Coma Author Robin Cook on How the Medical Thriller Genre Can Improve Healthcare

; Abraham Verghese, MD; Robin Cook, MD


August 30, 2021

This transcript has been edited for clarity.

Eric Topol, MD: Hello. This is Eric Topol with Medscape, with my colleague and co-host Abraham Verghese, and we've got a really special session today with Robin Cook, who I think has written 37 medical sci-fi thrillers. A new one just came out called Viral. Welcome, Robin.

Robin Cook, MD: Thank you. It's nice to be here.

In the Footsteps of Jaws and Love Story

Topol: We go back several years. I had a chance to visit with you in Boston and we've had you here for the Future of Genomic Medicine conference in San Diego. What's striking is that you started a whole genre in fiction many years ago. You were on a submarine when you wrote your first book. Can you tell us about that?

Cook: I had decided I wanted to write a novel about medicine during my first year of medical school. I had hoped that once I got to medical school, I could count on becoming the best doctor I could, without being competitive. But unfortunately, during our first meeting in medical school, the dean looked up and said, "Only five of you will be asked to stay." That told me what the competition was going to be like.

I decided to write a book about medicine because all the TV shows I'd seen and all the books I had read about medicine suggested that everything was fine in the medical arena. I could already see that that wasn't the case. So I thought that someone should write a fiction book and maybe make a TV series or a movie that showed medicine with its warts, so to speak.

Topol: You did that really well.

Cook: As a medical student, I didn't have time to write a book. When you finish medical school, you become a resident and then you have even less time. Then lo and behold, I got drafted after my surgical residency and found myself in the military where I volunteered for submarines. That's the perfect writing environment. You couldn't use the excuse that you didn't have time to write. You're not interrupted by sunrise or sunset. You work an 8-hour shift, and if you're lucky you sleep for 8 hours. Then there's another 8 hours, and I took that opportunity to write my first book.

Abraham Verghese, MD: You invented a genre, but were there any books that inspired you or that you took lessons from as you embarked on Year of the Intern and then Coma?

Cook: Yes, very much so, because I was very lucky to even get Year of the Intern published. That was my first book. In fact, when I got off the submarine, I came up the ladder clutching this handwritten novel and somebody asked me what I was holding. I said I'd written a novel, and they said, "Oh, that's interesting. Did you know it's hard to get a book published?" I had no idea. That's how little I knew about publishing.

So, the book came out but unfortunately, no one bought it. In fact, it's now a very rare book because they produced so few copies. I was very disappointed because I thought it was a very interesting issue and the public would like to know that perhaps we're not training doctors the way we should be. Since no one bought it, I thought maybe I should go back to the literature — that's what we learn to do in medical school. I hadn't read the literature, which was, what books are bestsellers? I picked a couple of very different books that had been written by unknown authors who had almost instant success with their books: Jaws and Love Story. Not only did I read them, but I also studied the way the whole process was put together, and then I imitated that perfectly for my second book, Coma.

Topol: That was a smashing success back in 1977 and really got your career into high gear. The three of us old dogs remember Coma and its impact. But here you are — you've sold more than 400 million books. Has anybody sold more than 400 million books?

Cook: James Patterson. And Stephen King.

Topol: Three of you. You're in a rarefied group, Robin. And you were also practicing ophthalmology?

Cook: I was a resident in ophthalmology when I wrote Coma. Since I loved being a student so much, as soon as I finished ophthalmology (my second residency), I matriculated at the Kennedy School of Government at Harvard. While I was a student I also had a small private practice. My beeper went off in the middle of a lecture and it was my agent calling to tell me that Coma had sold as a movie. I knew at that point that Coma had a good chance of following in the footsteps of Jaws and Love Story.

Viruses and Villains

Topol: Let's get into the new book, Viral, where you used the pathogen Eastern equine encephalitis. We're going to find out why you picked that particular pathogen and an outbreak in a woman, Mrs Emma Murphy, and then what happens to this family and dealing with the villain. I know that's in your magic formula; you have to have a villain, and actually the villain is the same from book to book. Give us the skinny on Viral and what it's about.

Cook: I have been very concerned for a long time about the erosion of medicine because of the intrusion of business interests. I wanted to write a book about how health insurance companies and chain hospitals have been taken over by private equity, but I could never think of a way of writing it. When I told my publisher I wanted to write a thriller about health insurance, they looked at me sort of cross-eyed — "You can't write a thriller about health insurance." It's perhaps the most boring subject in the world.

