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This book is dedicated to the democratization of medicine. PROLOGUE T he insulin molecules invaded like a miniature marauding army. Rapidly infiltrating the veins, they rushed headlong into the heart, to be pumped out through the arteries. Within seconds the invasion spread throughout the body, latching on to receptors on the cell membranes and causing the cellular gates for glucose to open. Instantly glucose poured into all the cells of the body, resulting in a precipitous fall of the glucose level in the bloodstream. The first cells to be adversely affected by this were the nerve cells, which cannot store glucose and need a highly regulated, constant supply of the sugar to function. As minutes passed and the insulin onslaught continued, the neurons, particularly those of the brain, rapidly became starved of their lifeblood glucose and their function began to falter. Soon they began either to send errant messages or to send none at all. Then they began to die. . . . WESTWOOD, LOS ANGELES, CALIFORNIA MONDAY, APRIL 7, 2014, 2:35 A.M. Kasey Lynch lurched awake. The nightmare had been a bad one, filled with progressing anxiety and terror. She was disoriented, wondering where she was. Then she remembered; she was sleeping in the apartment of her fiancé, Dr. George Wilson. She'd been staying at George's place two or three times a week for the past month, whenever he wasn't on call as a third-year radiology resident at the L.A. University Medical Center. He was sleeping next to her now. She could hear his soft, rhythmic, slumber-infused breathing. *   *   * Kasey was a graduate student specializing in child psychology at L.A. University, and for the past year she'd been volunteering in the pediatric department at the medical center. It was there that she met George. When she brought her pediatric patients into the radiology department for imaging studies, she immediately took note of George's easy confidence and his way with patients, particularly children. The handsome face and crooked smile didn't hurt, either. He was warm and personable, qualities she liked to think were part of her own personality. Just a mere four weeks before, they'd become engaged, although they still hadn't set a specific date for the wedding. The proposal was a pleasant surprise, perhaps because of her careful nature in all things "permanent," due to the reality of her health issues. But both she and George had been smitten, and they joked that the rapidity of their relationship was because they'd been unknowingly searching for each other for years. But Kasey was not thinking any of this at 2:35 in the morning. Instead she knew instantly upon waking that something was wrong, very wrong! This was far worse than just a bad nightmare, especially because she was sopping wet with sweat. Having had type 1 diabetes since she was a child, she knew all too well what it was: hypoglycemia. Her blood sugar was low. She had experienced it on a number of occasions in the past and knew she needed sugar, and needed it fast. Kasey started to get up, but the room began to spin. Her head flopped back against the pillow as a brief overwhelming dizziness engulfed her and her heart pounded rapidly. Her hand groped for her cell phone. She was always careful to have it within reach and had left it charging on the bedside table. Her thought was that she would speak with her new doctor for reassurance while she ran to the kitchen to get some orange juice. The new physician was incredible, available even at this hour. As her dizziness lessened she sensed this episode was worse than usual, probably because she had been asleep, giving the problem a chance to progress much further than it would have had she been awake and able to recognize the earliest symptoms. She always kept some fruit juice on hand for just this kind of an emergency, but she had to get it. She tried again to get up, but she couldn't. The symptoms were progressing with horrifying rapidity, draining the strength from her body. Within seconds she was helpless. She couldn't even hold on to her phone. It slipped from her fingers and landed on the carpet with a dull thud. Kasey quickly realized she needed help and tried to reach over to wake George, but her right arm seemed to weigh a ton. She couldn't even lift it off the bed, much less across her body. George was lying so close, but facing away from her, completely unaware of her swiftly deepening crisis. Using all her energy, she tried again, this time with her left arm; all she could manage was to extend her fingers slightly. She tried to call his name, but no sound came out. Then the dizziness came back with a vengeance, even worse than it had been moments earlier. Her heart continued to pound as she struggled to suck air into her mouth. It was getting harder and harder to breathe; she was being progressively paralyzed and suffocating as a consequence. At that point the room started to spin faster, and there was ringing in her ears. The sound kept growing louder as darkness descended around her like a smothering blanket. She couldn't move, she couldn't breathe, she couldn't think . . . *   *   * George's smartphone alarm went off a little after 6:00 A.M., rousing him from a peaceful sleep. He quickly turned off the alarm and slipped out of bed intent on not disturbing Kasey. It was their routine. He wanted her to sleep to the last possible moment, since she frequently had trouble falling asleep. He padded over to the bathroom, taking his phone with him. As with most people nowadays, the device never left his side. Ensconced in the tiny room, he showered and shaved in just under his usual ten minutes. He was proud of his self-discipline; it had served him well throughout his seven years as a medical student and resident--a grueling endurance race in which "survival of the fittest" was much more than just an abstract turn of phrase. Six twenty A.M.! Time to wake Kasey. He opened the bathroom door while briskly drying his hair and noticed that her eyes were open, staring up at the ceiling. That was unusual. Kasey was a heavy sleeper; it often required several attempts to rouse her. "Been awake long?" George called, still drying his hair with his bath towel. No response. George shrugged and went back into the bathroom to brush his teeth, leaving the door ajar. He wasn't surprised that Kasey was in a kind of trance; he'd seen it before. When she was really concentrating on something, she had a tendency to zone out. Over the past couple of weeks she'd been consumed in a struggle to come up with a topic for her PhD thesis. So far she hadn't been successful. They'd just had a long talk about it last night before George had nodded off to sleep. He walked back to the bedroom. Kasey hadn't moved a muscle. Odd. He approached the bed, still brushing his teeth, trying to keep from drooling on himself. "Kasey?" He half gurgled. "Still worried about the thesis?" Again, there was no response. She was staring upward, unblinking, with what looked like dilated pupils. A shiver of fear shot down George's spine. Something was wrong; something was terribly wrong! She was much too still. Panicked, George yanked his toothbrush out of his mouth and bent over the bed. Was she having a seizure? "Kasey! Can you hear me? Wake up!" He grabbed her shoulders and gave her a firm shake, sensing an abnormal stiffness in her body. That was when he realized she wasn't breathing! "Kasey, honey! Please, please, God . . ." George leaped onto the bed, searching for a pulse in Kasey's neck. The coldness of her skin unnerved him. He fought back a growing dread as he tore back the covers to start CPR. On the very first attempt, he sensed an unusual resistance and noticed her eyes were not just open, they were frozen that way. "My God . . . Kasey!" George shrunk back in horror. She was going into rigor mortis. She was dead! His fiancée--his world--had died during the night and he, a doctor no less, had slept right through it! George collapsed onto the floor, his back against the wall, and wept. It was twenty minutes before he could manage to call 911. 