I must have rolled my eyes. Feeling sorry for him, I assured him that his business would bounce back.
He shrugged. “I’m okay right now. I mean, my wife and I were able to put away some money—about ten million dollars—so I’m secure. But I’d like to make more.”
Ten million? And I was worried about making next month’s nursery school payment.
Though I didn’t bother to disillusion Stephen, most doctors today, whether in academic or private practice, have to constantly think about money, too. In 2009, Dr. Pamela Hartzband and her husband, Dr. Jerome Groopman, physicians at Beth Israel Deaconess Medical Center in Boston, wrote in The New England Journal of Medicine that “price tags are being applied to every aspect of a doctor’s day, creating an acute awareness of costs and reimbursement.” They added: “Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms.”
The rising commercialism has obvious consequences for the public: ballooning costs, harm to patients, and fraying of the traditional doctor-patient bond. What is not so obvious to most people is the harmful effects on doctors themselves. We were trained to think like caregivers, not businesspeople. The constant intrusion of the marketplace has created serious and deepening anxiety in our profession.
Not long ago, a cardiology fellow who had been interviewing for jobs came to my office, clearly disillusioned. “I was naive,” he said. “I’d never thought of medicine as a business. I thought we were in it to take care of patients. But I guess it is.”
I asked him how he felt about going into private practice. “I won’t have much time to think about it,” he replied. “I’ll be too busy vomiting for the first six months.”
Certainly, there has always been a profit motive in medicine, but financial considerations have never been as prominent as they are today, in part because so many hospitals and doctors, especially in large metropolitan areas, are in financial trouble. Even as payments by insurers are decreasing inexorably to control health costs, office expenses are increasing, and the economy is in recession. More and more doctors are trying to sell their practices or are negotiating with hospitals for jobs, equipment, or financial aid. At academic medical centers, uncompensated care is growing as patients suffering from the economic downturn lose health insurance. Admissions and elective procedures—big moneymakers—are declining. Hospitals are cutting administrative costs, staff, and services in an effort to remain profitable.
Of course, the blame for this commercialization doesn’t lie exclusively with doctors and hospitals. Politicians, insurers, drug companies, and even patients bear some responsibility, too. We are all in a tragic cycle of action and reaction, in which each party pursues its own ends without sight of the big picture, making the system more and more diseased. Self-interest doesn’t always work for the greater good. On the ramp to the expressway, you need lights to modulate the flow of traffic. Otherwise you get a jam.
Despite this, a part of me still wants to see doctors master the business side of our profession. When I hear about executives at health companies getting tens of millions of dollars in bonuses, the blatant profiteering sickens me. As a member of the guild, I want to see doctors exert more control over our financial house.
And yet the consequences of this commercial consciousness are troubling. Among my colleagues I see an emotional emptiness created by the relentless consideration of money. Most of us went into medicine for intellectual stimulation or the desire to develop relationships with patients, not to maximize income. There is a palpable sense of grieving. The job for many has become just that—a job.
Something fundamental is lost when physicians start thinking of medicine as a business. In their essay, Hartzband and Groopman talk about the erosion of collegiality, cooperation, and teamwork when a marketplace environment takes hold in the hospital. “The balance has tipped toward market exchanges at the expense of medicine’s communal or social dimension,” they write.
