Chapter 26

Chapter 26

Bath 1991 to 2001




The members of the Board of trustees of the Bath hospital, medical and administrative staffs received me with usual courtesy. I had meetings with the CEO and lunch with the medical staff. Except for a few who had joined the hospital since 1983 I had worked with, all the others previously. They welcomed me with open arms. Among the ones I had been close to dropped hints that things might not be as comfortable as they had once been, but I did not pay much heed to them. They were not in a position to come out openly and I told the CEO that I will wind up my affairs in Karachi expeditiously. He promised to help me renew my license to practice medicine in NY state and arrange for an office, malpractice insurance and all that went with reopening a practice.
. I flew back home and told my partners that it was all theirs. Some of them had wanted to take over, and run it along lines followed by other hospital owners; profit at all costs . They were not aware of it but were subconsciously following WB/IMF advice, and expressed formula regrets at my imminent departure.
It was a wrench. I had a comfortable life, was making enough money for my needs, had developed a circle of friends, most from my old days in the town, but some new ones too, the hospital was doing well and we had started making regular payments to wards the loan. I was fast developing a reputation as a highly accomplished orthopedic surgeon and as owner of a hospital was becoming a part of establishment with a lot of contacts among the bureaucrats and businessmen with out which nothing could be done in Pakistan. I had time to indulge in my favorite passion of launching organizations. My mother and sister would be left alone again. They were too set in their ways. My sister had a fairly successful law practice, and did not want to leave. It would also mean almost certain total loss of my investment in time and money in the hospital. But the fear of nearly anarchic-civil war situation, riots and curfews had kept me on edge. And above all, frequent kidnapping of children over rode all considerations and left me no choice.
The next few months were spent in arranging my affairs and developing a collegial system of administration in the hospital, Akhtar was designated acting MD-Chairman and I persuaded my friend Aziz to take over as DA&F. NY state education department asked me to take a test on an audio-cassette they had sent. Akhtar offered to and helped me with it. I asked him if he was facilitating my early departure. He had the grace to be embarrassed. All ends were tied by the end of October.
In November 1991, I arrived in Bath in the middle of a snowstorm. The hospital had set up an office for me; I hired a secretary on the recommendation of Karen Bailey who had worked with me between 1980 and 1983. There was one snag. One malpractice insurance company wanted to restrict me from performing joint replacements on the excuse that I had worked in Pakistan for the last eight years. I was not prepared to accept that. The CEO offered to put me on hospital pay roll and get insurance through its carrier. But I did not relish the idea of being an employee and approached another insurance carrier and it readily agreed to give me full coverage.
The hospital had offered me guaranteed income but I was confident of making a go of it with out it and had asked for a year’s malpractice insurance premium and rent free office. In addition had I asked for an interest free loan to make a down payment on a house as I did not want to subject my family to the privation of living in a small house .The hospital had readily agreed to my requests.
Now Physician colleagues I had worked with during my previous stay, were free to and had an opportunity to tell me that medical practice had changed in the eight years I had been away. There was far more state and federal regulation; health insurance companies had become emboldened and very intrusive, tiresome paperwork had become obligatory, billing agencies had sprouted, imbursement had been reduced uniformly, though cost of living and practice had gone up. I better buy a computer and get my staff trained to use it.
I could not believe them. I had been so busy and had made so much money between 1980 and 1983. But they were right. Insurances paid less for the same procedure in 1992 than they did in 1983, never mind the inflation. More forms with all kinds of codes had to be filled out; insurance companies made more objections . It was an uphill struggle with tons of paper work. I discounted all my friend told me. How bad could it be? I had worked day and night during my earlier stint. I was well liked by patients, had had referrals from all over the area including the families of employees of other orthopedic surgeons and was prepared to work hard again.
