Internis Dr. Sandeep Jauhar's story of his days and nights in residency at a busy hospital in New York City, a trial that led him to question his every assumption about medical care today. Residency--and especially its first year, the internship--is legendary for its brutality, and Jauhar's experience was even more harrowing than most. He switched from physics to medicine in order to follow a more humane calling--only to find that his new profession often had little regard for patients' concerns. He struggled to find a place among squadrons of cocky residents and doctors. He challenged the practices of the internship in The New York Times, attracting the suspicions of the medical bureaucracy. Then, suddenly stricken, he became a patient himself--and came to see that today's high-tech, high-pressure medicine can be a humane science after all.
Jauhar's beautifully written memoir explains the inner workings of modern medicine with rare candor and insight.
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Farrar, Straus and Giroux
January 01, 2009
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Excerpt from Intern by Sandeep Jauhar
I had been an intern less than an hour, and already I was running late. The sloping footpath leading up to the hospital was paved with gray cobblestones. My feet ached as my oversize leather sandals slipped on the rounded irregular rocks. The hospital was an old building browned by the passage of two centuries, with spidery cracks in its fa�ade. Founded in 1771, New York Hospital is the second-oldest hospital in the United States, a mecca for doctors and patients from all over the world. I had been in the building once before, six months ago, for a residency interview. I spun through a revolving brass door, nearly running into the burly security guard reading the New York Post. He looked up from the tabloid just long enough to point me in the direction of the elevator.
The tiled corridors were dark and dull, mixing shadow and light.
I darted past the chapel, past the caf�, around the information desk, which sat in the middle of the huge atrium like a fort, and entered a bank of elevators. Hanging on a wall was a portrait of a gray-haired lady in a blue dress sitting in dignified repose before an open book. She was a graduate of the medical school, class of 1899, ninety-nine years ago, who built a medical college for women in Northern India, on the banks of the Ganges, near where my father had his early college education. Nearby was a metal tablet in bas-relief: "She cared for all in need. For each, she made time to guide, to teach, and to heal."
When I arrived on the fourth floor, other interns were still filing into the auditorium. A woman handed me a manila folder, and I went inside and sat down. The orientation packet contained several essential documents: a house-staff phone card, directions for obtaining autopsies, instructions on how to use the hospital dictation system, and the residency contract. I leafed through it quickly. My salary was going to be $37,000 a year, about eight dollars an hour, I calculated, given the number of hours I was going to be working, but I didn't mind. Though I was a year shy of thirty, it was more than double what I had ever made.
My classmates, though younger than I, appeared older than I expected, casually dressed, all thirty-five of them, in khakis and polo shirts, faded jeans and sequined tops. Some of them evidently knew each other, because they were already chatting in small, insulated groups. They were from some of the best medical schools in the country: Harvard, Yale, Cornell, Columbia. Though I too had gone to a top school--Washington University in St. Louis--I had been feeling insecure about the prospect of working with them. For months I had feverishly been reading Harrison's tome on internal medicine and review articles in The New England Journal of Medicine to prepare for this day.
Someone in the front row stood up and turned to face us. It was Shelby Wood, the hospital's residency director. He was a serious-looking man of medium build, with straight brown hair and a long, aquiline nose. He was wearing a white coat and a fat blue tie that might have been in fashion twenty years earlier. My elder brother, Rajiv, a cardiology fellow at the hospital, six years ahead of me in his medical training (though only two and a half years older), had warned me that Dr. Wood was a bit of a grouch, but had added that he was also fair and decent and a strong advocate for his house staff. Wood, I was to learn, hailed from the old school, where you were expected to live and breathe medicine, stay late in the hospital, neglect your family for the sake of your patients, and emerge on the other side a seasoned physician.
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 caf�s, 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
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 long-standing 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 (tm) 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 G�del, 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 medium-size 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--"
"He says medicine is cookbook," my father interrupted. "He says he wants a challenge."
