The Society

man, he had been regaled by a surgeon, whose name he didn’t know, with the story of a woman whose HMO told her to wait awhile to have her thyroid biopsy repeated because the evidence of cancer from the first set of seven painful needle biopsies was inconclusive. Three months later, her husband was transferred to another state and assigned coverage with a different HMO. When the woman’s cancer suddenly began rapidly growing, the new HMO refused to pay for treatment, claiming it was a preexisting condition.

“Hey, Will,” Lemm called out as he approached, “this may be our largest gathering yet.”

He motioned to the crowd, and Will noticed as he followed the gesture that his partner, Susan Hollister, had just entered and was casting about for a seat.

Thanks for showing up, Suze. I owe you one.

“I’ve got a couple of cases, Tom. Do you think they’re appropriate given this latest murder?”

“Are they funny?”

“That depends.”

“On what?”

“On whether you mean funny, ha ha, or funny, all of a sudden I can’t see out of my right eye.”

“Which are these?”

“A little of both.”

“Well, you’re on the agenda. There’s more tension than usual from what’s going on, but I don’t see any reason to withhold an anecdote or two. Tonight it’ll be right after we finish discussing the status of the class-action suit. After your report, we’ll decide what we’re going to do about the big debate against Boyd Halliday next week.”

“What do you mean?”

“I spoke to him an hour ago. He says it would send the wrong message to the public and the killer if he called off the debate.”

The debate, billed as a forum, had been organized by the Wellness Project, a respected independent consumer health-care coalition, and was scheduled for venerable Faneuil Hall in downtown Boston. Halliday, the powerful and dynamic CEO of Excelsius Health, was to be matched up against Jeremy Purcell, a world-renowned surgeon, Harvard professor, philosopher, and former president of the Hippocrates Society. Thanks in large measure to Will’s efforts, publicity for the forum, which was titled Managed Care: Boon or Boondoggle, had been extensive, and a sellout was anticipated. Of course, the managed-care murders had only heightened interest in the event.

“How does Jeremy feel about it?” Will asked.

“I’m surprised you haven’t heard,” Lemm said. “Jeremy’s had a fairly large coronary. He had emergency bypass surgery at White Memorial.”

“And?”

“He’s reasonably stable now, but he won’t be ready for next week. We have to decide what we’re going to do.”

“Halliday’s a force,” Will said, in what he knew was something of an understatement.

“He is that. Listen, I’ve got to get this show on the road. Don’t worry about your stories. If people want to laugh they’ll laugh. I think one of the big reasons we’re getting more members at every meeting is you and your stories.”

“I don’t make them up, I just read them.”

“That’s the point. They’re real.”

“Okay, I’ll do my best.”

“Will, you’re doing great things for this organization, and don’t think we don’t appreciate it.”

“Well, garsh, thanks, Mickey,” Will said in his highly tuned Goofy imitation-the only one in his repertoire.

Lemm, a lean six-footer, shambled up to the podium and silenced the crowd with a few taps on the microphone.

“Three nurses die in an accident and are spirited up to the pearly gates,” he began, without any introductory remarks. “Saint Peter is there and asks each one, ‘Who are you, and why should you be allowed to walk through these gates?’ ‘I was a nurse in a private doctor’s office for forty-five years,’ the first responds. ‘I instructed patients on how to take their medicines; I gave out lollipops to the children-sugar-free, of course.’ ‘Go right in,’ Saint Pete says.

“The second nurse walks up. Same question from Saint Pete. ‘I was a nurse in a hospice,’ she says, ‘and for many years I soothed dying people’s fears of crossing over to the other side, and made the transition a peaceful and enlightening one.’ ‘Please go right in,’ Pete says again. ‘Milk and cookies are on the right.’ The third nurse comes forward. Again, Pete asks about her qualifications for admission. ‘I did case reviews for a managed-care company,’ she says. Pete checks his massive golden book. ‘Ah yes,’ he says, ‘I have you right here.’ He swings open the gate, and as she starts in, he adds, ‘But we’ve only got you scheduled for a three-day stay.’ ”

Laughter from the assembled was enthusiastic, even though Will suspected that most had heard the joke before. Lemm was right. These men and women needed to laugh. Their profession, in many cases their dream, was under constant attack, and the AMA, the organization they had counted on to man the battlements, had mounted a feeble defense. The well-oiled machine of the managed-care industry had cut through the various medical specialties like a thresher.

It probably wasn’t totally fair to draw the analogy between the way managed care overwhelmed the practice of medicine one specialty at a time (giving concessions to the ophthalmologists at the expense of the GPs, then suddenly regulating the ophthalmologists) and the way Hitler swept through Europe a country at a time, but Will was hardly the first physician to see it that way. There was a remarkable, intensely moving Holocaust memorial near Quincy Market in Boston. At the entrance was a quote from a Lutheran pastor named Martin Niemoller.

In Germany they came first for the Communists, and I didn’t speak up-because I wasn’t a Communist.

Then they came for the Jews, and I didn’t speak up-because I wasn’t a Jew.

Then they came for the trade unionists, and I didn’t speak up-because I wasn’t a trade unionist.

Then they came for the Catholics, and I didn’t speak up-because I was a Protestant.

Then they came for me-and by this time there was no one left to speak up.

“Let’s begin this meeting as we do all our meetings with a reading of the roll-physicians who have notified us they are leaving patient care or retiring from medicine prematurely. Their specific reasons vary, but the themes behind them do not. These physicians can no longer handle the paperwork, frustration, and inconvenience to their patients, if not actual danger, of corporate medicine.”

The reading of the roll, consisting of as many as twenty names each month, was, as always, painful. Along with most of the names was a short statement of the reasons this fifty-one-year-old family practitioner or that forty-eight-year-old obstetrician decided to look elsewhere for the emotionally fulfilling, economically rewarding life that they at one time felt was worth the years of sacrifice, exhaustion, and escalating financial outlay demanded by medical school and residency.

This month, three of the nine names on the roll were well known to Will. One of them had been a clinical instructor of his in med school. Half of all physicians recently polled, he was thinking glumly and angrily, had said that given the chance, they would not do it over. .

After the reading of the roll, Lemm called on the Society’s legal committee, which reviewed in detail the status of a class-action suit being brought against several of the largest HMOs by the Hippocrates Society in conjunction with a number of state medical associations and some individual physicians. The case, which had been plodding forward for almost five years but was now gaining some momentum, charged the HMOs with extortion and with violating the federal Racketeer Influenced and Corrupt Organizations Act.

Other legal actions from around the country were also reviewed, including a lawsuit in California accusing the health plans of interfering with physicians’ ability to make independent medical decisions. The plans threatened physicians with economic loss, the suit was charging, in an effort to deter them from fulfilling their duty owed their patients and encourage them to place unreasonable and often unsafe restrictions on the level of medical services that might be delivered to their patients.

The legal team’s presentation was interrupted a number of times by applause. In the analogies to the Nazi takeover of Europe, the lawyers and physicians of the legal team were the resistance-sniping at the enemy,