Alpha Docs (4 page)

It's my second day back, my case conference day, a command performance, Johns Hopkins–style, before my peers and my superiors.

In front of me are thirty-five impressive/intimidating doctors in a space that comfortably accommodates fifteen people. This room is normally a combination of meeting room and cafeteria, and it is littered with old paperbacks, empty soda cans, and worn chairs around a battered table. But on Wednesday mornings, it is also the conference room for the Fellows' case conference—and today is my day to present.

The conferences are ongoing teaching sessions through the first two years of the cardiology program in which one Fellow discusses a case with the other Fellows and the cardiology faculty. The conference begins with a twenty- to thirty-minute presentation of the case, including the patient's history, his or her EKG, test results, et cetera. Then come the questions about the patient's history, symptoms, tests—the whole gamut. The attendings ask and field most of the questions. Opinions fly, sometimes flaring into spirited disagreement. The presenter has to steer the conversation toward a consensus on critical factors, course of action, and prognosis. Meanwhile, since the Fellows are there to listen and learn, both the Fellows and the attending staff are scrutinizing the presenter, judging the case selection, the presenter's understanding, and his or her diagnosis. It's billed as a discussion, but you want to look smart, be prepared, and not wing it.

As soon as the case conference dates are set—mine was the second of all the Fellows—you start to consider each patient you meet as a potential candidate for the presentation. Is this case sufficiently interesting? Sufficiently puzzling? Sufficiently multidimensional to generate an hour's worth of discussion? Conferences are clearly the academic, esoteric side of medicine, in contrast to the pragmatic, deliver-basic-care-to-people-who-need-it-now side I'd witnessed during my time in Colombia. Sometimes I have to remind myself that the academic is what leads to better delivery of the pragmatic.

For faculty, attendance is optional, determined by the particular case and its relevance to their subspecialties within cardiology. For Fellows, attendance is “encouraged but not mandatory.” My being the second and not the first to present turned out to be significant. At the first case, most of the attendings showed up, but only four Fellows did. Dr. Quincy, who oversees the conferences, wasn't pleased and sent a none-too-subtle email to everyone explaining that when attendance is “encouraged but not mandatory,” it means “Be there.”

So here we are—room packed.

The case I chose was that of Mr. Zell, a thirty-six-year-old man recently diagnosed with a serious case of acute lymphoblastic leukemia and currently undergoing chemotherapy treatment. At the time, I was on the cardiology consult rotation, and I was asked to see him because a recent CT (computed tomography) scan indicated there was excess fluid around his heart; he was having difficulty breathing, and his heart rate was increasing. We'd first met on a Friday afternoon in a private room at the oncology center. Mr. Zell had his laptop open, his television on, and he was talking on his cell phone via Bluetooth, like someone in a private airline lounge at an airport. This is a surprisingly standard scene in oncology; refusing to give up the routines and diversions of their daily life, whether work or social media, is one way many patients deal with a devastating diagnosis.

The first thing I observed about Mr. Zell was how fast he was breathing. Lying in bed, doing nothing but tapping computer keys, he was huffing and puffing thirty-five times a minute, nearly double the normal respiratory rate. There were several possible reasons for his breathing difficulties: Does he have pneumonia? Does he have a blood clot in his lungs (a pulmonary embolism)? Does he have congestive heart failure? Does he have excess fluid in the sac that surrounds his heart? Finding the primary culprit was critical: Excess fluid around the heart can be extremely dangerous because it creates pressure on the heart. Enough fluid and the heart chambers can collapse, like what divers' lungs face in deep, pressurized water. With this in mind, I had one of the echo techs set Mr. Zell up for an echocardiogram, the ultrasound procedure that would reveal whether the fluid was compressing the heart, and force us toward a decision point: Should we go in with a needle and take the fluid out? And if so, should we do it immediately or should we wait? If the patient's heart rate or blood pressure drops precipitously, or if the patient is unstable or “coding,” the answer is clearly “immediately.” But when the patient's condition is less obviously dire, there is a chance that the problem might stabilize, or even slowly improve on its own. If there's any reasonable chance that things will get better without intervention, it's preferable to sidestep the risk of an invasive procedure, especially in a patient whose immune system and blood cell counts have been weakened by chemotherapy. With his body's defenses in a compromised state, Mr. Zell would be at higher risk of developing an infection from any invasive procedure. But waiting can be risky, since waiting itself can eventually precipitate an emergency, and any procedure that has the word
emergency
as a modifier is inherently more risky.