"He can do research, if that is what pleases him," the vet reminded.
"At least there is some surety in medicine," my mother echoed from the kitchen. She was a typical Indian mother, loving, caring, committed, but small-minded, too, in that only-concerned-with-my-own-backyard way. She had struggled alongside my father, raising the three of us kids, working full-time as a lab tech, making do with much less than she was accustomed to having, sacrificing so my father could write his academic textbooks, which sold a few dozen copies a year. (She always said that nothing good or substantial would come of writing books.) We lived hand to mouth in a house sparsely furnished with lawn furniture, kitsch, little tchotchkes and cheap knickknacks my parents picked up from garage sales. My parents took us everywhere with them, not because we were an extraordinarily close-knit family, but because we couldn't afford a babysitter. There was a time after my father lost his job that we were forced to live on my mother's lab technician salary of $11,000 a year. We couldn't tell anyone; we had to keep up appearances that my father was still working. "We have to live in society," my mother would explain.
"You will get a good job as a doctor," my mother said, bringing in a platter of sweets. "You will get izzat, respect. When you walk into the room, people will stand. At the university you may get nothing for your hard work."
"They never let you rise," my father said, shaking his head. "They preach human rights. They talk democracy. What human rights! Where are the human rights in this country? It doesn't matter if you are a citizen or not a citizen; it is the color of your skin. They will always hire a white American if they can. You have to be three times as good as them to get the same recognition. If I could start a practice, I would kick them. I would tell them to go to hell."
The irony of all this was that my father hated doctors. He thought they were all crooks. (He always said scientists like him, Ph.D.'s, were the real doctors.) I had heard the stories growing up: the urologist who told him he had testicular cancer when he had a simple fluid-filled cyst; the dentist who botched a filling and wanted to charge him to get it done over again; the rheumatologist who overtreated him with steroids; the pulmonologist who recommended surgery after a marginally abnormal chest X-ray. Dr. Gokhale, our family doctor, had bungled the stitches I needed after a dirt-biking accident, incorrectly diagnosed my brother with water on the knee, and almost killed my grandmother by giving her a drug for a blood disorder she did not have. My parents had a running joke between them about how much Rajiv was going to charge them for medical care in their old age. The clear if unintended message was that doctors were money-grubbers, distinguished from shopkeepers only by their higher education.
I too resented doctors for their money, their airs. At Indian social functions, the doctors would drive up in their fancy cars as we were getting out of our dilapidated old Buick. Their kids wore the best designer clothes: Le Tigre, Polo, Ocean Pacific, Vans. I hated how they looked down on us, on our shoes from Kmart and our jeans from Sears. One of them invented a rhyme about our shoes: "Buddies, they make your feet feel fine, Buddies, they cost a dollar ninety-nine, Buddies, I'll never show you mine . . ." I hated their spoiled daintiness, their self-appointed privilege. I fancied myself a champion of the underdog.
"Uncle, it is not for me," I said to the vet. I was too ambitious, too stubborn, to pay attention to pragmatic considerations.
"One day you may have regrets," was his reply.
I did give it a chance--once. During college, at my parents' insistence and following Rajiv's suit, I volunteered in the emergency room at Riverside General Hospital over Christmas break. The ER was quiet that first night. The biggest excitement was a teenager who came in with a cockroach stuck in her ear. She screamed as a doctor took the insect out, piece by piece.
I spent most of the shift in a back room, reading a book on quantum philosophy called Wholeness and the Implicate Order. At 9:30 p.m., when I was getting ready to leave, a call came in from paramedics. "Stick around," a doctor told me. "Things are about to get interesting." Within minutes a young man was wheeled in on a stretcher after crashing his VW Bug into an eighteen-wheeler. As he screamed horribly, the ER staff went to work on him, cutting off his clothes, immobilizing his head, wiping away blood. Someone inserted a catheter through the tip of his penis, which began draining red urine. Someone else prepared to insert a tube into his bleeding chest. That was enough for me. I quickly packed up and left, vowing never to return. Such excitement, I informed my parents, was not for me.
