The Cole Trilogy: The Physician, Shaman, and Matters of Choice

  She couldn’t let go.

  It was as if they were linked by … what? She felt faint with certain knowledge she hadn’t possessed a few moments before. She wanted to scream out a warning to Mr. Weiler. Instead, she muttered a dazed pleasantry and spent the next forty minutes poring over his records and taking his pulse and blood pressure again and again and listening to his heart. She told herself she was having a mental breakdown; nothing in Bruce Weiler’s chart or vital signs indicated that his mending heart was anything but strong and getting healthier by the moment.

  In spite of that, she was positive he was dying.

  She said nothing to Fritzie Baldwin, the chief resident. She was able to tell him nothing that made any sense, and he would have ridiculed her savagely.

  But in the small hours of the morning, Mr. Weiler’s heart blew out like a faulty inner tube, and he was gone.

  A few weeks later, she had a similar experience. Troubled and intrigued, she spoke about the incidents to her father. Professor Cole nodded, a gleam of interest in his eyes.

  “Sometimes doctors seem to have a sixth sense about the way a patient will respond.”

  “I experienced this thing long before I became a doctor. I knew that Charlie Harris was going to die. I knew it with absolute certainty.”

  “There’s a legend in our family,” he said tentatively, and R.J. groaned to herself, not being in the mood to hear family legends.

  “It was said that some of the Cole physicians down through the ages have been able to foretell death by holding the hands of their patients.”

  R.J. snorted.

  “No, I’m serious. They called it the Gift.”

  “Come on, Dad. Talk about superstition! That’s straight from the days when they prescribed eye of newt and toe of frog. Could they really have believed it?”

  He shrugged. “Supposedly my grandfather, Dr. Robert Jefferson Cole, and my great-grandfather, Dr. Robert Judson Cole, both had it when they were country doctors in Illinois,” he said mildly. “It can skip generations. Reportedly, several of my cousins had it. I was left the family’s prize antiques, Rob J.’s scalpel that I keep on my desk, and my great-grandfather’s viola da gamba, but I would have preferred the Gift.”

  “Then … you’ve never experienced anything like that?”

  “Certainly I’ve known whether particular patients were going to live or die. But, no, I’ve never had the sure knowledge of approaching death without signs or symptoms. Of course,” he said blandly, “the family legend also says the Gift is dulled or ruined by the use of stimulants.”

  “That leaves you out, then,” R.J. said. For years, until his generation of doctors had learned better, Professor Cole had enjoyed the frequent comfort of good cigars, and he continued to relish his regular evening reward of a good single-malt liquor.

  R.J. had tried marijuana briefly in high school but never had taken to either kind of smoking. Like her father, she enjoyed alcohol. She hadn’t allowed it to interfere with her work, but during times of stress she found a drink a distinct comfort, of which sometimes she availed herself greedily.

  By the time she finished the third year of her medical residency, R.J. knew she wanted to treat entire families, people of all ages and of both sexes. But to do so adequately, she wanted to know more about the medical problems of women. She sought and received permission to take three rotation periods in obstetrics and gynecology instead of one. When she completed her medical residency she took a one-year externship in ob-gyn at Lemuel Grace, at the same time taking advantage of an opportunity to do the medical examinations for a large research program dealing with the hormonal problems of women. That year she took and passed the examination to become a fellow of the American Academy of Internal Medicine.

  By that time, she was an old hand at the hospital. It was generally known that she had done a great deal of legal work for malpractice suits that often won large sums from insurance companies. Malpractice insurance rates were soaring. Some doctors said in open anger that there was no excuse for a physician to do work that would harm a fellow doctor, and throughout her years of training there were unpleasant moments when someone didn’t bother to hide the animosity they felt toward her. But she worked on a number of court cases in which her legal briefs for the defendant had saved the doctor who was being sued, and that became widely known as well.

