Intern Page 2
He cleared his throat and began to speak. His voice was deep but incongruously soft, and because I was sitting in the back of the sixty-seat auditorium, I only managed to catch snippets of his remarks. It was going to be a busy year, he said, as thirty-five heads stared motionlessly back at him. We were expected to devote ourselves fully to medicine. “You don’t learn French by taking classes at Hunter College. You learn it by going to Paris, sitting in the cafés, talking to people.” Likewise medicine: we would learn it by living it. “You are now ambassadors for the profession,” he said gravely. “So don’t let the students hear you complain. It sets a bad example.” If everything went as planned, he added, by next June we’d be ready to supervise the next batch of interns.
I glanced over at the pretty brunette sitting next to me. She looked back at me, rolled her eyes, and opened her mouth in mock panic.
Then Wood dropped the bomb. Every intern starting on the wards or in the intensive care units was required to come to the hospital every single day, including weekends, for the first six weeks. The only exceptions were interns starting in the outpatient clinic, which was only open from nine to six; they would have no evening call and weekends off for the first month. I later learned that this regimen was a longstanding tradition at the hospital, the most efficient way to get everyone up to speed. To me it seemed brutal, like a kind of hazing, not to mention a violation of residency work-hour limits set forth by the Bell Commission in New York in the mid-1980s. Uneasy murmurings reverberated through the auditorium as new interns rustled through their packets. I scanned the master schedule before breathing a sigh of relief. Along with six classmates, I was slated to start in the clinic.
“We are here to help you,” Wood said, raising his voice over the light chatter. “You should feel free to call on us anytime, day or night. The only mistake you can make is not asking for help.”
I was reminded of a residency interview in Chicago a few months earlier. The interviewer, a portly senior physician with an abundance of facial hair, had posed the following scenario: A nurse pages me in the middle of the night to tell me that a patient who just had hip surgery is short of breath. What would I do? “Go see the patient,” I said. I had enough sense to know that there was only one right answer to that question. Walking to the room, what would I be thinking about? “Pulmonary embolism,” I replied. Blood clots in the lung are a feared complication after hip surgery. When I arrive in the room, the patient is in distress. His heart is beating 130 times per minute and the oxygen tension in his blood is low. Now what? I went over the treatment options in my head—blood thinner, supplemental oxygen, arterial blood gas—but it seemed the examiner wanted me to say something else. I’d heard about the notorious “July phenomenon,” in which hospital mortality supposedly increases every summer with the entry of new and inexperienced hospital staff. “I’d call a senior resident,” I finally answered. Why? “Because I could be missing something.” My interviewer nodded; I had passed the test. Like all residency directors, he was looking for a soldier, not a cowboy.
Now it was late June, and we were the new hospital staff. For the rest of that first morning, we sat through a series of tag-team lectures. A woman from the blood bank talked about blood transfusions. A pathologist talked about the importance of autopsies. A psychologist spoke about work-related stress and told us that confidential counseling was available. A lawyer from risk management, the department that defended the hospital against lawsuits, informed us that at some point in our careers every one of us was likely to be sued, and that we could even be sued during residency. She offered some advice: Document your decision-making; document when a patient refuses treatment; never admit wrongdoing; never talk to an opposing attorney; and, finally, be nice to your patients. Doctors who were nice to their patients were rarely sued, even in cases of egregious malpractice. I looked around the room, trying to gauge the reaction of my classmates, frankly surprised that such a cynical thing was being taught on the first day of residency. No one’s eyes met mine.
At the midmorning break, I went outside. Stepping through the humid air was like sweeping away static. The sidewalk was buzzing in a kind of Brownian motion, with pedestrians sidestepping me as though I were a moving obstacle. A long line snaked from an aromatic hot dog stand. Buses and taxicabs were letting people off in front of the hospital. An ambulance whizzed by on the main thoroughfare, sirens blaring, lights flashing. The noise fed my sense of wonder. I had grown up in a quiet Southern California suburb, craving the excitement of a big city. Berkeley and St. Louis had their pockets of vitality, but nothing like this. Even the smell of the neighborhood—a mix of pizza, garbage, cigarette smoke, and fragrant fruit—was rich and seasoned, like wisdom wafting through the air.
