Article by Deepak Chopra MD
“DOCTOR, we need you on Surgical Four,” a nurse’s voice said over the phone. “We’ve had an expiration.”
“A what?” I asked
“An expiration,” she carefully repeated, “on Surgical Four. We need you to pronounce.”
“Oh, right.” Could I tell her I wasn’t catching on? It was midsummer of 1970 and my first night on call. I was the newest intern in a four-hundred-bed community hospital in New Jersey. Everyone here apparently knew what an expiration was. I didn’t.
“Doctor?” she said again. It was the voice of a veteran, I could tell. “We’ve just extubated him, so if you can come up. . .” I didn’t want to seem stupid. I was entitled to be called “doctor”, even as a first-day intern, but all the rungs of the system rose above me.
“I’ll be right there,” I said and headed for the wards. Just a year before, I had graduated from medical school in India. Six months of that year were spent in a village posting where the lights went out every time it rained. I had not actually set foot in an American hospital until I became a doctor in one. So far, all I knew about America came from watching two hours of color TV in my hotel room the night before. The hospital had wired me a plane ticket from New Delhi and cab fare to the hotel. I was supposed to rest awhile and then report for duty. All of this I learned long distance, but it was enough. I was very eager to train in advanced American medicine.
My wife, Rita, and I had never seen a color TV before. On the screen, two bodies were being wheeled into an emergency room after a police chase. We could see bullet wounds and blood. I was amazed. “Rita,” I said suddenly, “those men they shot, they’re taking them to my hospital!” What if I had arrived a day earlier? I went to sleep thinking about it.
Now it was the next night, and I was more than a little nervous about being on call alone. I was supposed to handle all the emergencies for the hospital and admit patients I deemed serious enough to need a bed. I was told not to wake up my chief resident unless the situation became impossible to handle alone. I was determined not to let that happen. They could shoot whom they wanted to. I waited. After two hours, the time began to drag, so I went to the cafeteria and bolted a sandwich. When I came back, the nurses said I hadn’t missed anything. I waited some more. At about eight the first call came. Surgical Four was having its expiration. There’s no limit to what they have in America, I thought.
When I stepped onto the ward floor, the first thing I saw was a small crowd, about eight people, gathered outside one of the rooms. A nurse softly padded over and whispered, “The expiration is in 441, Doctor. I’ll come with you.” She parted a way and led me into the darkened room. A certain unmistakable tone came from the visitors as I walked through, but I didn’t know exactly what I would see. The nurse had sounded routine, a little subdued. What attitude was I supposed to wear? Without warning, my heart started pounding . Real medicine. Real doctor.
So that’s what one looked like here. Surrounded by dangling IV tubes, oxygen tanks, a heart monitor, a respirator, and more metering gadgetry that I was as yet unfamiliar with, on a stark bed stripped of covers lay a man. He must have been about fifty-five. His frame was wasted and his skin looked yellowish. His bulging eyes stared at the ceiling without a blink. He was so still. His caved-in chest showed no sign of rising and falling. I glanced at the monitor. Nothing. My pulse went racing suddenly into my temples, and the floor sagged a few inches.
“Is he dead?” I blurted out.
“I told you we had an expiration.” The nurse searched me with a glance. A few seconds went by. “Why don’t you pronounce him?” she asked. “I have to get back to my station. Break’s in twenty minutes.”
A mortal body that has been discarded a minute before is not at all like a cadaver. If I wanted to press my palm against this human husk, it would feel just slightly cool, but it would get colder and colder as long as I held on. I had no notion of doing such a thing. Strangeness can be very close to dread. When I was five, my grandfather died of heart failure in the house one night. I was asleep. My grandmother bundled me out as quickly as she could so that I would not be frightened when the women of our house started wailing. I think I must have heard a little, anyway, or perhaps I confused it with the look on her face.
“What am I supposed to do?” I asked timidly
“Say he’s dead,” the nurse told me. She waited a second. “Only a doctor can do that over here.” She added a note of emphasis when she said “over here,” but she didn’t mean it personally. During the Vietnam doctor shortage, the hospital had scraped up five Germans and two Indians to be the staff physicians. At least the Indians spoke English.
I looked at the screens. Everything flat. I was like the last machine, the one that said the others were right. “Sure, he’s dead.”
“Then you’re supposed to tell the family,” she said. “That’s all of them, out there.”
We walked out to face the eight strangers huddled together in the corridor. They looked at me with that prepared look. The nurse nudged me from behind. I took my stethoscope out of my jacket and hung it around my neck. Oh God, I had forgotten to ask what the dead man’s name was. One of the men came forward.
“Doctor—"
I was trembling faintly inside, but I cut him short.
