Authors: Harry Stein
Besides, heavy rain was predicted; and, though he’d studied a map of the campus, Logan’s sense of direction was notoriously unreliable. He would surely need time to get his bearings.
It proved a wise precaution. The employee pass he’d received in the mail got him through the main gate, but he found himself turned away from the underground garage of the administration building by a uniformed guard. In the interest of sabotage prevention, it seemed one needed a special parking credential available only through ACF security. Then, just as he drew his newly purchased used Ford into the visitors’ lot several hundred yards beyond, the heavens opened.
Cursing himself for forgetting his umbrella, he made a dash for the building,
The Washington Post
his only shield. By the time he got there, he was soaked.
“Christ,” he muttered, staring at his matted hair in the men’s room mirror. To his further annoyance, the paper-towel dispensers were empty—in fact, the bathroom seemed surprisingly poorly serviced in general, more like the one in his old high school than what he’d expected to find in the nation’s top medical research facility. Doing the best he could with wadded toilet paper, he headed for the nearby cafeteria, got a cup of tea, and took a spot at a corner table to dry out.
He had just unfolded his soggy paper when he saw John Reston, moving his way with a full tray.
“Look at you,” noted Reston, grinning. “No security pass, right?”
Logan shook his head. “Do you have one?”
He set down the tray and withdrew an official-looking laminated card from his jacket pocket. “Just have to know the right people. Talk to Shein’s assistant, she’ll take care of it.” He smiled. “Or talk to Shein—if you dare.”
“How’d you find out?”
“Hey, some of us got here a few days early and asked around.” Sitting down, he indicated his plate, piled high with scrambled eggs and overdone bacon. “Hope you don’t mind me making a pig of myself.”
“Go ahead, it’s your body.”
“And I
looove
abusing it.” Reston crammed a forkful of eggs into his mouth. “You feeling all right? You seem down.”
“Aren’t you? After the other day?”
“Naaah. Look, guys like this, we’re hardly even in their field of vision. Anyway, they’ve already wrecked our personal and financial lives, what more can they do?”
Despite himself, Logan smiled. “So who’s running this orientation meeting?”
“Larsen.”
“Really?” Logan shuddered. “The guy hates me.”
“Welcome to the club.” He ran a napkin across his mouth. “But listen, I’m telling you, you can’t take these things personally. Junior associates aren’t important enough for a guy like Larsen to hate.”
“You’re probably right.”
“Aren’t you going to eat anything? That tea’ll go right through you on an empty stomach.”
“So?”
He shrugged. “Just a suggestion. My guess is Larsen won’t much like it if you keep jumping up from the meeting.”
Larsen was precisely as Logan remembered him. Sitting at the head of a large conference table, flanked on one side by his lieutenant Kratsas and on the other by his grim-faced secretary, the chief of the Department of Medicine ran the meeting with dry, humorless efficiency.
He opened by indicating the two thick spiral-bound notebooks that had been set down before each of the new associates. “For your first assignment, you will be expected to master the material in these books. All of it. No excuses or exceptions.”
That was it. No word of welcome. No banter. Not even the pretense of collegiality.
“Now,” continued Larsen, “you all know who I am and why we’re here. You have been accepted into this program because somebody thinks you’ve got what it takes to eventually make a contribution toward curing cancer. But it is my job to inform you that, at least for the first year, your role is to provide support for senior physicians. You are to do what you’re told, period. We are not looking to you for creativity.”
This did not come as anything like news to Logan or the others, of course. They’d always known that the ACF was a rigid hierarchy; and that as first-year fellows their chief concern would be not research but basic patient care.
Still, Logan wondered if any of the others were as put off by Larsen’s condescending manner as he was. He
quickly glanced up from the legal pad where he was scribbling notes. All of the others, writing dutifully, kept their heads down.