I had only arrived in Manhattan a few days earlier, moving into a one-bedroom apartment about a block away from the hospital. On the plane flight in from St. Louis, the pilot took a detour because of airspace congestion, he told us, flying into LaGuardia from the south, not the usual flight pattern. As we passed over the World Trade Center and then soared low over the city, I craned my neck to look down at the broad swath of Central Park. The brown buildings on its outskirts were arrayed like divers ready to jump into a pool. Down there, I had imagined, all of the metropolis’s unique charms were waiting for me: the old, stained sidewalks; the stealthy characters playing junkyard instruments on subway platforms; the deliverymen hurtling through traffic lights on their rickety ten-speeds, I NY plastic bags swinging from the handlebars. The first time I had been to New York was the summer before medical school, when I spent a couple of weeks with my brother and his wife in their tiny one-bedroom apartment across the street from the hospital, where he had just begun his fellowship. I wandered around the city, going on walking tours of Harlem, joyriding on the subway, chatting with bartenders late into the night. Like many visitors to Manhattan, I was swept away. The delicatessens, the dry cleaners, the corner convenience stores and smoke shops. Unlike in Berkeley, people weren’t just milling around, enjoying the sun. There was magic in the movement on the streets. So much was happening, and I could watch it all and remain a shadow. That was the wonderful paradox of Manhattan: you could be surrounded by people and yet be anonymous at the same time. “The United Nations is just down the street,” I wrote a friend. “The building they use to broker world disputes, just down the street from me!” New York cast a spell on me that summer that I could neither explain nor resist.
Back on the sidewalk, I felt a light spray from air-conditioning units outside the apartment windows above me. Heavy construction was going on in a lot nearby; large bulldozers were exhuming a deep hole, as if for a tomb, their blades ravenously picking up mouthfuls of yellowish dirt. I passed by an old church and stopped at a fruit stand to buy a nectarine. Then I ambled back to orientation munching on it. A plane flew overhead. Looking up at it streaking across the clear blue sky, sweet juice trickling down my chin and fingers, I couldn’t help but think that the abnormal flight path that had brought me here last week was an apt metaphor for my own twisting journey into medicine.
I STOOD ON THE BALCONY in Berkeley and lit a cigarette. My bags were packed, the bills paid, the car loaded. Most of my possessions had been sold, save for some clothes and a few boxes of books, which I forced into the trunk and backseat. After a week of sleepless nights, I had turned in my Ph.D. thesis on quantum dots that morning. I had even found someone to take over my apartment. Now all I had to do was leave.
It was late in the afternoon on Tuesday—August 1995—and the sky over the shimmering San Francisco Bay had turned a smoky orange. Medical school orientation was starting tomorrow. I would be in a Honda Civic somewhere in the Rocky Mountains. After explaining to the dean that I was delayed finishing my physics thesis, she had urged me to at least try to make it to St. Louis by Friday morning for the white-coat ceremony and the recitation of the Hippocratic oath. After speaking with her, I looked it up: “. . . To please no one will I prescribe a deadly drug,
nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion . . .” Arcane stuff. Perhaps, I wondered, she’d let me write my own oath. Perhaps that could be my first contribution to my medical education.
The air was warm, still, vaguely welcoming. The fraying eucalyptus trees in the backyard gave off a pungent fragrance. Taking a long drag, I felt buzzed, even a bit dizzy. For the first time in months, I was in the moment. But the carefree feeling quickly dissipated as the thought—the same thought that had plagued me for months—reentered my mind, even as I tried hard to resist it: What the hell are you doing?