1 NEARLY THREE MONTHS LATER L.A. UNIVERSITY MEDICAL CENTER WESTWOOD, LOS ANGELES, CALIFORNIA MONDAY, JUNE 30, 2014, 8:35 A.M. It was George's last day as a third-year radiology resident at L.A. University Medical Center. Tomorrow would mark the beginning of his fourth and final year in the hospital's residency program, and then he could start making some real money. After all his years of medical training and two hundred thousand plus dollars' worth of debt, the light at the end of the tunnel was finally visible. His focus on moneymaking was his way of surviving the devastating loss of the woman he loved, the only woman he had really loved. Although he knew it wasn't exactly the healthiest way to begin the healing, it was all he could come up with at the moment. Getting paid, and paid well, would at least be a vindication that all his years of education had been well spent, and he could begin to pay back the money he owed. At least his professional life was on track. Over the past three grueling months, George had pretended an amenable camaraderie with his coworkers, but the truth was that he had become a hermit. Anyone who tried to dig under the genial surface scraped up against a strongbox in which he kept his feelings. It was what held his demons at bay, or so he had thought. Actually he knew that he was going back on a sacred promise he had made to Kasey. When he had asked her to marry him, she had demurred, saying that it was unfair for him to tie himself down with someone with substantial medical issues. To George's consternation, she had been extremely serious and had agreed to marry him only when he had finally said that if something were to happen to her, he would not shut himself off from his friends and would ultimately find another relationship. Kasey had even made him give her a written statement to that effect. George sighed. He was exhausted. The previous night he had not been able to fall asleep until almost morning, overcome with guilt at having broken his promise and for the greater guilt at having slept through her death. He would never know if she had suffered or if she had died in her sleep. That was a question that would haunt him for the rest of his life. It kept him from sleeping well since her death, and his insomnia was getting worse. He looked at his watch. It was 8:35 in the morning. George was in the MRI unit, supervising second-year resident Claudine Boucher. The radiology department in general and the MRI unit in particular were large revenue generators, and their reward from the administration was an excellent location on the center's ground floor immediately adjacent to the emergency department. Claudine had been on her current rotation under George's tutelage for the past month, and at this point George's presence was superfluous. George was sitting off to the side, glancing through a radiology journal. Every so often he'd look up at the monitor as the computer generated image slices. He was too far away to see any detail, but all seemed in order. He continued sipping on a cup of his favorite Costa Rican coffee. He loved coffee. The taste. The smell. Its stimulative and euphoric effect. But he was highly susceptible to caffeine; his body didn't seem to metabolize it like those of other people. One cup in the morning was his limit. Otherwise, he would be bouncing off the walls into the early-morning hours with a crash-down throbbing headache rounding out the ride. In his present state of mind, indulging himself with even one cup was life on the edge. But George didn't mind since he felt as if he had already fallen off. A large thermo-paned window let the doctors see into the adjacent room, where the enormous MRI machine did its work. Only the legs of the current patient were visible as they protruded from the multimillion-dollar testament to advanced technology. A highly efficient radiology technician, Susan Fournier, was monitoring the progress of the scan. All was going smoothly. Claudine was seated next to Susan, looking at the horizontal slices of the liver as they appeared. Except for the muffled clunks of the machine coming through the insulated wall, the room was quiet. Inside the MRI room itself, the noise level was horrendous, requiring the patient to wear earplugs. The patient, Greg Tarkington, was a highly successful forty-eight-year-old hedge fund manager. All three of the medical professionals in the room were aware of this patient's history of pancreatic cancer. They were also well acquainted with the details of the extensive surgeries and chemotherapy he had undergone. The surgeries had made the man diabetic, while the side effects of the chemo had caused his kidneys to fail temporarily. At present, he was relying on dialysis to stay alive. Tarkington's referring physician, an oncologist, was particularly concerned with making sure the liver was normal. "How's it look?" George asked, breaking the silence. "Good to me," Susan responded softly. Even though there was no chance the patient could hear, the doctors and technicians tended to whisper when a procedure was under way. "To me, too," Claudine said, turning to George. "Take a peek?" George heaved himself to his feet and stepped closer to the monitor. He took his time, staring in silence as the images emerged. Susan was rerunning the film starting at the base of the liver and moving cephalically, or toward the head. "Stop there," George suddenly ordered. "Freeze it." The technician paused the frame as instructed. "Let me see the previous slice," George said, leaning in for a better look. Most people, George included when he had first started, thought radiology was a hard science, meaning the sought-after lesion was either there or not there, but over the previous three years George had learned differently. There was a lot of room for interpretation, especially with small irregularities. George sensed something abnormal in the image, just to the right of center. He rubbed his eyes and looked again. "Give me the slice one centimeter lower!" He studied the requested image and suddenly he was sure. There were two small irregularities present. "Go back to the original image you had up, the one that's still being formed." "Coming up," the technician responded. The irregularities were in this image, too. George took a laser pointer from the pocket of his white coat and lit up the irregularities. "That doesn't look good," he said. Claudine and the technician studied the frame. Out of the various shades of gray they could now see the two lesions. "My goodness," Claudine said. "You are right." "It's pretty damn subtle," Susan said. George stepped over to a hospital computer monitor and called up Tarkington's previous MRI, quickly locating slices from the same location in the liver. They had been normal. The lesions were new. George paused a moment to think about what that could mean. On one level, their discovery meant George was doing his job well. But to the anxious man in the adjacent room with his head stuffed into a 3.0-tesla-strength magnet--a magnetic field 60,000 times the strength of the Earth's--it meant something quite different. The incongruity of such a situation never failed to discomfit George. It also brought up his raw emotions about Kasey's sudden death. The image of her face in its mask of death--its frozen pallor, the staring eyes, the dilated pupils--confronted him. "You okay?" Claudine asked, eyeing him. "Yeah. Fine. Thanks." But he wasn't. Burying a problem only made it fester. The clarity with which Kasey's death face appeared in his mind's eye scared him. In the wake of her death he had discovered she'd just been diagnosed with very aggressive stage-four, grade-three ovarian cancer found by a CT scan she'd had at Santa Monica University Hospital. The test had been performed on the Friday before her death, which was early on a Monday morning, so she hadn't even been told yet. Since the hospital was a sister hospital to George's, he had used his resident's access code to view the study. It had