“He’s not going to take you back,” Rajiv barked, obviously frustrated. He didn’t need to remind me that the hospital had been providing malpractice coverage for my work with Chaudhry. Now, if I were going to moonlight someplace else, I’d have to purchase my own part-time policy—roughly $17,000 a year—which I couldn’t afford. Perhaps the best option now, Rajiv suggested, was to do private practice full-time. Before I could respond, his mobile phone rang. “Hello! Rajiv!” He listened for a few seconds. “Oh, yes, boss,” he said pleasantly. “How are you, boss?” Then he stood up and walked out.
Feeling desperate, I phoned Malik, the physician who performed Chaudhry’s treadmill tests. By then I had learned that Malik, though occasionally helpful, was a bit of a con artist. He had earned a medical degree in Pakistan but hadn’t passed the American board exams, so he wasn’t certified to practice independently (that was why he was working for Chaudhry and other physicians). He possessed a sort of worldly weariness, an international playboy charm masquerading as sincerity. He always said yes in the moment, deciding to worry later about the consequences of false promises. Like a politician, he rarely answered the question you posed, just the one he wanted to answer. But one often continues a farce for the sake of a friendship.
“You have to learn how to play the game,” Malik told me, trying to explain how I could get back into Chaudhry’s good graces. “Your brother knows how to play the game. When he’s with a Muslim, he says salaam alaikum. When he sees a Sikh, he says sat sri akal. Rajiv, Amir, they understand that medicine has become a business. You have to be friendly to have a chance to be successful.”
“I’m not friendly?” I blurted out, sounding pathetic even to myself.
“No, you’re friendly,” Malik said, though I could tell he was lying. “It just takes you time to open up.”
I heard him starting the treadmill. “You have to meet Amir face-to-face,” he said, as the heavy pounding of a patient’s feet began to reverberate in my earpiece. “Ask him what you need to change so you can go back to working every other Saturday. See, you don’t know how to manipulate a situation. If he asks you why internists are not sending you patients, appeal to his ego. Tell him, ‘They don’t want to send us patients because they are jealous of you.’”
I figured anything, even groveling, was worth a try. “So how is Amir’s office running without me?” I asked tentatively.
“It’s busy,” Malik replied. “He is looking to hire someone, even though he still has Ali,” the physician’s assistant.
“What about the echos?”
“Still piled up on his desk. He reads at night. He goes in on weekends. But a lot of the time he’s behind.”
That Chaudhry’s office was operating a bit less smoothly without me was a small but tangible satisfaction. I heard the treadmill speeding up. “So call him,” Malik said. “You have nothing to lose. Remember, he is your brother’s best friend.”
I phoned Chaudhry the following day. I wanted to meet in person, so he invited me to his home on Long Island. I drove there on a Saturday afternoon in the early summer. It was a stately house in Oyster Bay with manicured lawns and a pool and a tennis court about a mile from where Rajiv lived. I parked in the semicircular driveway. Giant gargoyle planters adorned the front porch. His eldest daughter let me in. Waiting in the ornate foyer while she went to get her father, I noticed a wooden plaque inscribed with gold Arabic letters. Underneath was written: “Even if you don’t understand them, these words will ease your daily stress and bring additional income from unknown sources.”
Chaudhry greeted me warmly and took me into the living room. He looked relaxed in shorts and a polo shirt. We sat opposite each other, a glass coffee table between us. My heart was beating so hard that my glasses were oscillating on the bridge of my nose. I started to explain my situation, leaning forward, palms open, in a pose of supplication, but before I could get very far, he quickly and mercifully terminated the conversation.
“Sandeep, you were always late,” he said with the condescending sympathy of an ex-girlfriend explaining why she’d broken up with you. “Ten, fifteen minutes is okay, but one hour? The girls came to me and said, ‘We cannot work with Dr. Jauhar anymore. The patients are coming to the front desk and cursing us.’ No offense to you, my friend, but I don’t think you are cut out for private practice.”
“I am a flawed person,” I said lamely, realizing full well that I had probably sabotaged the arrangement from the beginning—going late to the office, complaining about the work, not searching hard for new referrals.