I pulled out of the driveway and headed south toward the Berkeley campus one last time. I passed the International House, Sorority Row, and the dormitory where I had lived freshman year. Ice plant still lined the side of the road, and the landscaping was still immaculate, just as it had been a decade ago. Freshman year, I remembered, I had planned to major in history or political science, but Victor, my randy Russian roommate, had deterred me. He was a double major in math and physics. (And “love,” as he liked to put it. He put a mattress in our walk-in closet. Every night, moans from one of his girlfriends titillated me as I fell asleep.) Victor’s enthusiasm for his chosen subjects was infectious. He lent me books on abstract algebra. He explained to me the wonderfully nonintuitive ideas of Kurt Gödel, an Austrian logician who proved that all mathematical systems are necessarily incomplete. He told me about Ramanujan, the Indian mathematical prodigy who claimed that the Hindu goddess Namakkal whispered theorems about prime numbers to him in dreams. In freshman chemistry, when I had to memorize the rules for how electrons occupy atomic orbitals, Victor taught me where those rules came from, in a quantum-mechanical language that was both beautiful and inscrutable. The exactness, the inaccessibility, of quantitative science intoxicated me. In the social group I eventually joined, math and physics had prestige, a sort of intellectual exclusivity that was deeply appealing. The spectrum of talent in these subjects was so broad, much broader than in the social sciences or humanities or even the biological sciences, where it seemed that with enough study even the grade-conscious premeds could master the concepts. What separated me from the rest of the pack was what separated Victor from me, and what separated my friend Mike from Victor, and what separated the genius student David Moulton from Mike, and what separated the weird, stinky math professor who ambled around campus mumbling to himself from David Moulton, and probably what separated Einstein from the weird, stinky math professor. The brain function required was so specialized that math and physics seemed to me the truest tests of intelligence. So, by the end of my freshman year, my major had changed to physics, and my intellectual heroes had changed from Churchill and Gandhi to Einstein, Heisenberg, and Feynman, men who changed the world through the power of mathematics.
But by senior year it had become clear to me that theoretical physics, at least at the level I wanted to pursue it, was beyond my capabilities. So, like many of my friends who didn’t know what to do with themselves, I took the LSAT and applied to law schools. Trial law had always interested me; in high school I often fantasized about leading a courtroom charge like Atticus Finch in To Kill a Mockingbird. Law school, I hoped, would allow me to broach the big questions of ethics, philosophy, and politics that had always interested me. My father, a plant geneticist with a disdain for vagueness and imprecision (“Nonscience is nonsense,” he often said), thought it was a bad idea. He didn’t need to remind me of his opinion of lawyers. I got into the top schools and even deferred my admission for a year, but in the end I decided to stay at Berkeley for the graduate program in physics. I didn’t know what else to do. Though I thought I might like law school, somehow I knew I didn’t want to be a lawyer.
One thing I never thought seriously about was becoming a doctor. In fact, for most of my life, medicine was the last thing I wanted to do. My maternal grandfather had been an army doctor in India before he went into private practice. As a boy in India, before we moved to America, I used to watch him at work in his iodine-stained clinic on the ground floor of his palatial flat in an upper-crusty neighborhood of New Delhi. Pitaji’s clinic always smelled pungently of medicine, as did he. Through the drawing room window I’d spy him examining patients with boils or sepsis on the mosquito-netted veranda while lizards clung motionlessly to the limestone walls. It was fine, noble work—or so I was told—but it never caught my fancy. To me, even as a boy, medicine was a cookbook craft, with little room for creativity.
My family immigrated to the United States in 1977, when I was eight (we lived in Kentucky for two years, before moving to Southern California). Whenever the subject of lifework came up, I told my parents that I would never become a doctor. Unlike my brother Rajiv, who somehow always knew he wanted a career in medicine, I was more interested in books, literature, philosophy, the big questions of human existence, about which medicine apparently had nothing to say. Even when I experienced a flash of medical curiosity—say, when the pope got sick or a Soviet leader mysteriously disappeared for a few days—it would quickly dissipate or be subsumed by my interest in the politics of the event. I wanted to be a historian or a high-ranking government official or a famous lawyer or actor or a private investigator, something romantic, with character and flair. Medicine was so bourgeois! My father admonished me for being impractical. He wanted me to become a neurosurgeon—one trained at Stanford, no less. To him, that was the apogee of professional attainment. He understood well the privileges of being a doctor. Whenever he was on the phone with the airlines or with the bank, he always identified himself as Dr. Jauhar, even though he wasn’t a physician. (“It really gets their attention,” he’d explain.) My mother, too, wished for me to become a doctor. For her, medicine represented an honorable path to influence, power, and wealth—all the things that had eluded my talented father. But I wanted nothing to do with my parents’ dream. In immigrant Indian culture, youthful rebellion is saying no to a career in medicine.
