SUTTON’S LAW by Jane M Orient, MD, and Linda J Wright. Hacienda Publishing, Macon, Georgia, 1997, 299 pages, $22

Review by Del Meyer, MD

I first learned of Sutton's Law from my pulmonary professor Bob Green at the University of Michigan. When he was drilling a student or intern on the diagnosis of a chest x-ray, he frequently emphasized the obvious by referring to Willie Sutton's response as to why he kept robbing banks. "Isn't that where the money is?" Since Sutton's Law is a novel about For-Profit HMOs and managed care, are we led to believe that the bank robbing heists of today take place in health care? So that's "where the money is"--well, maybe not for doctors.

Dr Orient, Executive Director of the Association of American Physicians and Surgeons, is an Internist who has written Your Doctor Is Not In (Reviewed in Sacramento Medicine April 1995). Sutton's Law is her first delving into the medical suspense arena with co-writer Linda Wright, the author of the award-winning Caitlin Reece mystery series.

The novel starts in the ER (Isn't that "where the money is" even on TV?) of the former "Woodlands Hospital" which is now the "Texas University Regional Preventive Health Center" called TURPH for short. Dr Maggie Altman, a new Intern on her first day as a doctor, has a patient in pulmonary edema. After an injection of Lasix, she asks for a bed. Her request is interrupted by Dr Brent Stemmons, a resident, who asks her to bring all her questions to him. She starts to present the patient when she is again interrupted by Stemmons who is checking out the history online. "You see I already know more about your patient than you do. Problem 1 is noncompliance. Problem 2 is living arrangements. He has CHF, hypertension, COPD, and DM. Last admitted 3 weeks ago, discharged 13 days ago." Stemmons looked up. "CHF. Probably from failure to take his medicine or maybe an overdose of peanuts and pickles." Then scrolling to the main menu: "EQUACARE CRITERIA FOR ADMISSION TO AN ACUTE CARE FACILITY," he announces the patient is not a "keeper." "This is a chronic condition. We need to optimize his out-patient management. Just double the Lasix and see your next patient."

The next patient had been resuscitated in the field. At TURPH, a transthoracic pacemaker is placed, and the patient is admitted. Maggie finds that Stemmons has already punched the data in the computer, given him DRG 174, GI hemorrhage, severity 4, and complications and pronounced him a "winner." When Maggie questions his response, Stemmons says, "He has a rhythm, therefore, he's alive enough to count as an admission. The only good admission is a dead admission." This confuses our first day intern even more.

Confusion turns to high alert as the week progresses and our intern finds the computer history doesn't always fit her patient. She then finds old charts dumped beneath a dumbwaiter. ABG reports do not match the ones on the computer screen. Then one of her patients disappears. Willie Sutton used his gun to get the money "from where it is." As Altman tries to figure out who would do the same to keep the managed care money flowing into the right pockets, the title of the novel becomes ingenious.

But doctors don't need guns--there are other means with which to make almost any death look like an accident--whether to optimize patient care income or dispose of someone who knows too much. When Dr Altman suffers coffee ground emesis one evening, she's brought to TURPH, and becomes an easy target for foul play. The doctor in charge of the HMO Equacare pays a mysterious visit, and Dr Altman continues to have bright red blood in her NG tube. When a professor comes by and notices the blood doesn't clot, he gets protamine from the pharmacy and saves Dr Altman's life. He doesn't leave her side until she's stable, and then personally transports her to a horse ranch and gives her care safely away from the lethal HMO hospital.

While the professor is away, Dr Altman calls her fellow intern to come and get her and she returns to work. She wants to determine who poured the heparin into her while her ulcer was bleeding faster than blood could be pumped. She also needs to figure out if doctors have become villains. As Altman views the white coats, she wonders if she can pick the right one?

Sutton's Law is a well-written informed take on contemporary complexities of medical practice and management, HMO priorities, hospital finances, and how doctors are subverted "to get the money in," and suggests some of the dangers of our computer reliance, especially as other forces influence our decisions. Is this fiction? Remember healthcare fiction is 90% nonfiction, but is called fiction by the author's attorneys to prevent liability suits.

Del Meyer, MD