been a violation of HIPAA regulations, but at the time he couldn't help himself. He was lucky he hadn't been prosecuted, due to the circumstances, yet he had been worried. "Let's finish the study," George said, shaking himself free of his disturbing thoughts. "There's only fourteen minutes to go," Susan said. Returning to his chair, George forced himself to go back to flipping through the radiology journal, trying not to think. For a time no one talked. No other abnormalities were found besides the two small lesions, which were undoubtedly tumors, but the implications of that finding hung like a miasma over the control room. "I'm afraid," Claudine said, breaking the silence and giving voice to what they were all thinking, "that, with the patient's history, the lesions are most likely metastases of the patient's original pancreatic tumor." George nodded, and said churlishly, mostly to Claudine, "Okay, now, quick reminder: We do not say or indicate in any manner anything to the patient, beyond mentioning that the test went well, which it did. The material will be read by the senior radiology attending, and a report will be sent to the patient's oncologist and primary-care doctor. Any 'informing' will be done by them. Understood?" Claudine nodded. She certainly understood, but the admonishment and its tone came across harsher than George had intended and created an uncomfortable silence. Susan looked down, busying herself by arranging her paperwork just so. George realized how he sounded and launched into a little damage control. "I'm sorry. That was uncalled-for. You're doing a great job, Claudine. Not just today, but in your whole month of rotation." He meant it, too. Claudine relaxed visibly and even smiled. George sighed as the previous awkwardness dissolved. He needed to get a grip on himself. "What's our schedule for the rest of the day?" he asked. Claudine consulted her iPad. "Two more MRIs. One at eleven, the other at one thirty. Then, of course, whatever comes in from emergency." "Any trouble with the two scheduled MRIs, you think?" "No. Why?" "I have to step out for two or three hours. I want to go to a conference over in Century City. Amalgamated Healthcare, the insurance giant and our hospital's new owner, has a presentation planned for would-be investors. It's something about a new solution they have come up with to end the shortage of primary-care physicians. Can you imagine: a health insurance company solving the primary-care shortage? What a stretch." "Oh, sure! An insurance company solution to the lack of primary-care physicians," Claudine mocked skeptically. "Now, that sounds like a fantasy if I ever heard one, especially with Obamacare adding thirty million previously uninsured into a system that was already functioning poorly." "You sure the presentation isn't being held down at Disneyland?" Susan said as she prepared to go into the imaging room to see to the patient, who at the moment was being slid out of the MRI machine by an attendant. "Might as well be," George said. Even though they were making light of the situation, it was a serious issue. "I'm really curious what they are going to say. It would take a decade, at the very least, to train enough doctors to fill the gap, provided they can talk doctors into practicing primary care, which isn't a given. Anyway, I'd like to go hear what they have to say, if you don't have any problem." "Me?" Claudine asked. She shook her head. "I don't have a problem. Knock yourself out!" "Are you sure?" "Very sure." "Okay. Text me if you need me. I can make it back in about fifteen minutes if I'm needed." "No prob," Claudine said. "Gotcha covered." "We'll review them when I get back." He paused. "You sure you're okay with this--my leaving?" "Yes, of course. I'll be working with Susan again. She doesn't need either one of us." Susan grinned at the compliment. "Okay, great. Let's all go in and talk with the patient," George said, motioning them toward the door. They put on game faces and entered the imaging chamber. Tarkington was sitting on the edge of the bed, smiling nervously. He was obviously eager for some positive feedback. The doctors were all careful not to divulge the bad news, knowing that it would most likely mean more chemotherapy, despite the man's tenuous kidney function. Claudine spoke as reassuringly as she could while George and Susan nodded. Then, as the attendant and Susan got the patient onto his feet, George and Claudine retreated back to the safety of the control room. Talking with a patient destined to receive very bad news underlined the fragility of life. There was no way to be detached about it. "That sucked," Claudine said, sinking into a chair. "I hate not being forthright and honest. I didn't think that was going to be part of being a doctor." "You'll get over it," George said with a casualness he didn't feel. She looked at him, stunned. "I didn't mean it like that. But you will get over it." George didn't know why he had just said that. He hadn't gotten over anything of the sort. He hedged a little. "To some degree, anyway. You have to, or you won't be able to do your job. It's not the 'not being honest' part that bothers me as much as the shitty situation itself. We just had a conversation with a very nice man in the prime of his life, with a family, who will in all likelihood soon die. That will always suck." George busied himself with the files of the upcoming cases so as to not have to look directly at Claudine. "But you have to compartmentalize your feelings so you can continue to do your job, which will help save the lives of those who can be helped." She looked at him. George sensed her gaze and felt bad. Repeated exposure to such cases had not deadened his own feelings. He looked up at her. "Look . . . ," he said, searching for the right words. "It's part of why I went into radiology. So there would be a buffer between me and the patient. I figured if I could deal with the images rather than the patient, I would be better equipped to handle my job." He motioned to the adjacent room, where they had just left Tarkington. "But as you can see, the buffer has holes in it." They both sat silent for a moment, then George moved to the door. "Well, I have to get a move on--" "Me, too," Claudine said softly. George looked at her quizzically: Me, too, what? "It's why I went into radiology. And thanks . . . for the honesty." George gave her a melancholy smile and left the room. 2 CENTURY PLAZA HOTEL CENTURY CITY, LOS ANGELES, CALIFORNIA MONDAY, JUNE 30, 2014, 9:51 A.M. As George walked into the presentation, he felt like a fish out of water. It was obvious to him that the event was primarily for prospective investors in Amalgamated Healthcare. The room was filled with "people of resources." In other words, people unlike him. George was immediately struck by their custom-tailored business suits, four-hundred-dollar haircuts, and general air of superiority. He was aware that Amalgamated had recently acquired a number of health care companies and hospitals, including the medical center where he worked. The prospect of offering health insurance on a national scale rather than on a state-by-state basis had been part of their acquisition strategy. George assumed the company had thoroughly combed through the 2,700-plus pages of the Affordable Care Act--aka Obamacare--determined to exploit all of the changes mandating health insurance for everyone. George pushed through the crowd at the back of the room, thankful he had left his white coat back at the hospital. As it was, he wouldn't have been surprised if someone attempted to order him out, thinking he was crashing the party. As he walked down one of the aisles, someone handed him a fancy prospectus filled with spreadsheets and financial data. He felt a rush of déjà vu. It was as if he were glimpsing an alternative life he had turned his back on. When he first walked into Columbia University as an undergraduate all those years before, he had already narrowed down his career choices to going either into business or to medical school. By the end