Alpha Docs (2 page)

In the course of the fellowship, they will learn to practice cardiology at its highest level. They will learn to search for elusive symptoms, and cure what resists cure. They will attempt heroic treatments, some of which succeed and some of which do not. They will face terrified families and bring them near miracles. They will face hopeful families and have to deliver devastating news. The experience will be an exhilarating, wrenching, breathtaking, brutal ordeal, at once ego-making and ego-breaking, heroic and humbling, part science and part art.

Their story is my story. I am one of the nine, a cardiology Fellow at Johns Hopkins. I am living it daily, rotation after rotation, patient after patient, family after family, diagnosing and treating patients, staying up all day and then all night, learning from mentors, some geniuses, some egomaniacs, struggling to save lives, and coming to terms with losing them. This is my real-time, real-life chronicle of what it means to become a heart doctor at an elite cardiology program in one of America's most renowned hospitals.

I had no idea how demanding it was going to be.

July, one year later. I'm standing outside Johns Hopkins again, at an hour when most people are heading home from work, about to begin the first rotation of my cardiovascular training. Each rotation is an immersion in a subspecialty. Most run four weeks, some two, some repeat with two segments. By the end of the fellowship, not only are you supposed to be educated and proficient in every area, but it's assumed that you'll know what kind of heart doctor you'd like to be. Will you go to work in interventional cardiology, with caths and stents? Will you end up reading stress test films in nuclear? Will you be in preventive, changing patient lifestyles, or working in the more dramatic area of transplant? Fellowship is a countdown to yet another decision day.

Unlike residency, which is a form of group learning, fellowship builds individual relationships, one Fellow working closely with one or two attendings on each rotation. And unlike residency, the other Fellows aren't likely to become our friends and surrogate family. We'll see one another only occasionally, in meetings, in hallways, at a case conference.

Still, we'd all briefly met and sized one another up yesterday, during the cardiology fellowship orientation. Clasping our packets of information about the basics of parking, health insurance, campus map, phone numbers—papers we'll likely never look at again—we had smiled and shared small chuckles about our contracts. These papers state our salaries, benefits, et cetera, and we're supposed to read and sign them. The fact is, there's no reason to. We've been winnowed from thousands to hundreds to nine. We all want to be Hopkins cardiologists. We've already signed up for this deal.

Rotation order is mostly random, but sometimes the faculty can change it up and make judgment calls. I'm starting with cardiology consults, considered one of the most demanding rotations of all. I won't have total medical responsibility for any of the patients, but I will have cardiac responsibility for patients whose issues can range from a routine inquiry on the dosage of a beta-blocker to a postsurgical weekend jock who goes into cardiac arrest in recovery. I'm pretty sure I got consults first because of a Hopkins prejudice—that a Hopkins-trained resident is more ready for trial by fire. We know our way around the hospital, and that's no small thing whether you're looking for the SICU (surgical intensive care unit) or a bathroom. Other than that, the biggest difference between me today and me two days ago as a senior resident is the word
Fellow
stitched above my name on my white coat.

I look up at the dome on the roof of the old hospital building, the icon that says, “This is Hopkins—the best,” and think back on how I got here. I'm almost thirty years old, pursuing a career that often feels like a distant mirage: No matter how close I get, it always seems a little further away, and when I haven't slept for thirty-six hours, I wonder if my profession will ever start or if I'll forever be “in training.” I went to Princeton for four years, Johns Hopkins Medical School for four years, interrupted by a year at Harvard for a master's in public administration, then a Hopkins residency in internal medicine for three years, and now a Hopkins cardiovascular fellowship for three or four more years. Plenty of doctors choose not to do a fellowship in a subspecialty. After years of training, and after seeing their peers rise through the ranks in nonmedical professions, they want to get started. Many of my friends have earned hundreds of thousands of dollars in the time I've run up loans for nearly as much. But, after the impact on me of the events with Randy, I knew I wanted to keep going, to extend my training and pursue a fellowship in cardiology.

