols and aren't always truthful about that."

"Seriously?"

"Asks the woman who objects to the protocols prescribed by Doctor Forsberg."

"I'm pregnant, not sick!"

"And you're being treated for a condition, not an illness. Your metabolism, blood chemistry, emotional state, and a host of other things are affected by your condition, and Doctor Forsberg, through years of training and experience, not to mention a baby of her own, is advising you on the best course of action. She can't make you follow her advice, and she can't know if you are following her advice unless some test can show it.

"The thing is, those tests aren't necessarily definitive. Every woman is different and her body responds in a way unique to her. I know that sounds a bit contrary to what I'm saying, but it's not, really. In those unique responses, we spot trends, or typical findings, and based on those, we develop overall guidelines, which then have to be tweaked for the individual patient.

"You aren't anemic, but the treatment for that is usually iron tablets. Your blood pressure is fine, and there are various safe treatments for elevated blood pressure, and at this point, because Rachel is viable, a dangerous spike in your blood pressure would result in a C-section. That's what happened with Sasha. And they did the C-section based on the accumulated knowledge from those millions upon millions of unique cases.

"And that goes right back to the book-learning point I was making. So-called textbook cases are actually rare, because each patient is unique — their specific genetic code, their specific habits, their diet, their environment, and a host of other things affect their health and treatment outcomes. And we have to allow for that in treatment.

"A perfect example of something atypical can be found in the list of potentially serious side effects which come on information sheets for pharmaceuticals. A drug that works in 99.999% of cases might cause severe illness or death in the other 0.001% of cases. Or a drug might have side effects of which we're unaware. For example, thalidomide was hailed in the late 50s as an anti-emetic and a treatment for insomnia. Only nobody tested it on pregnant women and that led to disaster.

"Prior to that disaster, most scientists and physicians did not believe drugs could cross the placental barrier. Sadly, they were dead wrong, and horribly deformed babies were the result. Further research showed that if the drug was only taken after forty-two days of gestation, there were no birth defects, but if taken before, horrible birth defects occurred with alarming frequency. That incident led to strengthening the FDA rules for new drugs.

"The bottom line is, the standard guidance works for the typical patient, and pretty much anyone could treat them by following that guidance. Where the art comes is with the atypical patient, or the patient that does not respond to the standard protocols. That's where the greatest challenges and pitfalls lie for medical students, Residents, and Attendings. And those are the patients that we discuss in the Morbidity and Mortality Conferences — M & Ms."

"I understand better why you took Doctor Forsberg's side."

"It's not about sides, Kitten, it's about what's best for you. And in this case, you're well advised to follow the protocols that have led to reduced infant mortality and reduced deaths in childbirth. The system isn't perfect, and I don't think it ever will be because human beings are involved, both as patients and as physicians, but the accumulated knowledge shows us the best way forward. It's always subject to revision, of course, but we do the best we can with what we know and what we have."

"So, what are you going to do about the situation?"

"Discuss it with Doctor Mertens and find a way forward. And, as I said, speak with Mrs. Malenkov and Mr. Winston. Want to hear the cynical answer?"

"Probably not, but what?"

"The situation with Neil, if he reveals it to Doctor Cooper, which I suspect he will have already done, will make it much more difficult for her not to give me a strong evaluation, so long as I don't do something foolish or stupid."

Elizaveta laughed, "Wow! But doesn't that prove the system is horribly broken?"

"It's a weakness in the system," I countered. "And it's not the only one. That said, the system turns out tens of thousands of excellent physicians every year. That tells me the system needs tweaks, not an overhaul. And when Clarissa, Fran, Peter, Maryam, Nadine, and I are in a position to make those tweaks, we will. I'm fortunate in that I have an opportunity to help define my own training program, but it still needs approval from doctors and administrators whose natural reaction to change is negative. Think about the handwashing story I told you."

"How can people be so ignorant?" Elizaveta asked.

"You mean like believing, because they had no evidence to the contrary, that drugs could not cross the placental barrier? Terrible outcomes lead to change, but change is difficult precisely because the system basically works. Of course, necessary change is often delayed because of politics or outmoded thinking, and that's what we have to struggle against."

"It's really strange hearing this side of things," Elizaveta observed. "Mostly what I knew about doctors before came from my pediatrician and what I saw on TV or read in the newspaper."

"You can watch me roll my eyes at TV depictions of medicine! Of course, part of it is 'artistic license' but part of it is also dated. You've seen Medical Center and Emergency, and the medicine practiced in the 60s and 70s, especially emergency medicine, was very different from what we do now. Some doctors fought those changes, too.

"Emergency medicine, as we know it, basically didn't exist twenty years ago. Paramedic services didn't exist twenty years ago. Helicopter air ambulance services didn't exist in Ohio ten years ago, but the one based here in McKinley saved Jocelyn's life six years ago. Heck, 9-1-1 service didn't even exist here five years ago. You had to call the operator to connect you."

"I'll follow Doctor Forsberg's advice," Elizaveta said.

"Thank you, Kitten. I love you very much."

"I love you, too, Mike."

July 19, 1987, McKinley, Ohio

"Hi, Katy," I said when I walked up to her and her mother.