By Friday evening, the tech has performed the ultrasound. Mr. Zell's heart already shows signs of early collapse in the right-sided heart chambers, the right atrium and right ventricle. It's not an official emergency yet, but I don't see the situation getting better. The problem appears to be chemo-related, but Mr. Zell needs the chemotherapy for the cancer. I write up my impressions and present them to Dr. George, and he agrees. Sooner or later, Mr. Zell needs to have this fluid drained, and we don't want to wait until he “crumps”—medical slang for “fail fast.”

Dr. George and I go to see Mr. Zell, now with his wife at his bedside. There seems to be some sort of traditional machismo in play, as Mr. Zell is still insisting that he's “fine” despite his constant gasping and panting. We explain to him that his condition is not life-threatening at this moment but that it could be soon. “The chemotherapy, which you have to have for your cancer, is the most likely cause of the fluid accumulation around your heart. It won't get better on its own. We think it's time to consider having the fluid drained.” We carefully explain the procedure—pericardiocentesis—which involves inserting a long needle through the chest wall, into the pericardium, or sac that surrounds the heart muscle, and then withdrawing fluid from the pericardial sac until the pressure is relieved. Mr. Zell listens calmly, as if we were suggesting it might be time to get a haircut.

After we finish, he says, “I'll wait.” We're stunned. Dr. George says, “Our recommendation is to do it today, but we can watch you closely to try to avoid this becoming an emergency.” Mr. Zell nods and we exit.

But his wife follows us out of the room, saying, “Is it dangerous?” Is she asking whether his condition is dangerous or whether the procedure is? Or both? If she's like most people, Mrs. Zell heard “long needle,” “through the chest wall,” “into the heart muscle”—and it sounded dangerous. In fact, it's not a needle into the heart; the interventional cardiology team uses ultrasound and X-ray guidance to place the needle into the sac around the heart, an important distinction in terms of potential harm. The procedure carries risk, but it's often done without incident in the cath lab, where the team watches every second of the needle's insertion on a monitor to make sure that the needle's path steers clear of the heart itself. But in an emergency, the pericardiocentesis can be done at the patient's bedside, and we have to go in “anatomically”—which means that the team is aiming for the fluid collection without the video assistance of ultrasound or X rays. Mr. Zell's decision to delay potentially makes his situation more dangerous.

Saturday passes. Before I go home, I find the intern on call and tell him to check on Mr. Zell throughout the night and alert me if anything occurs. The intern's reaction is to wonder why anyone of sound thinking would wait. I can't help but agree—I'm fully prepared to get a 2:00 a.m. page that reads, “Mr. Zell is crumping.”

But when I return to the hospital on Sunday, it seems that Mr. Zell has changed his mind and is ready to have the procedure. Maybe he saw the light. Maybe his wife convinced him. Maybe he felt worse. Or maybe being asked “Are you okay?” every few minutes by a nervous intern on call rattled him. Nothing does more to convince you that you're not okay than someone constantly asking if you are.

I show both the “before” and “after” echocardiograms at the case conference. I want my audience's opinions as to whether Mr. Zell's heart chambers were in partial (i.e., early) collapse or full (i.e., more advanced) collapse. Neither answer is great, but one is definitely worse. Then, depending on their conclusions, what would they have done? Would they have pushed as hard or harder to tap him earlier? Would they have labeled it an emergency? Was the fluid around the heart the direct result of the chemo? Would they have presented the situation differently to Mr. and Mrs. Zell?

As I lay out the facts of the case, I am nervously trying to gauge the reaction of my audience. Basically, there are two nightmare scenarios for a case conference: Nightmare A is when you present to total silence, not because you've stunned the listeners with your brilliance but because your case is so obvious that there's nothing to discuss. In that nightmare, one of the attendings says, “Simple, straightforward, and no reason to be here at this early hour.” Nightmare B also ends in silence, but this time it's because your case is a statistical outlier, highly unlikely to recur, and therefore of little or no value. In that version, one of the attendings says, “Fascinating. Ellis–van Creveld syndrome, traced to a rare autosomal recessive trait, found in Amish people, resulting in atrial septal defects, sometimes manifesting in extra digits and dwarfism. That should be very helpful should a case come along again in this century.”