That meant entering the annual “match” last year. The match is the computer-assisted mating dance, which narrows applicant pools to on-site interviews before assessing the ranked preferences of the final applicants and the programs. Acceptance is based on a combination of clinical work during residency, evaluations of residency attending staff, research the candidate may have done, and a personal statement, the closest thing to a wild card or tiebreaker—what you've done that could set you apart from the hundreds of overachievers vying for the same few slots.

There is something called the rule of 10 in selection processes. It maintains that being chosen gets exponentially harder each time you take another step up the ladder, whether it's from the county beauty pageant to the state pageant, or from a high school team to Division I. If getting into the most selective colleges, on a 1-to-10 scale, is 10, then getting into the best graduate or medical schools is 10 × 10, and getting into the best residency is 10 × 100, and getting into the most selective fellowship is 10 × 1,000, or 1 in 10,000.

I still remember my interview day at Hopkins. After all the applicants were treated to an ironically high-cholesterol breakfast spread, Dr. Fitzgerald—the head of the program—walked in. He not only knew all of our names and where we went to school, but he created a story, in one endless sentence, weaving in our individual interests, hometowns, talents, siblings, foibles, everything. “Sara, we're glad you were able to travel all the way from Barcelona, especially since you'd probably rather be helicopter-skiing in the Andes, which Amit could appreciate, having just returned from Pakistan's K-2 summit, which he first climbed as an undergrad at Oxford, coincidentally where Maya studied Old English poetry before switching to premed (our gain, their loss), and the same could be said about Dan since he's divided his time between medicine and Washington health policy for the past three years, a far cry from Raj, who locked himself in a room to finish a book about…”

It was more than an entertaining performance or a stroking of our young egos. It also sent a message: “We know you. We put time into this because we will put time into you. Of all the candidates, we think you will become the best cardiologists if you come to Johns Hopkins.”

After a tour of the facility came the individual interviews with faculty members, each a medical version of a police interrogation. Where'd you grow up? Play sports? Travel? Where'd you go to college? I see you had a rocky year first year of med school. What happened? Too demanding? Why do you want to be a cardiologist? Why Hopkins? What makes you think you can make it here?

I went on nine of those tours and interviews: Johns Hopkins, Brigham and Women's Hospital (Harvard), University of California at San Francisco, Duke, Northwestern, Columbia, Penn, University of Virginia, University of Maryland. Then I submitted my order of preference to The Match process and the institutions did likewise—and where the two rankings intersect, the matches would be made…all very objectively, very algorithmically.

But not always. Sometimes, institutions can unofficially make direct human contact with candidates to signal their feelings.

I had one of those conversations when the same Dr. Fitzgerald asked me to stop by his office. One of his tasks was to target two or three Hopkins residents to stay at Hopkins for their cardiology fellowships. He was very up front with me: “Dan, you're at the top of our list for the cardiology fellowship program.” I was a little stunned. I'd hoped to match with Hopkins, but “the top of the list”? It wasn't easy to tell him I'd mentally ranked Hopkins and Harvard in a tie for first place, but I did. He said he respected my thinking, told me to take my time and then decide. In other words, come to Hopkins.

A couple of days later, I got virtually the same call from Harvard. Choosing between these two was a great problem to have, but not one I could share. Hopkins? Harvard? No one would sympathize. In the end, I made a rational-emotional decision. I'd chosen to become a cardiologist that day with Randy at Hopkins; Hopkins is where I'd see it through.

I called Dr. Fitzgerald and told him. He didn't seem surprised.

That was December. Now here I am.

I walk back inside. It's five o'clock. As of this moment, the system considers me a cardiologist. After all, I have a white coat that says so.

The cardiac consult team is lead by the attending physicians, the senior faculty members responsible for all recommendations and treatments. As a Fellow, I will work with one attending for the first two weeks, and another for the second two weeks. The first is Dr. George, an Australian with an Outback Steakhouse accent, in his late fifties, soft-spoken, a down-to-earth doctor's doctor, reassuring to his patients and to me. The second is Dr. John, an older, hardened Hopkins veteran, who I've heard is a firm believer in the hands-off approach, which, for a Fellow, means you're left on your own. You'll get to carry the weight—but that might not be best for either the student or the patient.

