She was a third-year law student when she met Charlie Harris—Charles H. Harris, M.D., a tall, skinny young man whose horn-rimmed glasses habitually slid down his long, freckled nose and gave his sweet amber eyes a quizzical look. He was just beginning a surgical residency.
She had never met anyone so serious and so funny at the same time. They laughed a lot, but he was humorlessly dedicated to his work. He envied her graceful scholarship and the fact that she actually enjoyed taking examinations, in which invariably she did very well. He was intelligent and had a good temperament for a surgeon but studying wasn’t easy for him, and he had achieved because he labored at it doggedly: “Gotta take care of business, R.J.” She was Law Review, he was on call. They were always tired and in need of sleep, and their schedules made it hard for them to see enough of each other. After a couple of months she moved from Joy Street into his converted stable off Charles Street, the cheaper of their two apartments.
Three months before she finished law school, R.J. discovered she was pregnant. At first she and Charlie were terrified, but then they were filled with radiance at the thought of being parents and agreed they would be married at once. Several mornings later, however, while Charlie was scrubbing for the O.R., he was suddenly doubled over by a piercing pain in the lower left quadrant of his abdomen. An examination revealed the presence of kidney stones that were too large for him to pass naturally, and within twenty-four hours he was admitted to his own hospital as a patient. Ted Forester, the best surgeon in the department, performed the operation. Charlie appeared to sail through the initial post-op period, except that he was unable to void urine. When he hadn’t urinated in forty-eight hours, Dr. Forester ordered that he be catheterized, and an intern inserted the catheter and gave him relief. Within two days, Charlie’s kidney was infected. Despite antibiotics, the staph infection spread through his bloodstream and localized in a heart valve.
Four days after the operation, R.J. sat by his bed in the hospital. It was obvious to her that he was very sick. She had left word that she wanted to see Dr. Forester when he came on rounds, and she thought she should telephone Charlie’s family in Pennsylvania, so his parents could talk to the doctor if they wished.
Charlie moaned, and she got up and washed his face with a wet cloth. “Charlie?”
She took his hands in hers and leaned over and studied his face. Something happened. A current of information passed from his body into hers, into her mind. She didn’t know how, or why. It wasn’t imagined, she knew it was real. In a way she couldn’t understand, she was suddenly aware that they wouldn’t be growing old together. She couldn’t drop his hands, or run away, or even cry out. She just stayed where she was, bending over him, gripping his hands tightly as if she could hold him back, memorizing his features while she still had a chance.
He was placed in the ground in a large, ugly cemetery in Wilkes-Barre. After the funeral R.J. sat on the cut-velvet chairs in his parents’ living room and suffered the stares and questions of strangers until she was able to flee. In the tiny toilet of the plane taking her back to Boston, she was racked by nausea and vomiting. For several days she thought constantly about how Charlie’s baby would look. Perhaps grief did her in, or maybe what occurred would have happened even if Charlie were alive. Fifteen days after his death, R.J. miscarried his baby.
On the morning of the bar examination she sat in a room full of tense men and women. She knew Charlie would have told her to take care of business, and she formed a woman-size ice cube in her mind and placed herself in its very center, cold-bloodedly putting grief and discomfort and everything else beyond her consciousness and turning her attention to the many and difficult questions of the bar examiners.
R.J. retained the icy shield when she went to work for Wigoder, Grant and Berlow, an old firm that practiced general law, with three floors of offices in a good building on State Street. There no longer was a Wigoder. Harold Grant, the managing partner, was crochety, dried-up, and bald. George Berlow, who headed Wills and Trusts, had a paunch and a veined, whiskeyreddened face. His son, Andrew Berlow, fortyish and bland, was manager of major real estate clients. He put R.J. to work researching briefs and preparing leases, routine tasks that involved using lots of computer boilerplate. She found it tedious and uninteresting, and when she had been there two months she admitted this to Andy Berlow. He nodded and told her dryly that it was foundation work, good experience. The following week he let her accompany him to court, but she remained unenthused. She told herself it was depression, and she tried to bear down hard during her workdays.
When she had been with Wigoder, Grant and Berlow not quite five months, she broke. It was not an emotional train wreck—more a temporary derailment. One night when she and Andy Berlow had been working late, she joined him for a glass of wine that turned out to be a bottle and a half, and they ended up in her bed. Two days later he took her to lunch and nervously explained that although he was divorced, he was “involved with a woman, living with her, in fact.” He thought R.J. was gracious in her reaction; actually, the only man who interested her was dead. The thought caused the ice cube to crack and fall away. When she began to weep she went home from the office, and she stayed home. Andy Berlow covered for her, believing she was prostrate with love for him.
She needed to have a long talk with Charlie Harris. She ached to be his lover again, and she yearned for his phantom child, his might-have-been baby. She knew none of these desires could be fulfilled, but mourning had reduced her to basics, and there was one area of her life that she had the power to change.
13
THE DIFFERENT PATH
Her decision to study medicine was what her father had always wanted, but Professor Cole loved her and approached it with caution.
