The following will be the last chapter of this mini arc, then comes the beginning of Vogler's end.
Enjoy.
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I definitely had not measured what my questions at the end of the initial presentation would cause because, when the presenting doctor said goodbye and we were told that the following parallel presentations would begin, the seats in the auditorium quickly began to empty with people heading to the exits ready to visit the convention.
Or at least that is what should have happened.
From the back row of seats. "Doctor Duncan" said a man I had never seen, "I am Robert McCoy I work for the Montana General Hospital" he added before I could clarify that I was not a doctor, "I would love to discuss more about your theory if you have the time for it" he added handing a business card.
Taking the card from the man's hand and about to respond, I was interrupted by someone at his side.
With a wide smile on his face, struggling to look approachable. "David Coulson" said the other man, stretching out his hand to also hand a card, "from Colorado, I would love to share some thoughts I have about it, I think I could add quite a lot to your research" added the man.
Not only were those two doctors interested in discussing 'my' theory, because, as if standing in the middle of the aisle in the auditorium was an invitation, dozens of doctors approached offering business cards and offers of cooperation in research work, which for some reason they assumed I would do.
It seemed surprising to me that for a couple of questions so many doctors were so interested in meeting me, I knew it might seem revolutionary but, at that moment still a hypothesis without much foundation.
There were so many doctors approaching to introduce themselves that even Doctor Cuddy had to come over to help, receiving business cards for me and even handing out her own cards, giving a kind of communication bridge between the doctors and me through the hospital, after all I did not have my own cards.
After what felt like hours, but surely it was only a couple of minutes receiving cards and hearing names, suddenly the noise around me as well as the cards being offered slowly began to fade, puzzled it did not take me long to discover why, given that, as if a magical bubble formed around him, people made way for a man.
In front of me, the presenter of the opening keynote lecture of the convention was smiling amused. "You are really young, much more than I imagined" said the doctor, who was easily in his sixties "from over there at the front it is not very easy to guess ages just with the voice" he added laughing softly.
Nodding amused. "I can imagine" I said, this time being the one to stretch out my hand, "Patrick John Duncan."
"I know son, that's why I'm here" said the man joking, "and all these people, come on it is starting to get hot in here!" he exclaimed, moving his hands as if he were shooing flies around him, quickly making the people who had been surrounding me begin to move away.
Secretly relieved to no longer be surrounded, I sighed putting the pile of cards in the pockets of my blazer, being more free, still standing in front of my presentation seat, I noticed how House had disappeared at some point, I did not understand how because I had never seen him even stand up, and even more surprising for someone who used a cane, since the aisle to the exit was completely crowded with people.
When people were finally far enough away, the doctor in front of me who was still smiling with interest shining in his eyes, seemed to want to continue talking, but from behind me, gently pushing Doctor Cuddy who seemed impressed by the doctor in front of us. "Doctor, nice to meet you I am Edward Vogler owner of Eastbrook Pharmaceuticals, we developed a new ACE inhibitor-" said Vogler stretching out his hand.
But, without even turning to look at him. "That sounds very interesting" the doctor interrupted completely uninterested, "now Patrick, can I call you Patrick?" he asked patting my shoulder.
Without needing to see Vogler's face, I could imagine the expression he had at that moment, so, amused without thinking I moved forward along with the doctor.
"Everyone calls me PJ" I said avoiding with all my being laughing loudly.
"Then PJ it will be" declared the man cheerfully, "I was not joking about how young you are, what are you twenty years old, are you still a student?" he added as we walked to the exit of the auditorium.
"Actually I am sixteen years old, in a couple of months I turn seventeen" I responded slightly embarrassed.
Opening his eyes surprised stopping suddenly. "Sixteen" exclaimed the doctor incredulous, "my god, you are not even twenty years old and you left me without an answer" he added snorting, "I have been practicing medicine for three times your age and I did not even come to imagine the possibility of your questions."
"I am sure that with time you would come to ask yourself the same" I said somewhat embarrassed.
Snorting, the doctor denied. "Ah you give me too much credit son" he said, "you and all those boot lickers" he added pointing to the auditorium with his head.