In addition to the attendings, there's a medical student doing a fourth-year elective rotation. Ours is Joseph, a high-caliber med student who was raised in upstate New York. He's from a large Italian family of academics, and we connect over our love of baseball. He's smart enough to assume responsibility when things get hectic. By all appearances, we're a very respectable team.

There's just one small thing: I don't know how to perform an echo (a cardiac ultrasound test), and without that skill, I'm not much use on the rotation. I was never taught in residency because it's not essential to a resident. Watching an echo being performed on Randy in the ER is as close as I've been. They're supposedly not hard to do; I just don't know how, and they're ordered day and night. During the day, the ultrasound team, led by a technician, takes the machine to a patient's bedside, administers the test, and the echo lab team interprets it. These daytime echoes are by and large routine. But after 5:00 p.m. today, when my consult rotation starts, until who knows when, there's no team, just me, the Fellow on call. And the middle of the night is when the nonroutine, emergency-type echoes seem to happen, and therefore fall to the cardiologists in training, such as me. So I really need to know how to do them.

I find the head of the echo lab, confess my ignorance, request a crash course, and ask for a pledge of confidentiality. She's sympathetic in a motherly, “This happens every year” way. I follow her down a hall to an oversize closet full of broken chairs, bed rails, bedpans, sheets, door handles, and IV stands. She uses the ultrasound cart to plow some of the detritus out of the way to create a work space, and closes the door. It's safe to say no one will come in, since no one has in years. For the next ninety minutes, she shows me how to do a basic echo, assessing for overall ventricular function and the presence of a pericardial effusion (fluid collection in the sac surrounding the heart, which, if severe, can be deadly). She takes me through the steps, over and over, until I've mastered Ultrasound for Dummies.

Now that I can do an ultrasound, the team is ready for prime time.

The unstated mandate of cardiology training is: Learn fast. We aren't technically on call all night, but the reality is that my pager beeps almost anytime, day or night. It can be a sixty-second query from a resident in surgery who needs cardiac-related recommendations for post-op care: Patient A just came out of gastric bypass surgery for obesity, and we need to know if there may be any adverse effects of administering fifty milligrams of atenolol, blood pressure medication. Or it can be a four-hour high-intensity drill: Patient B has developed severe hypotension—blood pressure drop—in the midst of bladder cancer surgery. What do we do? How do we do it? When? For the most part, I either know the answers or can come up with a strategy to arrive at them. When I'm sure, I make the call. When I'm not, I check with Dr. George. The key is knowing the difference.

This kind of pressure means that newly minted Fellows tend to share a dark humor: “Another good day. I didn't kill anyone.” That humor turns out to be one of the few bonds among us, as we intersect in hallways, on breaks, or when two of us are seeing the same patient for different reasons.

A few days go by, and just when I start to think that consults isn't so daunting, I'm thrown into a situation that reminds me of the gravity of what we do. It's my second week on the rotation, and I'm brought in on the case of an eighty-one-year-old woman, Midge, who has come in for surgery to remove a tumor on her liver. The tumor turns out to be malignant, and she's slated to begin cancer treatment. But it's only after complex surgery when she's in the intensive care unit (ICU) that a routine electrocardiogram (EKG) reveals strain on her heart with mildly elevated cardiac enzyme levels. I'm being consulted because we need to figure out whether (a) the EKG and enzymes are evidence of an evolving heart blockage or (b) they're relatively predictable signs of stress following major surgery. The stakes are high because the two possible diagnoses indicate almost polar opposite treatments. Post-op stress means Midge should be watched carefully. Evolving coronary blockage means a series of steps, including an invasive procedure such as catheterization, and/or blood thinners, which carry their own risk for a person who has just had abdominal surgery—that is, bleeding. There isn't any yes/no test to determine the right conclusion. It's a judgment call. And it's up to my team to make it.