But there was another complication. The hospital had not been able to find my replacement for four years after I left in 1983. That had driven a lot of patients out of the area. People get used to physicians and do not want to change unless driven by exceptional circumstances. My eventual successor was a true blue American and had demanded and got guaranteed income of $300,000.00 for three years with office, staff, and malpractice insurance thrown in. He had worked hard the first year and had exceeded the guarantee, but barely made the figure in the second year. The hospital had to make up a deficit of $75,000.00 in the third year, and refused to extend the terms for the fourth year, so he quit. He had also from his second year on, started transferring fairly routine and straightforward injuries to other hospitals, and so the trend of the patient population now was to go elsewhere had accelerated. To make matters worse, our hospital had not been designated trauma center, and ambulances were required to take patients away even from our catchments area.
To make matters worse the hospital was passing through a bad period it was actually in an acute financial crisis. Part of the reason was loss of trauma, the poor reputation because of bad mouthing by my predecessor and mismanagement. CEO was at loggerheads with the Medical staff, With the Board of Trustees unable or unwilling to mediate between the warring factions, it was a house divided against itself. Further the area was no longer as prosperous as it used to be. Many businesses and industries had left the region or gone bankrupt. Winemaking and farming the two main props of local economy were on a downward slide as manufacturing sector had moved overseas and cheaper farm produce was flooding the country . They had to close one of the two in patient floors. I did try to look for other practices and went for a few interviews. I had good offers too but more than a year had passed since our return, and my children had begun to settle down in their new schools. They had overcome the immense problems of changing from one milieu to another-different in every possible way. I did not want to change their environment yet again .
The major factor militating against resumption of good practice was the loss of major trauma. I had dealt with numerous such cases during my first previous sojourn in Bath. I was apprehensive that this time it would take me longer than a year to develop a good practice. I decided to ask for an income guarantee. The CEO, who had welcomed me back was the same one I had known well during my early nineteen eighties, was amenable to my request. But he himself was now in trouble. He had rubbed powerful interests the wrong way. He soon resigned and was replaced by a working nun. I told the interim administrator-CEO that conditions and climate of medical practice had changed very much for the worse since I left in 1983 and I could not work with out a minimum income guarantee. She was evasive and difficult so I called the President of the Board of Trustees and told him that I would have to leave if I did not get an income guarantee, and would try to return the loan the Hospital had given me when I could. He asked me to wait and see what he could do. In the event he came through with a guarantee for the first year's income. I now had more breathing space but things, did not work out as well as I had anticipated.
I had an out look very different from what I had during my 1974-1983 stay in the USA. At the time I was only biding time till I could save enough to live on in Pakistan till I had developed adequate private practice to meet our needs. Now we were here to stay Even before weather had improved I had started looking for a house to buy. My non-Rakhi sister Nasim accompanied me in the quest. We finally settled on a large five-bed room house on nearly three acres of land. It sat beneath a hill with a lot of trees and had the further advantage of being at walking distance from her house. Real estate had never been expensive in the region. With the economic down turn housing market offered attractive bargains. Larger houses with a heavier burden of maintenance costs were especially difficult to sell. This particular one had been bought by a speculator who I suspect was feeling the pinch and agreed to all our demands except that he wanted the rather expensive and tasteful curtains. Nasim asked me to tell him that if he wanted the curtains so desperately he could keep the house too. That did it, the man capitulated.
The person had neglected the lawns. Nasim’s husband Dr Husain who was a physician at the local VA Hospital worked with me for several weeks on practically a daily basis to root out the weeds and scrub.
