Brotherhood Dharma, Destiny and the American Dream (23 page)

“Now do you believe me?” he mumbled bitterly. And then he died.

What had happened was beyond comprehension. Some patients take bad news very hard. They decline rapidly despite every medical measure, and when they succumb, the doctor will say, “He died of his diagnosis.” But who dies from good news? By all normal standards this man had a healthy heart. I spent considerable time thinking about his case, and I finally reached the conclusion that he was the victim of fatal beliefs. Irrationally convinced that his heart was damaged, he had triggered a chain of disastrous physiological responses.

That was as far as the trail led. Medical science couldn’t follow the tracks that went from a mere belief to a massive event in the body. Some potent forces must have been involved; as yet they were elusive. But now I had firsthand experience of the mind-body connection, even though my training told me to dismiss it. Soon I became fascinated by the role that the brain plays in the endocrine system, while at the same time refusing to take the mind into account. They were the same thing to begin with. That was standard knowledge imparted in medical school. If thoughts left invisible traces, brain chemistry didn’t. The only reasonable choice was to follow the footprints you could actually see.

14

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A Giant in Medicine

Sanjiv

Sanjiv weds Amita during their final year of medical school in New Delhi, India, 1970.

I
N MEDICAL SCHOOL I WAS
taught how to be a doctor, but when I became an intern the most amazing and sometimes frightening thing was that people entrusted me with their lives. It was an awesome responsibility. My patients and their loved ones knew nothing about me, except for the fact that I was wearing a white coat, had a stethoscope strung around my neck, and a badge that read
DR. CHOPRA.
But that was sufficient for them; I was a doctor, their doctor. It is an amazing display of faith. They willingly divulged the most private information about their lives, often things they wouldn’t have told their family members or closest friends. They weren’t speaking to me, to Sanjiv Chopra. They were speaking to their doctor.

At Muhlenberg hospital, Amita and I worked very difficult hours. There was never enough time to do everything that needed to be done, but like all interns throughout history we somehow struggled through. I began working on the wards, presenting patients to the attending physician. After taking a detailed history and conducting an examination of each patient, I would formulate my diagnosis and prepare to explain and, if necessary, defend it. Attendings learn quickly which interns to rely on. Two months into my internship the chief of medicine, Dr. Paul Johnson, gave me an unusual promotion, allowing me to fill in as a resident at a Rutgers-affiliated hospital for a month. I’d thought I had exhausted all the hours in the day, but I learned there was no respite. Every third weekend, for example, I worked steadily from early Saturday morning through late Monday night. One time I had twenty-two admissions, making rounds in the coronary and intensive care units and the wards, seeing patients, writing orders and daily progress notes. Every few minutes my beeper would go off and the emergency room physician would call me with another admission. I had barely sat down after admitting the previous patient before the beeper would go off again.

I remember a patient with his leg in a cast who came into the emergency room complaining that he was having difficulty breathing. He had a history of asthma and had run out of his medication.

“I’m having a flare-up of my asthma,” he said. I was concerned, however, that he might have a pulmonary embolism caused by a blood clot in his immobile leg that had dislodged to his lung. This is a potentially fatal condition. A scan confirmed my suspicion, and we started the treatment that likely saved his life. Working with patients who trust your skill and judgment was thrilling to me. It meant that I couldn’t be wrong, especially if there was a life-threatening situation. As an intern there is a built-in safety net, a hierarchy: The intern can call the junior resident, who has an extra year of experience, to ask for advice. He or she, in turn, can call the senior resident, who can call the attending of record. By the time I had completed my year at Muhlenberg I was quite confident in my ability to diagnose patients with all kinds of illnesses.

Amita and I followed Deepak’s path to Boston, knowing it was a mecca of medicine in America, the big leagues. I accepted a position as a junior resident at Carney Hospital in Dorchester. The hospital was affiliated with Tufts University. Amita did her residency in pediatrics at St. Elizabeth’s Hospital. Not long after I had started working as a junior resident at Carney, I was summoned by an intern. One of his patients had a headache, a high fever, abdominal discomfort, and diarrhea.

“I need your help,” he said. “I’m trying to do a lumbar puncture and I’m having difficulty getting into the lumbar space to get the spinal fluid out. Can you give me a hand?”

I walked into the room, took a quick but focused history, and examined the patient. I then reviewed his laboratory studies and made a diagnosis.

“He doesn’t need a lumbar puncture,” I said. “He’s got enteric fever.”

The intern was quite surprised. “Why do you think so?”

While enteric fever, or typhoid, was rare in the United States, I had
seen quite a few cases in India. This was precisely the type of patient I loved, a mystery to be solved by the application of proven science.

“The patient complained of diarrhea,” I explained. “He’s got an enlarged spleen and a high fever, and despite that high fever his pulse rate isn’t that high. Normally for every degree a patient’s temperature goes up, his or her pulse should go up ten beats per minute. His heartbeat hasn’t gone up anywhere near that much. This is a condition called relative bradycardia. He’s also got a type of rash known as rose spots, and a low white blood cell count. This is a classic case of typhoid.”

This intern shook his head in bewilderment. “But he was seen by Lou Weinstein.” Dr. Louis Weinstein was a world-famous infectious disease consultant; he was considered the god of infectious diseases. I was a junior resident. I didn’t blame the intern for doubting me.

I told the intern to run some tests and do a stool culture. Meanwhile I called the patient’s attending with my diagnosis. He requested that I call Dr. Weinstein.

“Hello, Dr. Weinstein? I’m Dr. Chopra, a junior resident in medicine.” Once I’d reached him in his office I told Dr. Weinstein that I had examined this patient, reviewed all his laboratory tests, and concluded that he had typhoid fever.