I open the discussion by fielding questions from some of the Fellows, and then the faculty members weigh in. After scrutinizing the films, some faculty members see this as an open-and-shut case—the procedure should have been done immediately. Others think you could make a case, albeit a thin one, for waiting. The nuances of reading the films have proved, once again, that these tests are not yes/no data points but rather pictures subject to interpretation. What is “collapsed” to one set of eyes is “almost collapsed” to another. What is “a lot of fluid” to one expert is “too much fluid” to another. What constitutes an emergency is sometimes a matter of opinion. It is our job to make the subjective as objective as possible, to try to turn art into science—but even a roomful of experts cannot always reach a consensus.

Still, there is widespread agreement that we gave the patient and his wife an accurate picture of the situation and, if anything, would have been justified in being more dramatic. Success: The attendings and the Fellows believe that the case was handled appropriately. One attending even cracks that the patient's denial reminds him of the scene in
Monty Python and the Holy Grail
where the Black Knight has limb after limb hacked off by King Arthur in a duel. Even when the knight is nothing but a head and a torso on the ground, he still insists, “It's just a flesh wound!”

We all laugh, and the group files out. Good questions. Good answers. No nightmare scenarios. I survived. Then I remember Colombia and the conversations I had with myself on priorities and realities. In the real world, no one cares about your who's-smarter-than-who meetings or fancy credentials or elite hospitals, only about being sick and finding someone to help you get better. Yes, I made it through Fellows' case conference, but what about Mr. Zell, his cancer, and the fluid around his heart? Whose outcome is important here? A Fellow's or the patient's? How do I keep my perspective as I continue through more rotations, more training, and ultimately more years of practice?

The day after the case conference, I drive into the main hospital parking lot to begin the initial two-week segment of a four-week rotation in preventive cardiology. (I'll do the second part of it in a few months.) It's a clinical rotation, which means that we see patients all day, every day at Hopkins's Center for the Prevention of Heart Disease.

And it's intense. Not in the sense of endless days, sleepless nights, and dramatic paddles-to-the-chest resuscitation, but because of the single-minded determination to reform and alter a patient's lifestyle, to rewire human behavior from a live-for-today to a live-to-see-tomorrow attitude. On top of that, the center itself is so well respected that it is almost synonymous with the practice of preventive cardiology as a whole. It's a team of true believers whose members live, breathe, and eat (in moderation, of course) what they do.

Their leader is Dr. Franklin, a lanky and lean, six foot four sixty-year-old who looks more like a small forward for a Division III college basketball team than the embodiment of preventive heart care at Hopkins. I've heard that Dr. Franklin went to medical school with the idea of becoming a sports team physician or Olympic training doctor but that his interests in the heart evolved when he came to Hopkins for his cardiology fellowship. He helped to establish the center, and preventive has been his passion ever since.

At first glance, Dr. Franklin's office looks like a heart condition hall of fame. The walls are adorned with pictures of him next to somebody famous—a professional athlete, a coach, a team owner, a politician, a writer, an executive. It seems that even world-renowned specialists such as Dr. Franklin can have a weakness for stars. But Dr. Franklin speaks so enthusiastically about the work he does that it becomes clear that these pictures serve an ulterior purpose. He's dedicated, almost religiously, to preventive cardiology. He'll do anything to advance the cause and fortify the temple, the Center for the Prevention of Heart Disease. That takes money. And stars—business, Hollywood, sports, political—have access to money, whether it's through their own deep pockets or through their affiliations with foundations, important donors, or sources of government funding.

The center also needs young cardiologists. Not very subtly, Dr. Franklin wants to get me, and as many of the other Fellows as possible, interested in a career in preventive. He says, “The point of these two weeks is to teach you as much about prevention as possible, and have you see the patients,” then hands me a stack of articles on the latest prevention guidelines and adds, “When you get a chance, read these over and let me know what you think. There may be some ways we can improve upon these published guidelines.” I can't tell whether he seriously believes that I, a Fellow in training, can actually improve the guidelines or he's trying to woo me into his field through challenge and flattery. In either case, he leaves me feeling that the future of the guidelines rests on my shoulders…which makes me want to perform at my best, so his methods work.

For the next two weeks, my role is to be Dr. Franklin's advance man at the clinic: I'm him until he gets there. As the head of preventive cardiology, Dr. Franklin sees the patients with significant risk factors—very high cholesterol, very high blood pressure, pronounced family history of heart disease, major heart events—and/or the famous and powerful people who are concerned they might develop a serious heart problem.