Paro and children arrived in June 1992. We contacted our local school. Sarah, Umar and Sana were promised admission in appropriate grades. Hasan had a bit of a problem, which I have discussed in the chapter on children. But they were all much happier and thrived on the fresh and clean air, pastoral life and security
We tried to live as normal a life as we could. Children especially Hasan went through a difficult period of adjustment I have described in more detail in the their own section. Bath and the area surrounding it are very picturesque. We have parks, lakes, farms amusement parks zoos a notable glass museum The” famous” Keuka lake is eight miles from Bath. Our neighboring village Hammondsport sits on one end of the lake and Penn Yan town at the other. The lake is circumscribed by homes some of which are quite luxurious. The actor Paul Newman has a mansion. Boating fishing and cruises are quite delightful and popular. The whole area is studded with wineries of all sizes. We have wine tasting tours. They offer you substantial sips of different kinds of wine in six glasses for a dollar. I understand that busloads of tourists visit the tasting places and at the end of the day motel owners and bus operators “help” the guests in to their rooms/beds.
We went on day trips, picnics and traveled to Toronto in Canada and made several visits to Cape Cod. Children thoroughly enjoyed the museums and amusement parks in Toronto and Cape cod. Latter had additional attractions of whale cruises and boat trips. A month long charismas time visit to Pakistan remained a routine till my mother passed away in 1995
The interim administrator left. The new man brought a Medical Director with him. Medical Director is supposed to the Board's man on the Medical Staff whose members do not generally trust him, and regard him more or less as a fifth columnist. This man was particularly slimy. He had been a pediatrician who had to give up clinical practice because of his infatuation with the "daughter of grapes" and tried hard to ingratiate himself with the Medical staff.
I must confess to a weakness. I do not suffer fools easily. It would not be too bad if I kept my opinions to myself. In stead I make it a point to snub such persons. I am not so incensed by vagaries of the less favored, but cannot resist taking on persons who can harm me. I quickly earned the animosity of the Medical Director. We had several skirmishes. He once tried to get the medical staff to suspend my privileges. The staff, led by its President Dr Carol Holobinko supported me. I called my friend/attorney Joel Feffer. He gave me the name of a “muck raking” attorney who specialized in making life hell for hospitals. In view of the support of my colleagues I decided not to pursue and did not contact the scourge of hospitals. That was a mistake.
During my eight-year stay in Pakistan, another field of business had developed in orthopedic practice. This was Independent Medical Examinations (IME). If a worker who got hurt at work did not return soon enough to suit the employer, the latter would claim that the injury was not severe enough to merit a long absence and ask for an independent medical examiner to assess the disability. In effect, the matter would be dealt with between the insurance carrier of the employer and the attorney of the patient/worker. Attorneys would work on a contingency arrangement which I have described elsewhere. The employer's carriers would send the worker to a Doctor of their choice to perform an IME. Carriers could generally not handle the load of cases, so they would give sub- contracts to IME companies which mushroomed, each vying with the other to undercut their rivals. If, for example, one wanted $ 500.00 for an examination, the second would offer to do it for $ 450.00.
The problem IME companies faced were that of finding Orthopedic Surgeons to do this kind of work. (In 1994 one IME company owner had approached me. I had initially disdained the offer. Bath being too small to provide enough IME business, I would have to travel all over upstate New York, But my practice did not pick up to my satisfaction and in 1995I reluctantly made a deal with several IME companies
That went on for a long time and was getting on my nerves. I would have to get up in the middle of the night to attend to a person who had had a backache for years and had decided to go to the ER as his own doctor would not give him an early appointment. With several hours driving and more hours of tasteless and uninteresting work it was no fun. Worse still such patients generally did not carry any insurance and had no money to pay the bills.
In a clinical setting there is a lot of good will between the physician and the patient. The IME examinee (referred to appropriately as a client) on his part was apprehensive of the likely possibility of benefits being reduced or withdrawn all together. During the encounter, most of the examinees would be in a defensive mode of behavior. Their attorneys would often accompany them. The attorneys would behave in a professional manner, The doctors were under pressure from IME companies to try to favor their clients Some even went to the extent of advising the doctors that if they were not amenable to the request they would have to take their custom elsewhere and in my case would have if they had readily available alternatives). Further, one had to go to courts to defend the findings in IME reports.
