Author's Note: They say to write what you know and this is what happens when I finally listen. I hope you enjoy.
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Chapter 1: The Good Doctor
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"Where's Dr. Von Oyen?"
"Dictating in the staff room, where else?"
"'Where else?'" he scoffed. "The man dictates wherever he goes. I mean, things went a little differently the last war and he would be dictating to the country and not just this clinic after filling an even bigger power void than the one in this hospital." Caraway stepped into power after the war before Von Oyen could. This was likely a mixed blessing.
The medical assistant waited patiently for the house officers to conclude their nigh-subversive conversation. She always felt too small to interrupt even the least pertinent of a physician's discourse, and often, she learned something because of it. It wasn't always related to medicine.
After a few minutes of having her existence remain unacknowledged, she gave up and walked to the staff room. There, six physicians and their clinical assistants of various subspecialties sat reviewing patient charts on computers and discussing their cases with the nurses, residents, and medical students whom they were charged to educate. Today's clinic was for endocrine oncology and thoracic patients, with a handful of acute care surgical follow-ups.
She placed the folder in the rack next to the surgeon-in-chief's workstation, behind one other. The doctor looked up briefly and nodded, but frowned when he noted the folder's red color. Red meant the patient had no insurance guarantor and that he would be lucky to get any compensation for his work on that patient.
The University of Deling Heath System didn't have the luxury of many private practices, which could turn away all but the best insured, best paying, easiest to diagnose and treat patients. UDHS was the provider of last resort and hence legally obligated to take any person who should seek their care. This fact made the surgeon-chief angry, but then, quite a lot of things made him angry.
"…Review of 10 of 14 systems unremarkable except as noted above, period." He spoke into the receiver, taking the time to narrate the punctuation, so that the translational servicemen would be less likely to make formatting errors when they transcribed his account. "Family history is non-contributory, period. Next paragraph. Social history: Patient smokes one pack per day times 23 years, period. Drinks alcohol only occasionally, and denies illicit drug use. Next paragraph…"
The MA didn't stick around even long enough to admire the physician's handsome profile, for he had a tendency to be perspicacious about one's intensions, and that in the past resulted in far smaller merit salary increases. She decided it wasn't worth it. Besides, she saw the man almost every day, and had memorized his appearance. It never changed.
He was a young man. Younger than any chief surgeon should ever appear to be, but evidently, not so young as to not deserve to be. Tall, with dark hair that he combed always to his right. Though you'd possibly never know it, for he always wore a surgical cap that covered most of his forehead and hair. He was bearded thickly, but with a close cut, and growing silver under the chin and temples. He had the large, but fairly narrow hands that befit a surgeon, with what seemed to be too many knuckles placed too far apart. Strong-jawed, with brown eyes that sat behind a pair of rimless glasses and inside a scowl that never ended, he appeared to be constantly annoyed with his surroundings.
When not in long white coat monogrammed with his name, "A. S. Von Oyen, MD," he dressed in oxfords, slacks, and ties that never at outrance with primary or secondary colors, and seldom had patterns beyond pinstripes. His right leg shook endlessly whenever he sat to complete a task that required more than one track of thought. This pissed off a great number of people, since the desks in the clinic were at such a low height that his knee often knocked against them at about 10hz. Nobody said anything though.
His lab coat flapped behind him in the melodramatic style of a cinema villain as he stalked down the hallway to room 53 where his next patient sat waiting. Knocking only momentarily and while in the process of opening the door, he entered, then looked down at the folder which read Forre, Edward 32 and then at the elderly woman sitting in the room alone with him.
"Excuse me. I must have the wrong room," he apologized before returning to the hallway and nearly bowling over the residents who were just now catching up to him. The doctor turned down another hall papered with innocuous wall coverings and fake ash paneling and insinuated himself into the former closet which held the clinic's three patient intake personnel.
"Where the hell is Forre? Do you have to go moving the patients around after you've put them in a room?" he spouted, though quietly.
"I did mark room 48 on the billing sheet." One of the staff stepped in and pointed at the note with a pen. From a safe distance. "Right there..."
"Well, why does it say something different on the board?"
"I'm sorry, Doctor Von Oyen, you didn't get the e-mail that patient tracking would be unreliable today? They're updating the software."
He rolled his eyes. "I might allegedly be the man in charge here, but I'm always the last to know when something changes." Then he walked out without another word.
Once he was out of earshot, another of the staff remarked, "That's probably because everyone is afraid to give you bad news."
The residents parted to either side of the hall as he walked quickly past, turning to another branch and toward exam room 48. He performed the same ritual before entering as he did for the incorrect room. Inside there was a middle-aged man of considerable mass sitting on the table. The physician was introducing himself when his protégés entered.
"Good morning Mr. Forre. I'm Doctor Von Oyen and these two are my residents today, Vera and Vernon. They're here with me now to hopefully learn what they did wrong and missed when they were with you earlier." He smiled and the overweight man laughed, if a bit nervously. "I understand you're concerned about your thyroid. When did your symptoms begin?"
"Guess it's been about three months now. Felt a bump on the right side of my neck."
