I didn’t want to take another handout from Sonia’s father, so in desperation I again reached out to Chaudhry’s associate Malik to help me find additional work. At first he counseled caution—“you don’t want to get involved with doctors you don’t know”—but eventually he relented and suggested a few practices. So for a couple of months I found myself zipping around Queens and Long Island after my regular workday, rushing to make six o’clock meetings with internists or owners of testing facilities looking for someone to do their cardiac work. Malik’s friend Rakesh, a former stress test technician at NYU who was trying to build a business as a nuclear isotope supplier, frequently accompanied me to these conferences. Rakesh was a wiry Indian with a nervous smile and an unfortunately severe stammer. He once took me to meet a Malaysian businessman who called himself Johnny Miller. The meeting was to take place in a sterile office building in Jericho, New York, called (appropriately enough) the Atrium. We arrived a bit early.
“He wants to open up f-f-full-service cardiac centers with consultation and imaging,” Rakesh told me while we sat at a Starbucks next door, plotting my strategy. “He’ll s-s-say a lot of things, d-drop a lot of names. I don’t know whether he’s knowing these people or not. Best to say as l-little as possible. Don’t say two words when one will do.”
“He sounds like a crook,” I said, already regretting that I had agreed to come.
Rakesh started laughing. “You try to G-Google him, and nothing comes up, no trace of him or his company, yet he claims to run a multimillion-dollar business. I don’t know if he’s hiding his money or using a false name or whatnot, but that is none of your c-c-concern.”
“I’m not sure this is going to be such a good fit,” I said nervously. Just being at that strip mall felt shady, illicit—and sort of titillating, too.
“Just s-see what he has to say. Make it w-w-work for you.”
Inside the building we took an elevator to the second floor. The wood-paneled hallway was carpeted in vomit beige. A woman came out to greet us and took us into a conference room, where we sat at a table and waited.
Before long, Mr. Miller came in. He was a jowly, dark-skinned fellow with shiny white teeth and a sort of affected nonchalance. He started off by making strange small talk, asking me personal questions, the origins of my name, whether it was Muslim, and so on.
“I grew up in Kuala Lumpur,” he said. “There were many Muslims.”
“No, no, he is H-Hindu,” Rakesh assured him, as I looked on awkwardly. “He is from Punjab. Some went to P-P-Pakistan in the Partition. Some stayed in India.” Mr. Miller immediately appeared more at ease.
He eventually got around to telling me that he wanted to create full-service diagnostic centers where doctors not only would do procedures but would evaluate and manage patients, too. “Otherwise you have to keep feeding the primary care physicians for referrals,” he explained. “Then we are no better than Daval Diagnostics.” He told me that he already had a cardiologist on the payroll but that he needed to find a replacement because that doctor wasn’t board-certified. “He’s not proud of it. He’s studying for the board exams now. But there you go,” he said with a dismissive flick of the hand. More and more insurers, Miller explained, were refusing to pay for echos and stress tests ordered by non-board-certified cardiologists. “The last two patients we saw, we couldn’t bill for any noninvasive testing. One patient had asthma with coronary risk factors. You should do an echo, right?” Before I could respond, he said, “But we couldn’t do it. There’s no point doing the studies if we are not going to get paid.”
He had previously worked with a doctor who had been billing tests with his own provider number (something I didn’t quite understand), so all reimbursement checks had gone to him rather than to Miller. That doctor had left Miller high and dry. Miller said he was owed over $30,000. So that relationship had been a disaster, too.
“For echo, we get about three hundred dollars,” he went on. “For nukes, about six hundred and fifty. You can still make money on nukes, but I have to pay the technician, buy the isotope, cover the lease fee.” He was muttering numbers—“twelve thousand, sixteen thousand”—computing in his head. Finally he said, “So I am prepared to pay you forty dollars per echo and fifty-five for a nuclear reading. But the rest of the insurance money has to get paid to us in the form of rent. Fee splitting is illegal, and I don’t want to do anything illegal. The last thing I need is to get anyone else on my ass.”