I really did not know the man, which was strange but not impossible either.
Thanks to my time studying before and now, I knew many important names of the time and their work, because being contemporaries I read and absorbed everything new that came to medicine, no matter the area, I knew, with approximate certainty, dates of the vast majority of advances that would come to medicine for the next forty years and in general the names behind those advances.
But thanks to names like Doctor Grey and awards like the Harper Avary I had noticed that there were names I did not know at all, I mean, names like Doctor Thomas and medical pioneers like William Osler, Fleming, Lister and Blackwell still existed, but reading books of House and of the hospital, especially more current books, I came across names I had never heard before, like the name given at the beginning of the initial presentation and that belonged to the doctor in front of me.
Looking at me seriously. "I was serious up there, despite your age you are already studying medicine" declared the man with some certainty.
Moving my head a little not entirely sure how to respond, without more, I explained in general the reason why I was there, how House had 'taken me in' as his apprentice despite still being in high school, my work with Doctor Thomas and finally my presentation for my paper.
Denying amused, but with a gleam of fantastic incredulity in his eyes. "Recognition in the Nobel winning article and a paper of your own" murmured the doctor, "at your age I was drinking in secret in my father's barn" he confessed laughing dryly a moment later.
"I really did not help much Doctor Thomas, and my article is only a review" I explained a bit embarrassed, I did not know how else not to appear arrogant in front of the doctor.
"It does not matter, do you know what I would have killed for to at least have a mention in an article when I entered medical school?" asked the man, "let alone authorship in an article" he added snorting, "you will be able to enter the school you want without having to work hard to even ask if you can enter, in fact universities will fight for you to choose them" he declared laughing loudly.
I did not know what to say, I mean the man was right, I knew it, but it would be quite arrogant to brag about it.
"I cannot wait to see what you accomplish" continued the doctor, "starting with your presentation, it will be tomorrow right?" he asked.
"It is a little before noon" I responded nodding.
It would be before the first lunchtime interlude of the day, and also before the company presentations where House would speak for Vogler's pharmaceutical.
"Excellent" he said patting my shoulder, "what do you think if tomorrow we have a coffee after your presentation, I would love to talk more with you but unfortunately I promised some people a talk and I have to go" said the man checking a pocket watch.
"Of course doctor" I responded, because even though I did not recognize the man's name, due to his position and respect in the convention by being chosen as the keynote speaker, I knew that I could learn many things from him, just like with Doctor Thomas.
Taking a business card from his blazer. "It was a pleasure to meet you PJ" said the doctor, and like dozens of doctors before in the auditorium, he stretched out his hand offering me the card.
Taking the card almost immediately. "Likewise Doctor Tapley" I said saying goodbye to the man with a firm handshake once I put the card in my own blazer, with that one, I easily had a couple dozen cards stored, plus the ones I had from Doctor Thomas' party, maybe it reached sixty.
As Doctor Tapley walked away he moved forward to where the event organizer was along with a couple more doctors, all obviously waiting for the senior doctor.
Sending a couple of glances in my direction, the group, along with the doctor, walked away from where I was, chatting with interest with doctor Tapley.
Approaching from my back, appearing out of nowhere. "What happened?" asked doctor Cuddy quickly, surprising me.
Next to her was the head of the cardiology department of the hospital, both seemed equally anxious.
Seeing that she did not receive an answer immediately. "What did doctor Tapley and you talk about?" she asked me again.
"Ah not much, just about my future" I responded puzzled, apparently the doctor was more important than he seemed "he is going to attend my presentation" I added with interest in studying the reactions of the two doctors in front of me.
I immediately got what I was looking for, overly wide eyes and dropped jaws, the pair of doctors were speechless for a second.
It seemed that doctor Tapley was a bit more important than I had gauged.
Being doctor Cuddy the first to come out of the trance. "Walter Tapley is going to attend your presentation?" asked doctor Cuddy, "THE Walter Tapley" she added.
Yeah, apparently a bit more beyond what I imagined.
"Yes" I responded uncomfortably, patting where I had put the doctor's card, it now felt a bit heavy in my pocket.