"All right. Any fatigue, sweats, rapid heartbeat?"
"All those. And I put on quite a lot of weight."
Doctor Von Oyen wrote some notes on the patient folder, and then removed the sheet. "I see. I'm going to examine you now, Mr Forre, to see if I find any other worrisome symptoms and to try to palpate the mass you felt in your neck."
Mr Forre looked lost.
"I thought you'd just cut it out..."
The physician's eyes narrowed. "Palpate means feel, Mr Forre, now please remove your shoes and socks."
"The lump was on my neck, doc."
"Doctor Von Oyen," he growled. "Yes, I'll be checking your neck as well, but evidence of swelling in your extremities can cue me into what could be going on." Impatience was thick in his voice by this time. Mr Forre reluctantly removed his footwear.
He checked his patient's medical record, which had sparse content. "I notice that we don't have any ultrasound imaging or uptake scans in our system. Have you had an ultrasound?"
"Ultrasound? I ain't pregnant."
Von Oyen walked to the pedal-controlled sink and washed his hands. "Ultrasound imaging is used to determine the size, location, and characteristics of abnormalities of the thyroid and parathyroid glands. Without imaging I can't determine what is taking place in your neck, if anything. Especially with no obvious goiter."
Now wearing latex gloves, the surgeon pressed his fingertips into his patient's neck, pushing more deeply as they moved closer toward the larynx. He pulled back and observed as Mr Forre swallowed on request, then wrote additional notes after checking pulse, respiration, and bowel sounds. He washed his hands again.
"Well, Mr Forre... I was unable to feel anything abnormal under the unnaturally thick layer of blubber about your neck. If you'd be so kind as to have an ultrasound that shows a nodule with a diameter of at least one centimeter, I'd be happy to discuss surgery with you. The symptoms you described to me were characteristic of both hyper and hypothyroidism, which leads me to believe that you're a tachycardic, sweating, hard breathing slob, because you're fat, and that's not because of your thyroid, either. Everyone wants to blame the thyroid...
"So you can get me those images or you can get your ass off the couch: your health and my time would be better served in either event."
The man huffed in anger and exertion as he put his shoes back on and reached for his coat. Doctor Von Oyen handed him back his folder which he snatched away angrily.
"I know a good bariatric surgeon just down the hall if you'd like to become an even bigger blimp and take the easy way out. Insurance waives all other requirements if your BMi is over 50."
The door flew open and slammed shut.
Von Oyen walked out moments later, having just logged out of the terminal, while his residents lingered, briefly contemplating apologizing to the patient before deciding that their attending physician would be much harder to deal with. Cara leaned toward the more experienced Vernon. "He was in rare form today, eh?"
Vernon turned toward her, look of abject incredulity written on his face. "'Rare' form?" His face softened as he remembered that she'd just transferred from cardiac surgery only a week or so ago. "That's right. You haven't been in clinic with the good doctor before. Well, that is pretty much how he always is."
Cara frowned and wondered how the surgeon didn't get her name right when introducing her. Didn't he see the name tag?
"Then why do people keep coming to see him?"
"There's not much choice in the matter. There are only a handful of surgeons that can do what he does and he's the best in the country, maybe the world." He shrugged and started walking. "He just expects processes to work efficiently, patients not to be stupid, and for everyone around him to keep up," Vernon continued, with pointed emphasis.
"So, he expects way too much..."
And why not? People came from hundreds or thousands of miles expecting miracles of him and their expectations were almost always met. She watched as Vernon quickened his pace down the hall and she sighed.
Already she missed cardiac, where the surgeons acted as old gods, plotting and scheming against each other. They were easy to win over that way, to manipulate. It was clear already, that in the section of general surgery, polytheism was dead: there was one god whom it appeared all feared and resented. Few gods are more loathed than those who only provide for those who need, for few know if they need or want, and what.
The tacky watercolor reprints passed by on her left and right as she slowly made her way to the staff room. Inside, several physicians sat at their terminals and nurses reviewed messages from patient calls. Doctor Von Oyen was nearly done with his dictation and he pushed a billing sheet Cara to mark for a procedure done earlier. She took it to give to Vernon, since she knew nothing about it.
"...Patient is a well-developed, obese male who is in no apparent distress and appears his stated age, period. On focused examination, no lymphedema or swelling of the extremities and thyroid was difficult to appreciate bilaterally due to body habitus, period. I was unable to palpate any abnormal nodule, period. I suspect the nodule patient reported feeling was a piece of sausage lodged in his throat... Redact last sentence..."
Cara weaved her way around the bodies to her partners. Vernon was talking to the other general surgery resident on rotation that day, Nash.
"I'm telling you, she's easily the hottest girl I've ever seen," Nash was gesticulating over a red patient folder.
"Yeah, well, you don't get out much," the other man returned, smirking. Nash frowned and Cara was disgusted, but remained to see if something worthwhile might turn up during the conversation. She shoved the billing sheet in front of Vernon who hashed it up wordlessly.
"You'll see man. Chuck was so intimidated he didn't even get her vitals. Whoever gets her number doesn't have rounds for a month, deal?"