The way the court system works in this country, and for that matter in other countries too, is that hearings would be postponed at the last minute, or a settlement would be reached, making your appearance un-necessary. One of the attorneys might be held up in some other case and you would be left high and dry, after canceling office hours, rearranging all schedules and driving long distances. In the event no one was willing to compensate you for the lost time and hassle. Even if the attorneys and their staff knew postponement, cancellation or conflict of schedule they were not always meticulous in informing physicians.
You could name your fee in car accidents and liability cases but courts gave an award in compensation cases. It was never adequate to compensate for lost time. After being let down a few times I developed a technique. I would insist on advance payment with a proviso that the fee would be reimbursed if I were given seventy-two hours notice of cancellation/postponement; and the period would not include weekends. The attorneys protested, moaned and groaned but had to give in.
The work, for obvious reasons, was not very congenial. Very few orthopedic surgeons liked to do it. The IME companies were hard put to find the ones who were so inclined. They found willing workers in the rank of surgeons who did not have enough clinical work, wanted to ease out of active practice or had had too many malpractice suits and found patient dealing too stressful. I fell in the first category. But my problem was that I was located in a very small town. There could not be enough work of this kind in my area to give me adequate income. I would have to travel out of town and do "bulk" examinations.
I traveled over a wide area driving several hours each way and had to stay over night in motels twice a month to enable me to work the next morning. The advantage was that I could perform, on the average fifty examinations over three days, spend two days dictating and correcting reports and be home for a three-day weekend. I could save some time dictating while some one else drove. I took my secretary on day trips and at times my wife would accompany me on over night trips. It was good money but it was a hassle and driving was a great hazard in the winter.
There was another hazard as well. Many of the IME companies were of the "fly by night" nature. You were never certain when one would fold up and abscond with your money. Even the large ones would some times go belly up. One IME Company, which was a pioneer in the field, provided a sumptuous life style to its owners with a Park Avenue Manhattan Penthouse and all the other trappings. The main examining physician (I will call him A) was a friend of the owner who was a physician himself. The examiner had not been paid for months. He was owed nearly a million and when all else failed he decided to raid one of the main offices and took away all the files. There was a court case. “A” decided to launch his own IME Company and asked me to join him. The day I was supposed to see him to discuss terms, he called me at four in the morning to tell me that his antagonist had obtained a court order prohibiting him from talking to any physician who had worked for this particular Company. He was calling from a phone booth because he thought that private detectives were trailing him. It was quite cloak and dagger.
I still had a clinical practice and an office and was obliged to see inpatients* on a daily basis. I used to get up very early in the morning to make rounds and would have to wake my patients up. They did not like it. Being the only orthopedic surgeon on the staff I was on call every night and had to attend to who ever presented in the Emergency room. Orthopedic surgeons in neighboring towns readily agreed to share calls but when they discovered that pickings were sparse, they started making excuses. I loved the work but frequent absences had further reduced my workload and I did not make enough to justify the high mal-practice premium and proceed to the destination of the day
. I decided to give up clinical work and applied to the relevant hospital committee to change my privileges from active to honorary status. That way I would keep my hand in clinical work and it would also drastically reduce my mal-practice insurance premium . The Medical Director was dragging his feet. I reported him to the Health Department of the State. He retaliated by reporting my complications. The State bureaucracy wanted to make a big deal of the complaint. They have to, some how, justify their existence. I told them that I had no plans to resume surgical work and signed a deal with them. This was to have serious long-term consequences for me.
I did full time IME work between 1997 and 2001. The only part of the work I enjoyed was matching my wits with attorneys in court. Not all of them had dialectical skills needed for the profession. As one would expect the ones practicing in the higher courts were better debaters.