“I’m sorry to have to tell you this, sir,” I said, “but we have had an expiration.” Two of the women burst into tears and took comfort in each other’s arms. Another of the men popped up and said in a businesslike way, “I’ll get the funeral home.” He trotted off toward the phones.
I was staring at the floor, not wanting to say a word more but feeling that I should. The nurse tugged at my arm. She had a decent heart. “Come on, Doctor, we keep the coffee behind the station. Want some? The cigarette machine is over there.” I looked gratefully at her. She seemed wonderfully neutral just at that moment. Without any comment or bother, her expression simply said, You look like you could use something.
My first American patient had been a dead man. It wasn’t much as I had expected, and not just the corpse. Everything had been medically proper, yet so unhealthy. The machines were in the room and the family was outside the door. That and the machines are nowhere. I followed the nurse.
After a few hours, my shift became more and more hectic, but the rest of the night seemed not so bad. I worked hard for the next ten hours. I didn’t drink one cup of coffee to keep me going but five, and I smoked not one cigarette but a pack. I treated a middle-aged man for an overdose of barbiturates, a young woman with severe bleeding after she attempted to perform an abortion on herself, a vagrant drunk with several long lacerations to the scalp, and a retired lawyer in the throes of a massive heart attack. When the night was over and my shift on call came to its end, I almost felt like a hero. I had saved all these people. My chief resident congratulated me. He was happy that no one had waked him all night for once. He took me to breakfast in the cafeteria, and I dragged on the last couple of cigarettes and cups of coffee while I made my full report. He was encouraging.
“Keep it up and you’ll get out of here with a good recommendation. You want to make it to Boston or someplace like it not so far away.” I took his word for it. He was serious and imposing, a fat resident in his third year. Now that he was chief resident, he was used to being right. He said goodbye and told me to get some rest: I was on call again in twelve hours.
I went over to the dormitory where interns rested between shifts. I placed my clothes over the back of a chair and lay down on a cot, but I was too exhausted to sleep. Part of me went racing ahead, wanting nothing more than to get back into the ER and handle more patients. Another part kept touching a sore spot. The whole episode with my first patient couldn’t have lasted more than five minutes, seven at most, but I was nagged by a sense of failure. The restless emotions I felt then I can easily feel to this day. I blamed myself for not bringing solace to a dying man, yet we had no relation to each other at all. I had not even drawn a sheet over him or held him for a moment in my thoughts. All at once, but for good, I saw the great abnormality of my world.
I came to medicine when I was sixteen. On the day I graduated from high school, I surprised my father by saying, “Daddy, I want to be a doctor” ---blessed words in India when you are the eldest son and your father is a physician. He was overjoyed that, after years of indifference toward medicine, I wanted to be like him. Since boyhood I had been madly in love with soccer and cricket, and whenever I thought for a moment about my future, I saw myself probably as a journalist. Now I decided that medicine was the right pursuit for me, and my motivation grew the more I dwelt on it. I wanted to heal people and make them happy, I was sure of it.
I had been suddenly converted to medicine by reading Sinclair Lewis’s novel Arrowsmith. My father had seen patients every day of my life, of course, but they had not registered on me. It took a book. I can’t remember much about Arrowsmith himself, except that he was a heroic researcher, a microbe hunter driven by a dedication so incredible that it is painful now to recall it literally:
“God give me unclouded eyes and freedom from haste. God give me quiet and relentless anger against all pretense and all pretentious work and all work left slack and unfinished. God give me a restlessness whereby I may neither sleep nor accept praise till my observed results equal my calculated results or in pious glee I discover and assault my error. God give me strength not to trust to God!”
These words once thrilled me. I can hardly read them now, but I am glad that at that age I swallowed the story whole. It had what I needed—the hero was a doctor and the doctor was a hero. At moments he was almost a god, bringing healing to skeptical mortals like an angelic doctor. Arrowsmith spoke words that were more than words. They were sparks hammered hot from the anvil of his dedication. I embraced his dedication and his life, and I would go forth like him.
While I was going through this, I don’t believe I mentioned the book to my father. He must have considered , however, that I might be motivated by fantasy. He told me soberly about the burden of work I was taking on to become a doctor. Until then I had shown no interest in medicine, so my background in science was sketchy. He quickly filled my nights at home with tutors in math and chemistry, hired for his lagging but determined boy. The boy was ready to study now and burning to get ahead. My father, so immensely pleased, only repeated his cautions and tried to make me see that doctoring was not so idealistic as I thought.
