By Madhav C. Menon, MD

In the last year, as I traveled around the United States interviewing for a residency position, the question of why I chose America was put to me more times than I had anticipated. It was a staple in every interview; other times, it was asked by curious individuals I came across who had nothing to do with the residency program. With some discomfort, I had to dig deep into my life each time to try to find an answer for them.

When I was a third-grade student, I attended boarding school in India. My friend Balwinder went to America and brought back a most remarkable pyramid of chocolate. It was as big as my young fist! I had never imagined a piece of chocolate so big to exist. Astonishingly, Balwinder had a whole line of those chocolate pyramids. He described his trip to visit his uncle in America, telling us all about his uncle's mansion, which had its very own swimming pool. He talked about the wide roads, the big cars, and his trip to Disneyland, where he met Mickey Mouse (who, he observed, was much taller than one would have expected). I vaguely remember that something twanged within my heart just then, for America had conquered me from the moment I first laid eyes on Balwinder's bar of Toblerone.

In early middle school, paperback books became the rage. If I remember correctly, it was Ramswaroop who smuggled in the first Louis L'amour novel. In no time, the Wild West had been recreated in our little town of Lovedale in south India. The forested hillside of our school's large campus soon bore names like Dodge, Tombstone, Kansas City, and the whole area was referred to as Texas. Our free time was filled with talk of men and their reputations with guns, as well as reenacting shootouts. We were students by day and legendary gunmen by night. Vivid pictures of the rugged yet beautiful country described in those books were being etched, almost indelibly, in our imaginative minds. My heart silently yearned.

When you leave a boarding school to rejoin the rat race that is the real world, a part of you dies. You wake up, your head leaves the clouds, your feet find the ground, and you start to run in the race without even realizing it. It is that small death and your performance in the race that the world celebrates as success, so I kept running—right into medical school. In those long days of classes, mud and grime from twice-daily bus rides, and late hours studying, I had little time to dream of anything at all, let alone America.

In medical school, I decided that I was going to work hard, something I had not often done before, and I read all of the books I was assigned. There was a newfound joy in becoming knowledgeable. I noticed that America was more evident in medical school than ever before. Each subject came with a choice between two books: the cheaper, easier-to-understand, poorly presented abridged Indian version and the more complex, lavishly printed American textbook—the so-called "gold standard." In fairness, the Indian books never failed to convey all the information one needed; they were strewn with tables outlining all the causes of everything, from pallor to pericarditis. Yet, although they satisfied one's appetite for knowledge, they left me with a pervasive feeling of having done something sneaky, like I had taken a shortcut in a race. The American books encouraged me to read more; they made few assumptions and, when they did, they clarified them perfectly. In particular, they always seemed to me to answer the most important question: Why? I thought a lot about America and what it must be like to be a medical student there.

I soon realized that, no matter how informative, all the textbooks were outdated, and one had to read journals to keep up with medicine. There again, overwhelmingly, I found America. Nearly every original article, most clinical trials, and almost every new drug came out of America. I started to wonder whether everything original was American. I nearly exploded my brain studying all the textbooks I could find so that I could get a residency position at one of the best hospitals in India. I hoped that the training I would get from practicing medicine there (evidence-based being the proclaimed fad) would prepare me for the 'real deal.'

In my residency days, I silently endured a sense of helplessness, because nothing I had learned could be applied to the majority of patients I saw, who almost always faced a grim choice between bread for the family or treatment of their disease. In that argument, the former usually won convincingly. Even those who opted for treatment initially often quit midway due to their circumstances. Meanwhile, the resident was there at the patient's bedside as the patient died. The resident was well-read and could recite the latest guidelines off the top of his head, but, for reasons beyond the resident's control, he was unable to apply most of them. To the family, the resident was merely a bringer of bad news, a messenger of death.

I thought the solution might lay in working among those who could afford what I had to offer, which would let me see firsthand whether everything that those books assured me would cure my patients' illnesses actually worked. After completing residency, I worked hard to pass a seemingly never-ending string of examinations, traveling by air, train, or greyhound bus as needed. My purse felt the pinch, and I exhausted the goodwill of distant relatives and old friends. All the while, I hoped that somewhere toward the end of this long road lay the beginning of my inspiration.

Now, as I serve my internship in America, I have found over the last few months that it is less than my imagination sequentially built it up to be. I discovered that the Wild West exists no more (thankfully), the cold temperatures leave me feeling as though the blood in my bones will freeze, and snow only looks good in pictures, when it is undisturbed. I realized that the sizes of the cars do not matter if you do not own one and that poor people, at least relative to the cost of medical care, exist aplenty here and that often, paradoxically, they are obese. I have learned that one still has to look for inspiration but that the final words have not been spoken yet and I will learn more as I gain experience here. I also know that I am thankful I decided to make this journey, because otherwise I would have been dreaming about it all my life.

Whenever someone asks me "why America," many pictures flash before my eyes as I try to gather my thoughts: a chunk of Toblerone, gunfights on the hillside, textbooks with fancy print, the New England Journal of Medicine, all the deaths that I haplessly pronounced. Despite this collage of images, I have never figured out how to put everything together during those brief encounters to fashion a reply that was even remotely eloquent. I sincerely hope that I have done so now.