When I looked at movies, I realized that revenge movies are really popular. Just about every movie that I've ever seen was a revenge movie in some form or fashion. That gave me an idea of how to deal with the issue of business-types coming into medicine purely because the profits are so huge. When a famous outlaw was asked why he robbed banks, he answered, "Because that's where the money is." It's the same situation with private equity. The reason that private equity is so involved in medicine now is because that's where the money is.

So I decided to make Viral into a revenge novel because of some of the stories I have heard about how people are mistreated by insurance companies. They think they have health insurance, but they haven't read their policy. It was a way to create a story that a lot of people would be interested in reading and then think about later on. A number of great nonfiction books have been written about the problem of healthcare and the intrusion of business. They are really very, very good. I read two of them very carefully before I wrote Viral: The Price We Pay, by Marty Makary; and Elisabeth Rosenthal's An American Sickness.

The trouble with most books like that is, unfortunately, they are read by people who already know the problem. They read the book because it cements what they have already felt. That's why I turned to fiction — to try to get a huge number of people who have been affected or know someone who has been affected by the problem, and somehow to get the public behind what we need to do in this country. That is, to change the laws; to get our representatives to do something that will be very difficult for them because these stakeholders are giving them so much money and they don't want that to change. That's the background of how I came up with the idea for a revenge story.

You asked why I picked Eastern equine encephalitis. It's something we've had here in Massachusetts. Last summer we had quite a few cases. I haven't heard about many cases this year. Here in New England, we also have had a lot of Lyme disease (named for Lyme, Connecticut). Why have these diseases suddenly popped up? It's because of climate change. I just love to introduce different issues that are real in my books. So I thought, I'll choose a viral illness that climate change is making worse and putting us all at risk for.

A Spoonful of Fiction

Verghese: I was really struck by the fact that you have taken a good, strong stance on public health in a way that may be a departure from some of your previous books. Your book is dedicated to the "fervent hope that members of the US Congress will comprehend the need to enact, at the very minimum, a viable public healthcare option." You also mentioned in your preface, in your acknowledgments, some of your views, especially on SARS. I imagine that this is a controversial opinion, and you probably come up against a lot of pushback. But it's a wonderful way to try to overcome the kind of opposition to reality that we're facing out there.

Cook: Yes, and it's because of the power of lobbyists. And because the Supreme Court has decided that giving money to politicians somehow has something to do with free speech. That's why it's not going to change. The only way I see for it to change is if the public demands it. I hope we will be making a movie of Viral in the not-too-distant future. I wrote it as a movie first, in three acts; it is set up very carefully in a classic movie structure. If the book and movie are successful enough, it could change public opinion.

It's a way of appealing to the general public. I've always been impressed with fiction books that changed things, like Upton Sinclair's The Jungle. In that day and age, the rich people controlled these industries, and nothing was going to change until the public got behind it and said they were not going to buy any more frankfurters if they had to worry about who's in them. That's my goal. I'm hoping to use fiction to do that kind of thing.

Topol: Going back, Robin, you were an activist through your work long before physicians took on that role. The three of us are physician authors. We are happy to just have a podcast, while you are already writing the movie for Viral, which is amazing. You've had several movies and TV shows. But you always seem to predict the future. You may recall that you sent me this book called Pandemic, and you wrote (this is November of 2018), "I think you are going to enjoy Pandemic." Well, I wanted to tell you, I'm not enjoying the pandemic.

But the fact that you do this stuff, so many times you are ahead of the curve. You take on subjects that are so extraordinarily important, like the whole predatory insurance industry, which you did touch on to some extent in Cell, when these people were programing insulin pumps through smartphones to kill people and reduce their insurance burden. Some of the villains are the same over the years. But the fact that you can touch on such incredible issues, and do it in a way that you can't be sued, is pretty good.

Cook: When I went to college, I had to get good grades in order to get into medical school. Any writing I did was an attempt to impress my professors. When I decided to write fiction, I had to throw that idea out and realize that that's not the way you write fiction. You write fiction not to impress, but to entertain. In terms of entertainment, we're all more similar than we are different. We tend to like sort of the same things. The biggest problem for me was to transition from wanting to impress readers to wanting to entertain them and give them a good time, so to speak, so they would finish the book and then hopefully think about things to some degree.