I lay there in my dorm room that night thinking about it. In the end, after six years of studying, medicine was turning out to have too little to do with healing and making people happy. It had to do instead with my work in the hospital, into their lives, pronouncing a few of them, the most unlucky ones, as expirations. I thought about myself a lot before I forced myself to sleep, but, on reflection, I didn’t think about my patients much. We had all met and parted in a few moments. It would have been hard to look at them directly. The girl in desperate agony from her abortion was probably no better off now, even if she wasn’t bleeding anymore. The drunk reeled around the ER, out of his senses, oblivious to the streaming gash across his forehead. The gray-faced lawyer clutched at his chest, certain that at that very moment he was dying. The ashamed man with the barbiturate overdose—he was probably a respectable addict who had taken one too many that night, or maybe two. Maybe a lot more than two. I didn’t know any of their names. I was thinking of them, if I thought about them at all, as the abortion, the overdose, the laceration, and the heart attack. They were my America.
In a way, it was beginning to seem normal. The veterans had grown used to it. I wasn’t going to let it get to me, either. I could already see 1971 as the year I bagged a residency at a teaching hospital in Boston. I lay there dreaming of Harvard as much as anything else. The boy in me still burned to get ahead. I had been told that the ticket out was a good recommendation from the chief of medicine at this hospital. I could do what it took. I was making a good impression from day one. It was easy for me to mix with the nurses at their station, who sloughed off their boredom with jokes and coffee in between ambulances. When an ambulance did drive up, the scene changed in an instant, almost to hysteria. We moved.
I lived for that action, and I knew I would be good at it. But for one night I was more a stranger than anything else. Who were these people? How was my life connected with theirs? At some point I dozed off and then clicked awake with a feeling in my stomach that wouldn’t be denied. I made it to the bathroom in time and vomited up ham and eggs, coffee, and nicotine. We didn’t ingest such things at home. I lay down again, feeling wobbly and cold. Maybe I didn’t need a residency at Harvard that much. My first patient was slipping into a shallow grave, and I was marching on. I had meters to read. After a few minutes of these night thoughts, I slept like a stone.
But medicine should be about healing people and making them happy. I have had a great deal more time to think about that. Medicine began as more than either science or art. Hippocrates, who walks with every physician, really was an angelic doctor. He claimed descent directly from Aesculapius, the Greek god of healing. In his own lifetime he was revered. He did not just sew up wounds; he added a stitch toward his patient’s immortality. We do not know much about the methods of Hippocrates, but we have some of his words. His medicine was wisdom. In fragments of his teaching we can read such statements as this: “Even though a patient may be aware that his condition is perilous, he may yet recover because he has faith in the goodness of his physician.” In taking the Hippocratic Oath itself, every doctor swears to this: “I will keep pure and holy both my life and my art.”
Since we know very little about the practice of the art Hippocrates was master of, his noble words do not have much connection to reality anymore. The medicine I was taught had been stripped of ideals altogether in favor of a practical zeal for repairing the bodies of sick people. The best doctors I have met in every field are scientists of great integrity and skill. Their goal in life is to track down the cause of disease with precise objectivity and then, they hope, to wipe it out. I can state without even pausing to think about it that no colleague of mine has ever alluded to his pure and holy art.
For their part, the ancients appeared to have little in the way of a scientific foundation for their medicine, but they grasped the nature of man. Their first principle was that health requires a balance within the body. As a piece of received truth, this easy enough to roll off the tongue, but its implications have been carried far from the ancient world. Today we speak of the body’s homeostatic mechanisms, and we pursue biochemical research to discover such things as how the autonomic nervous system mediates the secretions of the endocrine glands. But we are still talking about balance within the body, and we still find it absolutely vital to preserve it.
The ancients also believed that man’s inner nature mirrors nature as we observe it around us. Cosmos, or the universe, comprised two fundamental and related realms, the inner and outer. Balancing their forces made it possible for life to continue in harmony. The two ran on parallel tracks, so to speak, and throwing either one into imbalance spelled disaster for both.
The ancient physicians thought they understood the universal basis of life, and they desired to live from its source. Their precepts for health may sound simple-minded to us now because they are not based on reliable information about the body. The Greeks had either bad data about physiology or no data at all. It is therefore hard to credit their view of medicine. Accurate information seems after all so much more real than wisdom.
Hippocrates knew nothing about so elementary a fact as the circulation of the blood. He thought of blood as a pure vehicle for the elements of creation—earth, air, fire, and water—and he held that the purest blood must reside nearest the heart, the seat of the purest affections. He and his contemporaries argued whether consciousness could be located in the brain or the bloodstream. Choosing one or the other put you into entirely different camps of Greek medicine.
