Brotherhood Dharma, Destiny and the American Dream (13 page)

My mother, who was a high school graduate with no formal medical training, learned quite a bit about medicine through my father and often asked insightful questions, which he always answered in great detail. She was always so inquisitive. Did you cure this? Did you fix everything? What will you do next? What have the tests shown? Sometimes, in fact, she would actually make the diagnosis herself.

At one dinner my father seemed unusually concerned about a patient.

“I am worried about this sister’s daughter,” he told us. “Sister” was the word they used to describe nurses at the time. He continued, “She’s a single parent with a thirteen-year-old daughter.” He looked directly at me and said, “You may have met her at one of the festivals.”

My mother asked her usual question: “What are her symptoms?”

“She has a high fever and an enlarged lymph node,” he said. “I’m hoping it’s strep throat.”

“I just hope it’s not Hodgkin’s disease,” my mother said. My father considered that for a moment.

“You know, you’re probably right.” Indeed, my father later diagnosed the little girl as having Hodgkin’s lymphoma. We followed her progress at dinner for several years, until, sadly, she passed away.

My father taught us that diagnosing a patient is an art that requires total focus. It’s rarely obvious from one or two symptoms. He took great pride in his ability to make difficult, sometimes obscure diagnoses, a trait that both Deepak and I inherited. He used to tell the story of his final examination for membership in the Royal College of Physicians.

“These are professional patients,” he said. “They are people with real illnesses, some of them rare, who are paid to present their symptoms to students taking examinations. When the patient saw he was being interrogated by an Indian doctor he became quite uncooperative. There was an attitude to his responses. After greeting him with the usual civilities I started taking a history. And he refused to give me a firm answer to any question. Do you cough when you’re in the hospital? ‘Maybe.’ Are you sleeping well? ‘Sometimes.’ After answering each question he would turn to the professional patient in the next bed and ask, ‘Mike, do I cough?’ ‘Mike, do I sleep well?’ Mike would answer, ‘Maybe’ or ‘Sometimes.’ It was impossible to get a direct answer.”

But as my father listened to this patient, he was also looking carefully for any unusual signs. He noticed that the patient’s eyes were moving slightly from side to side, a condition known as nystagmus. He also noticed that there was something slightly off about his speech.

“Please say ‘British artillery brigade,’” my father said.

The patient repeated the phrase, slurring the words slightly, a symptom known as scanning speech.

My father asked the patient to hold up a pen he had in his hand, and noticed that the patient had what is known as an intention tremor.

“How long,” my father asked confidently, “have you been suffering from disseminated sclerosis?”

It was the classic triad of symptoms—scanning speech, intention tremor, and nystagmus—seen in patients with disseminated sclerosis,
a condition better known in the United States as multiple sclerosis. The professional patient’s face lit up.

“My goodness, Doctor,” he exclaimed. “You are one of the very few who made the correct diagnosis.” Impressed, he went on to tell my father all the questions they would ask during his final examination—and reminded him of the right answers. That information helped my father pass with honors, an extremely rare accomplishment for a young Indian doctor at that time.

Unlike my brother, I never really doubted that I would become a doctor, and a great diagnostician, like my father. In India there are medical schools teaching science-based medicine, Ayurvedic medicine, and
Unani,
another form of traditional medicine, and graduates of all of these are considered capable doctors. I, on the other hand, was only interested in what I called modern medicine, the science-based medicine practiced by my father. While I believed other forms of medicine had their place, I felt that Western medicine offered patients the most sensible and proven forms of treatment. To me that was real medicine and that was the type of medicine I intended to practice.

The educational system in India is different from that in the United States. In America a student attends college before applying to medical school. In India there is one year of premed after high school and then students go directly to medical school. After completing my year of premed at Delhi University, I applied to three medical schools. My father was teaching at the Armed Forces Medical College at Pune and my brother was attending the All India Institute of Medical Sciences in Delhi, so I applied to these two medical schools and also to Banaras Hindu University.

I had decent scores on my premed exams, and I was immediately accepted to Armed Forces Medical College and to Banaras Hindu University. But I really wanted to attend the All India Institute of Medical Sciences, which was (and remains) the most prestigious medical school in the country. Unfortunately it was also the most difficult to gain admission to. Only thirty-five students were accepted each year from as many as ten thousand applicants. The admissions
council whittled down the initial pool to ninety applicants based on our scores, then called each of us in for an interview. During my interview with Dr. Keswani, the head of the anatomy department, he asked me why I didn’t want to go to the college where my father was a legendary professor.

“He was assigned there by the military service,” I explained. “He didn’t have a choice. I have a choice, and I want to attend this grand institution. This is a modern school with many brilliant people like yourself on the faculty, and there is modern thinking about medicine here. Many of the faculty have also trained in America.” America, I said specifically, not England. He felt that the postgraduate training in America was the best. Finally I added, just to be safe, “I also like the modern buildings and the fact that there are table tennis tables in the vestibule.”

“You want to play table tennis and study architecture!” he retorted, smiling.

I like to tell people that I was at the top of the admissions list, but truthfully I was at the top of the waiting list: number thirty-six. Number one in the entire nation was a lovely young woman named Amita Desraj, who had intended to join the Foreign Services and eventually become an ambassador. But like Deepak, she too had changed her mind and decided to go into medicine.

Fortunately each year three to four students among the thirty-five granted admission to the prestigious All India Institute of Medical Sciences chose not to attend the school because they received scholarships from other medical schools. As a result I was admitted to the medical school of my choice.