Snorting incredulous. "I can't believe it, 'The Right Hand of God' will go to your presentation by his own choice" murmured doctor Rivers, the head of cardiology.
Feeling my mouth dry for a moment, the figurative weight I felt for doctor Tapley's business card had increased, after all 'The Right Hand of God' was a very big nickname.
Thanks to a brief explanation from doctor Cuddy I discovered that doctor Tapley was a highly respected cardiothoracic surgeon in the field, with dozens of techniques, used up to that moment, under his name and research that had allowed him to be several times winner of awards such as the ACC, ESC and even WHF, all awards given to cardiologists in the country and the world, he had even won the Harper Avary for a modified bypass procedure, which I had to research, since it sounded extremely interesting.
Understanding now why leaving him without an answer, even receiving a compliment from the man, had been something so surprising for all the doctors who approached me, the man could very well be an idol for everyone at the convention, basically one of the founding fathers of cardiothoracic surgery.
Something that throughout the rest of the day I was constantly reminded of, apparently my identity as the young one who had surprised doctor Tapley was passed from person to person at the convention, making it so that while I visited each poster to see the advances of the time, almost at the end of the day, again, like so many times before at school, I felt everyone's eyes on me, even though at least the doctors tried to be discreet.
Back at the hotel, relieved that the day was over and I would no longer be pointed at and seen like an animal in a zoo, I lay on my bed taking off my formal shoes and tossing them far from my feet.
Being more than willing to sleep without dinner and even without changing clothes, I stayed lying down thinking about everything that had happened that day, unfortunately before I could fully calm down, two knocks on my door made me jump startled.
Pressing my hands to my eyes. "Yeah?" I asked exhausted.
"Finally" I heard someone say with relief, "PJ, it's me, doctor James Wilson" said the voice that I now recognized as doctor Wilson, with strange formality.
Snorting at the way the man had identified himself, I stood up approaching the door.
When opening the door. "Yes doctor" I said, finding doctor Wilson expectant.
"House wanted me to bring you to his room, there's a... small gathering" he said, strangely uncomfortable.
"A gathering" I murmured frowning.
Raising his shoulders doctor Wilson nodded.
With my shoes on again, I arrived just behind doctor Wilson at the door where House had entered the day before, where without bothering to knock, he simply opened and walked in.
The room was the same as mine, leaving aside the small fact that House's bed was moved from its place and where it should have been, there was now a long table with ten chairs occupied around it, occupied, mostly, by people I did not know.
Sitting in the middle of the table. "There he is, the wonder wid himself" declared House pointing at me, "didn't I tell you, he is my protégé" he added elbowing a man sitting next to him.
Noticing on the table a bunch of casino chips and cards, I immediately understood part of what was going on.
"Come on Kid, doctor Smith wanted to meet you" urged House for me to come closer, "I bet fifty" he added a moment later pushing chips from his pile.
Somehow House had organized a poker night with several doctors from the convention, hiring a couple of hotel workers to rearrange his room and serve drinks as if it were a casino, he had even managed to get a professional dealer to act as croupier.
My presence there, I quickly learned, served only to distract a couple of doctors who apparently had brought up my name at the table, giving House, as a gift, the perfect method to steal their money.
After answering a couple of questions from the interested doctors, especially about my conversation with doctor Tapley. "How many people can play this?" I asked interested, still remembering how I had won every time I had played against Meemaw.
"Ten people, do you want to play?" asked House, besides him there were eight other people, including doctor Wilson, who had significantly fewer chips in front of them compared to House.
"House" exclaimed doctor Wilson.
"What, if the kid wants to play then let him play" said House without even turning to look at his colleague, "did mom give you some money to spend on toys?" he asked me.
"A couple of dollars" I responded.
"Atta boy" declared House smiling widely, I could practically see in his eyes the idea of getting more money, specifically from my pocket, shining.
Taking a plastic chair offered by the hotel worker, "how do you play?" I asked.
"First of all, it's one hundred dollars to buy in, do you have it?" asked House suspiciously.
"Oh yeah" I responded, standing up again to take my wallet from my back pocket.