“That’s fine, Sandeep,” he said, shrugging, “but this is my bread and butter.”
“It’s my bread and butter, too, Amir. I can’t pay my bills without it.”
“No,” he said, “you have a secure job at the hospital. This practice is all I have, and I have to protect it.”
The best he would offer is that I could take more of his doc-of-the-day ER calls. He’d continue to pay me a modest flat fee to answer all his pages and admit all cardiac patients from the ER on a given night who did not already have a cardiologist. As per routine, he would bill and collect all the revenue. He promised to give me a few echos to read, too. It wasn’t a lot—much less than I’d hoped for—but with no leverage to negotiate, I quietly accepted the proposal. With another baby on the way and little in the bank, I had no other choice. For me it was a stay of execution.
* * *
“Mom, these tuna balls are cold! They have to be cooked through, Mohan can’t eat these. Mohan, stop it! Do you want mac ’n’ cheese? Oh God, the clothes are still wet! Only put a little bit of cheese, Mom, not the whole thing! Mohan, we’re making you mac ’n’ cheese, so delicious, do you want it? Sandeep, honey, I’ve got to go!” And then an abrupt click.
Our home life was increasingly frenzied as we prepared for another baby. We talked about putting up a partition to section a small nursery off the master bedroom, but we quickly abandoned the idea. Gerrymandering our tiny apartment wasn’t going to solve our space problem. I felt strangely aloof from all the planning. I wasn’t sure I even wanted another child, and the prospect of paying a second school tuition in three years filled me with dread. Vegetating in front of television sitcoms at night, I’d see reminders of the deficiencies in my life, accentuating my restlessness. For months the only reliable pleasure—transient, empty—was a quick masturbation or a late-night smoke.
Sonia insisted we needed more spirituality in our lives, so we spent a few Sunday mornings at the Self-Realization Fellowship Center on Twenty-eighth Street. Mohan would sit between us in the chapel, where huge wooden oms and stained glass graced the walls. We’d listen quietly to sermons or to a tone-deaf choir crooning “I Will Sing Thy Name.” Everyone at these gatherings spoke softly, deliberately, exuding inner peace (or perhaps cognitive delay). SRF was founded by Paramahansa Yogananda, the Indian guru who moved to California in the 1920s and popularized kriya meditation and yoga with his Autobiography of a Yogi. In the book, Yogananda writes that “one half-minute of kriya equals one year of natural spiritual unfoldment.” Sonia and I tried it a few times, but yoga provided little respite from our ceaseless bickering—over money, over whether (and where) we should move. (She wanted to go to New Jersey to be near her parents; I wanted to be on Long Island, closer to my work.) “You’re so smart, and what did it get us?” she cried out in a weak and tearful moment. “You have a Ph.D. in physics, for God’s sake! You should have done finance or derivatives.”
I, too, was prone to fits of temper, as though my neural circuitry had been pruned to ferry stimuli directly to my amygdala, bypassing reason. Once, I found myself yelling at Terence, the guy answering the phone at Asphalt Green, where Mohan took swim classes on Saturday mornings. I’d been unable to register Mohan online for the new semester. I had called the front office the day before but had gotten the runaround. The woman on the phone had been unable to confirm that Mohan was signed up because the computer was down. She said she’d c
all me back, but she never did. The following day, Terence tried to patch me through to Lewis, the regular guy, but when he couldn’t, I just lost it.
“I’ve spent hundreds of dollars at your school, and no one calls me back!” I screamed into the phone. “I’m going to report you to the administration! I spent an hour on the phone yesterday”—an exaggeration—“and I can’t do this anymore!”
“What do you want done?” Terence asked calmly.
“I want my son signed up for Super Sprites, not Dancing Dolphins, on Saturdays at nine-thirty!” I bellowed. And then I faltered, terribly flustered. It sounded ridiculous, even to me. For a moment there was silence.
“Okay, Doctor, I’ll take care of it,” he said sympathetically.
For a few moments I didn’t say anything. Finally, I said evenly, “His name is Mohan. Last semester he was in Dancing Dolphins, but this—”
“Yes, I know. I’ll take care of it. You’ll get a confirmation e-mail in a few minutes.”