Even then it took an act of Parliament for me to become a physician. At the time, to attend the All India Institute a student had to turn seventeen by August 1 of that year. In elementary school I had been promoted from first grade to third grade because the teachers and the principal thought I was bright, something colloquially called a double promotion. Since I would not be eligible for admission and would have to wait almost two years to enroll, my father mentioned the problem to one of his patients: the future president of
India, Fakhruddin Ali Ahmed. He requested that Parliament change the rule. Under the new regulations, I squeaked in by twenty-one days and became the youngest student admitted in the history of the medical school.

The school was not difficult for me. I had been raised in the world of medicine and was comfortable with the language and the tools. It all came relatively easily to me. Unlike American medical schools, in India we learned mostly by memorizing material. There was little analytical thinking, just memorization and recitation. In premed, we would stand in front of the class and recite the entire periodic table. It’s still right there in my memory. We used all types of memory aids. A symptom of liver disease, we learned in medical school, is that your palms get very red. It’s called palmar erythema. A second sign is that patients develop red spots on their body, usually on the upper torso, that look something like the legs of a spider. To remember that, we used a limerick, which I’ve never forgotten, coined by a Dr. Bean, from Boston:

An older Miss Muffet decided to rough it, and lived upon whiskey and gin

Red hands and a spider developed outside her, such are the wages of sin.

Deepak was two years ahead of me in medical school and had laid down a difficult path to emulate. My first year he would get very upset at me because instead of staying in my room and studying, I’d go to the movies or out with friends to coffee bars, returning very late. I also still cherished competing in sports. I was the best cricket player and the best table tennis player for a number of years and won many trophies. My brother, on more than one occasion, told our mother that he was proud of my athletic prowess but worried about my academic performance. My mother happened to be at a bank sometime later and ran into Dr. Keswani from the anatomy department. He went up to my mother and asked how her sons were doing.

“I have no worries about Deepak,” she told him. “He’s an academic, but I do worry about Sanjiv, who seems to be too fond of sports.”

“Don’t worry,” Dr. Keswani said. “I’ll take care of him.”

The student in the room next to mine was always studying. No matter what time I woke in the morning or came in at night, the light in his room was on and he was hitting the books. He had made it clear he disapproved of my study habits, which annoyed me, so when we were both about to be tested about the abdomen in Dr. Keswani’s anatomy course, I said, “I’d like to challenge you. I’ll bet you I get a better score than you in the abdomen!”

He accepted my challenge. This time both of us studied very hard, and we tied with the third highest score in the written examination. Then an interesting thing happened during our oral examination. Dr. Keswani asked me twenty questions, and I answered every one of them correctly.

“I’m going to give you ten marks out of one hundred,” he said. This was his misguided way of encouraging me to study even harder. I was dumbfounded and outraged.

In India we were taught that the person you showed the most respect for, even more than your parents, was your teacher. The teacher was always infallible. There were quite a few instances growing up when a teacher would say something that clearly wasn’t correct, but rather than speak up we accepted that we must be wrong and the teacher, somehow, right. Sometimes we would discuss it later.

“What the teacher said couldn’t be true, could it?” We would all agree that it wasn’t, but nevertheless the teacher had been saying the same wrong thing to students year after year and no one had had the guts to tell him he was wrong.

But this time I did something students in India almost never do. When Dr. Keswani told me he was giving me only ten marks I spoke back.

“I’m not leaving,” I said. The junior professors and demonstrators in the anatomy department looked at me like I had lost my mind. “I’m not leaving,” I repeated. “I studied very hard. I know my abdomen. I got the third highest score on my written examination. Dr. Keswani, I have a favor to ask. Go ahead and please ask me more questions.”

It was just like when I stood up to Roger the Bully. No one knew how to act. Dr. Keswani looked both amused and a little angry.

“Okay,” he mumbled. He asked me another five questions, and I answered each one of them correctly. “Very good,” he said. “I’m going to double your marks.” With that, he gave me twenty on the exam.

I was furious when I walked out of that room, but there was nothing I could do. So I called Deepak to lay the blame on him for telling our mother about my lack of diligence. Then I called my mother and told her the result of her conversation in the bank. But in my class I became known as the student who had the courage to speak back to Dr. Keswani.

For me my last term was the most exciting because we were finally allowed to put our theoretical knowledge to use, treating real patients. The All India Institute was a teaching hospital with more than a thousand beds. But directly across the street was the government-run Safdarjung Hospital, which also had a thousand beds as well as an additional two hundred patients sleeping on the floor or on mattresses. The range of patients we saw at those hospitals was remarkable. When a patient was diagnosed with an unusual condition we would all excitedly make rounds with our teachers. We saw tropical diseases that are rarely seen in the United States, treated every form of tuberculosis, and saw patients with rabies and even leprosy. The actual practice of medicine was as exciting as I had imagined it would be.

Although my class was small, there was an effort made to have a lot of diversity in the group. There were more women than men and 30 percent of the seats were reserved for foreigners and people of the scheduled castes. In the Hindu caste system these are the people who had been referred to as the untouchables. For some of those people the school presented a great culture shock. One of the students from a scheduled caste, for example, came from a very small village. He was scandalized to see female classmates wearing skirts or frocks, any garment that showed their legs, as this was forbidden in his village. He spoke poor English and was very shy when we started, but by the time we graduated he had become proficient in English and we had
become friends. And he no longer covered his eyes when a female classmate walked in wearing a skirt.

The person I became closest to, however, was Amita, the number one student in our class. I met her a few weeks after our first term started. There is a tradition at the Institute that the freshman class puts on a show for the other students. Amita loved music, and for that show she played the harmonica and convinced the whole class to sing along while she played. She also played the guitar and eventually organized a band at the school. I saw this as an opportunity to spend more time with her. Unfortunately I didn’t sing well or play any instrument. So when Amita asked me what I could do, I said, “I can clap and I can whistle.”