The result, as I witnessed at the Manhasset party, is exhaustion, depersonalization, and burnout. Approximately a third of physicians surveyed admit to signs of burnout. Burnout is associated with excessive workload, difficulty balancing one’s personal and professional lives, and loss of work control, autonomy, and meaning. It has been described as “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit and will.” The practice of medicine today almost seems to promote burnout. Doctors are working harder and harder, and many continue to demand perfection of themselves. We defer gratification, sometimes for many years. We no longer feel in charge of our professional destiny. A physician recently wrote online: “The reason we are feeling ‘burnout’ is that there does not seem to be any hope for things to get better.” Another said, speaking for many in private practice who stand to lose the most from policy proposals to restrict fee-for-service and encourage greater use of nurse practitioners and physician’s assistants to do what was formerly doctors’ work, “We look forward to a future of a fully implemented Obamacare where physicians are but meaningless pawns in the hands of those who are pushing this absurd social experiment.” Such irrational anger, the almost operatic self-pity, has become commonplace. I encountered it countless times those first few years at LIJ. Colleagues would complain: We are not being allowed to work in a market economy. We are not being allowed to charge what the market will bear, or for what we should be able to charge on the basis of our expenses and our education, thanks to the “price-fixing” that starts with Medicare and trickles down to other insurers. And yet there was almost never a sense that we were to blame, too. That we had abandoned our course. That many doctors had abused the public trust and taken advantage of the system. Doctors never seem to acknowledge that the widespread burnout in our profession is in part due to the behavior of doctors themselves.
ELEVEN
Devotion
What we call fate does not come into us from the outside, but emerges from us.
—Rainer Maria Rilke, Letters to a Young Poet, 1929
It was getting harder and harder to get started with the mundane tasks of the day. I was doing what was generally expected of me—the moonlighting, my regular job at LIJ, and, beyond that, taking Mohan to the park or Sonia out for dinner on weekends when I wasn’t on call—but I was getting accustomed to thinking that a three-quarters effort would almost always be enough. A kind of sluggishness had taken hold: a vague sort of queasiness, a hint of something that I was supposed to want but that was somehow beyond my reach, and a fear that I was not going to be able to let go of this feeling, that it was going to stay with me for some time. Sometimes I wanted to cry, but I almost never did. Even when tears did flow—for instance, at the conclusion of a marital spat (“Why are you so checked out, Sandeep?”) or after an unexpectedly kind comment from a friend or colleague—the relief was transient, and the heaviness always returned. This was a different kind of fear from what I had experienced in my youth, not so much of what the future was going to bring but that it had already arrived.
I wasn’t alone, of course; there is an enormous reservoir of subterranean depression in middle age. A recent study of two million adults in eighty countries found that middle age is the time in our lives when we are most likely to be unhappy. Regardless of wealth, gender, or social, marital, or filial status, the pattern is largely the same: happiness peaks in our twenties, dips in our forties, and rises again when we are older. Though one in five people will experience depression at some point in life, the frequency is highest among middle-aged adults. Men in their forties and fifties have the highest suicide rate, three times the national average. Among professionals, physicians have the highest suicide rate. One American doctor kills himself or herself every day.
* * *
Sonia had been practicing yoga for many years. Growing up in the Indian enclave of Edison, New Jersey, she had spent considerable time in the company of gurus who came to her home every week to engage in prayer and satsangs
(spiritual dialectics) with her father. Some in her extended family had followed the teachings of several famous yogis, including one I remembered from newscasts in the early 1980s.
“Wasn’t he the guy with the Rolls-Royces?”
“Yes, well, he did some bad things,” Sonia replied. “But they say he was a genius.”
“Wasn’t he screwing young women?”
“I don’t know. But he was enlightened!”
After we got married, Sonia discovered a deep-breathing exercise called Sudarshan Kriya that was touted to alleviate stress and anxiety. The few times she made me try it (“Don’t people in midlife crises investigate new religions?”), I did feel more relaxed (probably acute respiratory alkalosis caused by rapid ventilation, I hypothesized). I’d read about the benefits of yoga: stress reduction, beneficial changes in blood chemistry, better sleep patterns, decreased resting heart rate, etc. So in late November 2007, when the guru who had popularized kriya visited Sonia’s parents’ home in Edison, I went to meet him. I was looking for something that would lessen the weight in my chest, and even though I’d never had a strong religious faith, I was still hoping to reap some benefits from Guruji’s purported wisdom.
