“Good morning, Dr. Jauhar,” Samantha said cheerfully when, having nearly slipped on the front steps, I arrived at 9:00 a.m. Pulling off my coat, I nodded a perfunctory greeting and brushed past her to my office. “I’ll tell Malik he can get started,” she called after me. “There are already four patients waiting to see you.”
On my desk were stacks of lab results and radiology reports to review and a few echos to interpret. I set them aside and brought in the first patient.
He was a thin black man smelling of liquor and cigarettes who said he’d been instructed to see me prior to undergoing a hip operation. Before he even sat down, he told me he wasn’t going to have a stress test. He had had one a few years back, some outfit in Forest Hills, but he couldn’t recall where exactly. “Just clear me so I can have my surgery,” he said.
“That’s not how it works,” I replied, logging on to the computer.
“Oh, so you tell me how it works,” he retorted.
“You’re going to have to wait till I do my evaluation,” I said. “I don’t want you to waste your time or mine by telling me how to do my job.”
“I’m not doing no stress test,” he insisted.
“That’s fine,” I said, raising my hand to quiet him. “I don’t care.”
“Well, I know you don’t care. What do you think I am, stupid?”
He had been a construction worker but had been unable to work in recent months because of pain in his hip. The hip surgery had been put off because of his drinking, which had caused abnormalities in his blood count. I asked him if he had brought a list of his medications. He nodded. We stared at each other for a moment. “So let me see it,” I snapped. He laughed, then reached into his bag and pulled out a large Ziploc bag with twelve bottles. I entered the drugs into the computer. I asked him if he was taking any other prescription drugs. He said he had left a few at home.
“Are you taking a beta-blocker?”
“Yes.”
“Which one?”
“I don’t know.”
“Is it atenolol?”
“Yes.”
“Or Toprol?”
“Uh, yes.”
“Coreg?”
“Yes.”
“You were taking all three?”
“I think so.”
“That’s impossible. They’re all the same type of drug.”
He waved his hands dismissively. “I don’t have no problem with my medicine.”
“Well, were you even taking a beta-blocker?” I said. If not, I would need to start one to minimize the risk of the operation.
“I don’t know. Every doctor I go to changes my medicine.”
“Who is your primary doctor?”
“He’s on the side.”
“Which side?”
“That side.” He pointed at the back wall.
“What’s his name?”
“Singh … Singh something.”
I sighed. He smiled, apparently finding our jousting amusing. “I can’t believe I’m paying for this kind of abuse,” he said.
“I’m not getting paid enough to listen to you,” I retorted, though I was beginning to like him.
“Listen, kid—”
“Who you calling ‘kid’? I’m almost forty.”
“Wow, you look good.”
“Well, I don’t drink.”
“Oh, when did you quit?” I shot him a look. He smiled impishly. “Oh, you mean you never drank!”
And so it went on for several more minutes. After inputting his history into the computer, I told him I needed to examine him. He got up on a vinyl exam table covered with protective paper bearing a drug company logo. I asked him to hold his breath so I could listen to his heartbeat. He continued to breathe rapidly. Through the wall I could hear the thump-thump-thump of heavy steps on the treadmill. “Walk, walk,” I heard Malik bark. “Stand straight … Don’t look down … Look up!… Walk!” I pictured some overweight Indian bhainji in a sari and sneakers trying to keep up with the moving floor.
“Do you ever feel short of breath?” I asked my patient, putting away my stethoscope.
“Sometimes.”
“What about over the past twenty-four hours?”
“Well, I breathe through my mouth.”
“But do you get short of breath?”
“Sometimes.”
“What about in the past twenty-four hours?”
“Like I said, I mostly breathe through my mouth.”
“Okay, let’s try one more time. Do you get short of breath?”
“Yes!”
“What about in the past twenty-four hours?”
“No, I’m okay.”
A short while later I was recording my exam when Denis, the technician, walked in and asked me to come to the procedure room. “Patient is not feeling well,” he said drily.
I took a minute to finish up with my patient. I told him that because of his cardiac risk factors and my inability to assess his exercise capacity resulting from his hip pain, I was going to order a stress test with the drug Persantine, used to evaluate the hearts of patients who are unable to exercise. Once it was completed and interpreted, and assuming it was normal, I would write a note to his internist clearing him for the surgery. To my surprise, my reasoning seemed to satisfy him, because he immediately agreed to this plan. I told him to see Samantha at the front desk to make the arrangements. Then I hurried across the hall to the treadmill room. An old lady was sitting on an exam table, eyes closed, teetering precariously. She had a head of bushy gray hair on a thin stalk of a neck, like a dandelion. Dark coffee stains marred her misshapen teeth. A young woman was at her side, trying to support her.
“She started feeling dizzy at the end of the infusion,” Malik said, referring to the Persantine drip he was using.
I asked him if he had administered aminophylline, the antidote.
“I have it here,” Denis announced, holding up a syringe. “She was doing fine the whole time. Just at the end—”
“What is she feeling?” I broke in, irritated by the interruption in my schedule. “What’s wrong, ma’am?”
