Alpha Docs (20 page)

I have to make the hard decision. I've put it off as long as I could. Now…what kind of cardiologist will I be? My path took me through year one of my Hopkins fellowship, the chief resident year, and then the second year of the Hopkins fellowship. The following year, my wife, Kelly, also a cardiology fellow, and I moved to Duke, she for heart transplant experience, me for a year of clinical research. That was a big change—all study and no patient care, something I wasn't sure I'd like but ended up thriving on. The next year took us to Vanderbilt, with Kelly joining the heart transplant faculty and me completing the final fellowship year—a combination of clinical research and clinical work anchored in the CICU, with the ultimate goal of becoming an attending. One year later, I was named to the cardiology faculty of Vanderbilt.

After four years of med school, and residency, policy school, and fellowship; after all the rotations, all the attendings, all the patients, all the hours, and all the experiences—the fascinating and the mundane, the charismatic gurus and high-tech geeks, patient interaction and laboratory solitude, ICU drama and echo lab tedium, lives saved and lives beyond saving…after all of it, which did I choose? For now, a combination. But surprisingly, one not dominated solely by patient care, to which I have always felt a compelling bond, but by a combination of patient care and research…with the aim of delivering better care to more patients.

For me, it was as close to an aha moment as I've ever had. When it came time to choose, I realized the “how” behind making people better drives me as much as the “doing.” Beyond lowering one fever at a time, setting one fracture, or even restarting a heart is the research—studies of correlations and patterns of symptoms and living conditions, illness and lifestyle behaviors, laboratory discoveries that may turn odds around, theories and conclusions that can impact thousands, maybe millions, of patients at a time. As a physician, I want to make people well, but I want to make more people well, as many as possible, faster. Like many of my colleagues, I have an impatience with disease, an impatience I hope will lead to changes and improvements in care. Maybe the aha came as a result of my training, but as likely, it's also in my genes—my grandparents' quietly demanding standards, my parents' predilection toward academics and research, my own study of public policy and politics, my discomfort with healthcare inequality, a love of teaching…all coming together and crystallizing at the moment of decision.

Today, I am an attending—a researcher who treats patients…and teaches. Not only did I find what I want, but I found a position in which to do it.

My job is split between clinical research and patient care. My research focuses on how to improve healthcare through systems-based approaches. That's a very broad aim, and it takes several forms. One aspect is about improving outcomes by getting people to the hospital—to the point of treatment—more efficiently. For example, if someone has a heart attack, the sooner that person gets to the hospital and into the cath lab, and gets a closed artery opened up, the better the person's chance of survival. But it isn't just a matter of dispatching an ambulance more quickly or having the ambulance driver's GPS avoid traffic, though those things help. It involves myriad factors interacting to optimize the process: Transporting patients via ambulances versus helicopters (helicopters are faster but because of availability and deployment delays, not always the fastest means of transport), plus “decisioning” software that can help make that call. Transmitting key data from EMS teams in the field to receiving hospitals. Delivering treatments to patients in the field before they even get to hospitals. Improving ER throughput, or how efficiently a patient is logged in and treated once there, and how to shorten that time. It's about every minute a patient is not treated and how to eliminate those minutes, about coordinating all these factors.

I'm doing this work along with a group of like-minded colleagues, experts at Vanderbilt, collaborators at Duke, and others with national expertise. Our goals are aimed not only at getting people to treatment faster but also at unclogging the treatment process, getting less-sick people out of the way of the more sick. I'm part of a team submitting a research grant application to the National Institutes of Health. Every year, 7 million people present to an ER with chest pain. Some are having heart attacks; some have the risk of heart attack; and 1.5 million have similar symptoms but likely do not have cardiac issues at all, yet still get much if not all of the cardiac testing. Are there better ways to take care of the lower-risk patients, to identify them and get them safely out of the ER, in order to reach those at real risk faster, in time to save more lives? We think so, and we have specific ideas on how to do it. It would potentially be good for hospitals, good for healthcare costs, good for long-term health, and good for individual patients.

And that is where I am spending the rest of my time, in direct patient care, as an attending in the CICU and in my outpatient clinic. I treat patients who may or may not have heart disease, or just present with risk factors, some of which involves general cardiology, some preventive cardiology, some in the intensive care unit. I'm working with Fellows, residents, and sometimes med students. I teach to pass on what I know while working to fill the existing gaps in my own knowledge and understanding of disease (the process never ends). I treat because, at the most basic level, that's what people who are sick need most. Conversely, the clinical care that I provide, the time I spend at the bedside, is a vital ingredient in making my research efforts better, truer, and more real.

I think back to when I applied for the fellowship and looked around at my friends who were already out in the world, practicing their professions, earning a living, being adults, and wondered when and if this training would ever be over. Undergrad, medical school, master's, residency, fellowship, chief year, more fellowship, now research….Is there always more? Yes. Does it ever end, the learning and training and practicing and teaching and experiences? No. But it is no longer discouraging. It's good. It's good for doctors and good for patients. If it ended, it would suggest we'd found the answers, or given in to disease. This is how we do what we do. I've found my place…for now.

To Olivia, Lucas, and their superhero mother

To Ellen, as usual, as always

D
ANIEL
M
UÑOZ
, M.D., graduated from Princeton University with a degree in economics, working summers as an assistant in a neurosurgery lab and as an intern for Senator Edward Kennedy. During medical school at Johns Hopkins University, he took a one-year hiatus to earn a master's degree in public administration from the Kennedy School of Government at Harvard University. After earning his M.D., he was accepted as a resident in internal medicine at Hopkins, and later as one of nine fellows in the hospital's coveted cardiology fellowship program. After further training at the Duke Clinical Research Institute, he is now an attending cardiologist at Vanderbilt University Medical Center.

J
AMES
M. D
ALE
is an author and marketing consultant whose work includes books, articles, radio, television, sports, technology, media relations, and marketing. He is the former president of international advertising agency W. B. Doner, and the co-founder of Richlin/Dale business advisory.