Brotherhood Dharma, Destiny and the American Dream (22 page)

Dharma can be simplistic and crass. In the secular life that most educated Indians live, God is smiling on you if you are rich. Money confers a halo. Driving a Mercedes tells people on the street that the universe is on your side. In the scheme of things, poor people go to a temple with their troubles; rich people hire Brahmans as private gurus to offer soothing flattery.

In America it came as something of a relief to leave all of that behind. In the first years, if I gave two thoughts about dharma, I can’t remember it. Most of the other young doctors were single. I mixed in with them during extracurricular hours. Late Friday when we drank and smoked together was the shank of the evening for them. I got out quickly to go home to my family, just as things were revving up. In
good conscience, though, I could tick all the boxes of dharma, just as my father had done all his life.

A little boy in the West can take comfort in the image of Jesus, with a lamb in his lap, gathering a flock of adoring children around him. A little boy in India takes comfort in the image of Lord Krishna holding up a mountain with one finger. As the fable goes, a village was being threatened by torrential rainstorms, and to protect it, Krishna plucked up Mount Govardhan and held it over the village until the danger had passed. Often the image shows the joyful villagers using sticks to help Krishna hold up the mountain, the lesson being that God doesn’t need our help, but that we should do our part anyway. For Jesus to say, “Suffer the little children to come unto me” is kind. Krishna is more about keeping you safe.

When you go where your dharma leads, you are following a thread that will never break. Almost every choice a person makes in life must obey dharma, and if it doesn’t, bad things will follow. These can be everyday misfortunes or crushing calamities. Bad doesn’t just mean difficult or unpleasant, it means that you have lost your way. Since dharma is all but meaningless in the West, it’s worth considering whether India has found some kind of secret key or is simply following an old, worn-out belief.

Invisible laws are not reliable, so dharma has been outlined in specific rules that each generation imparts to the next. The whole scheme can become incredibly complex and suffocating. If a high-caste Brahmin followed every minute ritual laid down in Hindu scriptures, there would be no time left in the day to actually live. For practical purposes, though, the rules are loose. My father was in his dharma if he honorably pursued his profession; his sons took up the family dharma by becoming doctors in his footsteps. If my mother frowned occasionally because he gave too much money away, dharma saved him because general goodness is part of the law. Viewed with nothing else than these things in mind, dharma keeps people on the right track, the track of virtue. But having divine approval for how you live each day isn’t so different from devoutly following the Koran or the
prescriptions of the Talmud that dictate good behavior for orthodox Jews.

The peculiarly Indian twist is that dharma is ingrained in human nature: It’s instinctive. You can feel when you have stepped off the path. Self-awareness comes into play, and then the word “invisible” is inescapable. At every stage of my life I was building a self with invisible bricks. By definition I couldn’t see them, and yet if I looked in the mirror decades later and beheld a middle-aged man who was rigid, proud, selfish, obsessive, or anything else undesirable, the flaw would be the result of a process that took years to develop. I would have only myself to blame, my own lack of awareness. Dharma sends its signals every day. The smallest bad thing is actually a disguised message to the inner self. The self cannot be understood without thinking of a coral reef rising from the ocean floor, one tiny bit at a time.

The paradox of building a self is that the process never stops for a moment; you can never decide what you’re making. There is no master plan and no architect. All you can do is be self-aware. Let’s say that seeing dozens of patients a day during my years in practice made me callous. An especially annoying patient might push me too far. Every physician sees repeaters who bring the same minor complaint to the doctor again and again. After the third visit in a month, a part of you wants to say, “You have the medical equivalent of a hangnail. Go home and quit bothering me. One of us needs a life.”

If I ever caught myself actually saying these words, I might glimpse the truth: I’ve grown callous. But people are remarkably protected against self-awareness. It’s far more likely that the process of growing callous would escape my attention, and if anyone else pointed it out, I would react with blame and resentment. We don’t see the invisible bricks of the self, and there is barely a faint click as they fall into place.