Receiving a pile of chips in exchange for my bill, I sat down again before being dealt two cards in front of me.
"All right, we're in Texas, so this is Holdem" said House arrogantly, "you have to make the best possible hand with the five cards that will come out in the center."
Shaking his head, doctor Wilson rolled his eyes. "I can explain as things happen" said the always kind doctor.
Nodding "thanks" I said falsely relieved, because to be honest I knew poker and its rules perfectly, all thanks to Meemaw with whom in the past months I had played quite a lot.
Checking my cards discreetly, two Aces, I slightly frowned, hoping my acting would be enough to fool an excited House who was obviously reading my face.
As I had imagined, staring at me. "That's about it, do you understand?" asked House "five" he added tossing a chip, quickly studying the people around him, including me.
After him several doctors, even doctor Wilson called. "I think so" I said slowly when my turn came, "all in" I added pushing all my chips to the center.
Laughing House shook his head, my pile of chips was nothing compared to his. "Are you really sure you understand?" he asked throwing a chip into the center since the rest of the doctors had chosen to fold their cards, "two kings" he declared showing his cards.
"Oh you have two K's" I said pressing my lips as if I did not understand the situation, "I only have two A's" I added falsely disappointed as I turned my cards.
House's smile disappeared completely from his face, while doctor Wilson and other doctors laughed excitedly.
Even though I had a better starting hand than House, there was still a possibility he could beat me, depending on the five cards the dealer drew from the deck, but a large part of casino games like poker and blackjack relied fully on luck, there was some math as Diane had explained to me later, and according to Meemaw I had more luck than anyone she had ever seen.
The first three cards came out being the two remaining Aces in the deck and a two of diamonds, leaving House completely without a chance to beat me.
"Yeah, I'm pretty sure" I responded to House.
The game continued for several more hours, relying entirely on my luck and on the little knowledge of the game that both Meemaw and Diane had taught me long ago, I survived until only three people were left playing, House, a doctor who apparently did not care about losing money as long as he could listen in depth to my thoughts on atherosclerosis, and me.
From my achievement at the beginning of the game, House had focused all his attention, now seriously, on reading my face, thus managing to fold when I had good hands and bet when I did not, unfortunately it seemed I could not fully hide my expression from House.
Finally, past two in the morning completely exhausted from the day I had had and all the questions I had answered during the game, without checking my cards. "All in" I said staring at House.
Pushing the small pile of chips I had in front of him. "Call" said the doctor next to me, still completely uninterested.
House took a couple more seconds, checking his own hand while he seriously studied me, I was sure there was nothing to read, since I didn't know my hand, but I was already quite sleepy and if making the bet meant losing the hundred dollars I had started with, so be it.
Finally. "Call" said House, throwing a chip into the middle.
Doctor Wilson, who had been one of the first to stand up after losing all his chips three times, murmured excitedly.
Deciding to turn our cards over, House showed an Ace with a King, the doctor next to me had two tens and I had a six and an eight of the same color and suit.
"Oh" I murmured, because from what I had learned from Meemaw I was losing and by a lot.
Or at least that's what I thought, because in the first three cards came the seven, nine and five of the same color and figure as my hand.
Doctor Wilson who was behind me watching what was happening, took a couple of seconds to react, excitedly raising his arms triumphantly.
The next two cards were unimportant and somehow I had won ninety percent of the chips at the table, House still had a small mountain of chips, at least compared to mine.
"That's it for me" I said standing up to stretch.
House who was in complete silence staring into space while playing with a couple of chips, said nothing while I received the money the dealer had kept, paying a good tip both for him and for the waiter, saying goodbye a moment later, leaving the room.
It had been a good night.
The next day, being Sunday and having slept the previous night much later than usual, for the first time in a long time I ended up waking up late in the morning, this thanks to the alarm in my room.
Exhausted despite just waking up, I stretched scandalously before starting my morning routine.
Bathed and dressed for the day, I went back down to the dining room, which this time unlike the previous day was full of people having their lunch.
Upon finding the same table I had used the day before, again occupied by Cameron, Chase and their acquaintances, I approached drawing the attention of a couple of people at other tables who recognized me.
