Before I could finish writing, Guruji suddenly spoke up. “What do you say now? Talk!” he commanded.
An elderly woman in a drab yellow and purple sari made an appeal on behalf of her sick mother. “When she takes her medicine, she gets tight in the shoulders and shivers,” she said.
“How old is your mother?” Guruji asked gruffly.
“Ninety-four,” the woman replied.
There was silence, as Guruji appeared to collect his thoughts. “It will go away in due time,” he said. People began to laugh.
“But it is only you, Guruji,” the woman persisted, seemingly oblivious of the morbid joke. “Your powers are keeping her healthy.”
“She is ninety-four!” he cried. “You worry too much about your mother.”
Sonia’s father stood up. He was now wearing beige kurta pajamas and had a streak of red powder on his forehead. “Guruji, this is my son-in-law, Sandeep.” All eyes turned to me. “I mentioned him to you before. He is a doctor and a writer. He writes for The New York Times.”
I nodded respectfully. My father-in-law’s remarks were a bit surprising to me because he had long attributed my problems to identity confusion. “You have to decide what you want to be,” he’d said to me many times. “Doctor, writer, father—you have to make some choices.”
But now, before the group, he evinced only caring and pride. “He is a physicist and a scholar, too,” my father-in-law continued. “But his mind is restless. I would request you to speak with him.”
Guruji regarded me with intense curiosity. No one spoke. “So what is the problem?” he said.
A warm wave washed over me, and my mind started to race: I don’t know. On the surface things seem all right, yet I feel unsettled. I keep thinking there is something to worry about, but I can’t remember what it is. I am waking up with a fear that things are going to fall apart. I am dreading it, but it isn’t happening, so I keep waiting, almost wishing it would happen and be over with.
Of course, I didn’t say any of this. I just stared at him. “I don’t know,” I replied.
Guruji smiled sympathetically. “If you have a problem, you must go to the right person,” he said, as though reciting a line he had uttered many times. “A problem with your house, you go to the builder; a problem with e-mail, the engineer. And if you have a problem of spirit, you must take the advice of a guru.”
The woman next to me let out another piercing shriek.
“Disease occurs when one of the five elements of the body is off,” Guruji went on. “If a patient has loose motions, what does the doctor give? Saline through an IV. He treats dehydration with water. When it is cold, he gives you a blanket. For lack of soil in the body, you eat. When you are suffocating, he administers oxygen.”
He stopped, waiting for a response, but no one said anything.
“The fifth element is peace of mind,” he continued. “And what does the doctor do? He gives shock therapy. He treats stress with more stress!”
People murmured appreciatively. The woman beside me was now rocking back and forth and moaning.
“Yogis have a different way,” Guruji continued. “Your mind is the most wonderful computer. Man has made powerful computers, but nothing compares with the brain, which is natural. Scientists have allowed us to send e-mails, but before there were computers, the old yogis were sending e-mails back and forth only through their minds.”
I glanced at Guruji’s buzzing cell phone and nodded.
“My mission is to convey to the world the ancient scientific wisdom of the yogis,” Guruji went on. “The yogis knew that elements could be transformed into others just by changing the number of electrons. You go from four to six electrons, and you can change iron into gold! The yogis have known this for thousands of years.”
He was talking like one of those crackpots who attended the Berkeley physics colloquiums on Wednesday afternoons, spewing theories about things they did not understand. And yet even though I was skeptical and knew his reasoning was faulty, I needed help. I still wanted to hear what he had to tell me.
“The universe is three things: water, matter, and vapor. And these things when you get to a small enough scale all look the same. What is the smallest unit of matter?” he demanded. I hesitated. “Atoms,” he said. “And what is the makeup of the atom?” My mind was blank. “The universe itself,” he answered. “The whole universe is in the tiny atom. The power is all there.” He touched his forehead. “We just need to tap into it.”
People sounded exclamations of agreement.
“There is no question that you will find happiness,” Guruji said, quieting the group. “Just utter this mantra.” He whispered a few words. “If you say this several times a day, you will enter my magnetic field. The physicists have explained that a big magnet can make smaller magnets. Magnets are everywhere: earth, stars, moons, even atoms. If you do this, you will become a magnet, too.”
I nodded, feeling exhausted. Guruji stood up and announced that he was going upstairs to rest. The crowd parted to let him through.
The woman next to me remained on the floor, quietly sobbing. Tissues were wadded up into a ball on the rug. She was unable to speak. Someone said there was a remedy and dashed off to get it. He returned promptly, holding a banana.
Getting ready to leave Edison that night, I still felt the same sense of foreboding. My chest was still tight, a reminder that things weren’t right. Overall, the whole experience seemed to have been a wash. In the expansive foyer, as people were milling around in small groups, chatting, one of Guruji’s disciples came up to me. He was a stocky man in his fifties with a scruffy beard and a short graying ponytail, wearing a khadi jacket, leather sandals, and blue jeans that looked as if they needed washing. “Once you know and accept you are going to die,” he told me with a pleasant glint in his eye, “the future will not haunt you.” It was a line out of one of Guruji’s pamphlets, and he said it had given him succor in difficult times. I turned the dictum around in my head. More than anything else I’d heard that evening, the words had a ring of truth. I thanked him for the advice. Then I went to find Sonia to say goodbye. Shortly afterward I got into my father-in-law’s Mercedes for the ride back to the train station.