“Is it because you feel that somehow you have to take Charlie’s place?” he asked her gently. “Is it that you want to feel and experience the things he did?”
“That’s part of it, I admit,” she said, “but only a small part.” She had given this a great deal of thought and had reached a mature decision, realizing for the first time that she had stifled any early desire to be a doctor because of her need to stand up to her father. Their relationship still had problems. She found it impossible to apply to the Boston University School of Medicine, where he was faculty. She was accepted at the Massachusetts College of Physicians and Surgeons with a deficiency in organic chemistry that she made up in summer school.
Student aid was inadequate for medical students. R.J. was awarded a one-quarter scholarship, and she expected to fall deeply into debt. Her father had helped her through law school, supplementing her scholarship money and earnings, and he was prepared to help her through medical school, although that would have been a hardship. But the people at Wigoder, Grant and Berlow were intrigued by what she was undertaking.
Sol Foreman, the partner who managed medical litigation, asked her to lunch, although they hadn’t met before.
“Andy Berlow told me about you. The truth is, Miss Cole, you’re worth much more to our firm as a lawyer studying medicine than you have been as a law clerk in the real estate department. You’ll be in a position to research the facts of important cases from a medical viewpoint, yet you’ll be able to write briefs as a person educated in the law. We pay well for that kind of expertise.”
It was a welcome gift to her. “When do you want me to begin?”
“Why not try your hand at it straight off?”
So while she studied chemistry in summer school, she had also researched the case of a twenty-nine-year-old woman dying from aplastic anemia as a result of being given penicillamine, which had suppressed the blood-forming function of her bone marrow. R.J. became familiar with every medical library in Boston, and she delved into card catalogs, books, medical journals, and research papers, learning a great deal about antibiotics.
Foreman seemed satisfied with the result, and at once he gave her another assignment. She prepared the brief for the case of a fifty-nine-year-old ma
le teacher who had had a hip replacement in which deep infection, from inadequate filtering of contaminated air in the operating room, had smoldered for three years before bursting forth, leaving him with an unstable hip and a shortened limb.
Following that, her research led the law firm to refuse the case of a man who wished to sue his surgeon after a vasectomy had failed. R.J. noted that the patient had been warned by his surgeon of the possibility of failure and advised to use a contraceptive device for six months, which he had neglected to do.
The people at Wigoder, Grant and Berlow were very pleased with her work. Foreman put her on a monthly minimum retainer with an override that she earned more months than not, and he was willing to assign as many cases to her as she would accept. That September, in order to make things still easier, she took another medical student as a housemate, a beautiful, serious black woman from Fulton, Missouri, named Samantha Potter. With only minimal help from her father, R.J. was able to pay her tuition and living expenses and run her car. The legal profession she had rejected now made it possible for her to study medicine without financial hardship.
She was one of eleven women in her class of ninety-nine students. It was as though she had been lost and stumbling and had finally found a clear and certain path. Every lecture was a source of enormous interest. She discovered she had been fortunate in her choice of housemate. Samantha Potter was the eldest of eight children, brought up on a share-cropping farm that barely achieved subsistence in any given year. All the Potter children picked cotton and fruit and vegetables for other people, turning their hand to anything that brought in a little money. At sixteen, already a tall woman with broad shoulders, Samantha had been hired by a local meat-packing company to work after school and summers. The supervisors liked her because she was strong enough to lift the heavy frozen meat and was well-mannered and dependable. After a year of pushing an offal wagon, she had been taught to become a meat cutter. The cutters worked with power saws and knives sharp enough to slip through meat and connective tissue, and it wasn’t uncommon for a plant employee to be seriously hurt. Samantha sustained a number of minor cuts and grew accustomed to bandaged fingers, but she avoided a major accident. Working every day after school, she became the first member of her family to gain a high school diploma. She worked as a meat cutter for five summer vacations after that, while she earned bachelor’s and master’s degrees in comparative anatomy at the University of Missouri, and she came to the medical school’s first-year human anatomy class with impressive knowledge about animal bone, internal organs, and circulatory systems.
R.J. and Samantha developed a close friendship with one of the other women in the class. Gwendolyn Bennett was a feisty redhead from Manchester, New Hampshire. Medicine was changing quickly, but it was still pretty much a men’s club. There were five female members of the faculty, but all the department chairs and the school administrative posts were filled by men. Male students were called on frequently in class while women tended to be overlooked. The three friends, however, were determined not to be ignored. Gwen had had experience as a women’s rights activist at Mount Holyoke College, and she mapped their strategy.
“We have to volunteer answers in class. Faculty asks questions, we stick up our hands, right in their sexist faces, and give ’em correct answers. We get noticed because we work our asses off, right? It means we have to study harder than the men, be better prepared than they are, act generally sharper.”
It meant a crushing workload on top of the medicolegal research R.J. was doing in order to stay in school, but it was the kind of challenge she needed. The three of them studied together, drilled and grilled one another before examinations, and bolstered each other when they detected academic weaknesses.