"The only number you'll get is her BP, if you're lucky." To Cara's growing appreciation, Vernon didn't take the outstretched hand.
"Shouldn't you be discussing the next patient?" she asked, impatiently.
They both turned to her. "We are."
She drummed her fingers against her thigh and blew out her hair. She really missed cardiac surgery. None of their patients were good-looking... Angry, she snatched the red folder from Nash just as Von Oyen walked over to them.
"All right," he clapped his hands together and made as if to dust then off, smiling lopsidedly. "New girl. Tara, right? Tell us about our homeless patient."
"It's Cara," she said and he waved his hand as if to say 'close enough.' Cara went on peevishly after seeing his impatience grow even in a span of a few seconds. "And how do you know she's homeless?"
"Red folder. Means no insurance guarantor and might as well be homeless to me. This'll be a charity case."
Nash spoke up. "Well, she didn't look homeless. Could be self pay."
"Now, now, Nash. It's not kind to get your attending's hopes all up. Out with it then. What's the rich gal's story."
Cara started to read from the folder before Vernon interrupted her. "Well, we're not sure about the story, but according to Nash, you should appreciate the pictures."
The doctor rolled his eyes. "Listen, children; if you think I have clinic just to run some sort of fetishist pornography outfit, I have news for you. Normal vitals?"
"MA didn't get them," Cara answered.
"What? And I suppose," he turned to Nash, "Timmy didn't think to get them when he saw that they weren't taken?"
Shaking heads all round. Von Oyen sighed. He took the folder from the unresisting hands of his youngest resident.
"Seems I have to do everything around here... 'Amber Hillman, 29 F. Imaging on incidental X-ray showed high attenuation area 17 x 21 mm on adrenal gland. Suspected adrenocortical carcinoma.'" He read some more and pulled up the record of the radiology screens, rapidly flipping through different levels of brightness and pointed to the referenced abnormality for the others to see.
"Pretty rare to pick up an adrenal tumor on incidental x-ray, isn't it?"
The attending shook his head. "Not as rare as you might think, and generally far less useless than an incidental from ultrasound." He gave the folder back. "Check the questionnaire, will you? I need to see if we have any labs."
The pathology tab was empty.
"Damn... I guess we get to start from scratch."
"Questionnaire isn't very helpful. No family history. Very little medical history, period," Cara puzzled.
"Well, we will see what we can get out of her," Von Oyen said, and turned to the two male residents. "Tweedle-Dee and Tweedle-Dum here can sit this one out, since they had nothing to contribute to our discussion."
"Hey! You're just trying to keep the competition away, aren't you?" Nash rebutted.
The surgeon stood, rolling his shoulders and his eyes. "I think your definition of 'competition' is pretty loose. Certainly looser than any decent woman would be around you. Come on, Mara."
Cara stood and walked out with him, leaving a brooding pair of seventh year residents to explore their jealousy elsewhere. "It's Cara."
He slowed down enough to nudge her with an elbow. "I know. I'm just messing with you. Relax a little."
"It's pretty hard to relax around a world renowned miracle worker."
"Ahh... I'm not so different than anybody else. Exactly the same, in fact." He paused. "Only much, much better." He winked at her.
Cara blushed, taking note of the jutting cheekbones under the surgeon's beard and above an almost gaunt face. The hairs coming in were lighter, but the grey did nothing to mitigate his appeal.
He knocked and opened the door.
A startled young woman looked up at the opened door from her chair where she continued to fill out form after form about demographics, medications, and emergency contacts. She had her long, dirty-blonde hair pinned up in a peculiar style, reminiscent of the shape of a seahorse, and wore clothing that was mostly practical and covered most of her skin: a turtleneck for her top, pants under her skirt, and long gloves on her arms, though they and the almost bombastic brown color scheme only attempted to allay attention. So too did her unmarked flawless face. Calm, but sharp and dangerously angry, as if she hated the fact there was nothing to do to change its allure. She had matching piercing green eyes hidden behind glasses. In short, she was beautiful, and was doing her best to cover up the fact.
And she lashed out. Because her best was not enough. By a long shot.
"An attending so soon? I wasn't expecting you for at least another hour," she quipped.
Von Oyen regarded her coolly and almost warily extended his hand. She shook it with surprising force and stared a long while before ratcheting up the impatience written on her face. Eventually he introduced himself.
"Good morning Miss Hillman. I'm Doctor Von Oyen." He motioned to Cara who had partially hidden herself behind him. She stepped forward and shook the patient's hand. "This is Cara. She's here for eductive reasons."
"It's Missus Hillman. And I told the last one that I don't want any residents."
The surgeon looked down at the chart, frowning. "I apologize. Our information says you're single. And Mr. Nash is not representative of Cara here. She's with me and is a consummate professional. She'll be on her best behavior." He smiled.
Mrs. Hillman frowned. She fingered the ring on her left hand, and then nodded.
"I do hope that ogling me won't continue to be a part in this consultation."
He smirked. "Only insofar as it is clinically necessary, Missus Hillman."
She rolled her eyes.