“Each of you will be responsible for charting the progress of between one hundred twenty-five and one hundred and fifty patients,” Larsen continued, “of whom about twenty will be on site at any given moment. As you know, our job here is to develop and test new cancer therapies. Every patient at the ACF has agreed to take part in a carefully controlled course of treatment. A large part of your job is to see to it your patients in no way deviate from the instructions they have been issued. That they understand that if they fail to follow through in any way, they will be dropped from the program.” He paused. “Some lay people might see this as callous. As scientists, we know better. We understand that in a program of rigorous scientific inquiry, rules can never be bent.”
He paused, nodding in the direction of Kratsas. “Some of you are familiar with Dr. Kratsas. He will give you a brief overview of the trials currently in progress. Everything you will hear is privileged information. Divulging any of it without authorization shall be regarded as grounds for immediate dismissal.”
The threat was of course unnecessary, a pointless insult to the professionalism of the highly skilled young doctors present; yet Logan felt certain the man’s loutishness was not even intentional. His style reflected his essence.
“Dr. Kratsas,” he said, surrendering the floor.
Kratsas’s sudden smile was ingratiating, a conscious effect to dispel the chill that had settled over the room.
“First,” he began, “I want to extend a personal welcome. I’m sure I speak for the entire senior staff in saying that we are always available as colleagues and friends.”
Logan glanced at Larsen, who stared straight ahead, showing nothing.
Sure
, he thought,
that guy’ll be my friend, all right
—
the day jelly beans cure cancer
.
“Now, then,” continued Kratsas, “some of you may know I’m an avid fan of the film director Alfred Hitchcock.
I bring this up for a reason—because I believe Hitchcock would have made a magnificent cancer researcher. Why? He was canny, he was precise, he was resourceful and—a quality we must all nurture—he understood desperation and fear. Not only understood them, but knew how to
work
with them.” As he scanned the table meaningfully, there was not a doubt in Logan’s mind that he’d delivered these lines a dozen times before.
Kratsas smiled again and patted a notebook on the table before him. “Now, then, as I’m sure you know, our courses of experimental treatment fall into three categories. A Phase One trial is by definition a new and highly innovative form of treatment. Subjects’ malignancies are highly advanced and we obviously recognize going in that the chances of meaningful success are remote.” He paused and took a sip from the glass of water before him. “Indeed, in such trials our very definition of success changes. Usually, what most interests us is measuring toxicity—gauging the maximum dose of this new drug the human body will tolerate. Its impact on the malignancy is often of only secondary concern.”
He held up a notebook. “As you read through your material, you will note that we are currently conducting only two Phase One protocols here at the ACF. Which is to say, no one will be dealing with more than two or three patients who are participating in such research. Still, given such patients’ highly advanced levels of disease, they are likely to require a considerable amount of attention.” He paused, glancing at Larsen. “Obviously, we do not lie to patients. Ethics is a serious concern here at the ACF. But neither, when a patient’s situation is desperate, is it necessarily always the best policy to volunteer every scintilla of truth. Think of Hitchcock: patients who are led to feel there is no hope have precious little incentive to remain with the program.”
He cleared his throat and took another sip of water. “Now, then, only a small number of the drugs that go through a Phase One test, perhaps ten percent, move on to
a Phase Two trial—a more comprehensive test aimed at determining a compound’s effectiveness against malignancy in a specific organ. In turn, no more than about ten percent of those drugs—
one
percent of the total—are sufficiently promising to warrant Phase Three trials, which test the new treatment against the best existing therapy. When a patient signs on, he does not know whether he will receive an established or an experimental treatment. I can tell you, however, that it is our policy to never give any cancer patient a placebo. That would constitute deception of the cruelest kind.”
He paused. “We all know that lay people—and that includes our patients and their families—tend to have a wildly optimistic view of what can be achieved. They don’t come here merely because everything’s free; they’re hoping to be cured. We, however, are scientists. Our hopes may be great, but our expectations are realistic: a successful Phase Three trial is defined as one that produces a response rate only slightly better than the standard treatment, or one that meaningfully improves quality of life.
“Now, then, that doesn’t mean breakthroughs don’t occur. I presume you are all familiar with the drug cisplatin …?” He paused, surveying the serious faces around the table, seeming to wait for a response.