The strategy largely worked, despite the fact that they quickly developed a reputation as aggressive women. A couple of times they believed their grades suffered because of an instructor’s resentment, but most of the time they received the high marks they earned. They ignored the occasional sexual remarks made by male students—and even, on rare occasions, by a faculty member. They dated only once in a while, not out of disinclination but because time and energy had become vital commodities that had to be doled out stingily. Whenever they had a free evening, they went together to the anatomy lab, which Samantha had made her real home. From the beginning, everyone in the anatomy department knew that Samantha Potter was hot, a future professor in their specialty. While other students fought for an arm or a leg to dissect, there was somehow always a cadaver reserved for Samantha, and Sam shared with her two friends. Over four years they dissected four dead human beings—an elderly bald Chinese man with the overdeveloped chest that spelled chronic emphysema, an old black woman with gray hair, and two whites, one of them an athletic middle-aged man, the other a pregnant woman about their own age. Samantha guided R.J. and Gwen into the study of anatomy as if it were an exotic and wonderful country. They spent hour after hour dissecting, stripping the bodies down layer by layer, exposing and sketching muscles and organs, joints and blood vessels and nerves in exquisite detail, learning the wonderful intricacies and mysteries of the human anatomical machine.
Just before the beginning of the second year of medical school, R.J. and Samantha moved from the apartment in the mews off Charles Street. R.J. was glad to leave the converted stable; it was too full of memories of Charlie. Gwen joined them, the three of them renting a shabby railroad flat only a block from the medical school. It was on the fringe of a rough neighborhood, but they wouldn’t waste precious time getting to labs or the hospital, and the evening before classes began, they threw an open-house bash. Characteristically, it was the hostesses who shooed the guests out the door at an early hour so they could be up to form in school the next day.
When their clinical work in the wards started, R.J. met it as though she had been preparing for it all her life. She saw medicine differently from most of her classmates, very much through her own eyes. Because she had lost Charlie Harris due to an unclean catheter, and because she still was an attorney working constantly on malpractice briefs, she tended to search for dangers to which most of her fellow students were oblivious.
Researching a law case, she found a report by Dr. Knight Steel of the Boston University Medical Center, who had studied 815 consecutive medical cases (excluding cancer, which carries a large risk of adverse results from chemotherapy). Of the 815 patients, 290—more than one out of every three—developed an iatrogenic illness.
Seventy-three people, nine percent, had complications that threatened their lives or left them permanently disabled—catastrophes that wouldn’t have happened to them if they had stayed away from their doctors or their hospitals.
The mishaps involved drugs, diagnostic tests and treatment, diet, nursing, transportation, heart catheterization, intravenous treatment, arteriography and dialysis, urinary catheterization, and a myriad of other procedures that compose a patient’s experience.
Soon it was clear to R.J. that in every aspect of medical care, patients were at risk from their benefactors. As increasing numbers of new drugs were put on the market, and as increasing numbers of tests and lab studies were ordered by doctors to protect themselves against malpractice suits, the possibilities of iatrogenic damage increased. Dr. Franz Ingelfinger, the very respected professor of medicine at Harvard and editor of the New England Journal of Medicine, wrote:
Let us assume that 80 percent of patients have either self-limited disorders or conditions not improvable, even by modern medicine. In slightly over 10 percent of the cases, however, medical intervention is dramatically successful…. But alas, in the final 9 percent, give or take a point or two, the doctor may diagnose or treat inadequately, or he may just have bad luck. Whatever the reason, the patient ends up with iatrogenic problems.
R.J. saw that despite the high costs in human suffering and in money, medical schools weren’t making students aware of the dangers of human mistakes in treating patients, nor were they teaching them how to re
act to malpractice suits, despite the proliferation of legal action against doctors. In the course of her own ongoing work for Wigoder, Grant and Berlow, R.J. began to accumulate an extensive file of cases and data in both these areas.
The trio was broken up after graduation. Samantha had always known that she wanted to spend her life teaching anatomy, and she accepted a residency in pathology at Yale-New Haven Medical Center. Gwen hadn’t had the slightest idea about a specialty through most of the four years of medical school, but ultimately her politics influenced her to choose gynecology, and she took a residency at the Mary Hitchcock Hospital in Hanover, New Hampshire. R.J. wanted it all, everything being a physician had to offer. She stayed in Boston, taking a three-year residency in medicine at the Lemuel Grace Hospital. Even during the worst of times—when dirty jobs were piled on her, and during the terrible grind, the sleeplessness and the marathon hours—she didn’t doubt what she was doing. She was the only woman among the thirty internal medicine residents of her program. As in law school and medical school, she had to speak a little louder than the men, work a little harder. The doctors’ lounge was male country, where her fellow residents hung out, spoke obscenely about women (gynecological residents were known as “connoisseurs of the cunt”), and mostly ignored her. But from the start she kept her eyes on her goal, which was to become the best doctor she was able to be, and she was good enough to rise above sexism when she met it, as she had watched Samantha rise above racism.
Early in her training she had revealed evident talent as a diagnostician, and she enjoyed looking at each patient as a puzzle to be worked out by using her brain and her training. One night, joking with an elderly male cardiac patient named Bruce Weiler, R.J. took both his hands in hers and squeezed them.