Cook's Recipe for Writing Success

Verghese: Many years ago at a drug company conference in Naples, I was taking a lesson with the teaching pro on the tennis courts. I looked over and the pro told me, "That's Robin Cook." I was too much in awe of you to talk to you. But I'm a very keen tennis player. And I remember watching you and thinking that there was a metaphor there for the doggedness of your tennis playing and the way you have successfully turned out bestsellers, one after the other.

It harks back to a question about your writing methods. I'm sure everybody asks you this, but do you have a method for each book? Before you sit down, do you know where it's heading? Could you share some of that with us?

Cook: I plan very carefully. I make extensive outlines on large pieces of paper, with tiny writing, so I can get as much on that paper as possible, and then I draw arrows and move things around. If I learned anything in college, going back to the beginning of the computer age and learning how to program computers, I learned that you had to know exactly where you were going. I apply that same sort of methodology to planning a book. I didn't outline my first book very well, but I outlined Coma extremely well so that when I started writing, I knew everything that was going to happen. That's how I've continued to write my books. If I was a more trained writer, I might not have to outline as much as I do.

It's a very frequent question, especially about a book like Viral, which takes a right-hand turn. I've already gotten some feedback where people say, "Wow, where did that come from?" What I don't know, however, is exactly what my characters are going to say. I create biographies of all the main characters. So I have a biography and a story line. I write from page one all the way to the end, and when I switch from one character to another, I always pick up my biography of that character and try to get a sense of how this person would think. The fun that I have when I'm writing is that sometimes the characters say things that I don't expect, because if your character is presented with a situation or a comment and if you're in character, I think, Well, you know, they might say this, even though I hadn't planned on it. Sometimes that makes it difficult because I have to get to the end of the scene; it has to go where I need it to go.

Topol: With respect to the key components, you've mentioned revenge and the need to have a villain. Are there any other critical components of your successful template?

Cook: You have to keep the pot boiling in a certain sense, and also, because I'm writing books about medicine, I have to be quite accurate. I spend a lot of effort when I write a book if it deals with an issue that I don't have that much personal experience with or hadn't experienced for a long time. Then I will go back and talk to some specialists, or even go back into the operating room, which I have done a couple of times. In one book, I was going to write a couple of serious heart operation scenes. Although I had spent a lot of time doing that as a resident, I hadn't done it for a long time. So I called up a friend — luckily I do still have some friends in the field — and he invited me to the operating room. I scrubbed in and did a few procedures. It was the same with anesthesia; the last couple of books had some anesthesia issues, so I did have to go back and review that.

Topol: In one book, there was CRISPR genome editing. You're getting it right, and this has been a consistent theme throughout. You've had 37 bestseller books and you said you weren't trained in writing. If you're not trained in writing, I don't know who is!

Hiding From the Plague

Topol: What's next? Are you going to keep writing?

Cook: Yes, but since I wrote Pandemic, I feel a little bit responsible for coronavirus. When it first started, I thought, We are going to have a vaccine, but the problem here is testing. So I teamed up with three other people and we've come up with a new way to test for coronavirus. So we started a testing company. Just a few days ago, our machine got the European approval (the equivalent of the FDA in Europe) and we're waiting for FDA approval as well. This is something that I've put a lot of effort, time, and thought into as a physician. Our test is very fast. It's very accurate and painless. So I think it's going to have a big impact.

Verghese: When you were attending the Kennedy School of Government, were you thinking of a career in government? What was the motivation behind that? And it leads me to ask you whether you've considered running for office because Florida could possibly use some new ideas from political leaders.

Cook: That was exactly the reason that I decided to go. Since I'm interested in public policy, and with my background, I thought that maybe I could run for office: Could I become a senator? (You might as well think big.) But I have to tell you that the Kennedy School very quickly cured me of that idea. I realized that I was not cut out to be a politician. Like their law school, the Kennedy business school teaches using the case method, in which you're given a problem and you are assigned to be on one side or the other, irrespective of what your beliefs are. I could understand the rationale for that, but I realized that it was very difficult for me. If I have a strong belief in something, I'm not going to want to compromise.

It was during that time that Coma suddenly exploded and I realized that I had an alternative way of influencing public policy.

Topol: Speaking of public policy, you already mentioned COVID. But I'd like to get your sense of where we are now and where we're headed. Several of your books have been about infectious diseases and their impact. You've been following this very carefully. What is your assessment right now of the United States and our Delta wave, and where are we headed from here?