My father-in-law picked me up at the train station in his black Mercedes. It was an overcast day, and the trees along the road were leafless and gray. I felt the strange disquietude that autumn always seems to bring, only that year it was more intense than usual. We passed by doctors’ offices, physical therapy suites, and MRI centers—the drab medical-industrial complex of the Garden State in its concrete glory. Stopping at a traffic light, my father-in-law broke the silence. “The water is the same, whether it splashes you in winter or summer,” he said, staring ahead. “It is your sensation that changes.”
I looked over at him and nodded politely. I knew he was trying to help me, even if I didn’t know what he was talking about.
“We have control over our responses,” he said. “We can choose to be happy or not.”
I nodded again, feigning understanding. Though he was a successful doctor, my father-in-law more than anything was an aging mystic.
“You should think that everything is going to change for the better,” he went on encouragingly. “Think: I have never been born; I will never die. This embodiment is around my eternal bliss. Try to relate to that bliss.” He touched his chest. “It is yours. You just need to tap into it.”
A Sanskrit devotional was playing on the stereo. He recited a verse from it, which he translated: “‘You have bred an explosion of joy in my heart, so that I am floating on a breeze’—like you float on the ocean when you are surfing,” he added, interrupting himself. “‘And I am feeling a breath of fresh air flowing all over me.’” He turned to me, looking mesmerized. “It is a beautiful ghazal about prana. Do you know what prana is?”
“Is it energy?”
“No, it is breath; it is life. When someone dies, we say, ‘Prana khatam,’ meaning ‘He took his last breath.’ Guruji says you can direct the prana. Like when we prayed that you and Sonia would have children.”
The light turned green. The car jerked forward. I went back to staring out the window.
“One day I have to sit down and explain to you the meaning of all these things,” he said. (He had been promising this for some time.) “I’m sure the mind has healing powers. I see it all the time in the hospital. People who are depressed or angry don’t do as well.”
I nodded but didn’t say anything. Nothing would have made me happier at that moment than to feel different.
“Believe in the power of prayer,” he went on. “There is a lot of evidence that prayer by or for you promotes healing.” I wasn’t so sure. I’d seen the pattern many times. Sonia’s father would pray for someone who was sick, and she would get better, and he’d attribute the recovery to prayer, but that person was probably at the tail end of her viral illness anyway.
“The key is to be happy,” he declared as we pulled onto his street. “Happy every single moment of your life. Be happy, not angry. It makes me sad to see you this way.”
The house was a whitewashed colonial sitting on thirty acres at the end of a long tree-lined gravel drive. Sonia met us at the back entrance, looking relaxed in jeans and a sweater, obviously pleased that I had made the trip. We went inside, where shoes had been stowed in a foyer alongside statues of Hindu deities. A poster-size picture of Guruji hung over the doorway leading into the living room. I saw him sitting on the rug. He had long black hair intermingled with thick gray strands and a long, flowing beard. He was wearing an orange vest that revealed hairy armpits. People, hands clasped, were kneeling before him, vying for his attention. A young man in an argyle sweater was curled up at the entryway, looking crazed. “I feel so incredibly close to him,” I heard him say. “He feels like a dear, dear friend.”
The house was overrun with Guruji’s devotees: wealthy Indians, middle-class Indians, crunchy-granola whites. In the kitchen a group of his disciples were assembled at a table, participating in a kind of dialectic. The leader, a young woman with a blond ponytail, was explaining that kriya meditation had to be practiced regularly. “You must do it for at least forty consecutive days,” she said with spurious precision. “That is how long it takes to integrate into your system. Anything less than forty days, you will have to start all over again. If you do it for thirty-seven days and then skip a day, you will have to start from day one.”
Someone asked about how to conquer unhappiness. The key, the young woman replied, was to dispense with desire. “Expectations kill the joy,” she declared. I had heard this axiom many times, but it had never made much sense to me. Doesn’t such a strategy conquer happiness, too? Isn’t desire just an appetite for joy?