The basic issue is one of supply versus demand. Supply issues are what heart attacks are made of. An acute compromise of blood supply (coronary plaque rupture/clot) results in an urgent or emergent trip to the cath lab while blood thinners are administered, similar to what happened with Randy. Unless the supply is reestablished by angioplasty (opening the blocked artery), the heart muscle begins dying, meaning that, without intervention, the patient may also. On the other hand, an increase in myocardial demand (the heart muscle's need for oxygen and the blood's nutrients) can induce strain on the heart muscle, and sometimes result in heart cell death. The solution to this problem is different, since it involves relieving the stress, treating the infection, eliminating the dehydration, controlling the bleeding. In this case, you have to fix the underlying stressor.

In Midge's case, we need to figure out whether she is having a heart attack caused by plaque rupture and a new clot lodging in one of her coronary arteries, or is simply experiencing postoperative cardiac stress because of her surgery. Heart cells die when supply and demand don't agree. Figuring out why they're out of balance, and what to do, is part of the nuts and bolts of cardiology.

I spend a full hour going over Midge's chart. I question the surgical resident. I speak to the ICU nurses. And I attempt to assess her directly, although Midge can't talk because she's been intubated and is currently dependent on a mechanical ventilator. The resident introduces me to Midge's family as the cardiologist who will care for her heart while Midge recovers from surgery. It's a small untruth: There's no upside in telling nervous relatives you're only “studying” to be a cardiologist. I take my time to understand Midge's background, and ask her daughter and a family friend about Midge's level of physical mobility and about any previous heart problems. I learn that Midge leads an active lifestyle: She walks for forty-five minutes to an hour every day with her daughter, has no history of heart problems, and is an avid gardener.

I ask the surgical team to order an echo (done by the in-house tech). The ultrasound can reveal critical information about what region of Midge's heart might be injured. If Midge has a new blockage or clot resulting in a decreased blood supply, then a part of the heart wall wouldn't work as well and the ultrasound would indicate that. From that standpoint, her echo images are reassuring, showing the heart squeezing as it should. I also ask the surgical team to check cardiac enzyme levels every six hours, since a blockage or clot can also cause enzymes to leak into the bloodstream. A day later, the results come in: Midge's cardiac enzyme levels were mildly elevated but fortunately now seem to be trending down.

This news is good but not definitive, and the surgical resident needs a conclusion. I explain that I do not think Midge is having a heart attack, but rather is experiencing postoperative cardiac stress. For the time being, all we should do is keep a careful eye on Midge.

Over the next several days, the immediate evidence seems to confirm my judgment. It turns out that pneumonia was the likely stressor. When I visit Midge later, she is no longer hooked up to as many tubes and monitors and, now surrounded by her daughter and grandchildren, appears the image of a strong, resilient matriarch. Although Midge later develops other complications, which require two more trips to the operating room, her heart functions well under the strain. I had made the right call: Because she was never put on blood thinners—as she would have been if there had been a clot or blockage—she was able to have these surgeries without additional risk.

I survived my first real test. Unfortunately, Midge has a particularly awful form of liver cancer. Statistics say she has only eighteen to twenty-four months to live. Even though I made the right call, and even though we fixed the heart problem, we cannot fix the cancer. It's not a victory—just a delay.

My attending, Dr. George, is a reassuring, hands-on mentor, who guides me through each case and outcome, including this one, showing me what I did right and what could have been done better. He's always there with the safety net, just in case. Working with Dr. George, I feel as if I'm doing well, although I see so little of the other Fellows that I have no point of comparison (as is usual in fellowship).