I STOPPED MY LOADED-UP HONDA at the traffic light at Bancroft and Telegraph. The food carts were still out; Berkeley would obviously carry on without me. Freshman year, a chemistry professor had told me that some people believed the world begins and ends at this intersection, and in a sense it had for me. Snaking up the hill behind me was Cyclotron Road, where E. O. Lawrence had built the world's first atom smasher and where I had spent the past five years doing my graduate studies on quantum dots. The research had been published in the most important physics journals. But after a while, the research didn't matter to me anymore.
On my right was Sproul Plaza, where I had spent many afternoons sitting on the steps of the student union playing chess with a demented old man who took my pieces with strange exuberance (and sometimes cheated), while the hippies played guitar or the evangelists and other cranks hollered inflammatory oratory in the background. One of the evangelists got kicked off campus for uttering a vulgar epithet--a controversial action on a campus that had given birth to the free speech movement--but he eventually came back. Berkeley had a way of doing that, pulling you back in.
As I waited at the stoplight, my eyes wandered over to the Carlton Hotel, a single-room-occupancy dwelling where my girlfriend Lisa had lived. She was from Los Angeles, and we had met my junior year in the dorms, when she was still a freshman. When I was in graduate school, we had had a standing date for lunch at least once a week at the little Chinese place on the north side of campus. I looked over at the stone bench near the dried-up fountain where she first told me about her illness: lupus. I stared at the spot, reliving the moment; sadness washed over me once again. I pictured her in her white sweater, looking delicate and pale, her skin the color of milk, with me holding her tightly and whispering that one day she was going to be cured and that I would see her through it. She cried hard that day, and so did I. For her and for myself.
The disease aged her, sapped her of strength, inflamed her joints, sullied her unblemished complexion. Her hair thinned; her fingers became swollen, like sausages. The membranes around her lungs became inflamed and protein started spilling into her urine. For weeks she could hardly get out of bed. And the worst part was that there was no cure! At first I didn't believe it. There were entire libraries devoted to medicine, with hundreds, even thousands, of journals. Surely the answer had to be in one of them.
I brought to my girlfriend's disease the kind of can-do optimism that is typical of graduate students, a belief that if I looked hard enough, I would find a solution. The concept of chronic illness was completely foreign to me. Disease came and went; it killed you or you got better. Perhaps there were better doctors somewhere--with better knowledge, better command of the medical literature--that could help her. I called top researchers. I read medical textbooks. I pored over Lupus Foundation of America newsletters cover to cover. I asked my brother, then a new intern, to inquire about emerging therapies. I spent lonely evenings staring into drugstore windows, wondering if the answer could be found inside the panoply of vitamin bottles. I went to support group meetings, often without Lisa. One night in San Francisco, a scientist from UCSF delivered a lecture on the frontiers of research into lupus. He was a short man with an imperious air, and I found him pompous and a bit pedantic, but when I looked around the dimly lit auditorium, all eyes were fixed unwaveringly on him. The woman with large discolorations on her face sitting next to me was in an almost meditative trance. Clearly everybody there was awaiting a cure, hoping for deliverance.
When I drove back across the Bay Bridge to Berkeley that night, I gave the idea of going to medical school serious thought for the first time. My physics research had slowed to a crawl. I was spending most of my time in the lab tweaking a malfunctioning laser or trying to fix a broken vacuum pump, not collecting publishable data. Quantum dots, I feared, were never going to make much of an impact on people's lives. Practical considerations of this kind had never been important, but now, in the shadow of physical illness, only the usefulness of medicine seemed to matter. Physics had been a way to set myself apart. Now, its exclusivity had become its main liability.
My thoughts remained unformed while I tried to muster the cour-age to discuss them with my family. What would my parents say? Would my father think I was being farsighted or irresolute? Would he think of me as a quitter?