He asked me when I wanted to get started. I told him I’d get back to him.
A few weeks later, Rakesh told me that Mr. Miller had disappeared. Rakesh had left several voice messages that had not been returned. “It’s a b-b-bad situation,” he said nervously. “B-b-best not to g-g-go there.”
Of course, I felt disgusted with myself. Four years earlier I’d decided to specialize in congestive heart failure because I wanted to develop long-term relationships with patients. I’d made what I considered a moral choice; income wasn’t part of the calculation. Now everything had been turned upside down. The words of Dr. Dowton, my medical school commencement speaker, often flashed through my mind: “Work out what things in life you care about, the beliefs you hold near and dear, and stick to them.” I’d been so busy trying to navigate the new world in which I had landed that I hadn’t given much thought to this advice. The past four years at LIJ had been such a turbulent time, both professionally and personally. I’d been so occupied with the heavy lifting of establishing my career that I hadn’t given much thought to my “value system” or to the kind of doctor—and I don’t mean specialist—that I wanted to be.
But now, as I was skirting the murky border into knavery, a decision was at hand. When I stepped back and looked at what I’d been doing for nearly two years, I almost couldn’t believe that I was the same person who had decided to become a heart failure specialist. I had been buoyed by the force of a nebulous idea: that it wasn’t really I who had subverted the ideals with which I’d entered my profession—giving paid talks for pharmaceutical companies, working with someone like Chaudhry—but some other person being forced by circumstance. However, this rationalization was starting to break down. I was rapidly approaching the point where I had to make another moral choice.
Malik knew an internist named Anwar Hasani on the South Shore of Long Island who was doing very well—making close to a million dollars a year, Malik claimed—and needed a cardiologist to read his studies. “How is it he’s making more than five times what an average primary care doctor makes?” I asked. “Is it just about procedures?”
“Of course it’s about procedures,” Malik replied, “but how do you get procedures? Some guys have no clue how to do it. I told one doctor I was working for, this patient can get a thyroid sonogram, this one a kidney ultrasound, that one a nerve conduction study, peripheral vascular, carotid, echo, stress echo, but he had no clue how to make it happen. Guys like Amir and Hasani treat it as a business. Do the study as long as it isn’t illegal. The patients don’t mind.”
By then I had seen enough of the underbelly of private practice to be unfazed by such a sordid remark. “Who reads his studies now?” I asked.
“Some guy named Ferraro. But they had a falling-out. He is looking to make a change.”
Malik took me to see Hasani one evening after work. We parked next door in the lot of an electronics emporium. “Don’t tell Amir I came with you,” Malik said, furtively checking the rearview mirror. “He hates Hasani.”
“Why?”
“He used to read Hasani’s studies, but Hasani never paid him. He owes him a lot of money.”
Wearily, I opened the car door. I could hardly believe I was spending another evening away from my family.
“Hasani wants to do more carotid ultrasounds,” Malik said.
“I don’t read carotids,” I said immediately.
“Well, hear what he has to say. He has a lot of volume. He could open a lot of doors for you.”
“Honestly, I don’t k
now if I’m going to have the time,” I said, just wanting to go home.
“If you spread it on the table, it won’t be as much work as you think,” Malik said encouragingly. I stepped out of the car. “Just remember, he is a businessman,” Malik said in parting. “He is going to lowball you. That’s why he drives a Bentley.”
Hasani kept me waiting in his cramped office for half an hour while he discussed something with his office manager. (Malik remained in the parking lot.) When Hasani finally walked in, I was feeling unusually edgy. I had just scratched a scab off my shin. Blood was trickling down my leg as I swabbed the wound with my bare, reddened fingertips. Unperturbed, he handed me a box of tissues.
He was in his mid-fifties, a short, balding Egyptian with a stethoscope draped over a fashionable beige turtleneck. He sat down in a red leather chair behind his desk. He spoke slowly and deliberately, with the confidence of the owner of a successful enterprise.
