“ I was waking up each day, dreading what would go wrong.”
When I was growing up, it never occurred to me to contemplate why I was alive, my real purpose, or what I was truly passionate about. Most young people don’t think about it: they are either too busy trying to excel in academics or not to flunk out. Most of us were conditioned to excel; that is the Asian culture. But I and many others like me were just unsure why we even woke up each morning, let alone excel… Suffice it to say that I was neither bright nor smart enough to accomplish anything that I took up in a stellar performance: I was trying hard not to flunk out! I had a horrible fear of mathematic and physics. But for some reason, I had a fascination with the human body, the miraculous intricacies of it, and the amazing way in which the mind and body functioned and coordinated with each other, in good or in bad. As such, the medical profession looked appealing. The problem was I hardly had any idea of how I would get into medicine, let alone become a surgeon( a specialty that excited me as a teenager).I was pleasantly surprised when I saw my name hanging in the list of students that had been accepted. There was just so much to learn and put to memory. Being a mediocre student, the struggle to get assignments done and somehow scrape through basically involved every breath of my existence. I was always playing catch up. I was amazed to see how some, including my brother, could understand and finish course assignments in record time while I persevered long and hard hours to come up with an average grade. But for some inexplicable reason, I struggled on. I never received a high ranking on any subject, and my overall grades were always in the mid percentile.
The country (Bangladesh) had just been liberated (1971) as we graduated, but the possibility of advancing in medicine (after graduation) was a far cry. I felt I needed to get out and took the qualifying exam (for foreign graduates wanting to train in America) and again scraped through. I applied for a position in a hospital in the US and got accepted. When I finally made it to America to pursue a career in medicine, it got tougher. Medicine and specially Surgery is neither for the faint-hearted nor for the one who is less than sharp. I was up against the brightest and the best from all over the world: Chinese, Indian, Korean, Pakistani, and of course the homegrown Americans were all vying to finish Surgical Residency in the NY City Hospital System, which had pyramid programs( each year half of the cohorts were eliminated, starting at 16 residents in the first year and ending with four as Chief Residents). I could see myself slowly falling off the curb as the brightest and best took me to task on theory and practice. I knew that my whole survival was at stake. There was no point of return. There was no going back. Returning to Bangladesh without completing what was started would be an abysmal display of failure. I dreaded getting up each morning to face the onslaught. Always expecting something to go wrong. I was smoking a lot. At the end of my rope, I was frantic to prove myself or do better.
I had remained fascinated by human anatomy and physiology. I loved the precision, the cellular framework, and the coordination of all organ systems that made the human bodywork like a miracle. In short, I loved medicine and, more specifically, surgery: the blood and the guts. But that was not enough. My pace was slow, and my fellow residents did not have any time for slowpokes. One night in the operating room, I was paired with the Chief Resident taking care of a multiple gunshot wound. “OK, Ajmal, you do the case, and I will assist you” An immediate nervousness overcame me, and I started floundering. He said,” Ajmal, slow down, don’t worry about the time or me, do it right. There is no room for mistakes here. You leave a hole unrepaired; the patient will have peritonitis and end up with a fistula or sepsis. So, be calm, forget about everything else and repair this fellow’s intestine, one by one, and with meticulous care. I will be right here with you, assisting you. But you call the shots. You follow the procedure and let anesthesia keep the patient alive. You are the surgeon; you need to fix what has been broken. You have no control over whether this guy will live or die at the other end. That’s not up to you. Your job is to fix this guy, so fix him. As he said all this, I felt like he was my father who had just infused in me a wealth of confidence and love. As he held the retractors and cut the sutures while I did the case, I suddenly realized that I could not move forward without staying in the moment. I finally finished the case. My Chief Resident had stepped aside before the skin was closed. But he was waiting for me after I finished. Before I could say “Thank you,” he said: Ajmal, you are a good surgeon. It’s just that you were going ahead of yourself. Take it, one step at a time, and forget about all the other cases waiting for your attention. What you are doing now is of paramount importance. You lose your focus; you lose a patient. I will always remember that.