People seemed to know the house belonged to a doctor because the discussion quickly turned to health and disease. A woman outfitted in a bright sari and sparkling jewelry said she had recently been diagnosed with diabetes, with a blood sugar level of 400, dangerously high. “Doctors said that if I had waited a couple of days, I would have gone into a coma,” she said, seemingly directing her comments at me. Now her blood sugar was controlled with “a single pill only,” a situation that she attributed to the power of Guruji. “It was a miracle,” she said. “How can anyone deny this was a miracle?”
I couldn’t help thinking that a $10 co-pay was the best deal on a miracle she was ever going to get.
She said that she had once seen Guruji in her bedroom in the middle of the night. “I woke my husband and told him there was somebody in the house,” she recalled. “I was scared, but I knew it was Guruji; I knew he had come.” About a half hour later, she said, Guruji called her from India and asked if she had called him. Terrified, she hung up the phone, but she dialed him the next day. “I asked, ‘Guruji, were you in my house last night?’ and he said yes.” She looked around the table. “Now, you tell me that is not a miracle.”
I stared at her impassively.
“I kept saying, ‘I can’t believe this,’” her husband said. It was evidence, to him, of “superpower.”
Another person said that he had recently been on a plane set to fly to Sedona, Arizona, but that he did not want to go. A few minutes before takeoff, with 150 passengers on board, the flight got canceled. He was sure this had some special meaning.
“Perhaps it was a coincidence,” I blurted out before Sonia pinched me. People always seemed to want to attribute a grand design to random events. It required a constant recalibration of one’s thinking that I found disingenuous and dangerous. “What about the folks who wanted to go to Sedona?” I said.
“They didn’t want to go either,” the man replied pleasantly. “They just didn’t know it.”
A pudgy middle-aged man standing next to me whispered, “Hi, I’m like you. I also hear these stories and the other side of my mind wonders, Is it real? Is this the only explanation? So you must be thinking the same thing.”
I nodded politely.
“Guruji protects all his
devotees,” the man said.
“Why doesn’t he protect everyone?” I asked.
“Because we are in his inner circle,” he replied. Then he quickly added, “You must have faith, Doctor. It all depends on faith.”
As a boy I’d had faith. I’d believed there were people who possessed special knowledge that I could not access. When I was in trouble, I prayed. But this all had changed. I no longer believed in prayer. I no longer trusted there was a greater source of truth than the thoughts in my own head. I was now apt to ignore the pronouncements of those in authority. Still, I missed that time when I thought others knew more than I about how to live my life. As much as the need for their approval had once unnerved me, my lack of faith was just as unsettling.
Since Sonia’s family was playing host, I was accorded a coveted seat next to Guruji in the living room. He was delivering a mini satsang, saying things like “War cannot exist without peace” and making other such pithy pronouncements. Every once in a while he answered his cell phone or checked it for text messages. Sitting next to me on the floor was a young woman with ash blond hair and purple toenails, wearing yellow sweat pants and a Rutgers sweatshirt. She would cry out every once in a while with the annoying shriek of a true believer.
“This body is the temple of the Lord,” Guruji declared to murmurs of assent. “Our purpose is to use this body for good. Not by going to middle schools and high schools talking religion, but rather spirituality. Spirituality and religion are very different. Spirituality unites; religion divides.” He paused for a moment. “Write that down,” he commanded an assistant.
After Guruji had finished his sermon, we were instructed to prostrate ourselves before him and touch his feet. After doing so, I was handed a metal plate sprinkled with rose petals and red powder. I moved it in a circular fashion in front of him and passed it along. A few of his disciples stared at me, seemingly jealous of my proximity.
Guruji asked us to write down some things we wished for but did not have. On a piece of paper I scribbled: “spontaneity and joy of childhood; peace and harmony in my marriage; self-confidence and centeredness.” Then he asked us what we wanted from the practice of kriya. I wrote, “I hope to get a means to put myself in a confident frame of mind—”
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