Dharma recognizes that people have a stake in not knowing themselves. In an ideal world everyone would ask “Who am I?” every day, and since “I” is constantly shifting, each new day would bring a new answer. India has existed too long to wait until the ideal life arrives. The rules of dharma tell you how to build a self that will be approved by God automatically. Every traditional society has some version of
this, but in India there is a force running through each individual, which is the same force that upholds creation. As in the Krishna fable, if you drop your stick, you aren’t doing your part to keep the mountain up. (In Sanskrit the word “dharma” can be traced back to the verb “dhar,” meaning to hold or support. Dhar is even older than Sanskrit, which makes it one of the oldest words—and concepts—in human language.)

To an outsider it may look as though dharma is oppressive in its insistence on following tradition, and there’s no doubt that in India a son who lives in the house where he grew up, goes to the school his family has always attended, and works at the profession of his father and grandfather will win social approval. The groove seems mindless if you haven’t grown up in the system. But turn the picture around, and following the American dream seems wildly reckless. American sons can’t wait to move out of the house, find work that is anything but what their fathers do, and move to a city where life is better than where they grew up.

I can accuse myself of not having enough self-awareness those first years in Boston. I ignored the signals that were coming my way. So I was about to be shocked by the instability of happiness. No one told me about the risk of teetering between two worlds. The dream was coming true on the American side. How can you fail at your dharma when you are breaking your back trying to fulfill it?

A woman in her thirties goes to the psychiatrist. She’s a new patient, so he starts to take a medical history. Although in general good health, the woman is more than fifty pounds overweight. She is married with five children, a stay-at-home mom. She reveals that her husband is currently out of work. The psychiatrist writes it all down.

“So, what did you come in for today?” he asks.

“I feel kind of depressed,” the woman replies, “and I can’t figure out why.”

This isn’t a wry joke that one doctor tells another. It actually happened to a psychiatrist in training that I knew. In a way, it mirrors a truth: It’s not up to the patient to know why she feels bad, even if the
reasons are staring her in the face. Today the punch line would be “I’m fat, I have five kids at home, and my husband just lost his job. Do you have a pill for that?”

It was a surprise for me to see how many patients in America believed in a pill for everything. The notion that your lifestyle can make you vulnerable to illness hadn’t taken hold, and the solution—change your lifestyle if you want to get better—was even more tenuous. At the Lahey Clinic I was low on the totem pole, and the patients I examined were well to do and often very influential. A labor leader who could sway the votes of millions of workers came to Lahey grossly obese, wheezing with every breath, and abusing alcohol and tobacco from the moment he woke up in the morning to the moment he lay down at night.

What was my duty to this patient? I was given very clear instructions: “Be gentle, and whatever you do, don’t tell him the truth.”

Today such a code borders on the unethical. Back then, discretion was considered more ethical than anything else. Cancer patients were routinely not told their diagnosis. It wasn’t a patient’s right to know, and many were afraid of knowing. (It still isn’t in many countries. One reads that Emperor Hirohito of Japan, who died of duodenal cancer in 1989, wasn’t told his diagnosis even up to the end, despite the fact that he had been operated on as early as the fall of 1987.) I have come to feel that it borders on the unethical not to tell patients about the impact of their lifestyle choices.

I was far from feeling this way when I was a young doctor, though. What made you a hero was spotting the right diagnosis and not much more. The
Physician’s Desk Reference
told you what to prescribe. When you handed a prescription to the patient, there was such a look of relief and respect that you grew to believe it was deserved—the drugs you dispensed out of a handbook were the symbol of your wisdom. On the medical pecking order surgeons stood at the top because they had skills that went far beyond writing a prescription (when they chat, surgeons say things like “Did you see that melanoma I saved today?”) while psychiatrists were at the bottom because they had almost no drugs they could prescribe beyond a small array
of tranquilizers—antidepressants hadn’t yet come into their own. We didn’t disguise our scorn for a doctor who spent his whole day listening to patients talk about their problems and then did nothing better for them than talk back.