“The most important thing is that we have good studies,” he said once we started discussing the work arrangement. “I will give you a tape and you tell me if it meets your standards.”
I nodded, wanting to get out of there.
“I want only one person, so you’ll have to read carotid ultrasounds, too,” he said. (That meant interpreting digital images he’d provide on a compact disc.)
“Well, as I explained on the phone, I am not yet certified in carotids.”
“That’s okay,” he said quickly. “The insurance companies are not requiring board certification at this time anyway. I suggest you get trained quickly, but meanwhile, you should just start reading. Most of the studies are normal anyway. If anyone has real pathology, I send them to the hospital to repeat the test.”
I must have squirmed, but I didn’t say anything.
“We don’t want a rental arrangement,” Hasani continued. “We want to do the billing ourselves. I want you to run my whole cardiovascular program: reading echos, supervising echos, doing consultations and stress tests. If you can take over my entire service, you can make eight thousand dollars a month. Once we start nuclears, you can make an extra fifteen hundred to two thousand a month.” He wanted me to help him accredit his echo and stress labs, too. In short, he said, he was looking for a “comprehensive arrangement.”
I told him I would think it over and discuss it with my department head.
“We want your hospital name on the building,” he said quickly. “We are talking to St. Francis and Winthrop, too. But if your hospital is looking to do the billing and just pay me rent, then it won’t work out.”
When I got back to the parking lot, Malik was still waiting in the car. “So what do you think?” he said.
I replied that I didn’t think the hospital would agree to Hasani’s terms.
“Well, see what they say,” he said, starting the car. “Everybody is trying to make money. That’s the bottom line.”
As Malik drove back to Queens, chattering about this and that, I remained lost in thought, paying only intermittent attention. I ran my fingers across my sweaty brow. You have to get out of this situation and never come back, I told myself. You don’t want to feel this way anymore. It’s not about anyone else. It’s about you, who you are and what you do, how you receive the gifts that are your life.
At one point, Malik mentioned that Hasani had applied for a state inspection to start a nuclear lab. “A nuclear is serious stuff,” Malik said. “I asked him, ‘Do you know who’s going to stand in front of this thing and going to monitor this stuff?’ and he said, ‘Oh, I haven’t thought about that yet.’ That’s how much thought he’s put into it.”
“Sounds like it’s all about the business,” I said, gazing absentmindedly out the window.
“Yeah, like a lot of doctors, Hasani just cares about the numbers. Patients come down to the treadmill with a cane. I say, ‘Why is this person here for a stress test?’ It’s like, who’s ordering this?”
“Who is ordering it?”
“Him and his PA. I mean, seventy-five-year-old, four stents, diabetic, and I ask why they are having a stress echo. I mean, nuke them if you have to. But he’s just biding his time, waiting for his nuclear license.”
“He sounds like a dick.”
“You’re right. Do you know what the litmus test is? Amir could not work with him. And Amir would sell his mother for a few more dollars. If Amir couldn’t work with Hasani, that should tell you something.”
I stared at the road ahead. This was not how things were supposed to have turned out. At the very least, this was not the conception of doctoring that I’d had when I started in practice. Of course, you’re supposed to make compromises as you get older, as you accrue responsibilities for other people—your children, your spouse, your parents—but it felt as if I had made a Faustian bargain. Having my eyes opened to the reality of contemporary medical practice had been painful. Now I had to make a choice. Continuing on this path was leading to ruin.
“We are in a terrible situation as doctors,” Malik said. “Things are drying up. Before, when you mentioned diabetes—boom!—you got approved. Now you say even chest pain and the insurance company has twenty more questions. If the PA ordering the test doesn’t know his clinicals, it isn’t going to get approved.”
By then I had stopped paying attention. What Malik was saying no longer mattered. I wasn’t going to work with Hasani or Miller or Fibak or Bennett or anyone else he had introduced me to. I was done driving around, rushing to this place and that, meeting knaves looking to exploit the system, and constantly thinking about how to make more money for myself so we could maintain a life that was probably unsustainable anyway. Just as condensation droplets on a windowpane merge to make a tiny stream, my thoughts at that moment seemed to coalesce. I wasn’t going to waste any more time. The way forward had become clear.
