Fatal Cure by Robin Cook. G. P. Putnam's Sons, New York, 1993, 477 pages, $22.95. Audio Renaissance Tapes, read by Barry Bostwick.  Four Tapes, 6 hour abridgement, 1994, $24.95.

Review by Del Meyer, MD

Robin Cook, M.D. (Medicine, Columbia; Ophthalmology, Harvard), who is currently on leave from the Massachusetts Eye & Ear Infirmary, has a new medical thriller. Cook has had an unbelievable chain of 14 best sellers since COMA in 1977 which highlighted the black market in organ transplantation. Last year's TERMINAL treated the problem of the extremes that hospitals undergo to obtain research funding. When Cook was in Sacramento in February 1993 to promote TERMINAL, he hinted that his next volume would deal with what's happening in Washington with the new administration and health care reform, and its potential problems. He points out the incentives in the past were for putting patients in the hospitals and the current incentives are to keep patients out of the hospital. He saw abuse developing. FATAL CURE also spent many months on the NY TIMES Best Sellers list.

Our protagonists, Drs. David (an internist) and Angela (a pathologist) Wilson, who have just completed their residencies, move to Bartlet for practice. David makes $41,000 working for Comprehensive Medical Vermont, (CMV) and Angela makes $82,000 working for the hospital. On his arrival David learns that his intended office partner, Dr. Portland, committed suicide. He buys a home and discovers the previous owner was a doctor from CMV who disappeared six months earlier. The hospital, which is being paid by capitation (a fixed amount per patient regardless of costs), has a Drastic Utilization Management program (DUM) to control utilization which in turn controls costs. Mrs. Beaton, the hospital president, proposed to change it to Drastic Utilization Control, (DUC). She felt DUC sounded better than DUM. The chairman of the board agreed that DUM was more appropriate. It reminded him that is was dumb to set the capitation rate so low.

Dr. David's cancer patients die in the hospital even though they are all in remission of their cancers and have been off chemotherapy for over 6 months. Two exceptions were healthy non cancer patients who died. David and Angela have a daughter Nikki with cystic fibrosis. She requires hospitalization. The hospital board becomes aware of what CF is. Actuarial costs are stated to be $20,000 per year with patients sometimes living 50 years (Projected one million dollar life time health care costs.) Then Nikki's friend, Caroline with cystic fibrosis is hospitalized and dies. David and Angela now become greatly concerned. The solving of this mystery becomes a real page turner.

I listened to the four-tape six-hour abridgement in my car before reading the book. The reader, actor Barry Bostwick, does a fine job of keeping the several voices distinct and gives good inflections and emphasis. In fact, the tape was more effective and dramatic in CMV managed care's evaluation of our protagonist, Dr. David Wilson. Everyone should listen to this tape to get the full effect of what managed care's visit to a doctor's office is like. It can be chilling. Some physicians have stated that they wished they had dropped out of pre-med and switched to political science and law school. The "Managed Care" evaluation reads as follows:

Mr. Kelley, the regional manager for CMV, interrupts Dr. David's patient schedule to inform him, "Your productivity is not satisfactory. You are in the lowest percentile in the whole CMV organization according to the number of patient visits per hour. Obviously you are spending entirely too much time with each patient. To make matters worse, you are in the highest percentile in ordering laboratory tests per patient from the CMV lab. As far as ordering consults from outside the CMV community, you're completely off the graph. And that's not all. Too many of your patients have been seen in Bartlet Community Hospital emergency room rather than in your office." "That's understandable," David said. "I"m fully booked out for two weeks plus. When someone calls with an obviously acute problem needing immediate attention I send them to the ER." "Wrong!" Kelley snapped. "You don't send patients to the ER. You see them in your office provided they're not about to croak." "What's the ER for?" David asked. "Don't try to be a wiseass with me, Dr. Wilson," Kelley said. "You know damn well what the ER is for. It's for life-and-death emergencies. And that reminds me. Don't suggest that your patients call an ambulance. CMV will not pay for an ambulance unless there is pre-approval and pre-approval is only granted in cases that are truly life-threatening. CMV doesn't operate a bus service. All this is pretty simple. Let me spell it out for you. You must seriously increase your productivity, you must lower your use of laboratory tests drastically, and you must reduce, or better yet stop, using consults outside the CMV family, and you must keep your patients out of the ER. That's all there is to it. Understand?"

Dr. Cook dedicates this book to the "spirit of health care reform and the sanctity of the doctor-patient relationship. It is my fervent hope that they need not be mutually exclusive."

I'm sure many of us feel the happenings in this book are "far out" and others will feel that these things could really happen. I would think we could all suspend our disbelief and enjoy the narrative, whether the tape in our car or the book at our bedside table or our favorite chair. Sometimes it takes the improbable to understand the possible.