  R.J. had a quiet reply for anyone who attacked her: “The answer isn’t to eliminate malpractice suits. The answer is to eliminate habitual malpractice, to teach the public to do away with frivolous claims and awards, and to teach doctors how to protect themselves during those times when they make the mistakes that happen to every human being.

  “We feel free to criticize otherwise-honest police officers who protect crooked cops because of their Blue Code. But we have our White Code. It allows some doctors to get away with clinical shoddiness and bad medicine, and I say to hell with it.”

  Someone was listening. Toward the end of her ob-gyn externship, Dr. Sidney Ringgold, the chairman of the department of medicine, asked if she would be interested in teaching two courses, The Prevention of and Defense Against Malpractice Suits for fourth-year students and The Elimination of Iatrogenic Incidents for students in their third year. Along with the instructorship in the medical school came an appointment to the medical staff of the hospital. R.J. accepted at once. The appointment created grumbling and several complaints in the department, but Dr. Ringgold weathered them calmly, and it had all worked out well.

  After residency, Samantha Potter had gone straight into the teaching of anatomy at the state university’s medical school in Worcester. Gwen Bennett had joined the established practice of a gynecologist in Framingham and already had begun working part-time in the Family Planning abortion clinic. The three of them remained close friends and political allies. Gwen and Samantha, as well as a number of other women and several forward-thinking male doctors, had backed R.J. resolutely when she proposed the establishment of the Premenstrual Syndrome Clinic at the hospital, and after a period of infighting with a few physicians who thought it a waste of budgetary funds, the PMS clinic had become an established service and part of the teaching curriculum.

  All the controversy had been particularly hard on Professor Cole. He was very much a member of the medical establishment, and the harsh criticism of his daughter, particularly the implication that she was sometimes a traitor to her fellow physicians, had been hard for him to bear. But R.J. knew he was proud of her. He had stood by her repeatedly despite their earlier difficulties. Their relationship was strong, and now she didn’t hesitate to turn to her father again.

  14

  THE LAST COWGIRL

  They met for dinner at Pinerola’s, a restaurant in the North End. When she had first gone there with Charlie Harris she had to walk down a narrow alley between tenement buildings, then up a tall flight of stairs into what was essentially a kitchen with three small tables. Carla Pinerola was the cook, assisted by her elderly mother, who shouted and grumbled at her a lot. Carla was middleaged, sexy, a character. She had had a husband who beat her; sometimes when R.J. and Charlie came into the restaurant there was a bruise on Carla’s arm or she had a black eye. Now the old mother was dead, and Carla was never visible; she had bought one of the tenement buildings and gutted the first and second floors, turning them into a large and comfortable eating place. Now there was always a long line of patrons waiting for tables, businesspeople, college kids. R.J. still liked it; the food was almost as good as in the old days, and she had learned never to go there without a reservation.

  She sat and watched her father hurrying toward her, slightly late. His hair had become almost completely gray. Seeing him reminded her that she was getting older, too.

  They ordered antipasto, veal marsala, and the house wine, and talked of the Red Sox and what was happening to theater in Boston and the fact that the arthritis in his hands was becoming quite painful.

  Sipping her wine, she told him she was preparing t
o go into private practice in Woodfield.

  “Why private practice?” He was clearly astonished, clearly troubled. “And why in such a place?”

  “It’s time for me to get away from Boston. Not as a doctor, as a person.”

  Professor Cole nodded. “I accept that. But why not go to another medical center? Or work for … I don’t know, a medical-legal institute?”

  She had received a letter from Roger Carleton at Hopkins saying that at present no money was budgeted for a position that would suit her, but he could arrange to have her working in Baltimore in six months. She had received a fax from Irving Simpson saying they would like to put her to work at Penn, and would she come to Philadelphia to talk about money?

  “I don’t want to do those things. I want to become a real doctor.”

  “For God’s sake, R.J.! What are you now?”

  “I want to be a private practitioner in a small town.” She smiled. “I think I’m a throwback to your grandfather.”