Cook: Unfortunately, the coronavirus is going to be with us for some time, maybe as much as influenza, as most epidemiologists know. I'm not an epidemiologist, but I feared a pandemic was coming, which is why I wrote the book Pandemic. It was a way of dealing with this CRISPR/Cas9 and the potential downside of the technology. I had read a lot of material and I knew this pandemic was coming. In fact, I had stockpiled N95 masks because I was sure it was going to come. I have a small ski house way up in the mountains. I stocked it with the N95 masks, food, etc. I would be like Newton escaping the Great Plague of London. I was going to leave Boston if need be and hide out.

Topol: It exemplifies your futuristic thinking — not just in writing books, but how you practice your daily life, planning ahead. This country seems to be trying to do everything it can to do it badly, whether it was the initial pandemic management or the vaccination effort now. We just can't seem to get out of this and do it right. I just wonder what your frank assessment was. It's great that you're working on a better testing solution. That's only one of the many dimensions of the problem, don't you think?

Cook: Yes, but the real benefit, and what has made me feel the best, is that this COVID pandemic has shown the need in a very direct way of how important it is to have the infrastructure in place for vaccine development. In 2010 I had written an article for Foreign Policy, and my main point was that I hoped that governments would pool money to increase the infrastructure for vaccine development so that it could be geared up much faster. At that time, I didn't realize how much the work being done in genetics was going to influence that. But anyway, to me, that's one of the things that makes me feel able to go to sleep at night — that at least now we have realized the importance of the infrastructure for vaccine development because there are going to be other infectious agents.

I really did not expect it to be coronavirus; I expected it to be influenza. When I stocked my ski house to live in it for 3 months, it was back when the swine flu and the bird flu appeared at the same time in the same section of China. And I thought that if the bird flu and the swine flu got together — because one was lethal and the other was transmissible — that was going to be the problem. I never expected the coronavirus because that's the common cold and it's been around for a long time.

Verghese: You've been very generous sharing your writing tips. I know that our listeners will not forgive us if we don't ask you whether you write on a computer or on paper.

Cook: I do a little bit of both. I still do all my notetaking and outlines with pen or pencil and paper. I wrote my first book and several books after that longhand. Now I write on a computer. I've made the adjustment.

When Coma came out, quite a few doctors in my hospital were a little bit jealous, I guess, and decided that they were going to write a book. I remember one of them stopped me in the hall, grabbed my arm, and said, "Guess what? I've started on my novel," and I said, "That's great, Jerry, I'm really pleased." He said, "Yeah, it's going really well. I'm on page 65 already." I said, "Wow — you are really moving along. What's it about?" And he said, "Well, I don't know yet." It underlines the importance, in writing novels, at least, of having a good outline and knowing where you're going.

Topol: Robin, you're really a legend in the community of physicians. I don't know if there is anyone like you, no less among authors in general. We want to congratulate you on yet another contribution and hope that it won't be your last. Even if it were, you have 37 books and 400 million copies out there. You're amazing — that's all I can say. And you're still going strong. You're a phenom.

Cook: Well, in thinking about health insurance, I hope we do at least get a public option. I've come 180 degrees on that. When I started out as a medical student, I didn't even like the idea of health insurance. I felt that the relationship between a patient and a doctor should be very fiduciary based, and each one values the input of the other. Health insurance was originally just to help with hospitalization. The whole concept of health insurance has been a disservice in the sense that it's the cause of all of the inflationary pressure in medicine. People who have good health insurance don't even look at the bill. They went to the hospital and had their appendix out and they don't care what it cost. This has been a green light for the private equity people. "Hey, nobody cares what the cost is. Let's jack it up."

Topol: The fact that Viral gets into this critical issue about exploitation and the predatory nature of our health system — it's great that you zoomed in on that. I hope it will have an effect. Abraham and I share your concerns about our lack of having universal healthcare and the business of medicine having led to erosion of the trust and the relationship of patients and their clinicians. So thank you so much for this contribution and for joining us today. As we know, the Medscape audience will get a kick out of it for sure.

Cook: Thank you for inviting me. I enjoyed it as well.

Eric J. Topol, MD, is one of the top 10 most cited researchers in medicine and frequently writes about technology in healthcare, including in his latest book, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.

Abraham Verghese, MD, is a critically acclaimed best-selling author and a physician with an international reputation for his focus on healing in an era when technology often overwhelms the human side of medicine.

Robin Cook, MD, has written dozens of medical thrillers. He also co-founded an internet software company and is an investor/partner in a New Hampshire sports complex and a New Hampshire ski area. He splits his time between Florida, New Hampshire, and Massachusetts.

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