"Good morning" I said as I took a seat in a free spot at the table.
My words caused whatever they were talking about at that moment to stop completely, and before I could avoid it, the questions returned.
The day continued with visits to posters with presentations that lasted barely minutes, a lecture somewhat smaller than that of Doctor Tapley and several unimportant exhibitions, like mine, that did not receive more than fifteen people in the audience, finally, an hour before noon, the moment of my presentation arrived.
Behind the small stage, in a small hallway separated from the small auditorium in which I would present, a couple of minutes before the scheduled time. "Are you okay? Do you want some water?" Doctor Cuddy asked me.
"I'm fine, thank you" I replied and surprisingly it was true, for some reason I did not understand I was not worried at all, in fact I was extremely calm.
Which seemed strange to me, because even for fighting, minutes before any fight I could feel a little nervousness forming in my stomach, but at that moment I was even uninterested in presenting, maybe the idea that really only a couple of people came to these exhibitions removed the pressure completely in my mind or maybe because I had my presentation mastered, the important thing was that I felt good.
"Great" said Doctor Cuddy relieved, "all right, have fun up there" she added patting my arm gently.
"Thank you" I said smiling at the woman.
Nodding, Doctor Cuddy walked toward the entrance door to the auditorium.
Calm, I watched as the woman opened the door causing what before was a silenced noise by the thickness of the metal door, to come in fully, dozens if not hundreds of voices were speaking on the other side, causing both Doctor Cuddy and me to freeze at once.
Turning slowly to look at me, Doctor Cuddy shared with me a shocked look before stepping out into the auditorium, immediately returning. "It's completely full" she said surprised.
I didn't know why, but I knew it was because of my luck and therefore I was not surprised.
Only one minute before my presentation, now hearing the number of voices I had to present in front of, I definitely felt nervous.
Wishing me luck once more, Doctor Cuddy left the hallway entering the auditorium, the heavy metal door behind her closed isolating almost completely the noise on the other side.
"Cool cool cool" I murmured walking in small circles, surely somehow the fact that Doctor Tapley would visit my presentation had spread, or maybe someone recognized my name on the program sheet, the important thing was that dozens of people were out there waiting for me.
Taking a deep breath of air, I nodded leaving the hallway to the small space behind the platform.
Looking at me with a relieved smile. "Without further ado, it is a great honor for me to present to you 'PJ,' Patrick John Duncan" said Doctor Cuddy, causing a small and polite applause from the audience, applause that quickly died when they saw me climb the stage.
As I passed by her I took the woman's hand in a firm shake, continuing my way to the center of the platform, at no time letting my eyes wander toward the audience.
Finally, when I raised my gaze I found myself with lots of expectant faces and complete silence, someone had even coughed at the back of the auditorium being heard everywhere.
With a loud fan noise, the student in charge of moving the slides of my presentation, turned on the projector, slowly giving an image behind me.
Passing my eyes over all those present, seeing Doctor Tapley sitting calmly, and the doctors from my hospital. "I don't know what they promised you to come, but I doubt very much that we have enough money to pay you all" I said joking after what seemed like painful hours in silence.
Fortunately a couple of laughs were heard, and like a fire the rest of the people followed.
"Not seriously speaking, thank you very much for taking a part of your time to come" I said much calmer, moving in the space of the stage, "as Doctor Lisa Cuddy said, my name is Patrick John, but everyone calls me PJ, I'm not a doctor yet so sorry for what you are about to see" I added, showing an exaggerated apologetic expression on my face, causing many to laugh again, "but despite that I have an article to be published in Circulation" I added lowering my head slightly, a signal for the student to move to the next slide.
As I had practiced last week, I gave my presentation making small jokes here and there, always achieving what I was aiming for, I developed each point on the slides without any problem and finished the presentation.
"Thank you very much for your attention, we can start the questions if there are any" I said, and immediately hands were raised.
Pointing to one of the doctors. "The Physicians' Health Study showed a reduction in myocardial infarction, yes, but the British doctors' study found no benefit. Aren't you being premature in recommending this, ignoring the real risk of cerebral and digestive hemorrhage?" the man asked.