of his first year he had veered toward medicine, a choice Kasey had made him come to understand. Had he taken the alternative, he would have felt at home here. This could have been his life. He might even have some money in the bank rather than a mountain of debt. He tried to shut off such thinking; that was another life, another world, another dream. He forced himself to focus on the moment. There was seating for several hundred people in the room. He noticed several IT barons representing Apple, Oracle, Google, and Microsoft, along with a few well-known hedge fund guys in a reserved section at the front. George frequently watched CNBC while on the treadmill, so he recognized some of the players. The gathering here was like the Fortune 500 version of an Oscar party. Attendees were being served refreshments by a flock of extremely tall and gorgeous young women in futuristic white uniforms. On the dais at the front of the room were four stainless-steel-and-white-Ultrasuede modern club chairs. Expensive-looking, even from a distance, each one probably worth more than George's car. Directly behind the stage was an enormous LED screen with two other equally sized screens on either side, at forty-five-degree angles. Amalgamated Healthcare was spelled on each in bold black letters. The room itself also was mostly white, with row upon row of padded Ultrasuede seats with folded writing arms. Also white, of course. George was impressed, making him wonder if the presentation had been arranged by the same consultants who handled the iPhone and iPad product releases for Apple. George took a seat in the very last row and waited. At exactly ten o'clock the room lights dimmed, and four people appeared on the speakers' platform: three men and one woman. At the same time, a choral group, reminding George of Celtic pop music, could be heard very faintly from hidden speakers, giving the event an ethereal atmosphere. George's eyes were drawn to the woman. He recognized her immediately. Her name was Paula Stonebrenner, and it was because of her that he'd been invited to this presentation. Paula was dressed in a smart business suit, with just enough white ruffles around her neck to broadcast her femininity. She was attractive in a classic, Ivy League fashion. Paula had been George's classmate at Columbia Medical School, and he had gotten to know her reasonably well back then. "Reasonably well," as in they hooked up once or twice. They had been attracted to each other in the first weeks of medical school and ended up going out for drinks with some other new friends, and one thing led to another. "Another" being the roof of Bard Hall, the medical school dorm at Columbia. George still considered it the most risqué sexual episode of his life. After the initial sparks George's interest abruptly waned when he discovered another Columbia classmate, Pia Grazdani. Pia was dark, exotic, and an off-the-charts gorgeous mix of Italian and Albanian heritage. Her mere presence swept him off his feet. Her aloof manner captivated him. And her callousness stomped on his heart. She resisted any and all attempts at friendship, let alone romance. Throughout high school and college George had never had trouble getting women to go out with him. He had an outgoing personality and was a starter on all the right sports teams. He was used to being the one to call the shots. Not so with Pia. Prior to Pia, George had been one to avoid commitment. He would rationalize his quick departure from relationships as his version of "compassion," likening his exit to a girl getting stung by a bee. It hurt briefly but was quickly forgotten. And it wasn't like he was being selfish--all through high school and college his desire to succeed, whether as a doctor or businessman, had taken precedence over social attachment, which for him had been more about entertainment than an opportunity for self-learning. George understood all this now, even though he hadn't in the past. And again, it was all because of Kasey and her unique understanding of interpersonal relationships. She had a natural intuition about people that had drawn George to her like a hungry mouse to cheese. Kasey was the first woman who had become a best friend and confidante to George before becoming a lover. It had been a revelation for George, a kind of rebirth that made him understand what he had been missing. Today George had to admit that Paula looked fantastic. He also had to admit that he really didn't know anything about her other than she was smart as a whip, fun to be with, and what he used to call a "live wire." After being essentially dumped for Pia, Paula had acted the part of spurned lover. She wouldn't even talk to George for the rest of that year. But by the second year, she didn't seem to care. They happened to live in adjacent dorm rooms and had a hard time ignoring each other anyway. By their final year they were friends, or at least friendly acquaintances. For a moment George entertained the idea of walking down to the dais and saying hello to Paula, but then chickened out. Instead he watched with growing fascination as she interacted comfortably with the three men on the stage and with some of the financial VIPs in the reserved section at the front. She took a seat in one of the club chairs with two of the accompanying men. The third man stepped forward to speak. From George's perspective he was extremely impressive. He was meticulously dressed, standing ramrod straight with a commanding, almost military presence. His graying hair literally sparkled in the glare of the halogen spotlights. On the huge LED screen behind him appeared his name: Bradley Thorn, Amalgamated's president and CEO. "Welcome!" Thorn boomed with a broad smile. Without a visible microphone, his voice filled the large room. George wasn't surprised. Everything was wireless these days. Conversation hushed. People who had not yet found a place now rushed for a chair. George glanced back at Paula as well as the other two men seated beside her. With sudden shock George recognized one of them, and scrunched down in his seat, as if that would keep him from being seen. His pulse picked up. "Oh, shit," he murmured. 3 CENTURY PLAZA HOTEL CENTURY CITY, LOS ANGELES, CALIFORNIA MONDAY, JUNE 30, 2014, 10:02 A.M. Sitting on the stage was the internationally known radiologist Dr. Clayton Hanson. He was also the chair of the residency training program at L.A. University Medical Center, someone George happened to know quite well, better than any of the other professors and attendings. He was essentially George's boss, and George was currently playing hooky. The reason they knew each other well was because, besides being George's superior, Clayton considered himself to be a lothario (the man was not without ego), and he had hit on Kasey even when he knew she and George were an item, although that was before the engagement. The year before George arrived on the scene, Clayton had divorced a fading actress after twelve years of a dysfunctional marriage and was intent on making up for lost time. George had heard rumors that Clayton's frequent transgressions had been a significant factor in his former wife's decision to seek the divorce. As George was one of the few unmarried residents, Clayton had initially sought him out for hints on how to meet some of the young fillies (Clayton's word) that he assumed George would be privy to. That had never come to pass, but over time Clayton and George had established a friendship of sorts that for the most part had evolved into Clayton's trying to fix George up with the women so that he, Clayton, could meet their friends. George's immediate problem was that before coming to the presentation he hadn't bothered to get permission to leave the hospital, so he was AWOL with one of the radiology bigwigs onstage in front of him. Even though it was his last day of an easy rotation, and he had covered himself, he felt uncomfortable. He considered getting up and walking out but decided doing so would call more attention to him than just remaining in his seat. Luckily