“She doesn’t speak English,” Malik said. He said something to the young companion in Urdu. She repeated it loudly for the old woman, who said something in a dialect I did not understand.
“She feels weak and fatigued, and she has a headache,” the young woman said.
“I am ready with the aminophylline,” Denis reminded me.
“Well, what are you waiting for?” I barked. “Open your eyes, ma’am! Open…” I turned to her companion. “Can you tell her to open her eyes?”
When she did, bloodshot conjunctiva stared blankly at me. The young woman said something.
“What’s wrong with her eyes?” I asked.
“I forgot to tell you, she is blind,” Denis replied. After hooking up the syringe to her IV, he injected the aminophylline into her vein. We waited. The teetering gradually lessened. After about a minute, the old lady said she was feeling better. With Denis and her companion on either side, she stood up and was escorted to the nuclear camera to begin image acquisition. Malik tapped on the keyboard to close his report. Dreading having to see another patient, I returned to my exam room.
In the late morning I took a short break and walked up Jamaica Avenue to a nearby deli for coffee. It was one of those hole-in-the-wall joints doubling as a convenience store. The burly guy behind the counter was scraping the grill, metal on metal, waiting for an order. I ordered an omelet sandwich and poured myself a cup of coffee. The Persian cashier demanded to know why I had taken two cups. I told him that the coffee was too hot, that it was burning my hand. He gave a surly laugh. “I don’t care, man, take all the cups. Throw them out. I don’t care.”
And so it went for the morning and early afternoon. One patient I saw was a Caribbean woman with a bewitched look who nodded off while I was examining her. I called her name a few times, getting ready to shake her, before she woke up. I asked her what was wrong, but she
didn’t seem to know what I was talking about. I kept pushing her, but she was infuriatingly noncommittal. (“How are you feeling?” “Not so bad now.” “Are you back to normal?” “Almost.” “Are you weak?” “A bit, but better.”) For a moment I wondered if she’d had a seizure, but she seemed so normal afterward, not at all confused, so I let it go. I sent her to an adjoining room for an echo. A few minutes later, Eva, the sonographer, came out and told me the patient was “twitching, like.” When I went in, she was lying completely still on a vinyl procedure table. She did not respond to her name or to my repeated entreaties to tell me what was wrong. What finally got her attention was when I threatened to call an ambulance.
“What for you going to call an ambulance?” she said, opening her eyes.
I told her I was afraid she was having a stroke.
“No, I get these vibrations sometimes,” she explained. “Just the spirits calling me.”
And was she taking medication for this condition?
“What for, medicine?” she demanded. “Just ask my son, this happen to me now and then.”
“Well, please don’t do it here,” I said.
“You think I can control it, Doc? This been happening all my life.”
“Well, if it happens again, I’m sending you to the hospital.”
Though she was obviously annoyed, the spells stopped for the remainder of the procedure.
Between patients I quickly reviewed echos and nuclear scans. By then I had learned that the company providing echos to Dr. Chaudhry was run by his cousin Faisal, a chubby, mealymouthed fellow who occasionally stopped by the office to make sure I was reading his studies. The pictures were often difficult to interpret, blurry from either too little ultrasound signal or too much. But Chaudhry had instructed me not to write “technically limited” on my reports because it reflected poorly on the company.
“Amir set me up when I came here in 2006,” Faisal once explained. His company was performing echos for internists and family physicians all along the South Shore and Queens. He told me companies like his were doing many things: mammograms, bone density radiographs, carotid ultrasounds, even nerve conduction studies. “Most internists are only doing EKGs in the office. If you chip in another service, they like it.”
He said that doctors wanted everything done in their offices so they didn’t have to worry about their patients’ venturing out and being snatched up by another physician. Moreover, the imaging companies were paying them a couple of thousand dollars a month in rent. “But it isn’t free money for them,” Faisal said. “They have to give us patients to do echos on,” which would then be reimbursed to the company by insurers. And what was in it for the patients? I asked. He replied: “Patients don’t want to do a lot of driving. If you see a 7-Eleven and a Shell station, which one will you prefer?” He paused for a moment and then answered his own question. “The Shell station—because it has gas and coffee. The 7-Eleven only has coffee.”
He told me that some of his competitors were outsourcing test interpretations to India, receiving reports that were generated by a machine, not a physician.
“Is that legal?” I asked, dumbfounded.
He laughed. “The market is so bad since the Russians came in. They go to school for echo; then they buy a machine and start doing tests. A doctor I know was working with one of these companies. I asked him to send me a male and a female report. They were exactly the same: same measurements, same conclusion, everything. It was all made up. Only the name was different. See, we are professionals, Dr. Jauhar. Not like those other guys.”
By the time I was finished that Saturday afternoon, I had made up my mind I was going to quit. I was seeing so many patients, reading so many unnecessary tests—and Chaudhry was keeping most of the revenue anyway. Working with Chaudhry, I’d decided, was like allowing your eyes to close momentarily while driving late at night. You know it isn’t a good idea. You know your judgment is impaired. But you think you can control it.