I first talked to my parents about my intentions a few weeks later on a family trip to San Diego, where Rajiv was in his second year of residency at UCSD Medical Center. Rajiv was two and a half years older than I, and as with most brothers of roughly equal age, ours was a complicated relationship. Growing up, he was my playmate, rival, and exemplar. There are faded pictures of us as children, dressed in school uniforms, hugging each other in the smoky air of Old Delhi. In America, we were latchkey kids. When we got home from school, Rajiv would fix me a snack--usually a bowl of cornflakes with a heap of sugar--and we'd sit in front of the TV and watch cartoons. As we got older, we got more competitive, especially in sports. We'd go to public tennis courts in the summer or on weekends and play from morning till night, often evenly splitting our matches. In high school, I edged him out for the final spot on the local team going to the California Interscholastic Federation tennis tournament, but my father forced me to give up my spot because Rajiv was a senior and it was his last oppor-tunity to play CIF. When Rajiv went to college at UC Riverside, only a few blocks from our high school, our relationship changed once again, and he became more of a guardian over me, always inquiring about the minutest details of my life at his old school, closely monitoring and supporting my attempts to break into "the Hill" and other popular social groups. Though I had always done better in school than he, Rajiv possessed an easygoing charm that made people instantly comfortable and won him friends and popularity. If he was a politician, I was a political consultant.
Now I was a graduate student with misgivings and he was a doctor with a degree from the University of Chicago. My parents and I were sitting in Rajiv's sunlit living room, just a stone's throw from Solana Beach, when my father asked me how my research was going. When was I going to start collecting data? I told him that I didn't know.
"But you've been setting up your experiment for over a year," my father said, leaning forward on the black leather couch, the breast pockets of his short-sleeved cotton shirt thick with pens. Even though he had never really supported my decision to go to graduate school, now that I was there he wanted to see me finish up and get on with my life. "You have to learn to focus. I have done a Ph.D. so I know--"
"You can't stay in graduate school forever. You have to look for a job, start a family--"
"Okay!" I shouted. I got up and went to the bathroom, where I splashed cold water on my face and coughed into a towel. Then I went back to the living room, where my parents were sitting quietly. My father was leafing through papers in his ever-present briefcase, which was resting on his lap. I sat down on the love seat. "I'm thinking about applying to medical school," I announced.
My mother, dressed in a conventional flower-patterned sari, looked at me quizzically. She turned to my father, who was expressionless. "You can't go to medical school now," she declared.
"Why not?" I replied. I had it all figured out. Over the next two years I could finish up my thesis and take the prerequisites. By the time I matriculated, I would be only twenty-six.
"And then four years of medical school, then three years of residency, maybe even a fellowship. Look at your brother. Do you think you can work like him?" Judging from her tone, she did not.
"It's only a few years," I snapped. Unlike in India, life in America wasn't set in stone once you turned twenty-one.
"I always wanted you to be a doctor," my mother said. "Remember? It was always my dream that both my sons become doctors. But that time has passed."
Her last remark was particularly cutting. It saddened me to think about how many years and how many opportunities had slipped away. My father appeared deep in thought. "What are you thinking?" I demanded.
After a long pause, he said: "Don't change horses in the middle of the stream. Who knows if you will even like medicine?"
That night, we went to the Old Town district to have dinner with my brother and some of his colleagues from the hospital. We sat outside on a cobblestone square illuminated by gaslights, drinking margaritas out of salt-crusted martini glasses while a mariachi band serenaded my father with "Happy Birthday." At one point Rajiv's beeper went off. He stood up and went off to answer the page. My father and mother beamed proudly.
