Doctored (23 page)

We did stress tests on at least three-quarters of the patients who came in. There is almost no evidence to recommend stress testing in patients with recent coronary stenting, but Chaudhry's staff did this routinely. There is no evidence that stress testing for coronary artery disease in intermediate-risk adults without symptoms is beneficial, but this was the bulk of the practice. The more tests you perform in a lower-risk population, the more falsely abnormal results you are going to get, leading to further testing and potentially harmful invasive studies like cardiac catheterization. (This is often referred to as an example of Bayesian probability: a positive test result is more likely to be false as the prevalence of a disease drops in the population being studied.) “Thank you for referring your patient for cardiac catheterization after a positive stress test” read a typical letter from an interventional cardiologist to Dr. Chaudhry. “Cardiac cath revealed normal coronaries and normal left ventricular function. The patient was reassured and discharged home under your care.” It was a self-sustaining machine, and a whole network of doctors benefited from it; it was our lifeblood.

Every office procedure generated a follow-up visit so patients could discuss their results. However, a lot of the time the echos or EKG monitors hadn't even been read—more often than not you could find insurance documents or preauthorization forms but not the test results you were looking for—so you'd have to scramble to interpret them on the spot or promise a phone call or set up another visit. Once, I asked a patient who'd had a normal stress test if she was still having chest pains, and she told me she didn't have chest pains—she'd never had chest pains!—even though it was written all over the chart. In residency, if you didn't want to be bothered to admit a patient with chest pain in the middle of the night when you wanted to sleep, you'd push hard on her ribs and ask if it hurt, and if she said yes, you'd diagnose benign musculoskeletal pain and turn away the admission. In medicine we so often choose to see what we want to see, and Chaudhry's staff was no different. There were few checks and balances. You could document whatever you wanted. Anything to justify a procedure.

I rationalized my involvement by telling myself that I was carrying out orders, that I myself hadn't requested the unnecessary tests, that I could limit testing in any new patients I evaluated, and that if I quit, Chaudhry would just get somebody else. Still, I felt tainted. I worried about what my colleagues would say if they knew what I was doing. Did the fact that I had opted to work with Chaudhry mean that I was less upstanding than I gave myself credit for? Or that he was simply more honest about the realities of medicine?

One typical Saturday morning I pulled myself out of bed just after eight o'clock, the hour I was supposed to have arrived at Chaudhry's office. Lead-footed, I stepped groggily to the bathroom. A morass of cotton filled my head. At the mirror I rubbed the detritus of sleep from my eyes. They were bloodshot.

“Sandeep, where are Mohan's shin guards?”

I splashed cold water on my face.

“Sandeep! Where are his shin guards?”

I applied a dab of toothpaste.

“Sandeep!”

“I don't know,” I mumbled.

“He can't play soccer without them.”

“I don't know where they are.”

“But you brought him back last time.” I started to brush my teeth. “Where did you put them?” I squinted at my reflection. “Sandeep!”

“I don't know. He just took them off. You'll find them.”

“But where!”

By the time I got into my car, it was almost eight-thirty, and I was already a half hour late. Traffic on the Grand Central was light; debris jutted out of dirty snow piles on the side of the road. Speeding to Queens on that lonely stretch of freeway, I felt ashamed about how I had lost my temper with Sonia the previous night. The irritations were accumulating. I was juggling too many different things. Spending so little time with my son was gnawing at me. My obligations were like the concrete embankments along the expressway, preventing me from getting off.

“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.”