  Professor Cole struggled for control, studying his poor child who had chosen to swim against the current all her life. “There’s a reason why seventy-two percent of American doctors are specialists, R.J. Specialists make big money, two or three times more than primary care physicians, and they get to sleep through the night. If you become a country doctor, you’ll make a harder, tougher living. You know what I would do if I were your age, in your position, no dependents? I’d go back for all the training I could force myself to accept. I’d become a superspecialist.”

  R.J. groaned. “No more externships, my Poppy, and certainly no more residencies. I want to look beyond the technology, beyond all those machines, and see the human beings. I’m going to become a rural physician. I’m prepared to earn less. I want the life.”

  “The life?” He shook his head. “R.J., you’re like that last cowboy fella they keep writing books and songs about, who saddles up his bronc and goes riding through endless traffic jams and housing tracts, searching for the vanished prairie.”

  She smiled and took his hand. “The prairie may be gone, Pop, but the hills are right out there on the other side of the state, full of people who need a doctor. Family practice is the purest kind of medicine. I’m going to give it to myself as a gift.”

  They took a long time over the meal, talking. She listened carefully, aware that her father knew a great deal about medicine.

  “A few years from now, you won’t be able to recognize the American health care system. It’s going to change drastically,” he said. “The presidential race is waxing hotter and hotter, and Bill Clinton has been promising the American people that everybody is going to have health insurance if he is elected.”

  “Do you think he can deliver?”

  “I really think he’s going to try. He seems to be the first politician to give a damn that there are poor people without care, to confess he’s ashamed of what we have now. Universal medical insurance would make things better for you primary care physicians, while lowering the incomes of specialists. We’ll have to wait and see what happens.”

  They discussed the financial requirements of what she proposed to do. The house on Brattle Street wouldn’t bring much money after all the debts were paid; real estate prices were very depressed. She had made careful assessments of the money she needed to set up and equip a private practice and get through the first year, and she was almost fifty-three thousand dollars short. “I’ve talked with several banks, and I can borrow the money. I have enough equity to cover the loan, but they insist on a cosigner.” It was a humiliation; she doubted they would make the same stipulation to Tom Kendricks.

  “You’re absolutely certain this is what you want?”

  “Absolutely certain.”

  “Then I’ll sign the note, if you’ll permit me.”

  “Thank you, Pop.”

  “In a way it drives me crazy to think of what you’re doing. But at the same time, I have to tell you how much I envy you.”

  R.J. raised his hand to her lips. Over cappuccino they reviewed her lists. He said he thought she had been too conservative and that the figure she was borrowing should be ten thousand dollars higher. She was terrified of the financial depths and argued forcefully, but in the end she saw that he was right, and she agreed to dive even deeper into debt.

  “You’re a pistol, my daughter.”

  “You’re a pistol too, my old man.”

  “Are you going to be all right, living up there in the hills all by yourself?”

  “You know me, Dad. I don’t need anybody. Except you,” she said, and leaned forward and kissed him on the cheek.

  PART TWO

  THE HOUSE ON THE VERGE

  15

  METAMORPHOSIS

  She took Tessa Martula to lunch. Tessa wept into her lobster stew and was by turns sullen and heartbroken. “I don’t know why you have to cut and run,” she said. “You were going to be my elevator, up and up.”

  “You’re a hell of a worker, you are going to do just fine. And I’m not running away from this place,” R.J. said patiently. “I’m running toward a place I think will be better for me.”

  She tried to feel as confident as she sounded, but it was like graduating from school all over again; she had so many fears and uncertainties. She hadn’t delivered many babies in recent years, and she felt inadequate. Lew Stanetsky, the chief of obstetrics, gave her some advice, his manner a cross between concern and amusement. “You’re going to be a country doc, eh? Well, you’ll have to hook up with an obstetrician-gynecologist if you’re going to deliver babies out there in the hinterlands. The law says you have to call in an ob-gyn if you run into the need for things like cesareans, forceps births, and vacuum extractions.”