My eyesight had been gradually getting worse. I had developed cataracts and had to have surgery in February and march 2001. I was not able to go on the road for several months and did not feel like starting on the same grueling routine again any time soon. But the clincher was that the NY state passed a law that any one who had made a deal with the Health Department may nor do IME's. This law did not make sense as I could treat such cases and I still had specialist rating with NY State Compensation Board. But that is politics and impact of powerful lobbies on legislatures One of my secretaries had worked with our state senator and got an appointment for me to see the legislator. He did call the compensation board chairperson but could not persuade the bureaucrat to let me continue to work till I had approached the courts and a decision was handed down. I asked my malpractice attorney to file an appeal against the decision. The court said that their job was to interpret laws and not change them.
IME work gave me free weekends. After I had examined the “clients” dictated reports, corrected the drafts my time was my own and once again could indulge in my favorite passion of launching organizations. I had the good fortune of coming across an academic from Cornell University Dr S.Naqi, who though a practicing Muslim, was a high minded, liberal, thoughtful, tolerant, very well read and widely informed gentleman. Naqi Sahib called a meeting at the home of a Corning Inc scientist Dr Hoda . After a lively discussion we decided to launch an organization Naqi was elected the President and I accepted my favorite position of General Secretary Several other persons offered to serve on the executive committee (EC) The EC met frequently and discussed byelaws Our meetings were well attended and input of participants serious and productive .The person assigned the task of drafting them presented a document which emphasized our religious affiliation this was not acceptable to me. I offered amendments and vigorously supported a secular stance. The majority of expatriates belonged to other creeds. Hindus among them made up the largest number. They would not be attracted to what they generally regarded Islam as their nemesis. But what won the day was the argument that to promote our cause we needed the backing of the “natives” who were not Muslim. In spite of vociferous protests from the local Muslim community we decided to adopt strictly secular byelaws. Several names were suggested. We finally settled on Concerned Citizens For Peace and Understanding (CCPU)
We launched a membership drive. Initially our approach evoked generous response from local expatriates academics, scientists physicians and other peace groups) We decided to broaden our quest and practically every weekend drove to towns as far away as Rochester, Syracuse, Binghamton and Buffalo; a range of eighty to one hundred twenty miles. I was surprised to learn that larger towns were more worked up about our secular stance . I even addressed a large gathering at the annual function of Rochester NY Islamic center, which had the local congresswoman among those present. She was very receptive and offered help.
We meticulously planned our first general meeting. Naqi Sahib as usual worked day and night calling speakers, contacting other like-minded groups and persuading persons of intellectual attainments to address us. I occupied myself with logistics. Dr Rizvi another professor on the staff of Cornell and his wife Naz generously helped the effort. I must special mention of the late Dr Ishrat Mustafa She was a tireless social worker and political activist. She had two PhDs from Cornell but devoted all her time to public service. She was an invaluable help. Other activists from the area were also unstinted in their support.
Our first public meeting was a full day session held in a hall in Cornell University. Shibli Telhami then a professor at Cornell addressed it, among others. (Now he adorns the Sadaat chair of Public affairs at Johns Hopkins. Delegates from as far away as Boston MA and Long Island NY attended. American Muslim Alliance ((AMA), a liberal Muslim organization) sent its national vice-President who pledged cooperation but asked us to form an AMA chapter as well. We had annual meetings attended by people of all creeds, Muslim, Christian, Hindu, Jew and others. Naqi Sahib used to organize seminars every so often. One degenerated into a shouting match between Palestinians and Zionists* .
I did end up founding a chapter in the fond hope that Muslims in the area will participate in and be politically energized by the name. We again visited all the major cities in up state NY areas-Rochester, Buffalo, Syracuse and Binghamton- ranging from eighty to one hundred twenty miles from Bath and held meetings with local activists in Islamic centers, offices and homes. The response was tepid and reaction equivocal. Our (sub-continental) culture is not conducive to working together. I attribute it to long years of colonial rule, which stifles initiative and dampens self-confidence, and its after math
Naqi retired; I went to the UK. Our organizations are person and event centric. Both CCPU and AMA chapter “gracefully” subsided.