EIGHTEEN
Diversion
Childhood’s joy-land.
Mystic merry Toyland,
Once you pass its borders,
You can never return again.
—Victor Herbert and Glen MacDonough
The moment when I finally decided it was time to leave Manhattan, I was sprinting across the West Side Highway through heavy traffic. It was a bright Saturday afternoon in the summer, five years after I’d started working at LIJ. That morning, Matt, a lawyer who lived in my building, had invited me to play tennis at 119th Street in Riverside Park, but since our passes had expired, we weren’t allowed to get on a court. Someone told us you didn’t need a pass to play on the red clay courts at 96th Street, so we decided to walk there. It was a beautiful day. Sailboats were out on the shimmering Hudson, and fluffy white clouds extended like a mattress across the light blue sky. When we arrived, forty minutes later, all the courts were occupied, and because we didn’t have valid passes, we weren’t allowed to reserve a court for later in the afternoon. If we were willing to wait, a court might open up, but it was impossible to predict when that would happen. Someone told us there were public courts at the middle school on 116th Street and Lenox, so, desperate to play, we decided to walk back uptown.
The bridge over the West Side Highway was at 125th Street, and because we didn’t want to waste time walking an extra eighteen blocks, we impulsively decided to cross the highway right where we were. Cars whizzed by us as we took refuge between lanes, as if we were participating in a real-life game of Frogger. It was at that moment, risking my life for a chance to play tennis, that I decided I no longer wanted to live in Manhattan. Even if I were to find more moonlighting work, the sacrifices required were just too great. Sonia, frantically trying to enroll in overcrowded “Mommy and me” classes, had begun to feel the same way. (And the courts at the school turned out to be unplayable anyway.)
In the fall, we started to look in earnest for a house. It wasn’t a perfect solution to our financial situation, but at least it would allow me to forgo any more private moonlighting. I had convinced Sonia that I couldn’t make the commute daily from New Jersey, so almos
t every weekend, Sonia, Mohan, and I (we left Pia at home with a babysitter) drove out to Long Island and walked the naked floors of homes for sale in Manhasset and Roslyn. We looked at single-family houses, rentals, condos, even gated communities, but nothing seemed quite right. The centrifugal force of our financial troubles was balanced by the competing weights of inertia and familiarity. I tried to picture us in a suburban house, easily putting our well-rested kids in their cute animal pajamas to bed and then retiring to a den with a fireplace, an armchair, and high bookshelves, but it was all so hard to imagine. What was I going to do at night without the buzz from the street to soothe me to sleep? When Sonia asked me what was wrong, I told her I was worried about Mohan, about taking him away from his school, his friends, his neighborhood—were we being fair to him, changing his way of life?—but in truth I was more worried about myself.
With generous help from my father-in-law, we eventually signed a contract of sale for a three-bedroom house in the town of Glen Head, about a fifteen-minute drive from LIJ. By then, Mohan had a vague idea that we were moving, though I’d never sat down to talk with him about it. I dreaded telling him.
Shortly after the purchase was finalized, I took my son for our usual Saturday outing in Riverside Park. He looked adorable in his Bermuda shorts and green polo shirt. At the corner of 110th and Broadway, we negotiated where to go first.
“I want to go to the park,” he said.
“Let’s first go to the bookstore,” I said.
“No, park.”
“Come on, can we go to the bookstore for a minute?”
He thought for a moment. Then, like an old friend, he said, “You want to see your book?” (The paperback had been released.)
At the bookstore, he sat quietly while I perused the new titles. He whispered to himself as I thumbed through periodicals. Then we sat in a chair, and I read him Little Quack, about ducklings reluctant to move to a different pond. When we were done, we rode the escalator back upstairs. He mimicked my stance, straddling two steps with his diminutive legs. Outside on the sidewalk, he cried out in relief: “We can talk now! We can talk now! We can be loud now! I’m so happy!”
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