TWELVE
Denial
Private practice today is like surfing. If you don’t stay on top of it, you could go under real quick.
—Comment overheard in doctors’ lounge
Sonia had gone to a board review course in Cleveland. When she returned, on a staid, languid Sunday afternoon, Mohan and I went to pick her up at the airport.
In the Lincoln Tunnel on the way there, Mohan, strapped into the child seat in the back of the car, complained, “We’re going so long, Dadda. I can’t see the clouds or the trees or the sky.”
I said it was because we were stuck in a tunnel.
“What? We’re stuck?”
“No, we’re not stuck,” I said quickly. “We’re just going very slow.” I discerned some relief in his face.
“You know what this is called?” I said.
“Lincoln Tunnel.”
“What does the Lincoln Tunnel mean?”
“It goes underwater, under the Hudson River.”
“That’s right!” I smiled proudly, amazed that in three and a half short years my son had already developed into a thinking person.
When we met Sonia at the curb, she cried, “Mohan, I missed you so much, my darling. Did you miss me?”
“Guess what?” he said. “A big blue rocket goes up really fast.”
Sonia smiled. “Does he seem bigger to you? I can see he’s grown, he’s more verbal.”
She’d been away only a few days, but she was probably right. I said, “Mohan, Mama is going back to being a doctor soon. She is going to start working.”
He didn’t respond.
“Mohan, do you want to be a doctor?” I asked.
“No, a nurse.”
“Not a doctor?” Sonia said.
“No, I like nurs
es. They take care of people.”
* * *
I had been taking most of Chaudhry’s doc-of-the-day calls. Over a twenty-four-hour period, several times a month, I admitted cardiac patients from the ER who did not already have cardiologists. However, insurance companies were denying the necessity of (and therefore payments for) about 30 percent of these admissions, meaning a lot of lost revenue for Chaudhry’s practice. Chaudhry had been grousing that I wasn’t bringing in enough money to cover the salary he was paying me, so I became more aggressive about appealing the rejections, which until then I had been ignoring.
“Yes, this is the CareAllies medical director.”
“This is Dr. Jauhar. I called a couple of times yesterday. I know you’re aware of it; but you didn’t call me back, and this is the second time I’m calling today.”
“I apologize for that. What can I do for you, Dr. Jauhar?”
“It is clearly stated in the appeals document that I’ve read and shown to people in my department that you are supposed to take my phone calls.”
“Dr. Jauhar, I’m … there’s nothing I can say. I am sorry we didn’t get back to you in a more timely manner.”
“As you probably know from my messages, I want to discuss the denial on James Castle.”
“I am not able to approve this admission, Doctor. As our nurse informed you yesterday, this chest pain workup did not have to be done in the hospital. I understand you may disagree with this judgment, and you do have the option of an appeal. The best thing is to have your hospital send us a copy of the chart.”
“To whom?”
“To CareAllies, along with the denial.”
“I don’t understand. This was a fifty-four-year-old smoker who was having palpitations and chest pain. Why do you feel he didn’t need to be admitted to the hospital?”
“Doctor, I am not in any way questioning the services that you rendered in an extremely timely manner. But those services could have been done under an observation level of care.”
“But we don’t have an observation unit at my hospital!”
“I am sorry, Doctor, but that does not oblige us to pay for a level of care that was not warranted.”
Whatever the case, it meant Chaudhry and I weren’t getting paid. I sent in the required paperwork, filled out the appropriate appeal forms, and followed up to make sure they were received. But we never did get reimbursed for that admission.
When I checked with Liam, a billing clerk in my department, he told me that payment denials by managed care companies had become routine. “You have to take out the shovel and dig hard to get paid what’s rightfully yours,” he said. “By the time I’m done digging, we probably get paid about eighty percent of the time. But it isn’t easy. They have all sorts of excuses: ‘didn’t get billed right,’ ‘didn’t get it on time.’ Come on, ‘didn’t get it on time’? I have three confirmations, and you’re going to tell me you didn’t get it on time? Please. Sometimes they won’t release the funds; then you ask them and they say, ‘Oh, yeah, now I see. Don’t know why that wasn’t paid. I’ll release the funds.’ My boss hears me saying on the phone, ‘How’s the baby, Alice?’ and there’s a reason for that. You have to get the insurance company on your side. I can’t say, ‘Hey, I want to get paid.’ I have to say, ‘How are you?’ That works better than anything else.”
As the months wore on, Chaudhry was beginning to sound irritated whenever we spoke. “I thought I was making money on you,” he said on the phone one morning. “But when Jean, the biller, sent me this report, I had no choice but to talk to you and say, ‘Sandeep, this is ridiculous.’”
I closed the door to my office so the conversation would not carry into the hallway. “I can give you some money back,” I said quietly, even though I knew it had already been spent. “I don’t want to keep your money if it isn’t being earned.”