That was my moment of epiphany. My Chief Resident had done me the biggest favor. My colleagues were a bit taken aback by my new found energy. It is not that I had become better at what I did, but I tried far harder and made fewer errors. This new found energy started paying dividends. As I finished my training and started practice, I had to appear in Board Certification Exams. There again, I struggled. I could not finish the first time around, but I finally did. The surgical practice was equally strenuous. In America, private practice is cherished by doctors and patients, but the art of building up such a practice requires more than talent.It requires being business savvy, which has nothing to do with medicine. Forty years back, beginning practice in the deep south for someone who was neither white nor black was arduous at best. Moving one more time from the deep south( South Carolina ) to slightly less (Virginia) was only a marginal improvement. Whereas in South Carolina, I was one of very few Surgeons, in Virginia, I was one of many, and most of my colleagues were Caucasians, and they were local boys. Frustrated by the slow pace of growth in the practice, I started moonlighting in Emergency Rooms in outlying hospitals, further depriving sleep time and time away from family. I would eagerly wait for a call from the Emergency Room. When the call would come, I would be there in moments. In one such case, I came to see an elderly female patient who had an acute abdomen( peritonitis, possibly due to perforation). Before I could approach the patient, the nurse rushed to me and whispered, “Doc, can I speak with you before you see her” I said,” sure” “Doc, she does not want you to see her,” I said, “ why not, didn’t you just call me in to do just that” She said embarrassingly “ Doc, she wants Dr. X to come in” It suddenly dawned on me why the old lady did not want to me to take care of her. I never faced overt discrimination before, but the lady did not want a brown-skinned foreign-born doc to touch her skin. A certain degree of humiliation and anger took over me. The nurse noticed my countenance and said, “ Doc, I am really sorry, she is really old school,” I said “ no problem” and left. Outside in the parking lot, I sat in my car, lit a cigarette, and said to myself, “is this what I will have to go through all my life here.” But the anger relented; I knew I could not change the historical feeling of race and color. Within my heart, I forgave the old lady. With time the practice slowly grew. I decided that there were no more moves left for me: I would either make it or break it. With extreme perseverance and keeping up many late nights, I built up a reasonable practice.
The fear of discrimination never really panned out in the long run; the perception was more than reality. But between raising a young family and building up a surgical practice, I do not believe I could credit myself with flying colors in either. Fortunately, I managed and survived with both family and the practice. And yet, there was something still missing. What was missing was a clear understanding of the reason for my being, for my existence, my purpose in life. I felt like I was one step away from disaster. In looking forward to what may happen one hour, one day, or one month later, I had lost sight of what was happening now. I was never in the present moment. My full concentration was lacking in such a mindset, and the dread of the future loomed ahead. By the time I was forced to retire due to a visual disability( Corneal Dystrophy), I had almost reached a burnout point. Even with a Corneal Transplant, it was impossible to do Microvascular Surgery But as soon as I retired, something changed in my mentation. It was akin to a breath of fresh air, a new lease on life. If one could combine the two words: epiphany and serendipity, it would best describe my state of mind. I could finally pursue a path that was dear to me: medical missions, and children’s education for the poor in the homeland. The desperate ruminations that had paralyzed me in the past for some reason came to a standstill. The ill-conceived notion of survival rooted in the ego seemed to dissipate but did not disappear. All of this did not materialize overnight. It began with meditation/contemplation and taking long retreats. There was more time spent in nature, in the mountains, taking tortuous treks, and long walks in the countryside. And love for animals, especially dogs, grew deep. There was something about the way dogs saw humans, the sheer unconditionality of their love. The association with animals and nature brought enormous joy. I searched less and less for happy moments, which seemed to have a peak and a trough. I was more imbued with joy by serving humans and animals, who were vulnerable. And yet the drama of the moment, a painful humiliation, be it within the family or outside, slowly ate away at the ever-resilient ego. Life has so many irreconcilables: pain and suffering are part and parcel of it. Physical pain is hard to resolve without medicine, but suffering is, for the most part, optional.