These casual prejudices were deeply embedded in the profession. It took a crooked path for me to find my way out. The first steps were unwitting, more or less. I had begun to feel a genuine calling toward endocrinology. When my two-year residency ended I passed the boards in internal medicine and could have gone straight into general practice. But it was more prestigious to specialize. Rita and I had decided by this time not to return to India. Our parents took the news as best they could. My father, at least, understood that I wanted to progress in my career.

The most prestige attached to getting a research fellowship, and I was fortunate. I was offered one in an endocrinology program at a hospital affiliated with Tufts University that took only two or three new fellows a year. It was headed by a world-famous researcher in the field. My time would be divided between laboratory work, which would lead to publishing research papers, and seeing patients in the clinic.

Nothing about this was unusual for a young doctor on the rise. I was fascinated by being in the lab, and there was no way to foresee the blowup that would end my fellowship and almost my whole career. What mattered was the subtle interplay of hormones in the body, which is what endocrine research is all about. The field had miles to go before a complete understanding would be reached. The next turn in the road would lead me to studying the hormones secreted by the brain, not just the thyroid or adrenal glands. The brain, of course, is only a step away from the mind.

It wasn’t a step I was willing to take yet. No one around me believed that the mind was a serious medical subject; science couldn’t prove that the mind existed. Psychiatrists, it was widely said, wound up there because they weren’t good enough to practice hard medicine. The human brain is soft in texture to the point of mushiness, but it called for hard medicine nonetheless. Human beings are beset
by many mental woes. It amazed me that so many Americans, given their prosperous and easy lives, were under such a cloud of malaise. Mysteriously, to an Indian doctor, every day was filled with people complaining of depression and free-floating anxiety. It was vital to find an answer, which must lie in the brain. Somewhere in that chemical labyrinth lay the secret of happiness.

There was a kink in this logic that took me a decade to find. This is where the unwitting part comes in. At random I was given a clue about the mind-body connection. I was working full-time at a suburban emergency room in Everett after my Tufts fellowship came to a crashing end in the confrontation with my enraged adviser. One evening, a beefy Irish fireman came into the ER complaining of severe chest pains. When I examined him I could find nothing that indicated a heart problem. After I gave him the good news, saying that it was probably a muscle contraction around the sternum, the man didn’t look relieved. With a scowl he told me I was wrong. He knew he was having a heart attack. What’s more, he insisted that I write it up as a heart attack so that he could retire with a disability pension. When I told him I couldn’t do that, he stormed out looking angry and depressed.

Several nights later the fireman returned, complaining of even worse chest pains. The doctor on call examined him and also found nothing wrong with his heart.

When I came in I inquired with the attending physician.

“He’s malingering,” he said. “It’s a scam to get a better pension.” After doing a second exam and finding no cardiac irregularities myself, I tended to agree.

Over the next few months the fireman returned to the hospital regularly. I tried to overcome my skepticism; I listened to the patient’s detailed description of his symptoms and sent him for an echocardiogram, which came back normal, then for angiography to determine if his coronary arteries were blocked. Every test came back negative, but he couldn’t be shaken from his belief that he had heart disease. For whatever reason, he could no longer function as a firefighter, so I reluctantly agreed to recommend that he be retired on disability.

His case came under departmental review several weeks later. Often this is a perfunctory hearing, but as the recommending physician I had to appear to defend my recommendation. I explained my reasons as best I could, but when I was flatly asked by the medical officer if I had detected any abnormality in the structure or function of my patient’s heart, I admitted that I hadn’t. Application for disability retirement was denied.

Two nights later I was called down to the ER. My patient was back. I shook my head in frustration when I heard it was him, but stepping into the treatment room, I saw that he was stretched out on a gurney with an oxygen mask and cardiac monitor hooked to him. He had suffered a massive heart attack, which had severely damaged the heart muscle. He had barely enough strength to open his eyes. He recognized me as I approached the gurney.