This seems like a ridiculously primitive disagreement, but the ancient physicians collectively held on to some invaluable assumptions that no one debated. They assumed that man and the entire world were endowed with life, intelligence, and a soul. Since they believed that every bit of the living world contributed to human well-being for better or worse, the ancients built their centers of medicine at sites of great beauty and sanctity. A hospital was very much like a temple. Patients came for inner as well as outer restoration, and their physicians found the fresh air and sunlight to be highly beneficial for both. In his counsel to doctors, Hippocrates wrote one great dictum: “Nature is the curer of sickness.” His famed center of medicine on the island of Kos was reputed to contain six thousand medicinal plants, but he knew stronger remedies than any of them: “Leave your drugs in the pot at the pharmacy if you cannot cure the patient with food.”
His complete trust in Nature sounds radical now. But if he turned out to be right, wouldn’t we all feel nothing less than immense relief? The ancients proposed that nature, meaning our own inner nature, had sufficient means to keep us completely healthy. Their ideal was a state of health that harbored no thoughts of sickness at all. (I am reminded of the old custom in India whereby a physician was paid only if everyone in his village was well. Even if he could cure them, cases of disease were charged to the doctor’s neglect.) In other words, health was like freedom. A free life did not confine itself to boundaries and precautions. It was lived spontaneously, taking its nourishment from air, sun, food, and philosophy, and the more spontaneous it could be, the stronger it stood.
Nothing in our medical system comes close to this sort of inspiration. In exchange for ideal health, we accept a view that is more practical and (so we say) more rational. Our science attempts to understand the body one piece at a time, in terms of cells, tissues, and organs. It protects our health the same way, one disease at a time.
But a rational system can wander so far from the source of its inspiration that it turns back on itself. I recently had lunch with the dean of social medicine at a prestigious medical school. We had not met before, and this talk was at my request. I was proposing to him that a conference be held at his school on the medicines of the East, which are the last repositories for the old ideal of man in harmony with Nature. The dean is a physician, an expert in diseases on the larger social scale, including the Far East, but he was skeptical about what I proposed. He adamantly declared that he could not understand why anyone praised Eastern medicine, whose concepts were utterly mumbo-jumbo as far as he could tell.
“I’ve heard from Eastern doctors, and their heads are filled with mystical ideas. We won’t have to listen to all this mystical rubbish, will we?” he complained. That I was from India and might have a personal stake in such ideas didn’t phase him.
“The belief that man and Nature are bound up together in one body is part of these systems,” I said, a bit coolly. “It’s not some kind of mystical nonsense. They have found therapies that works as well as ours. It’s just a different basic concept. Our medicine is based on a concept, too, as you know.”
He snorted.
I will not be forced to invent that he was a fat man in a pinstriped suit smoking a cigar, because he actually was all of that. He also made the memorable remark, “For God’s sake, if you do hold this conference, don’t let me hear from those holistic health people. I’ve got enough trouble from them already.” The dean glared down at his luncheon plate, probably thinking about the holistic menace. No one who really believed in the medicine he practices could be that aggressively closed-minded.
After we parted, I became angry that his attitude had forced me to act like an enemy to real medicine. His sort of real medicine has its glaring faults, though not mystical ones. It is not news that confidence in doctors is becoming rare. The incredible expense and complexity of the present system is known to everybody.
What is less well known, because doctors do not discuss it very openly, is the futility of practicing medicine without a basic ideal. What kind of holistic rubbish would the dean have found in these two lines:
Rejoice at your inner powers, for they are the makers of wholeness and holiness in you,
Rejoice at seeing the light of day, for seeing makes truth and beauty possible.
They happen to come from Hippocrates, and as long as they have meaning, medicine is saved from becoming soulless.
I was probably lucky to go through a dark night in New Jersey. In a moment of insecurity, I felt that not the physician but the disease had the upper hand. My rational methods, the machines I controlled, and my concepts of treatment seemed to have too little to do with life and too much to do with death. Practicing medicine as we do now makes a doctor’s life as nerve-racking as a soldier’s. It consists of an endless struggle to conquer disease, and to keep at this, a doctor must deny to himself that disease, and to keep at this, a doctor must deny to himself that disease ultimately wins. If you feel called to practice medicine, these are not the kinds of thoughts you permit yourself. But doctors do face up to them from time to time and wonder what the work is for.
After my troubled night, I became what I was headed for. I got to be a resident and a specialist. Like the big third-year man who urged me on to Boston, I became a chief resident myself, and so I got used to being right. The dormitories of large teaching hospitals became a second home to me; in time, I had my own practice. Success in the system, however, depended on believing in the system. I used to be much better at that than I am now. My beliefs have been changing very fast, and now I am probably part of the dean’s holistic menace. I am amazed at how long it took me to discover something that is almost absurdly simple: a physician must trust in Nature and be happy in himself.
But when you are starting out in New Jersey, it takes time to rejoice at your inner powers.
