The Cole Trilogy: The Physician, Shaman And Matters Of Choice Part 128

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 h.e.l.l 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 amus.e.m.e.nt. "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 G.o.ds are cruel, R.J. thought, they are b.a.s.t.a.r.dly 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 b.u.mper. 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 advertis.e.m.e.nt 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 s.p.a.ce 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 s.p.a.ce, 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.

"But I depend on my rents to live, you understand, so I cannot come down on the price." Nor could she afford to do the renovations R.J. would need, she said; but she would give permission for them, as well as whatever painting the doctor might like to have done at her own expense.

"It'll cost you to renovate and paint," Markus told R.J. "If you go for it, you ought to protect yourself with a lease."

In the end, that's what she did. The painting was done by Bob and Tillie Matthewson, a husband-and-wife team who doubled as dairy farmers. The place was full of antique woodwork that they brought back to a soft l.u.s.ter, and worn and scarred random-width pine floors that she had them paint teal blue. They covered the dead or dying wallpaper in every room with two coats of washable off-white. A local carpenter put up lots of shelves and cut a large square hole-behind which the receptionist would sit-through the interior wall of what used to be the parlor. A plumber put in two additional toilets, placed sinks in both the former bedrooms that would now be examining rooms, and added a tankless boiler to the furnace in the bas.e.m.e.nt so R.J. would have hot water on demand.

Buying furniture and equipment should have been fun but was a source of anxiety because she had to keep one eye on her bank balance. Her problem was that she had been accustomed to ordering the best of everything when it was needed at the hospital. Now she settled for secondhand desks and chairs, a gem of a Salvation Army rug for the waiting room, a good used microscope, a rebuilt autoclave. But she bought new instruments. She had been advised she needed two computers, the first for patient records, the second for billing, but grimly decided to make use of one.

"You met Mary Stern yet?" Sally Howland asked her.

"I don't believe I have."

"Well, she's postmistress. She owns the heavy old upright scale that used to be in Dr. Thorndike's office. Bought it at the auction after the doctor died twenty-two years ago. She's willing to sell the scale to you for thirty dollars."

R.J. bought the scale, scrubbed it, had it checked and rebalanced. It became part of the office, a link between the town's old doctor and the new one.

She had intended to advertise for help, but there was no need. Woodfield had an underground communications system that worked efficiently and with the speed of light. Very quickly she had four applications from women who wanted to be her receptionist, and three applications from registered nurses. She was careful and took her time choosing, but Toby Smith, the personable blond woman who had driven the ambulance the night Freda Krantz had been shot, was one of the applicants for the receptionist job. She had impressed R.J. from the moment they had met, and she had the added attraction of heavy bookkeeping and accounting experience, so she could keep the financial records. For her nurse R.J. hired solid, gray-haired, fifty-six-year-old Margaret Weiler, who was called Peggy.

She felt guilty when it came to discussing money with each of them. "What I can pay you at the start is less than you would be paid in Boston," she told Toby.

"Listen, don't you sweat about that," the new receptionist said forthrightly. "Both Peg and I are tickled to be able to work right here in town. This isn't Boston. Jobs are hard to find in the country."

David Markus came around to the emerging office now and then. He cast an experienced eye on the renovation work and sometimes offered her a quiet word of advice. A couple of times they had lunch at the River Bank, a pizza joint on the outskirts of the village-twice he paid, once she did. She found herself liking him, telling him her friends called her R.J.

"Everybody calls me Dave," he said. Then he smiled. "My friends call me David." His blue jeans were faded but always looked freshly washed. His ponytailed hair was always very clean. When they shook hands she could feel that his palm was muscular and work-hardened, but his nails were cut short and looked cared-for.

She couldn't make up her mind whether he was s.e.xy or just interesting.

The Sat.u.r.day before she moved from Boston, he took her on a real date, to dinner in Northampton. As they were leaving the restaurant, he took a handful of candy from the bowl by the front door, bits of coated chocolate. "Mmmm, upscale M&Ms," he said, offering her some.

"No, thank you."

In the car she watched him chewing and lost a struggle to keep quiet. "You shouldn't eat those."

"Hey, I love 'em. I don't gain weight."

"I love them too. I'll buy you some in a nice clean package."

"You a cleanliness freak? I got these at a nice clean restaurant."

"I just read about tests that were done on candy from restaurant candy bowls. They found that in most cases the candy contained traces of urine."

He looked at her in silence. He had stopped chewing.

"Male diners go to the men's room. They don't wash their hands. On their way out of the restaurant, they reach into the candy bowl ..."

She knew he was trying to decide whether to spit or to swallow. There goes this relationship, she thought as he swallowed, lowered the car window, dumped the rest of the candies.

"That's a terrible thing to tell somebody. I've been enjoying restaurant candy for years. You've absolutely ruined that pleasure for me for all time."

"I know. But if I had been eating them and you knew, wouldn't you have told me?"

"Maybe not," he said, and when he started to laugh, so did she. They chuckled halfway up Route 91.