They had always favored my brother, their firstborn, and Rajiv demanded it, too. He knew the privileges of being the eldest son in a traditional Indian family and guarded them closely, like a trust fund. Watching him that night, I thought of all those times I had pitied him studying organic chemistry or preparing for the MCAT while I read novels or blasted Rush records on our turntable. Why do you begrudge him his happiness? I asked myself. He earned it. I remembered the summer I visited him in Chicago. He was a third-year medical student and would usually leave the apartment for the hospital before six in the morning. I'd sleep till noon, get up, eat lunch, read the newspaper, do some sightseeing if it wasn't too hot, and usually end up roaming through bookstores in Hyde Park. Rajiv would trudge in at 6:00 or 6:30 p.m., always looking a mess but claiming he felt great. Now where was he, and where was I?
His colleagues asked me about my research, but I couldn't bring myself to say much about it. Now that I had lost my enthusiasm, I couldn't imagine anyone else finding it interesting. So I asked them about residency, hospital life. They were working hard but it was obvious that no one had any regrets. Like my brother, they seemed to have embraced their training as a sort of boot camp, a necessary hardship on the way to a fulfilling career. One of them boasted that he had recently diagnosed a case of malaria by examining a smear of a patient's blood under a microscope. Someone else told me that he was in the process of applying for a hematology-oncology fellowship. Listening to them, I felt envious. They possessed everything that I was lacking: passion, confidence, a sense of purpose. Graduate school had left me feeling lonely, marginalized, like an interloper in the real world.
Riding home that night, I was surer than ever that I wanted to become a doctor. Choosing to do so now was as much of a rebellion as dismissing it had been years ago.
The next day Rajiv took me to the hospital. Walking through the teal double doors of the intensive care unit was like entering a sanctuary, scrubbed and sanitized. I had never been in an ICU before. Residents were moving quickly, purposefully, dressed in light blue scrub uniforms and fanny packs. Rajiv took me from room to room, telling me about each case. We passed a young man on a ventilator. A middle-aged couple was sitting quietly at his bedside. "He'll be gone by the afternoon," Rajiv whispered casually. We walked on as he continued talking. After a few paces, I stopped. "What did you mean back there?"
"Where?" Rajiv said.
"Back there. You said that guy was going somewhere. Where is he going?"
"To the morgue!" Rajiv replied. "He has AIDS. He's circling the drain."
I searched his face, bewildered by his lack of feeling. At one time he had been so sentimental. He had wept when I left for college, and again when he went off to medical school. Now he seemed so different, so hardened, like the sort of person who might pick up a ringing phone and shout, "Talk to me!"
"You've changed," I said, not even trying to hide my disappointment.
"So you'll be a different kind of doctor," he shrugged. "Once you get out of the ivory tower." We continued walking while I seethed quietly.
When I got back to Berkeley, I met with a campus psychologist, a balding, bespectacled man who specialized in career counseling. He asked me to take a career interest inventory test. A few days later I went back to discuss the results with him.
"Well, Mr. Jauhar, the test indicates that you have little interest in medical science." The occupations I seemed best suited for were lawyer, college professor, human resources director, and flight attendant.
When I told him I had already decided to apply to medical school, he asked me why. Judging from his tone, he didn't think it was a good idea. If I wanted to do biomedical research, had I considered seeking a postdoctoral fellowship after I finished my physics Ph.D.? If my reasons were primarily pragmatic (the hope of a high salary), what about options requiring less training, like management consulting, investment banking, or business school?
I was yearning for something I couldn't quite put my finger on. "I just want to get out of the ivory tower," I blurted out, and of all the possible reasons that had gone through my mind, that one probably best explained my motivation. I had begun to despise academia. I had been enmeshed in the world of esoteric ideas, and where had it gotten me? The lupus support group meetings had reinforced my belief that the work I was doing was going to have little impact on people's lives. Physics was an enterprise of reflection, ideas. Medicine was an endeavor of prescription, of action. Becoming a doctor, I hoped, would bring me back into the real world. It would make me into a man.
Excerpted from Intern by Sandeep Jahuar. Copyright (c) 2008 by Sandeep Jahuar. Published in 2008 by Farrar, Straus and Giroux, LLC. All rights reserved.