  He arranged for her to spend long hours alongside the interns and residents in the hospital maternity clinic, a large room filled with birthing stools occupied by straining, sweating, and often cursing inner-city women, most of them Afro-American, allowing R.J. to oversee two lines of brown and purple pudendas stretching in the natural violence of the act of birth.

  She wrote a solid and laudatory letter of recommendation for Tessa, but it wasn’t needed. A few days later Tessa came to her, all smiles.

  “You’re never going to guess whom I am going to work for. Dr. Allen Greenstein!”

  When the gods are cruel, R.J. thought, they are bastardly cruel. “Is he going to move into this office, too?”

  “No, we’re getting Dr. Roseman’s office, that beautiful, big corner office, opposite end of the building from Dr. Ringgold’s.”

  R.J. hugged her. “Well, he’s a lucky man to get you,” she said.

  It was surprisingly hard to leave the hospital, much easier to leave the Family Planning Clinic. She gave Mona Wilson, the clinic director, six weeks’ notice. Luckily Mona had been beating the bushes for a replacement for Gwen. She hadn’t found a full-time person, but she had hired three part-timers and had no trouble staffing Thursdays without R.J.

  “You gave us two years,” Mona said. She looked at R.J. and smiled. “And you hated every second of it, didn’t you?”

  R.J. nodded. “I guess I did. How did you know?”

  “Oh, it wasn’t hard to see. Why did you do it if it was so difficult for you?”

  “I knew I was really needed. I knew women had to have this option,” R.J. said.

  But as she left the clinic, she felt light as thistledown. I don’t have to come back! she thought exultantly.

  She faced the fact that while it gave her enormous pleasure to drive the BMW, the car didn’t make sense in terms of the spring mud and unpaved mountain roads she would come up against in Woodfield. She carefully inspected a number of four-wheel-drive vehicles, deciding finally on the Ford Explorer, ordered with air conditioning, a good radio and CD player, a heavy-duty battery, and wide tires with a tread designed for muddy roads. “Want my advice?” the salesman said. “Order a come-along.”

  “A what?”

  “A come-along. It’s an electric power
winch that’s attached to the front bumper. Runs off the car battery. It’s got a steel cable and a snap hook.”

  She was dubious.

  “If you get stuck in the mud, you just wrap the cable around a big tree and winch yourself out. Five tons of pulling power. It’ll cost you another thousand, but worth every penny if you’re going to be driving bad roads.”

  She ordered the come-along. The dealer turned a cagey gaze on her little red car.

  “A-1 condition. All-leather interior,” she pointed out.

  “I’ll allow you twenty-three thousand, trade-in.”

  “Hey. This is an expensive sports car. I paid more than double that.”

  “Couple of years ago, right?” He shrugged. “Check the Blue Book.”

  She did, and then she put an advertisement in the Sunday Globe. An engineer from Lexington bought the BMW for $28,900, paying for the Explorer and giving her a small profit.

  She drove back and forth between Boston and Woodfield. David Markus suggested she would be best off with an office on Main Street, in the center of the village. The street was built around the white, wood-frame Town Hall that had been converted from a church more than a century ago. It was adorned with a spire in the Christopher Wren tradition.

  Markus showed her four places on Main Street that were empty or soon would be. The prevailing wisdom was that a doctor required from 1,000 to 1,500 square feet of space for an office suite. Of the four prospective properties, R.J. ruled out two of them at once as eminently unsuitable. One of the others appealed to her but would be cramped, having only 795 square feet. The fourth property, which the canny real estate man had saved until last, looked promising. It was across the street from the town library and a few houses away from the Town Hall. The outside of the house was well preserved and the grounds carefully tended. The interior space, 1,120 square feet, was shabby, but the rent was slightly less than R.J.’s estimate in the budget she had agonized over with her father and other advisers. The house was owned by an elderly woman named Sally Howland. She had plump red cheeks and a nervous but benevolent glare, and she said it would be an honor to have a doctor in town again, and on her property.