In India I would not have felt comfortable challenging a man of such distinction, but Louis Weinstein’s ego was not a factor at all. There was a period of silence, then he asked me pleasantly where I had trained. I told him I had graduated from the All India Institute of Medical Sciences in New Delhi.

“That’s a pretty good school. Did you see a lot of cases of typhoid there?”

“Dozens,” I said. “We had wards filled with patients with infectious diseases, and many of them had typhoid.” I told him what tests I had requested, then said I wanted to begin treatment with an antibiotic. He agreed. The next day the test results confirmed my diagnosis. The story of the junior resident who had correctly diagnosed what was a rare case of typhoid fever in Boston spread rapidly throughout the
hospital. My reputation was assured at Carney. I was the guy who had trumped Lou Weinstein.

A few years later I applied for a fellowship at the Jamaica Plain VA hospital—where Deepak was already chief resident. Deepak had chosen endocrinology, but the specialty I chose was gastroenterology, the study of the digestive system, and its subspecialty, hepatology, focusing on the liver. Even when I was in medical school I was fascinated by the liver. The liver is an amazing machine. It’s the largest organ in the human body and, for me, it has always been the most interesting; it does about five thousand different jobs. It handles so many complex, different functions. I would say to my cardiology colleagues, “You know, the only reason for the heart to exist is so it can pump oxygenated blood to the liver.”

The head of the Division of Gastroenterology at the VA hospital was a legendary clinician and scholar, Dr. Elihu Schimmel, who said to me during my interview for a gastroenterology fellowship, “Sanjiv, if you have the same genes as Deepak, you’re in.”

That year was the only time in our lives that Deepak and I worked at the same hospital. As it turns out, there was actually a third Dr. Chopra at the Jamaica Plain hospital, a kidney expert. The staff would continually get us confused. Imagine: Three Indian physicians with the same last name. Sometimes an intern would walk up to me and say, “So, Dr. Chopra, you think this patient has hyperparathyroidism?” and I would have to tell him, “I think you need to talk to my brother, he’s the endocrinology fellow.” Or they would ask Deepak, “Dr. Chopra, when are you going to do a liver biopsy on our patient?” To which he would reply, “I think you need to talk to my brother.”

But while we were at the same hospital, we never worked together unless we happened to be consulting on the same patient. At times when we were together in the doctors’ lounge or at home we would discuss our most interesting and challenging cases, as we probably would have done with any other colleague, but that was the extent of it.

With each year of training I was gaining confidence in my ability to diagnose even the most challenging disorders. But very soon after
I arrived at Jamaica Plain, I received a very good lesson about how much I still had to learn when it came to the practice of medicine. The first week of my gastroenterology fellowship I was presenting a patient to Dr. Schimmel. I’d taken my time to prepare this presentation, knowing how important it was to get off to a good start. Before presenting the patient I put up a type of abdomen X-ray called a KUB or flat plate. I flicked on the X-ray view-box light and before I could switch it off, literally in seconds, Dr. Schimmel said, “Stop.” I stopped. He stared at the X-ray for about thirty seconds.

“Sanjiv, this patient is a chronic smoker and an alcoholic. He has diabetes. He also had polio as a child. He needs to have his gallbladder removed.”

I was stunned.

“Eli,” I began (by that time I had grown accustomed to, if not entirely comfortable with, the informality of addressing senior attendings at American hospitals by their first names). “Which one of the other fellows presented this patient to you?”

“None of them,” he replied.

“Then how can you fathom all of that from one X-ray?”

He explained: “His diaphragm’s flattened and his lungs are hyperinflated. That’s a sign of his being a smoker, emphysema of the lungs. I can see pancreatic calcification, so he’s got chronic pancreatitis from alcohol. He has aseptic necrosis of the head of the femur and kyphoscoliosis, which can be a result of polio in childhood.”

There were six of us in that room listening to him, enthralled and mesmerized. Nobody said a word and I’m sure we were all thinking the same thing: We are watching a virtuoso performance.

Dr. Schimmel continued, “Now, here there’s a little rim of calcification on the wall of his gallbladder. When you see this it’s called porcelain gallbladder, and up to sixty percent of such patients develop gallbladder cancer, so he needs his gallbladder taken out. Questions?”

I had one. “How can you tell he has diabetes?”

“Good, yeah,” he answered. “He has a calcification of the vas deferens. If you see that in a developing country like India it’s tuberculosis, but in the West it’s diabetes.” In a few seconds Dr. Schimmel
had demonstrated his mastery as an astute clinician. For me it was an extraordinary application of medical science to a real patient. It showed me what was possible.

Of course further testing proved Dr. Schimmel was absolutely right. Dead-on. That day has been imprinted in memory forever. People without a medical background can’t truly appreciate the difficulty of what he did. I’ve often told this story to colleagues in medicine over the last three decades and they are inevitably awestruck.

I knew I was in a spot of tremendous learning and I developed a close relationship with Dr. Schimmel. He was to become an inspirational mentor who has shaped the way I think. It has been my good fortune to have worked with physicians like Eli Schimmel. In America physicians become chairmen of major academic departments because they have earned it, whereas in many places in the world seniority and nepotism can be more important than merit. From Eli Schimmel I learned the right approach to medicine and I’ve taken that with me throughout my career. I was also privileged and fortunate that the following year I was chosen to do a hepatology fellowship with Dr. Raymond Koff, one of the world’s most respected hepatologists.

Once, one of the other gastroenterology fellows was presenting a patient with an intestinal bleed to the fellows, medical students, and several faculty members. He related the history, explained the physical examination, and said, “The patient required four units of blood. So we—”