he was a good distance from the dais, and Clayton showed no sign of having spotted his resident. George took a deep, calming breath and directed his attention back to Paula. She certainly did look terrific and impressively "together." He found himself regretting that he hadn't followed up with her back in medical school and wondered if reviving an acquaintance with her would fulfill his promise to Kasey. George's musings were interrupted by Thorn launching into a slick presentation of Amalgamated Healthcare's spectacular growth. He explained that the company was positioned to take full advantage of the Affordable Care Act, something most other insurance companies thought impossible, given the law's restrictions on profit, but he and his inordinately competent team had figured out a way and were leading the charge. All they needed was an infusion of more capital to continue their spectacular expansion. "The politicians, whether they meant to or not, have put the health insurance industry in the driver's seat to manage what will more than likely balloon to nearly twenty percent of the United States' GDP," Thorn continued. "Most of us know deep down that they should have passed a kind of Medicare for everyone. But they didn't have the courage. Instead they have handed the keys to us on a silver platter. This is an unprecedented opportunity, particularly in view of what you're going to learn today. The world, not just the United States, is on the cusp of a paradigm shift in medical care as the profession is dragged kicking and screaming into the digital age. And we, Amalgamated, are going to be leading it." George felt a jolt of electricity surge through his body. Thorn had hit a nerve. Over the last several years, George had become vaguely uneasy about what was happening in medicine in general and in the specialty of radiology in particular. There were somewhat fewer positions available and salaries were heading south. It wasn't an overwhelming change but nonetheless noticeable. Consequently Thorn's words were jarring, giving substance to a nebulous yet vexing fear that he was entering the medical profession after it had passed its zenith. "Our country," Thorn continued, "is going to experience a democratization of medicine that is going to catch the medical profession by surprise, but not Amalgamated. Already the general public's main source of medical information is not doctors, as it's been for a number of centuries: it is the Internet and social media. To illustrate my point, compare the medical profession as you know it today to another industry, dominated by the iconic Eastman Kodak Company. Kodak thought it was in the film business rather than the image business." He paused. "We all know how well that went." The audience laughed. Kodak had filed for bankruptcy in 2012. "The medical profession thinks it's in the sickness business. It is not. It is in the health business. Preserving and maintaining health and preventing disease are the future of medicine, not treatment in the form of ever more drugs and procedures. And I'm not talking about prevention in a passive sense. I'm talking about prevention as an active process, but not wasteful, like yearly physicals and full-body CT scans. And when treatment is needed, it will be directed for the individual, not some imaginary person representing the statistical mean. "This is important, because a third of the almost four hundred billion dollars the public pays the pharmaceutical industry is totally wasted. That's one hundred thirty billion dollars going down the drain. The drugs involved often have no positive effect on a specific individual. If a drug trial showed that it only helps five percent of patients, that means it doesn't help ninety-five percent, even though side effects are pretty close to one hundred percent. Bad odds! "We at Amalgamated don't want to waste money on useless drugs and dangerous procedures. We want to treat the individual, not a statistical construct. How will this come to pass? Through this app!" Thorn waved toward the LED screens behind him as if he were a conductor of a symphony orchestra. Coinciding with his gesture were the first thirty seconds of Beethoven's Fifth Symphony. Simultaneously the word iDoc flashed onto the screens in foot-high bold black letters. After pausing for effect, Thorn turned back toward the audience: "A glowing example of the failure of current medicine is the fact that the shortage of primary-care physicians has never been solved. As a result, there are too many unnecessary and expensive visits to emergency rooms, too many specialists seeing patients who don't need to be seen by them, too many procedures on patients who don't need them, and too many patients being prescribed unneeded drugs. All of which means a massive number of unnecessary, wasteful payouts . Well, my friends, all that is going to change; there's a new doctor in town! The twenty-first century's primary-care physician is an FDA conditionally approved smartphone app, and its name is iDoc!" Thorn again gestured toward the giant LED screens as the images of three smartphones made by the world's largest manufacturers--Apple, Samsung, and Nokia--flashed. The phones displayed a single app: a white square containing a red cross with iDoc spelled out along the horizontal arm. George caught his breath from another jolt. He'd seen the icon before. "iDoc and its incorporation into the smartphone application platform is a result of our close working relationships with leading smartphone manufacturers and developers. The end result is a marvelous convergence of the Internet, mobile phone technology, quantum cloud computing with our state-of-the-art D-Wave quantum supercomputer, social networking, digital medical genomics, wireless biosensors, and advanced imaging. iDoc will be the doctor of tomorrow, and we have it today! "We've licensed the distinctive symbol of the International Red Cross, as we felt it imperative to use a universally recognized icon. Amalgamated Healthcare will also be making an additional donation to the organization with each download of the iDoc app. And we're not stopping there. Amalgamated will mimic the Affordable Care Act in--what else?--affordability! Enrollees with incomes of up to four hundred percent above the poverty line will either have their smartphones subsidized or given out free. Regular phone plans will stay in effect for enrollees, but data plans will be converted to unlimited. Our subsidization of the data plans will again mimic that of the ACA. All data generated by the app will be stored on our cloud services, enabling an acceptable baseline phone configuration of three-G capability with a minimum of thirty-two GB of memory. Any current enrollees who now fall below those smartphone specifications will be upgraded at our expense." Now George felt a chill descend his spine. He had the distinct feeling he was witnessing history in the making. With the idea of a smartphone functioning as a primary-care physician, something he had thought about in the past, he was in shock. His mental association of the Amalgamated Healthcare presentation with one of Apple's product releases was magnified. This was a big deal. He was also amazed that Amalgamated would be able to absorb all these costs and still have a profitable business plan. What was he missing? 