For the first half hour, I see the patients, take their history, do the preliminary examination, and look at their charts, so that when Dr. Franklin walks in, I have a summary ready: “Mr. McDonnell is back for his regular yearly visit, and here are the issues….” Normally, the next step is for Dr. Franklin to ask his own questions and draw his own conclusions—but what he does first is formally introduce me to each of his patients as well. “Mr. McDonnell, Dr. Muñoz is one of our finest cardiology Fellows, a graduate of Johns Hopkins Med School and residency, whom we're honored to have in our program. Dr. Muñoz is destined to be one of the stars of the field.” This introduction may sound impressive, but the reality is that it's better than the alternative: “This is Dr. Muñoz. He's just learning to be a cardiologist.”

Once the flattery is over, Dr. Franklin zeroes in on key areas, based on his experience and instinct: It could be the patient's cholesterol, blood pressure, most recent EKG, or even how the patient reports feeling. With every patient, we ask the same questions—habits, meals, snacking, drinking, work patterns, stress levels, family history, prior treatment. And with every one, Dr. Franklin uses the patient's answers to piece together what appears to be a custom-tailored routine that he is careful to call “our” plan: “Dan and I feel that the best course would be…,” or “I concur with Dr. Muñoz's recommendation for a test of…” In reality, the conclusions are his, but his implication that I've been an integral part of generating the recs is part of his teaching and subtle recruiting method. He is constantly enlisting those around him—Fellows into his preventive enterprise, patients into adopting better approaches to their health. It's strong-arming with a smile, rather than through fear or intimidation.

Nearly every patient's plan follows an ordered mnemonic device known as A-B-C-D-E. A is aspirin; B is blood pressure control or beta-blockers; C is cholesterol; D is diet; E is exercise. Dr. Franklin hits every one, in order, with every patient, and he does it in a conversation, connected by clues the patient gives him.

In most cases, the people who visit the center are still relatively healthy. A forty-year-old man comes in, panicking because his dad died of a heart attack at age forty and he now thinks his own arteries might be closing. A woman comes in with dangerously high cholesterol, even though she hasn't eaten fatty food in two years—just a case of bad genetics. Another guy is flirting with disaster because he smokes, is gaining weight, can't walk a block without panting, and wakes up every third night with chest pains. Here's a diet. Here's a calorie count. Here's a portion-control guide. Here's an exercise regime. Here's your target weight. Make an appointment for six months from now. It could easily get mundane.

But even when the patient gets the standard A-B-C-D-E review, Dr. Franklin makes the effort to create a personal connection: “Middle-aged paunch? We all get it.” “You play golf? Me too. I never take a cart. Walking relaxes me, and you get three miles of exercise.” He will tell patients to lose five pounds instead of twenty-five because twenty-five is discouraging, but an initial five is doable. His method is so smooth and natural that it is almost an art form. He says, “Switch to Miller Lite,” even though he means, “Stop drinking beer.” But Dr. Franklin wants allies, not enemies—he understands how people work and think. It's my job to learn by observation, and I'm truly struck by Dr. Franklin's deftness in plying his craft, how attuned he is to each patient's personality, cooperation, or level of resistance. He seems to have mastered the notion that practicing medicine is more than just a series of tests and cases; he grasps that being a doctor is more than just the procedures that save lives, but also involves the lives that the patients lead. Again, this brings to mind my recent thoughts on the basic human need for practical, effective, realistic doctors. And it drives home to me that this is the kind of responsiveness and empathy I want to master.

Dr. Franklin's ability to listen and connect to his patients also means that they are often extremely well informed. They know their own conditions and take an interest in the preventive practices that can change their fates. They can rattle off their family histories, their parents' cholesterol levels, as well as their own levels, exercise routines, and weight goals. Sometimes, they even speak the language of heart disease, using words like
triglycerides
and
stent
and
bypass
as easily as other people spout sports jargon. They become proactive authorities on their own health—and all because Dr. Franklin gets through to them.

It helps that Dr. Franklin practices what he preaches. He wears a fitness tracker at all times and is a “walking” ad for it, directing patients to a website that sells them. Every day he measures how many steps he takes, with his personal goal of ten thousand steps, or five miles, in mind. At the end of the day, if he comes up short, he takes the stairs in the parking garage. If he's still short, he walks around his neighborhood with his wife. On weekends he still plays basketball and lacrosse, and boasts a single-digit handicap in golf. He coaches neighborhood kids' sports teams as well. He eats right. The message to patients is clear: If I can do this, so can you. By the time we finish an exam, the patients always seem rededicated to losing another five pounds, walking farther, doing more push-ups, or lowering their stress. And I'm recharged to go to the next exam room.