There is a Japanese word/philosophy called Ikigai, which is the reason for being in simple English. There is also a French word: Raison d’etre. The French word basically means the reason for existence or a reason-based conceptual framework; rather sterile. The Japanese word Ikigai is more complicated and nuanced: a meaningful direction or purpose in life, resulting in personal well being and longevity: a more holistic approach to life. And as the Japanese say, each human has his or her own ikigai. But finding one’s own ikigai requires more than wishful thinking. It combines passion, mission, profession, and vocation. Passion implies a fervent desire/love, mission signifies what the world needs, the profession involves material benefits to survive, and vocation signifies what one is good at. The concept of ikigai in Japan and elsewhere has been touted towards good health and longevity. They have discovered that people who are inhabitants of Okinawa live long lives, many of them over a hundred years of age. And the reason given is that they have found their ikigai. What it does not imply or explain is spiritual growth but in subtle ways. And as such, it has been used by business and social groups as a means of ‘success” and long life and material aggrandizement. Unquestionably, the Japanese would cringe at the idea of Ikigai being used for prosperity alone.
What I have discovered is that it is near impossible to focus passion, mission, profession, and vocation into one singular entity to achieve what may be the most satisfying reason for being alive. Besides, excitement does not always entail a positive outcome. Someone can be very excited to be a gamer or a gambler, but that can hardly be described as a life of purpose. In other words, aspirational desire can be wholesome or less so. When desire turns to crave, it initiates suffering. When desire leads to the fulfillment of the next and the next, it becomes suffering.
It was only after my retirement( 14 years ago) that I believe I found Ikigai. Though it did not happen in any singular ‘eureka “ moment, it had been growing for a while. Before a true reason for existence can come to fruition, I needed to look at my “self” or turn the gaze inwards, and that became my focus. It is only through contemplative prayer or meditation that one can find the reason for one’s existence. It is surely not in the accumulation of wealth as we know it, greasing one’s ego or performing good deeds to attain an after the life of bliss. Neither is it the absolution from the fear of death or the fear of the afterlife due to omission or commission of sins. What I discovered in pursuing a reason to live was a compilation of things: the immense beauty of the living earth, the brilliance of nature, the miracle of the human body, and the animals that enrich us all with their presence. All these had a humbling experience for me. Humility being the opposite of pride and arrogance, I had a lot of work to do. Pride and arrogance are traits that just do not want to go away. Having been empowered to become a physician, it was imperative to listen carefully to the patients suffering: both physical and mental, and advice without preaching, and show compassion without judgment. Being fascinated by the human body and the human mind, I endeavored to heal as many as possible within the powers of medicine and surgery. But my surgical skills were not exemplary. I needed to go beyond my own skills and harness the skills of others. In so doing, it was possible to bring people with extraordinary skills and channel them for service.
It was the same with animals. Animals in their natural habitat, jungles, and forest, do not require our help except for a forest fire or injured. Our duty is not to violate their sanctuary. But those animals that we have domesticated or are stray on the streets: dogs and cats require our protection. And those animals that we have decided to sacrifice for our appetite need to treat humanely, so they suffer little or no pain. Humans have this enormous responsibility towards the animal kingdom when they are slaughtered: to live in harmony with them and be their protector. However, Ikigai that promotes durability or longevity did not strike me as being of paramount importance. I did not see that as a natural outcome but only a possible corollary of a purposeful life. Longevity is not a panacea: death needs to be celebrated just as life is, death need not be shunned. The desire to help those who are suffering: man and beast, and to love and save nature from human exploitation, can themselves lead to the one’s ikigai moment. At least, that is how I perceived Ikigai.
Regardless of what excites me or what constitutes Ikigai for me, each person has their own, and it can be as varied and as exciting. Ugur Sahin and Ozlem Tureci, the founders of BionTech, have given the world a vaccine based on mRNA, which essentially and hopefully will save millions of lives. Through their academic and scientific brilliance, they are destined to save humanity as we know it. What more of an ikigai could they possibly have. Consider someone who writes beautiful poetry, an inspiring book, or is a spellbinding orator. Or even someone who washes dishes with meticulous care, finds pleasure in feeding animals, or empathizes with the plight of the children kidnapped in Africa or languishing in refugee camps in Syria or Turkey, and raises funds for their benefit, each one of us has our ikigai and raison d’etre. None of this is possible without introspection or looking within. We owe it to ourselves to remain in the moment to do just that. We all can do it. It is never too late to venture into something exciting that will make one wake up with a purpose. But it will not happen without conscious effort. In the world of today, human intelligence and intellect needs to be used to make the world a better place for all of us.