"The hemorrhagic risk is the main concern, yes" I responded immediately, "but when grouping the data from all these studies, you see a significant reduction of around 25 to 30% in the risk of a first myocardial infarction in high-risk groups, without a significant increase in cerebral hemorrhage in studies that use low doses, like the 100 mg that are proposed. The key, I believe, is not to recommend for everyone, but to identify those high-risk patients, such as men with multiple cardiovascular risk factors, where the benefit may outweigh the risk."
Giving the floor to another doctor. "Isn't that too low a dose? Do we have evidence that it consistently inhibits platelet aggregation adequately?" he asked.
Shaking my head gently. "Pharmacokinetics shows us that even very low doses, from 30 to 50 mg, can irreversibly inhibit platelet cyclooxygenase. The UK-TIA study, which focused on patients with TIA, used 300 mg and 1200 mg per day and found no differences in efficacy, but did find a higher risk of bleeding with the high dose. The trend, which is being seen in newer studies, is toward lower doses."
Several more questions came and fortunately they were questions I was able to answer without any problem, I saw no end to the raised arms until finally, thanks to Doctor Tapley raising his own hand, all the others disappeared.
"Doctor Tapley" I said nodding.
Smiling gently. "Considering the interindividual variability in platelet acetylation, the possible aspirin resistance and the impact of first-pass pharmacokinetics on COX-1 inhibition, what biomarkers or clinical criteria do you propose to reliably identify the patients who will truly obtain a net benefit? And additionally, how do you suggest controlling the risk of chronic subclinical gastrointestinal bleeding that could go unnoticed in a prolonged treatment regimen?"
Opening my mouth slightly, I saw the doctor's expression change to one of amusement, I could see what was happening, it was a sort of revenge.
Nodding, I breathed deeply preparing to speak. "Thank you, Doctor Tapley, it is a critical point" I replied, causing many to look at me even more surprised, the question was difficult.
"Regarding the identification of patients with net benefit, I believe we should rely on a combination of clinical factors rather than biomarkers, at least with what we have available today. At this moment, the strongest criteria to select candidates are a clearly elevated cardiovascular risk profile: men over 50 years old with two or more factors such as hypertension, dyslipidemia, smoking or significant family history. In these patients, the baseline probability of a coronary event is enough for platelet inhibition to provide a tangible clinical benefit."
"As for the variability in the response to aspirin, I agree that there is heterogeneity in platelet acetylation and in sensitivity to the drug. While we still do not have a standardized test for 'aspirin response', optical aggregometry could become a tool to detect hyporesponse; however, I understand that it is still limited to research contexts."
"On the second part of your question, the risk of subclinical gastrointestinal bleeding, I believe that the key is in prior stratification. I would exclude from primary prophylaxis patients with a history of peptic ulcer, erosive gastritis or chronic use of NSAIDs. For those who are candidates, the use of low doses seems to minimize mucosal damage. And for prolonged treatments, I would propose periodic follow-up with blood counts to detect iron deficiency anemia as an indirect marker of chronic bleeding."
"In summary, doctor, I believe that the balance between efficacy and safety depends on strict patient selection, low dose, and active clinical surveillance to detect early toxicity. Until we have more reliable biomarkers, individualization will be our best tool" I finished, recovering the air that it had taken me to speak without stopping.
Doctor Tapley's smile only grew as he nodded gently. "Thank you" he said crossing his fingers.
Fortunately after the doctor no one else asked questions allowing me to end the presentation and step down from the stage.
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Author Thoughts:
As always, I'm not American, not a doctor, not a fighter, not Magnus Carlsen, not Michael Phelps, not Arsene Lupin, not McLovin, not Elliot, not Capone not Tiger Woods and not Phil Ivey (Although as a good Math major, I am a decent poker player).
Another chapter has passed, so new thanks are in order. I would like to especially thank:
11332223
RandomPasserby96
Victor_Venegas
I think that's all. As always, if you find any errors, please let me know, and I'll correct them immediately.
Thank you for reading! :D
PS: PLEASE LEAVE A REVIEW.