During the rotation, I also work with the other doctors on Dr. Franklin's team, each of whom specializes in a specific aspect of prevention. One is the world's expert on lipids and cholesterol, and sees only patients who have horrifically high cholesterol. Like Dr. Franklin, he combs through the clues of each patient's lifestyle, looking for ways to modify his or her behavior, and prescribe the right combination of drugs to stave off deadly LDL (low-density lipoprotein) advancement.

Two days later, I follow the team's ace diabetes doctor. Our first patient, Adele, is forty-five years old, five foot two, and weighs 212 pounds. She has two daughters: a sixteen-year-old who is the same height and weight as her mother, and an eight-year-old who already weighs more than 100 pounds. Since diabetes is a significant risk factor for coronary disease, controlling it helps prevent heart trouble. But the converse is also true: If the patient can't control his or her diabetes, the probability of coronary disease skyrockets.

Adele is on cholesterol medication and following a diet that she is struggling to maintain. She and her daughters live on her welfare check, and for better or worse, it goes pretty far at the neighborhood fast-food joints. Since she started coming to the clinic six months ago, she's lost fifteen pounds, but her weight loss has plateaued since her last visit three months ago. The doctor says, “You've made some progress. Keep it up. What did you eat this week?” She tells him, and he winces. He encourages her to cut back on fried foods, to go to KFC no more than twice a week. Adele promises to try. Her younger daughter, hearing only “KFC” in an otherwise dull conversation, asks, “Can we go on the way home?”

This doctor, dealing with the consequences of diabetes daily, preaches some version of this to a patient population that grows every year, figuratively and literally. Obesity is becoming commonplace in America, and diabetes, unfortunately, often coincides with obesity. According to the Centers for Disease Control, from the late 1990s to 2014, the incidence of diabetes in the United States more than doubled. Type 2, formerly known as adult diabetes, is now rampant in a substantial portion of adolescents and young adults. The size of the problem and of the patients is not a fluke; it's driven by business—supersized, sweetened, salted, corn oil–injected, drive-through, fast and cheap food—and exacerbated by a lack of physical activity.

That night, I drive out of the clinic parking lot, and in the space of ten blocks I count six high-cholesterol chains: KFC, Applebee's, Wendy's, Burger King, Pizza Hut, and Bob Evans. Suddenly, I have a craving for a plate of wings or nachos. But after a day of working alongside Dr. Franklin and his team, observing the effects of fast food and sedentary lifestyles, I change my mind and opt for a run and a salad. Still, my moment of weakness highlights what is most difficult and frustrating about preventive cardiology. We know a lot about diabetes, what doctors can do, what patients should do. But preventive cardiology requires the patient's initiative, and its success relies on his or her ability to master every single moment of weakness, to consciously choose salads and push-ups over cookies and sleeping in. Preventive isn't just fighting heart disease; it's also an uphill battle against human nature.

Even the most successful, educated, and privileged people can fall into, and become comfortable with, their bad habits. Plenty of Dr. Franklin's celebrity patients—the business tycoons, movie moguls, pro athletes, media stars, Washington politicos, and Wall Street executives—ignore his wisdom. They may try to follow their plan, but they struggle exactly the way Adele and her daughters do. And some of them just want medicine to “fix” the problem.

In the middle of my second week, we see a certified hotshot who has been referred to us by his internist. The patient, Mr. Gardner, was an Ivy League undergrad who went to an Ivy League law school and is now an attorney at a prestigious firm for high-profile clients. He wears an expensive suit and is articulate and funny—not arrogant, totally likable. Once a track athlete, he still looks fit enough to run the hundred-yard dash. But these days he can't run a hundred feet without getting winded. His cholesterol levels are off the charts, with high blood pressure to match, unlucky genes that he shares with his father and his older brother. In fact, his family is the reason he's here: Mr. Gardner is devoted to his wife and two kids, and his wife made a point of bugging him until he agreed to come to the center.

In the course of our conversation, it quickly becomes clear that the patient is a denier. Dr. Franklin's questions and Mr. Gardner's answers are revealing. He tells us how good he feels, and how tough he is. He apologizes for wasting our time, and says he shouldn't be here, that he came only to mollify his wife. Even as he recounts the story of his father's two massive coronaries—complete with ambulance, EMTs pounding on his father's chest, and a subsequent bypass operation—he jokes that he's too young to worry, and that his high cholesterol and blood pressure are just by-products of representing fat cats in court and racking up billable hours. Even the fact that his older brother is going through the same situation—same genetics, same symptoms—doesn't seem to alarm him. Instead, he cracks a joke: “My brother is four years older, and he never could catch me on the lacrosse field.”