We had left India to advance my father’s career as a plant geneticist, but in America my father never achieved the kind of success he felt he deserved—denied, he believed, by a racist university tenure system, which forced him to take postdoctoral positions with no long-term stability and left him embittered and rigid and in a constant state of conflict with professional colleagues. He learned to approach life’s conundrums as if they were Aesopian fables. He adopted the habit of distilling life’s problems into simple aphorisms dealing with faith, persistence, the value of work—Booker T. Washington stuff. He was always saying things like, “The happiest of people don’t necessarily have the best of everything; they just make the most of everything that comes their way.” Or he’d say, “Success is to be measured not so much by the position one has reached in life as by the obstacles one has had to overcome.” Or, “It is not falling in water but staying there that drowns a man.” Or, “Work is worship.” Or, “I’m a tremendous believer in luck. I find that the harder I work, the more I have of it.” (Or sometimes he’d mangle the adage, as when he’d say, “Don’t change horses in the middle of the ocean.”) He believed strongly in focus, determination—he’d written a plant genetics textbook in the back bedroom, littered with scientific papers and electron micrographs, while working full-time as a postdoc—and also that the mind is malleable, that satisfaction is a state of mind. He felt an overwhelming urge to keep my brother, Rajiv, my sister, Suneeta, and me from repeating his mistakes.
When I was in middle school in Riverside, California, a mediumsize suburb of tract housing and strip malls tucked away in the smog-ridden Inland Empire, my parents invited a veterinarian over to the house for tea. He too had emigrated from India, a lanky man in his forties with a curly mustache, a Nehru jacket, and baggy brown pants that looked like they needed washing. He sat on the ragged couch in our living room loudly munching on my mother’s pakora fritters. He and my father talked about the evils of Reaganism, but the conversation quickly turned to medicine.
“I always wanted to become a doctor,” he said, looking straight at me. “But I could not afford to go to medical school.”
“I wanted to be a doctor, too,” my father said, pulling up on his fraying brown slacks so that the hair on his shins peeked out over his blue socks. Then he retold a story I had heard many times. My paternal grandfather had died when my father was only thirteen. After his death, the family spiraled into poverty. My father, an able and devoted student, was forced to read his schoolbooks under streetlamps because there was no electricity in the house. For an indigent boy growing up in rural Kanpur, medical school became an impossible dream. My father flirted with the idea when we first came to the United States, but by then he was thirty-seven, with a wife and three young children, and it no longer seemed practical.
“Why did you go to vet school?” I asked our visitor, trying to change the subject.
“Because that is all I could afford,” he snapped. “If I could have paid the tuition, I would have preferred medicine.”
“I want to be a professor,” I announced preemptively. I desired the academic, retiring life of my father.
“He talks like a kid,” my father said sadly. “He thinks he is smart, but he is going to land in a ditch.”
“Brother, the kids have to make their own mistakes,” the veterinarian replied gravely.
“But they should learn from others’ mistakes!” my father exclaimed. “You don’t have to touch the stove to know that it is hot.”
The vet turned to me. He spoke in the stern tone of someone who wasn’t used to being challenged. “We are foreigners, you understand? As a doctor, you won’t have to depend on anyone.”
“They say equal opportunity,” my father said disgustedly. “It is an eyewash, a joke.”
“You have opportunities that your father and I did not have. You’re a smart kid. You do well in school—”