I took a deep breath, and my eyes watered with relief. “Thank you, Terence,” I whispered.
* * *
With the additional doc-of-the-day calls, my life became even more hectic. Every Monday I’d typically get paged all night long. On the phone I’d take down the names of patients being admitted to me and discuss a rudimentary treatment strategy with the ER. Then, early Tuesday morning, prior to starting my regular workday, skipping breakfast and groggy from lack of sleep, I’d rush to the hospital to see the dozen or so patients who’d been assigned to me the night before. The diagnoses were always the same: chest pain, shortness of breath, syncope. Syncope, or fainting, was the most common.
When people stand up, about half a quart of blood initially pools in the legs. This decreases blood flow to the heart and brain, and that would make you faint if it weren’t for a chain of reflexes that kick into action. Adrenaline is released, which speeds up the heart and increases its pumping force. It also tightens up the blood vessels to force the blood northward, most importantly to the brain. The net effect is that when you stand up, you stay up.
For reasons we don’t understand, this response can go awry. The adrenaline surge can lead to vigorous contractions of a heart that doesn’t have much blood in it. The body is fooled into thinking it is physiologically overexcited, so the heart slows down, blood vessels relax, blood flow to the brain drops, and eventually so does the body.
The common faint was enshrined in my adolescent imagination by movies. Remember the beautiful heroine—fainters on film are always women—overcome by shock, touching her brow with the back of her hand, and falling limply into waiting arms? Her faint was stereotyped and contrived—yet riveting. It made fainting seem benign, almost glamorous.
But in the ER, syncope was a decidedly less romantic disease. “Syncopizers”—often elderly patients on multiple medications—were some of the most dreaded patients I saw on my postcall days because I never knew what to do with them. Send them home and I’d worry they’d drop dead from an arrhythmia. Admit them to the hospital and I’d think of all the money being wasted on a most certainly useless diagnostic workup—EKG monitoring, echo, head CT, etc.—that would provide an answer less than 20 percent of the time. (Yet out of fear of missing something, I’d almost always order it.) “Gomers go to ground”—old people tend to fall—was a maxim from residency. Did every demented octogenarian who’d fallen really need to be admitted to the hospital?
Mrs. Hines had an egg-shaped welt on her forehead and two black eyes, like a raccoon’s, the result of a flop on her kitchen floor. She was in her late eighties, carried a diagnosis of dementia, and took about twelve different medications, including two that can cause orthostatic hypotension, in which blood pressure drops precipitously on standing. “I’m going to take her home,” her husband said when I went to see her in the ER in the very early morning. “She doesn’t need to be here.”
“Then why did you bring her in?” I said, barely suppressing a yawn and thinking ahead to the seven other patients I had to see: Eleanor Murphy, also with syncope; Jose Ruiz, two days of left leg numbness, cardiac enzymes borderline positive; Fumaria Raghavan, shortness of breath and palpitations for three days, now with slurred speech …
“I don’t know,” Mr. Hines replied, nonplussed. “Home attendant told me to. I made a mistake.”
She was lying on a stretcher, her hands clasped across her chest. She appeared disoriented. “My toes are broken,” she said. “A bar of wood fell from the shed.”
“I was told you fell in your kitchen, ma’am,” I said.
Momentarily, she looked perplexed. “No, it was out in the fields, I think. I was with people. They didn’t tell me not to be there.”
I examined her digits. “Your toes don’t look broken to me.”
“Yes, they’re okay now. See, I can wiggle them.”
I took out my stethoscope. I asked her if she felt dizzy. She said no.
“Have you ever gotten dizzy?”
“No.”
“Are you sure?”
“Yes, I’m sure.”
“I was told you came in because you were dizzy.”
She thought for a moment. “Yes, I get dizzy sometimes, but only after I fall.”
Dizzy from a lack of sleep, I felt like falling over myself. There was no doubt that after such a traumatic spill she would have to be admitted. I slipped my stethoscope under her gown. After a few seconds she pushed me away. “That’s it, no more, no more.”
“Excuse me?”
“No more freebies, sonny.”
“I’m sorry?”