4 CENTURY PLAZA HOTEL CENTURY CITY, LOS ANGELES, CALIFORNIA MONDAY, JUNE 30, 2014, 10:14 A.M. George glanced around the room at the other attendees. No one spoke. No one coughed. No one moved. The only sound was that of the faint Celtic choir in the background. George redirected his gaze toward the dais. Thorn was still twisted around, staring up at images of the smartphones like a proud father. When he turned back the crowd burst into applause. "Hold your excitement," Thorn said. "There's more. Shortly you are going to hear brief presentations from our three other speakers this morning. First will be Dr. Paula Stonebrenner." He gestured toward Paula, and George looked over at her. She stood briefly and nodded to the audience. If she was nervous, it didn't show. There was a smattering of applause. Thorn continued. "Dr. Stonebrenner, I know, doesn't look old enough to be an MD, but I assure you that she is. She will be giving a very short overview of iDoc and its capabilities. She is the best person for this task, as she is the individual who gets the credit for the idea of a smartphone functioning as a twenty-first-century primary-care physician. There have been multiple apps for smartphones configured to do various and sundry medical functions, but it was Dr. Stonebrenner who came up with the brilliant concept of putting them all together in a purposeful algorithm to create a true ersatz physician on duty twenty-four-seven for a particular individual, truly personalized medicine." "Holy shit!" George whispered to himself. He felt a surge of color suffusing his face. He couldn't believe what he'd just heard and didn't know whether to be angry or flattered. Suddenly George realized why Paula had invited him to the presentation. They'd had a conversation about this years before. She hadn't come up with the concept. She'd gotten the idea for a smartphone primary-care physician from him! When George had first come out to L.A. for his residency, he'd known that Paula was coming, too, not for a residency but rather for a job with Amalgamated Healthcare. They'd talked about being in the same city before graduation. She'd been in the MD-MBA program during medical school, a fact that they'd argued about on occasion. It had been George's opinion that she shouldn't have taken a slot to become an MD if she had no intention of ever practicing medicine. There were too many people who really wanted to be doctors who couldn't get a spot in medical school, and that was leading to a shortage of primary-care doctors. Paula, of course, had seen the issue differently. It had been her contention that the business of medicine was so important there had to be people who understood all sides of it. Neither convinced the other. When George arrived in L.A. he tried to contact Paula a few times, but she never returned his calls. He didn't have her home number or address, so he'd only left messages at Amalgamated's main number. He never knew if she got them or not. But then, after an emotionally draining trip back home for Thanksgiving 2011, he made a more determined effort to track her down. His mother, Harriet, had died unexpectedly while he was home and, coming back to L.A., he had never felt more alone. He hadn't been particularly close to his mother, but watching her die was one of the most painful episodes of his life. George's father had died when he was three and his mother remarried when George was four, but George never got along with his stepfather. On top of that, his stepfather had a son three years older than George. Then his mother and his stepfather had a daughter, and George ended up the odd man out, spending his high school years living with his grandmother, with whom he had a close relationship. During medical school his stepfather died, and his mother developed a series of health issues from smoking and obesity, which turned out to be deadly just four days short of her sixty-seventh birthday. The day had started out routinely, but by early afternoon Harriet began wheezing and then developed chest pain. When George suggested that they call her doctor, she said she didn't have one. Her primary-care physician had changed his practice to the concierge model, which Harriet had refused to join because she thought the yearly payment way too steep. When Harriet turned sixty-five, she tried but failed to find a doctor who would accept Medicare. So on that fateful Thanksgiving Day there was no doctor to call or see. And she refused to go to the hospital. George pleaded with her to go but was accused of meddling. He tried to call a few of the local physicians that he could find online but wasn't able to get anyone on the phone. He needed someone either to see her or tell her to go to the hospital. While he was making the calls, his mother became short of breath and began to perspire. He called 911. The dispatcher said the local ambulances were all occupied but that one from a distant town would be there ASAP but couldn't give an ETA. With growing consternation George watched his mother turn ashen. Realizing he couldn't wait any longer, he managed to get her into the backseat of her car despite her reluctance, and rushed her to the local hospital. When he pulled up to the ER, he discovered it had been closed. "Consolidation" was what the corporation that bought the facility had called it. George drove as fast as he could to the next closest hospital, which was owned by the same corporation. It was located a half hour away, and by the time George pulled in, jumped out of the car, and opened the back door, his mother was dead. The sheer frustration of it all nearly drove George mad. He had never cried much, even as a child, but on that cold, dreary day he sat in that car and wept. 5 CENTURY PLAZA HOTEL CENTURY CITY, LOS ANGELES, CALIFORNIA MONDAY, JUNE 30, 2014, 10:18 A.M. George reached up with both hands and rubbed his eyes to get himself under control. It always bothered him to think about his mother's passing, and since Kasey's death the unwelcome remembrance of the episode had become more frequent. The two episodes shared a similarity: Both had occurred in his presence. Blinking his eyes open, George looked back at the dais. Paula had sat down and Thorn was saying, "I am also pleased to introduce to you Dr. Clayton Hanson." Thorn pointed over to Clayton, who, like Paula, rose to his feet to acknowledge a bit of applause. From the standpoint of appearances, Clayton looked as good as Thorn, decked out in equally expensive gentlemen's finery. Where he surpassed Thorn was his overly tanned face, accentuated by his carefully coiffed silver hair. He was old enough to appear learned and young enough to attract women of any age. "Dr. Hanson, vice chair of academic affairs for the L.A. University Medical Center's department of radiology, will be giving us an overview of iDoc's advanced imaging capabilities, but before Dr. Hanson, I would like you to hear from Lewis Langley. He'll be saying a few technical words about the unique character of the iDoc algorithm." Langley nodded slowly at the mention of his name but didn't stand. He didn't look anything like the typical software guy and was miles away from the other two men with whom he was sharing the dais, wearing shit-kicker boots with black jeans that were topped off with a huge, silver-plated Texas longhorn belt buckle. To round out the outfit, he wore a black sport jacket over an open-collared black shirt. For the next few minutes George found it hard to concentrate on Thorn's words. His unexpected trip down memory lane of that awful Thanksgiving Day and his mother's death had him freaked out. On the flight back to L.A. after the funeral, he had found himself agonizing over the way the lack of primary-care physicians had contributed to the nightmare. As fate would have it, the airplane magazine had an article about a phone app that could anticipate heart attacks. That had been the stimulus that made him think about the phone as a primary-care doctor. There were already six billion cell phones in the world and the technology was there; it just needed to be channeled. Although he didn't do anything about this revelation--what could he do as a first-year resident--he did mention the idea to Paula when he finally did get in touch with her. They had met for a drink, and after some small talk he told her his mom's sad story and his idea of a cell phone functioning as a full-blown primary-care physician. He was convinced a device like that would have been a godsend to his mother and probably would have saved her life. Paula was immediately taken by the concept and told him the idea was perfect for Amalgamated, which alarmed George. It was his belief that if anybody did it, it should be the medical profession, not an insurance company, since the smartphone, in a