On the drive back up into the hills, and then sitting in his parked pickup truck in front of her house, they told each other about their lives. He was a jock as a youth, "just good enough to get a lot of injuries in a lot of sports." By the time he reached college, he had been hurt enough that he didn't play varsity anything. He majored in English at Hamilton College, did graduate work about which he was vague. Before coming to the hills of Ma.s.sachusetts he had been a corporate real estate executive at Lever Brothers in New York, the final two years a vice president. "The full catastrophe-the 7:05 train to Manhattan, the big house, the pool, the tennis court." His wife, Natalie, had developed amyotrophic lateral sclerosis, Lou Gehrig's disease. They both knew what was involved; they had watched a friend die of ALS. A month after her diagnosis was confirmed, David came home to find that Sarah, then nine years old, had been left with a neighbor, and Natalie had placed wet towels around the garage doors, started her car, and died listening to her favorite cla.s.sical music station.

He had hired a cook and a housekeeper so Sarah would be cared for, and he had gotten drunk regularly for eight months. On a sober day he had realized that his bright, coltish daughter was failing in school and developing psychological problems and a chronic, nervous little cough, and he had gone to his first meeting of Alcoholics Anonymous. Two months later David and Sarah had come to Woodfield.

He nodded when he heard R.J.'s story a little later, over three cups of strong coffee in her kitchen.

"These hills are full of survivors," he said.

16.

OFFICE HOURS.

She moved from Cambridge on a hot morning in late June, under high, dark rain clouds that promised thunder and lightning. She had thought she would be happy to leave the house on Brattle Street; but in the last days, as some of the furnishings were sold and some went to storage and some went to Tom-as piece by piece was carried out until her high heels made echoes in the empty rooms-she looked at the house with the forgiving eyes of a former owner and saw that Tom had been right about its dignity and splendor. She was reluctant to leave it; despite her failed marriage, it had been her nest. Then she remembered that it was like a large hole in the ground into which they had poured their money, and she was content to lock the door and drive out of the driveway, past the brick wall with sections that still needed work, her responsibility no longer.

She was aware that she was driving into the unknown. All the way to Woodfield, her mind grappled with medical economics, fearful lest she was making a disastrous mistake.

For several days she had toyed with a fantasy. Suppose she were to operate a practice on a cash basis only-able completely to ignore the insurance companies, whence came most of the bad stuff that on occasion made doctoring unpleasant? If she were to drop her fee for an office visit steeply-say, down to twenty dollars-would enough patients come to keep her afloat financially? Some would come, she knew, sick people who weren't covered by medical insurance. But would anybody covered by Blue Cross/Blue Shield forget about the fact that he or she owned a paid-up insurance policy and volunteer to pay cash at Dr. Cole's office?

She realized regretfully that most people wouldn't.

She decided to try to establish an unofficial fee of twenty dollars for those who were uninsured. Insurance companies would pay their usual forty dollars to sixty-five dollars for an office visit by one of their clients, depending on the complexity of the problem, with an additional charge for house calls. Full physical examinations would be billed at ninety-five dollars, and all lab work would be done at the medical center in Greenfield.

She put Toby to work two weeks before the office officially opened, programming all the insurance company doc.u.ments into the computer. She would do most of her business with the five largest insurance companies, but there were fifteen other companies from which many patients bought insurance, and about thirty-five smaller, marginal companies. All of them had to be in the computer, multiple forms from each firm. The exhausting programming was a one-time job, but R.J. knew from experience that it would have to be updated constantly as companies discontinued some forms, revised others, and added new ones.

It was a major expense, one with which her great-grandfather had not had to contend.

A Monday morning.

She arrived at the office early, her hurried breakfast of toast and tea turned into a cold ball of nervousness in her stomach. The place smelled of paint and varnish. Toby already was at work, and Peg arrived two minutes later. The three of them grinned at one another foolishly.

The waiting room was small, but suddenly it looked enormous to R.J., deserted and empty.

Only thirteen people had made appointments. People who had been twenty-two years without a local doctor must have grown accustomed to the fact that they had to go out of town, she told herself. And once people had forged a relationship with a physician, why should they go to somebody new?

Suppose no one showed up? she asked herself in what she recognized as unreasonable panic.

Her first patient was there fifteen minutes before his appointment, George Palmer, seventy-two years old, a retired lumber miller with a painful hip and three stubs where fingers should have been.

"Morning, Mr. Palmer," Toby Smith said calmly, as though she had been greeting patients for years as they came through the door.

"Mornin', Toby."

"Morning, George."

"Mornin', Peg."

Peg Weiler knew just what to do, ushered him into an examining room, filled in the top of his chart, took a set of vitals and recorded his data.

R.J. enjoyed taking a very relaxed history of George Palmer. In the beginning, each of the office visits would require a lot of time because every patient was new to her and would require a full workup.

In Boston she would have sent Mr. Palmer and his bursitis to an orthopod for a shot of cortisone. Here she gave the injection herself and asked him to make another appointment to see her.

When she stuck her head into the waiting room, Toby showed her a bouquet of summer flowers, sent by her father, and a huge ficus plant sent by David Markus. There were six people in the waiting room, and three of them didn't have appointments. She told Toby to practice triage; anyone in pain or severely ill should be worked in quickly. Others should be given the first available appointment. She realized suddenly, with a strange mixture of relief and regret, that she didn't have time to spare, after all. She asked Toby to bring her a cheese sandwich on a kaiser roll from the general store, and a large decaf. "I'll work through my lunch hour."

Sally Howland was coming through the front door. "I have an appointment," she said, as if she expected to be challenged, and R.J. had to restrain herself from kissing her crabby landlady.

Both Peg and Toby said they would work through the lunch hour too, and that they had better order sandwiches of their own. "I'll pay," R.J. told Toby happily.

17.