“Any investor will invest if the revenue is coming in,” Chaudhry said, ignoring the offer. “The problem is when the revenue is not coming. You know how much I am now getting for stress tests after expenses, Sandeep? Two hundred dollars. You know how much Oxford is paying me for a new consult? Ninety-eight dollars, and only twenty-two for a follow-up! I am taking home just enough money to pay my bills.”
I was dubious, but I kept quiet. I needed to keep the moonlighting going for as long as possible, and I was afraid of saying something that could make Chaudhry terminate the deal. Nonetheless, I didn’t know how much longer I could go on denying the unseemly reality of it all.
“The problem, Sandeep, is that your hospital patients are not following up in my office for tests,” he said. I told him that I had been handing out his business card and offering the patients timely appointments to see me on Saturdays when I came to the office. I did not understand why they weren’t coming.
“Hospital patients have their own doctors,” Chaudhry explained in the pedantic tone he had increasingly been using with me. “When they go back to their internists and ask for a referral for Chaudhry or Jauhar, the internist will say, ‘Why are you going there? Go to this other cardiologist. I know him.’ So the chance of those patients coming to us is maybe five or ten percent. What you are doing is not wrong. This is just the dynamic of private practice.”
In order to capture more of my doc-of-the-day admissions, Chaudhry told me that in addition to passing out his card, he wanted me to call Samantha, his office manager, with every patient’s demographic information, as well as to fax her the insurance information. Though I was offended at having to do such scut work, I said I would.
“If you want to increase your revenue, Sandeep, you have to get into the practice,” he urged. “We must figure out why more doctors are not sending us patients. What is the reason?” He mentioned that even Dr. Oni, the Nigerian internist, had stopped referring patients to the office.
Oni had been one of Chaudhry’s most loyal referral sources, supporting him from the time Chaudhry opened his practice in 2002. When I started taking ER calls, Chaudhry had instructed me to refer my patients to Oni for general medicine consults to give him some extra business. I had done this for a while, but in recent months I’d stopped.
“If you send one or two extra patients to Oni, it will help us in the long run,” Chaudhry lectured. “See, this is called connection. At the end of the day everybody should be happy. I’m not saying send every single patient to Oni—you don’t want people to think it is automatic—but keep him in the loop. How did I get a connection with Dr. Mazer? If I have a GI issue, I use him. If he has a cardiac issue, he uses me. This is called channeling.”
Chaudhry proposed a new plan. He wanted me to start seeing patients at various internists’ offices where he was paying rent (essentially a fee to sit on their premises and see their patients), referring those patients back to his main office if they needed cardiac procedures. “Right now I am giving you a piece of my pie, but we have to make the pie bigger if we want this to work.”
I told him I would try.
“You will be a great asset to me if you can go to Ozone Park,” he said; it was about an hour’s drive from my apartment. “I also have a connection in the Bronx. Just give me a few months the way I am explaining, and you will see a huge difference in your revenue.”
“What about stress tests and echos?” I asked. By now I had learned the real money was in testing.
“I can give you some studies,” he said. “But then you have to come to the office to read them. The problem, Sandeep, is that you don’t want to come. See, everybody wants to spend time with their family, but you have to make some sacrifice, too. Until you invest time and energy, how do you expect to make more money?”
I could tell he felt obligated to give me another chance, and for a moment I actually felt sorry for him. I felt undeserving of his patience and saddened that he felt coerced by his friendship with Rajiv to continue to work with me.
“You have to be a little lovey-dovey with patients, Sandeep. Private practice is lovey-dovey. Let’s say I a
djust the antihypertensive. I will tell the patient to come back in a few days to check the blood pressure. If I am ordering a test, I will tell them to come back to discuss the results.”
“Sure, boss,” I said, just wanting to get off the phone.
“Look, I am very fair,” he said. “You and me should promote together. Let’s take out an hour from our busy schedules and meet some physicians in Queens. Once they see us together, maybe some of your brother’s friends will start sending us a few patients. If you could get one or two internists who are not sending me patients to start sending you patients—if I can get four or five new patients a month through you who are getting everything done in the office—then it is a plus point. That is all I am asking. I am not asking for a hundred percent of their business.”
I told him that I would try to make this happen. When I got off the phone, I felt nauseated. I took a deep breath, and a dry heave welled up in my chest. Water filled my eyes. It was all I could do to keep from vomiting.
THIRTEEN
Deluge
Midway on our life’s journey, I found myself
In dark woods, the right road lost. To tell
About those woods is hard—so tangled and rough …
—Dante, The Inferno, Canto 1, translated by Robert Pinsky
To his credit, Chaudhry did try to make it work. We experimented with different arrangements—seeing patients in Valley Stream, reading echos in Richmond Hill, even doing stress tests on weeknights after I left the hospital—but nothing gelled. For a few months I even went to an office in Harlem, not far from where I lived, where Chaudhry rented space from a jowly, phlegmatic Bangladeshi internist who seemed to think the world of himself. On my first day he gave me a tour of the facility, which occupied the entire second floor of an industrial office building next door to a McDonald’s. “You are from India?” he asked with a strong accent.
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