“Active against testicular cancer,” spoke up Reston.
“Yes, but that’s hardly the full story. I suppose you’re all too young to remember a movie called
Brian’s Song
, but it was a great success when I was your age. It was based on the story of a football player who died of testicular cancer as a very young man.”
“Brian Piccolo,” said Logan softly, from his seat beside Larsen’s secretary.
Larsen looked at him sharply. “This is not a free-for-all, Doctor. Or a television quiz program.”
“Now, then,” continued Kratsas, “in those years, the early seventies, the cure rate for metastatic testicular cancer was on the order of thirty percent. Today it is what?”
Silence.
It was Sabrina Como, the Italian, who finally spoke up. “I believe it is seventy-five percent,” she said.
Kratsas nodded. “Actually, with cisplatin, it’s closer to eighty.”
He picked up one of the spiral notebooks and let it fall to the table with a bang. Several of the young associates started. “Heavy, huh? It contains, among other things, a rundown of all current protocols—thirty-six in all. You shall be expected to have familiarized yourself with them all by Wednesday. Because that is the day you assume charge of your full complement of patients.”
Even during their long years as interns and residents, none of the younger doctors had ever heard anyone suggest such a workload: in two days each would be handed over one hundred patients desperately ill with cancer—patients whose course of treatment, whose very medicines, at this moment they knew
nothing
about.
“For your benefit,” picked up Kratsas, “the senior associates have dictated a full history of each case. Later this afternoon, you will learn from the communications people how to do proper ACF evaluation dictation. Such an evaluation will be expected whenever a patient is discharged, or otherwise passes from the program.” Logan could scarcely suppress a smile;
passes from the program
—the euphemism was a new one to him, even after Claremont. “These evaluations must be letter perfect,” Kratsas droned on. “Master the form! By Wednesday, you will also be expected to have full command of the computer system.”
Logan paused in his note taking to chance a quick smile in Reston’s direction: this was so overwhelming, there seemed no other possible response.
“As for hospital duty, at least one of you must be on the patient floor at all times, day and night. It is expected that you will divide up the night coverage equitably among yourselves. If you want some sleep, I suggest you find an empty patient room.”
He turned back to Larsen. “Now, then, I think that about covers it.”
Larsen nodded crisply. “One thing I wish to emphasize. Every doctor here of course has a responsibility to his patients. But his primary responsibility—his overriding priority—must always be this institution. Is that understood?”
Larsen’s fearsome gaze swept the table. Then, tentatively, a hand rose into the air. Barbara Lukas.
“What is it?” snapped Larsen.
Clearly, this was not easy, and her voice quavered slightly. “It’s just a small thing. In referring to a doctor, you keep saying his responsibility and
his
priority. I was just wondering, since there are also quite a few of us women here, if you might be a bit more inclusive.”
There was total, stupefied silence. Larsen’s face visibly reddened, and Logan thought he could see a vein in his temple start to twitch. In an effort to distance themselves from this kamikaze mission, most of the other women present stared down at the table.
But, incredibly, Larsen seemed to keep his cool. “What,” he said, tight-lipped, “would you suggest?”
Lukas seemed to gain in confidence. “Perhaps
he or she
, something like that. Just a little more sensitivity.”
He drummed his fingers on the table, appearing to consider this. “No, Dr. Lukas, NO!” With a sudden crack, his hand came crashing down on the polished wood. “Maybe young people get away with bullying their elders at Duke these days, but it will not happen here!”
He paused, then resumed his former tone. “After your patient-care year, you will in turn pass on your patient roster to next year’s incoming fellows. And, assuming we are pleased with you”—here, stopping for a millisecond, he shot Lukas daggers—“you will then be attached to a laboratory in which to pursue your specific area of interest.”
Abruptly, a bell sounded in the corridor outside the conference room, followed immediately by a commanding female voice on the loudspeaker. “Code blue. Twelfth floor. Room thirty-eight.”