On return from England, at the request of politically aware segment of our area I founded a regional community organization (RCA). A few like-minded persons and I visited several cities in the region again and were offered tea and sympathy. We had an inaugural meeting and several monthly meetings of the executive committee. But I soon realized, that when I called a meeting a few persons attended. If I did not remind, no one complained. In one meeting the president didn’t turn up. On being questioned he stated that he had forgotten.
The most important activity of RCA was enthusiastic participation in the local congressional race. We met with two candidates. The third, and the eventual winner couldn’t find time for us. We raised funds for our candidate, the Democratic Party nominee. I have a lurking suspicion that the enthusiasm we brought to the campaign had more to do with the fact that she was a young - she graduated MBA Harvard during the campaign- and attractive lady, than with her platform. One physician who shall remain unnamed was especially enamored of her. She lost narrowly, raising our hopes that she might win next time. She was pitted against an entrenched politician, the republican nominee, with 25 years in the state senate. He had an efficient machine to back him up and had done favors to a lot of people. Our area is republican any way.
A young colleague Zaffar Iqbal. introduced me to a secular democratic group “Develop In peace” (DIP), DIP was founded by two Indians, one Amit Shah a physician in North Carolina and his friend Gautam Desai a finance man resident of the same state. Zaffar is passionate about his convictions, and work against discrimination based on sex, color, race, or religion. The group sponsored a seminar on future of democracy in Pakistan, simultaneous with an APPNA annual session. The seminar attracted a larger audience than Association of North American Physicians of Pakistani Origin (APPNA) sessions and evoked a jealous response from the establishment of the group. DIP also supported a magazine “Chowrangi” and gave sustenance to Asian American Network against Abuse (ANAA).
ANAA is an advocacy group. Initially an offshoot of APPNA, ANAA President Dr Amna Buttar, was at one time co-chair of APPNA women’s caucus. Amna has a passion for social causes and is dedicated to the struggle against violation of women’s rights. For lack of resources, it focuses on the social evils in Pakistan. ANAA has been instrumental in bringing Mukhtaran Mai, a punchayat gang ordained rape victim in Pakistani Punjab, to the USA. Its campaign foiled attempts by GOP to keep Mukhtaran and another rape victim Dr Shazia Khalid, this time the heinous act allegedly perpetrated by Pakistani army officers on duty to protect personnel working in a natural gas installation. Shazia was one of the workers and had spurned the advances of an army officer.
Amna has given talks in seminars and Radio-TV shows and led several street demonstrations in DC and NY, the last arranged to coincide with Musharraf’s book tour. Naturally the GOP got together a rent a crowd rival demonstration and not unexpectedly NY police favored the sycophants of the American satrap in Pakistan.
Episodic political activity, voracious reading and voluminous correspondence on the Internet did keep me fully occupied, but I missed work. I explored the possibility of postgraduate work in literature, politics, economics and history. I even contacted law schools in the area. But logistics got in the way. I did not want to live away from home, neither was I inclined to fritter away my now fixed assets. Writing my autobiography was more fulfilling and I had resigned to the mode of life when my wife and I had a motor vehicle accident. Paro was badly hurt. She had conventional orthopedic treatment, but was troubled by residual pain and discomfort. Our physician and friend Humayun Mirza suggested we try Acupuncture treatment. We had grave misgivings, but it did not involve any medications and was relatively non-invasive.
To my surprise we experienced nearly complete pain relief. I discussed the prospects of training in the field with my therapist. He told me that several Medical Schools had developed a program specific to the requirements of physicians. I chose Down State Medical Center Brooklyn NY. It was six month long course. The sessions spanned the whole weekend, every week foot the first three and every other later. We were given lectures, on hands training and supervised treatment in clinics in Queens, and Manhattan. At the end of the course NYS Education department gave me a formal certificate to practice Acupuncture.