Weeks three and four are another story. My new attending is Dr. John, a sharp contrast to Dr. George; his approach is to let me find my way. I'm on my own, almost being dared to fail. Over the next two weeks, I see patients throughout all parts of the hospital—as many as six or eight a day. Each time my pager beeps, I run a mental drill of what I will do: Take a deep breath, clear my mind, and then call the doctor back (urologist, surgeon, gynecologist, ENT [ear, nose, and throat] specialist). I listen to the case, ask key questions, and examine the patient. Then I process all the information and determine the next steps in diagnosis and/or treatment. But before implementing a plan, I call Dr. John, who listens to my summary as if he were preoccupied with something else, waits for my assessment, then grunts “Uh-huh,” and hangs up. His near silence is his form of approval. Working with Dr. John is cardiology without training wheels.

Case after case after case: I'm on a roll. A woman coming out of labor with a fast heart rate. A young man with a drop in blood pressure after a bowel resection. Several elderly patients with swelling that might be due to congestive heart failure. The closest Dr. John comes to “input” is one case in which I conclude that the patient's post-op arrhythmias warranted a transfer to the cardiac intensive care unit. This time, I'm surprised to hear him say “You sure?” I double-check the data and realize that I
am
sure, and go ahead with the transfer.

It's my last week on cardiology consults when I am called by the trauma surgery team to see a fifty-two-year-old man, Mr. Rosen, who has been brought in by ambulance following a car accident. After his lacerations are cleaned, Mr. Rosen reports feeling chest pain. His EKG looks normal, apart from a couple of small vagaries. The trauma team is worried about acute coronary syndrome, which is a catchall for clinical symptoms of acute myocardial ischemia (insufficient blood supply to the heart), which can come in varying degrees of severity.

On my way to the ER, I call Dr. John with a run-through of the case. He says, “Tell me how it goes afterward.” He doesn't ask anything more about the patient's condition. He doesn't ask for my take on the situation. He doesn't tell me to call if I have a question. He just assumes I'll know what to do…or I'll call if I need him.

In the ER, I check on Mr. Rosen's electrocardiogram. It appears to be normal, which is reassuring—the “vagaries” don't mean anything unless there are other indicators. I examine Mr. Rosen and see no signs of congestive heart failure, no fluid backing up into his lungs.

What he does have is profound wheezing, very labored breathing. I look at his X ray with the surgeons: no punctured lung, no obvious fractures, no evidence of pneumonia. The one notable finding is the degree to which his lungs are hyperinflated (expanded), a telltale sign of a smoker's lungs or COPD (chronic obstructive pulmonary disease), most commonly known as emphysema. I decide to administer steroids and a series of nebulizer breathing treatments. Mr. Rosen relaxes, and his breathing and chest pain get better. I report this to Dr. John. He grunts his “Uh-huh.”

I did this cardiac consult solo, and it went fine: It turned out that Mr. Rosen's possible angina was just a breathing issue related to smoking. The Dr. John method worked. That night I find myself thinking about which attending's style is better—hands-on or hands-off. The answers, for patients or for young doctors, are almost diametrically opposite. Before this rotation, I would have said the hands-on method is better, the safety net for patients being obvious. But then doctors such as me would never learn to do what we have to do. And now that I've succeeded without a net, I realize that maybe a little fear is a good thing. For learning, anyway.

Perhaps the net was there all along—I just didn't see it. And because I didn't see it, I learned to rely on myself, to trust my judgment even when Dr. John second-guessed me. Maybe Dr. John knew that I could push myself further and handle the pressure. Maybe. But doesn't a patient deserve more than a young cardiology Fellow hoping that he or she has made the right call? It's a trade-off, teaching versus treating. The answer is clear. You have to teach…but, as popularly paraphrased from the Hippocratic oath,
first, do no harm.

Okay, I've made it through cardiac consults—an onslaught of cases, questions, diagnoses, and decisions, almost eight weeks of hours packed into four—a total immersion. Still, I am no closer to knowing what kind of cardiologist I will be, but, I rationalize, this is only the first rotation. And I'm learning some key lessons—how to perform an ultrasound, to “consult” on what may or may not be cardiac issues and know the difference, to trust my instincts a little more each day, and, as in the case of Midge, accept that even when we win a heart battle, sometimes another illness trumps and we lose the war.