I popped my head into the treadmill room to say goodbye to Malik. He must have seen something in my expression because he put away his reports and asked me to sit down. I didn’t want to talk, but I sat down anyway.
“Look, I can see you’re unhappy,” he said as I fidgeted like a student at the headmaster’s office. “When you leave fellowship, you have this idealistic notion of the way things should be. All this running around burns you out, but it pays off in the end.”
I nodded impassively.
“Amir is a businessman, you understand,” Malik went on. “That’s the way you have to be if you want to survive today. In my neighborhood I see electricians and plumbers. Time was, those guys couldn’t afford to live in a doctor’s neighborhood, but now they’re making more money and doctors are making less. The status has changed.”
Eva came in to tell me that my car was blocking the driveway. Always the last to arrive, I was usually the first to leave, too. I told her I’d be right out.
“Most doctors want to help people,” Malik said. “But to make money for the ex-wife or the fancy house, they are starting to do stupid things. I know doctors who are doing treadmill tests on patients with emphysema who cannot exercise. Their heart rate doesn’t budge, but they inject them with the isotope anyway. They know it’s useless, but they don’t want to lose the revenue.”
“It’s fraud,” I said, unable to hide my disgust.
“It is,” he said calmly. “Deep down they know it’s wrong, which is why they are so depressed.”
It occurred to me that this assessment might also apply to me. I had been practicing a sort of ethics of double effect. The double-effect principle, as I had learned at the hospital ethics committee a couple of years back, states that actions in pursuit of a good end are acceptable even if they result in a negative outcome, as long as the negative outcome is unintended and not a direct consequence of the good one.
In my case, I had been trying to meet the expenses of my family. I was putting in the extra hours so that my son could go to an independent school, not the overcrowded local one. The waste, the overtesting, were unintended, a function of circumstance. I didn’t want to participate in this deception, but at the time it seemed the only way I could remain in my apartment, pay down my debt, and give my family what I thought they deserved. Of course, good intentions didn’t exonerate me. Even beyond the wasted money, what about the false positives, the radiation exposure, the downstream invasive procedures? Even if I wasn’t primarily responsible, even if I was just the guy following up on tests that other doctors had ordered, the consequences were the same. I used to despise the unethical behavior of doctors in private practice, but in reality I was no better than they were.
“I often wonder, Why am I doing this?” Malik said, as though reading my mind.
“Why are you doing this?” I asked.
“Because, like you, I have to pay my bills. But one place was so bad I had to quit. They were doing stress tests on healthy eighteen-year-olds who could run fifteen minutes on the treadmill without even breaking a sweat.” He shook his head, as if to banish an uncomfortable thought. “You think New York is the worst? No, Dr. Jauhar, this kind of stuff goes on everywhere. West Coast, New Jersey—it’s just the degree.”
I slung my bag over my shoulder and got up. “Just try to be accommodating,” he said gently, reaching out to stop me. “In the beginning, when I go to a new place, I go the extra step. Then they become dependent on you, and you can do what you want. But if you show that you don’t want to do this, Chaudhry is just going to get someone else. There is only a finite amount of work, but an infinite number of doctors who are prepared to do it.”
I nodded and moved to leave.
“You are very principled,” he said. “But in the end, what does it get you if you go home and have a headache?” He gave a small laugh. “Anyway, make your decision and let me know. And maybe I’ll see you next Saturday.”
Outside, the sun was blazing, though the temperature wasn’t much above fr
eezing. I backed out of the driveway. The neighborhood was teeming with ethnic life. I drove past farmacias, halal butchers, and ninety-nine-cent taco stands. Steam rose from gutters. The whirring of the treadmill—dum-dum, dum-dum—kept reverberating through my head.
In the car I called Rajiv. If I’d expected any sympathy from him, that hope was quickly dashed.
“You don’t understand!” I said as the conversation got heated. “You’re his best friend. You don’t have a business relationship.”
“He created his empire,” Rajiv snapped. “What incentive does he have to pay you more money?”
“How much do you suppose he makes on any given—”
“That is none of your concern! He is giving you an opportunity.”
“Fine, but suppose he makes seven hundred dollars—”
“You are such an asshole! It’s like Dad all over again!” he bellowed, referring to my father’s lifelong discord with colleagues. “I want to pull my hair out when I talk to you, because you just don’t get it. Or you don’t want to get it.”
“Calm down,” I said. “I’m not saying—”
“What are you going to do if you can’t find other work? They’re going to foreclose on your apartment!”
“Okay, stop.”
“Like Dad, you’re going to screw this up and then try to fix it afterward. God, I wish I had never helped you. He is twenty percent of my cath volume! You’re going to screw up my relationship with him, too!”
“It’s not like that,” I said weakly.
“He calls me and tells me you are late to the office. Why can’t you get there on time? He is trying to run a business!”
“Listen—”
“Why don’t you understand, Sandeep? You need him! He is helping you in your time of need. A year ago you were crying in my backyard. Now you’re showing an attitude?”
“Stop. Just listen—”
“No, I am sick of you! You’ve got a good thing going, and you still don’t know how to be happy. Like Dad says, you love blowing on cold milk.”
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