“You know, feeling me up. Getting something for nothing.”
I had to laugh. “I just need to examine you, ma’am.”
“I’m not sick!”
“Then why are you in the hospital?”
“I like to come to the hospital,” she replied. “There are smart people here. Good people, bad people, dumb people.”
I helped her sit up so she could dangle her legs. I was trying to reproduce her symptoms by causing blood to pool in her lower extremities, setting off the fainting cascade. If she didn’t feel any symptoms or if her blood pressure didn’t drop, I was going to stand her up to stress her even more.
It didn’t get that far, though. After less than a minute of sitting, she said she was faint and closed her eyes. When I checked her blood pressure, it had dropped fifty points. The test was positive; we could stop. I tried to tell her, but she was already out. I called for a nurse and moved on to my next patient.
With so many patients to see after a call night, things would sometimes get mixed up. I remember one patient, Ajit Singh, a Sikh man with congestive heart failure who was about to be started on dialysis. He was sporting a red turban and a long white beard, tied into small knots. “Do you get short of breath?” I asked him in Punjabi, thumbing through his chart.
He nodded. The chart said he had renal failure, a consequence of his heart disease. There was a plan to place a catheter in his arm to start dialysis, but when I mentioned this to him, he pretended to know nothing about it. I pointed to his wrist, where the fistula would go in. Yes, he said, they had put a needle in his vein not long ago, some test. I explained to him that this was a sign that his kidneys were about to fail and that he would have to be hooked up to a machine to clean his blood three times a week. He stared at me, in shock.
A nurse walked in. “Mr. Singh is in the other bed,” she said. I’d been talking to the wrong patient!—though one who also had heart failure. (The nurses often roomed patients with the same diagnosis together.)
Fool! I screamed into my head. I quickly explained my mistake and apologized. Instead of being upset, the patient was effusive. “Thank you, thank you,” he said in Punjabi, clasping his hands together and obviously relieved. “Next only to God is the doctor.”
My doc-of-the-day patients were often frustrating to manage, and not just because of the volume. A big reason was their limited resources. They rarely saw a doctor
regularly, and poverty and lack of health insurance or social support were constant stressors in their lives. A social worker on one of my cases told me that for most patients, domestic problems or destructive habits were entrenched. There was little that could be done for them in the hospital, and patients were often lost to follow-up after discharge. She did the best she could, but there was only so much that could be done. Though she was trained as a clinical psychologist, most of her work revolved around mundane issues like insurance forms and discharge planning.
Juana Morales, in her late thirties, was writhing when I first met her: mouth foaming; teeth clenched; in severe abdominal pain, which a cardiac catheterization confirmed was due to heart failure compromising blood flow to her gut. A blue plastic tube was feeding oxygen to a pressurized ventilation mask that was strapped tightly to her face. A nurse was at the bedside, adjusting the oxygen. “What do you want me to do?” she asked me impatiently. “Morphine, Lasix, albuterol, what?”
“Let’s try Lasix first,” I replied.
“Caliente, muy caliente,” the patient cried when her mask was briefly taken off, complaining about the temperature in the room. Her husband was with her, along with their eight-year-old son. They were from Ecuador. Father and son looked alike, sporting dark hair spiked with gel and pressed Le Tigre shirts and crisp blue jeans. Her husband demanded to know why we couldn’t adjust the air-conditioning for his wife. “The heat is not good for her,” he cried. “She can’t breathe.” I told him I would request that the thermostat be adjusted, but that her shortness of breath was due to heart failure, not the temperature in the room. She would require intravenous medications to relieve her symptoms.
She had no health insurance, though the chart stated that her husband did. I asked him if she had a green card. Immigration status was going to be very relevant in deciding how we were going to manage her. As a cardiology fellow at NYU, I had treated several illegal immigrants with end-stage heart failure. Usually there were hospitals in their native countries that performed heart transplants, but if they went back home, they would not be allowed to return to America, so they almost never wanted to discuss that option. (And none of them could afford transplants in their native lands anyway.) In many cases, the only hope for an illegal immigrant with end-stage heart failure was to raise the quarter of a million dollars for a cardiac transplant herself.
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