very real way, would be practicing medicine. Paula's response was to laugh, pointing out that the medical profession would never get around to it, having dragged their collective feet at the idea of competition of any sort as well as their disinclination to embrace the digital world. In the end, George's effort in reconnecting with Paula didn't pan out. As busy as he was with his first year of residency, he didn't call her for months, and when he did, she declined the offer of getting together. The next time he had heard from her was just the previous week, when she texted him the invitation to the event out of the blue. The fact that the presentation was about the smartphone being a primary-care physician was a complete and total surprise. George again considered getting up and walking out. She obviously latched on to his idea and ran with it without any attempt to connect with him even just to acknowledge his contribution. George squirmed in his seat, his mind racing to think of what to do about it. He shifted his weight to stand and leave. The man next to him even moved to let him by, but George didn't get up. Instead he relaxed back into his seat. What purpose would it serve to walk out? Just wanting to get away was a childish response. It ended up being a good thing that he stayed, too. Thorn still had a few surprises. "Amalgamated Healthcare is proud and will be announcing to the media that we are near the end of a very successful beta test of the iDoc algorithm and app. For almost four months, twenty thousand people here in the Los Angeles metropolitan area, who had signed strict NDAs, or nondisclosure agreements, have been using the iDoc app with truly phenomenal success. As a primary-care physician, iDoc has proven itself to be utterly reliable, far better than a flesh-and-blood general practitioner under our current health care system. And this sentiment comes directly from our participant surveys. Enrollees love it!" George swallowed with some difficulty. His mouth had gone dry. He'd seen the iDoc app on Kasey's phone but had not known what it was, and she hadn't told him. She had been part of Amalgamated's beta test! The news also gave him a queasy feeling in the pit of his stomach. As Thorn went on to explain that iDoc would be immediately and immensely profitable, George shook his head with a mixture of disgust and admiration. iDoc was going to be performing an end run around the whole medical industry. It was about to become the doctor! "Please!" Thorn called out after allowing the excited murmuring that had erupted to continue, obviously enjoying the moment. "Let me make one more point before I turn the floor over to Dr. Stonebrenner to provide technical details. With the success of iDoc's beta test, Amalgamated is about to launch the program nationally. Concurrently, we will also be looking to license the program internationally, particularly in Europe. To that end we've been in negotiations with multiple countries, particularly those with extensive, dependable wireless infrastructure. I can confidently report that negotiations are rapidly progressing. The need for iDoc is global. Of course, this underlines how very good an investment in Amalgamated Healthcare is. We are about to conclude deals with several hedge funds, but another round of funding will be required. Our market is global. Our market is massive. Now let me turn the floor over to Dr. Stonebrenner." As Paula stepped forward, George did a rapid Internet search for the meaning of a beta test. He vaguely recalled hearing the term but wouldn't be able to define it if he was pressed. He quickly found out that it's a term for the second round of software testing in which it's used by a limited but sizable audience to ascertain user acceptance while at the same time seeking to identify and fix glitches or problems. As Paula began speaking George wasn't sure how he felt about her taking over his idea without even getting in touch with him. At the same time he realized he hadn't exactly pursued her. "Think of iDoc as the Swiss army knife of health care," she was saying. "Attachable sensors and independent probes that communicate wirelessly will make the phone a versatile mobile laboratory." As Paula spoke, a slick video presentation demoed the app's capabilities. "The property of capacitance is what enables smartphone touchscreens to sense our fingertips. But the screens also have the ability to detect and analyze much smaller things, like DNA or proteins to enable it to identify specific pathogens or particular disease markers. An Amalgamated client could simply place a saliva or blood sample directly onto the touchscreen for an analysis, and treatment would be based on the patient's past medical history and unique genomic makeup. Recent leaps forward in nanotechnology, wireless technology, and synthetic biology make iDoc possible. With our supercomputer we will constantly monitor, in real time, a host of physiological data on all iDoc users of all vital signs. The sky is the limit. iDoc can even extend into the psychological realm because iDoc has the ability to monitor the client-patient mood, particularly in relation to depression, anxiety, or hyper states, and then communicate with the patient accordingly for on-the-spot counseling or referral to a mental health specialist." Paula then went on to describe how the app is able to monitor many of these functions, in particular those followed routinely only in an intensive-care unit, by the use of a bracelet, ring, or wristband with built-in sensors that communicate with the phone wirelessly. She demoed special eyeglasses that can be worn for additional monitoring of the real-time function of blood vessels and nerves in the retina of the eye, the only true window on the interior of the body. She explained that a continuous recording is made of the EKG and, if needed, the smartphone can function as an ultrasound device for studying cardiac function by merely having the patient press it against his chest. Paula paused for a moment and stared out at the audience. From their stunned silence she knew she had their undivided attention. "Okay," she said soothingly, switching gears, "so the question then becomes, what will iDoc do with this enormous wealth of real-time data? I will tell you. It will do what any good doctor would do and do it better, much better. Thousands of times a second all the data will be correlated via its cloud service by the Amalgamated supercomputer with the client-patient's full medical history, the client-patient's known genomic information, and the totality of current medical knowledge that is being updated on a continuous basis." Paula then gave a specific example and talked about the app's ability to diagnose a heart attack, not only when it is happening, but also well before, so that it would have the ability to alert the patient days before the attack was going to occur. Paula then touched on iDoc's ability to follow and treat chronic diseases like diabetes. With iDoc and an implanted reservoir of insulin, blood sugar could be tracked in real time and the correct amount of insulin could be released automatically to keep the patient's blood sugar continually normal. In a very real way, for a diabetic, iDoc is essentially curative. George found himself nodding. It was apparent to him immediately that iDoc had handled Kasey's diabetes and why she didn't talk about it. Kasey's word was her bond, and she had obviously signed a nondisclosure agreement. He remembered how pleased she was at the time, being free of her usual burdensome monitoring. George even knew she had had some sort of implanted device. Now he knew what it had been. It had been a reservoir just as Paula was describing. Paula concluded by saying that embedded reservoirs have been and would be used for various ailments, and not just for chronic diseases, noting that it would be the answer to the problem of poor compliance that a number of patients demonstrate when it comes to taking medications as instructed. Despite his irritation at having been, in his words, ripped off on the concept, George became progressively impressed by what he was hearing. He could tell everyone else in the room felt the same. Paula was offering understandable specifics, and everyone was listening with rapt attention. George could easily see why iDoc would make a superb primary-care doctor, especially when the doctor was available 24/7 to answer a patient's questions without the inconvenience of having to make an appointment, travel to an office, and wait to be seen by someone who might be rushed, distracted, or not able to find the appropriate patient records, and, worse yet, might have forgotten half of what he or she learned in medical school. "From the outset," Paula continued after another astutely planned pause, "we wanted to make iDoc extremely personable. The client-patient can choose the gender of his doctor avatar as well as his or her attitude in relation to being paternal or maternal in tone. So far there is also a choice between forty-four languages and several accents. There are also choices available regarding how the patient would like to be notified when his iDoc doctor wants to have a chat when stimulated by a change in the client-patient's constant physiological or mental monitoring. "I want to emphasize that iDoc never has a memory lapse, never gets tired, never gets angry, is never on vacation, and never has a drink, pain reliever, or sedative. And lastly, client-patients can select a name for their avatar doctor, either made up or from a preset list. If they don't want to be bothered, a name will be selected for them with a choice of ethnicities. For privacy concerns, if a client-patient's speakerphone is activated, iDoc will ask patients if they are alone and if it's okay to have an open audio conversation. iDoc will strictly guard patient confidentiality, using the full gamut of biometric identifiers. "What I have just given is a rapid, superficial overview of iDoc. It uses an extraordinarily versatile algorithm. As Mr. Thorn mentioned, the reception by our client-patients throughout the beta test has been exceptionally positive far beyond our expectations and hopes. People love iDoc and already are telling us they don't want to give it up at the conclusion of the test period and are eager to share their experience with family and friends, which they have been strictly forbidden to do. iDoc has already saved lives as well as time and inconvenience for the patients that have it, and it has saved money, too." Paula paused on that note, letting the audience absorb the information. When everyone realized she was done, applause erupted. Paula waited a few beats, acknowledging the audience's response, then said a quick thank-you. George marveled at why other people had not come up with the iDoc idea. After Paula's presentation it seemed intuitive, given current technology. He watched Paula return to her seat as the third speaker approached the front of the stage. George hoped he might catch her eye, but she didn't look in his direction. Lewis Langley addressed the audience for only a couple of minutes. Even from where George was sitting he could see his cowboy-style fitted shirt had snaps instead of buttons. With his hair that was cut long, giving Langley a rather wild, artsy look, George got the impression he was the right-brain, creative type in contrast to his left-brain colleagues. "I'm not going to take much of your time," Langley said with a discordant New York accent. "There are only three things I want to convey above and beyond what you have already heard from Mr. Thorn and Dr. Stonebrenner. First off, and most important, the iDoc algorithm was written to be heuristic so that it would improve itself by learning on its own over the course of time. This has already proven to be the case to a marked degree during the beta test. As a backup to iDoc, Amalgamated has employed a large group of internists, surgeons, and other specialists who rotate through a twenty-four-seven state-of-the-art call center. At any given time there are at least fifty of them on hand. "These doctors assist iDoc's automated decision making as a default mechanism whenever there is the slightest problem. At first, at the outset of the beta test, there were quite a few calls, maybe as often as twenty percent of the episodes. But that changed rapidly, and during the course of the three-month beta-test period, the number of calls coming into the center dropped by eleven percent, meaning the iDoc logarithm is indeed learning. "The second issue I want to explain is that important subjective issues have been meticulously researched and included in the iDoc algorithm, such as pain and suffering associated with treatment options and possible outcomes, something traditional medicine has always had great difficulty considering. Cost was another issue taken into consideration in the iDoc algorithm. For example, generic drugs are prescribed, provided the efficacy between the generic and the brand-name drug is equal. If the brand-name drug is superior, it is prescribed. "The third and last issue I want to mention is that it is my firm belief that iDoc will bring about a miraculous democratization of medicine, somewhat akin to what the Gutenberg Bible did for religion. iDoc will free the general public from the clutches of doctors and the medical profession just as the Bible freed the public from the clutches of priests and organized religion. iDoc will be making the paradigm of the practice of medicine personal, meaning that if a drug is prescribed, it will be prescribed because iDoc knows that it will benefit the specific patient rather than knowing it will benefit five percent of patients with the hope that the specific patient will be part of that five percent. Because of this democratization of medicine, I believe the introduction of iDoc will prove to be on par with or more important than other major technological milestones, such as the development of the computer, the Internet, the mobile phone, and DNA sequencing." Dr. Clayton Hanson was the final speaker to address the audience. Despite acknowledging to himself that he was acting ridiculous, George flattened himself down in his chair throughout Hanson's brief talk. His remarks, in contrast to those of the other speakers, were pedestrian. He talked briefly about the medical imaging capabilities of iDoc, particularly ultrasound in conjunction with a wireless handheld transducer. He listed as an example the cardiac function tests that could be performed from the privacy of the patient's home. Until now these tests required multiple hospital visits and thousands of dollars. His point was that not only was iDoc a better primary-care physician than a flesh-and-blood individual, it was also going to save society a significant amount of money immediately and over the long haul. Thorn stepped forward again as soon as Clayton finished and took his seat. "Thank you all for attending. And before I open the floor to questions, I want to remind you that we'll be having a reception and buffet lunch in the restaurant on the first floor of this tower immediately following our presentation, so we all have a chance to speak personally. Okay, who's first?" A number of hands shot up. The excitement in the room was palpable. 6 CENTURY PLAZA HOTEL CENTURY CITY, LOS ANGELES, CALIFORNIA MONDAY, JUNE 30, 2014, 11:00 A.M. George took the elevator down to the first floor and walked toward the restaurant's entrance with a number of the other attendees. He was deep in thought, debating what to do next. He knew he should head back to the hospital but couldn't let the opportunity to confront Paula pass, even if he risked being seen by Clayton. He rationalized that he wouldn't be long, and he hadn't received any texts or calls from Claudine Boucher, so things were undoubtedly fine in the MRI unit. George wasn't surprised, since Claudine was one of the more accomplished residents on her last day on an MRI rotation; she knew the ropes in spades. Excerpted from Cell by Robin Cook All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.