by DANIEL MUÑOZ
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.
3
ROTATION: NUCLEAR MEDICINE, PART I
Anything “Nuclear” Sounds Impressive
My next rotation is in nuclear medicine, which sounds impressive but just means reading stress tests. And even “stress tests” sounds more impressive than the reality: putting people on treadmills to see how fast and far they can go without pain. These tests are prescribed for patients who might have abnormal blood supply (ischemic heart disease) or who need a prognosis for recovery from a heart attack (myocardial infarction). For the Fellows, stress testing means less stress compared to other rotations, especially after four weeks of cardiology consults. Whereas cardiology consults can be eighty-hour weeks, nuclear weeks are technically forty hours, with the actual work time a fraction of that. Again, the rotation order is supposed to be random, but the ups and downs seem planned. They run us until we drop. They let us recover. Then they run us again.
The skills that nuclear hones are fundamental to cardiac care and clinical decision making. We’re not observing the administration of the stress tests; we’re learning to read the results. Although we’re welcome to watch the actual test performance, there’s not much to see that we haven’t seen as med students or residents—sweaty, panting patients on a treadmill and, once in a while, chest pain that stops the test.
So three afternoons a week, we sit in the back offices, overseen by nuclear attending staff, as the results come in from the Hopkins main downtown hospital and from all the outlying Hopkins clinics around the city. We read five to ten studies on Mondays, Tuesdays, and Thursday, from four in the afternoon until six or seven. All told, an entire week of nuclear is eight to ten hours, with plenty of time between the tests for coffee, conversations, and bathroom breaks.
The reason for this stark time disparity is because there are no patients. In nuclear, we see only data, pictures on screens. There are no human beings, and no human empathy. Empathy can’t help you read the path of dye in someone’s heart muscle. Instead, we study the paths with wise, experienced readers looking over our shoulders.
The tech administers the test but doesn’t read it. He or she is the monitor, making sure the radioactive tracer injection goes in, following each step, and taking care of the patients while they are on the treadmill. After the radioactive tracer is injected, the patients have “resting” images taken of their hearts. Then they exercise while another injection is given, so that a set of “during,” or midtest, images is taken. Afterward, a final set of “recovery” images is taken. Nuclear looks at each of these images in order to assess how the heart muscle “uptakes” the radioactive tracer. The manner and the intensity with which the tracer is taken up by different regions of the heart muscle can reveal an area that might not be getting enough blood supply during exertion (stress), which would indicate a possible or developing blockage. Basically, we’re looking for traffic jams before an accident occurs.
Although we were given preparatory reading material before starting this rotation, the reality is that we learn by watching the images on the screen and listening to the attending describe what’s there. Some attendings are better than others at explaining and passing on their skills. Some are so good at spotting blockages they seem like seers. Reviewing a series of images, the attending will point to an innocuous-looking area and zoom in. “Aha, an occlusion of the right coronary artery.” Really? Where? We all nod in agreement, even though we’re scrambling to mentally record the image, trying to learn to see as the attending sees.
Every day has a set, calm routine now. I head to the hospital in the afternoon, go into the nuclear lab, and plow through the tests from the previous day. We don’t read the results in real time while the test is given. Instead, we log our assessments in a computer report as the test is read, and those assessments are accessible to anyone in the Hopkins network.
Ultimately, there are only two possible errors you can make in nuclear. One is not calling something you should call—an abnormal study you read as normal—in which case, the patient could experience a heart attack because you didn’t catch it. The other error is calling something abnormal when there’s nothing there. The treating doctor is then obliged to o
rder more tests, medicines, procedures, or even surgery, which may or may not be necessary. I find myself wondering how often invasive, risky, costly procedures are ordered because of a misread stress test. Since few patients complain when their test comes out negative, it’s impossible to gauge. Still, there’s something about nuclear that plants nagging questions.
But I can’t help noticing that the doctors who work in nuclear tend to be calm, relaxed, sane, and older. They go over test after test with remarkable efficiency. A few of them also see patients, which creates a balance of clinical medicine and eyes-on-screen analytics, but most seem content with the steady routine of pure nuclear. It seems that I’m the only one who feels guilty about working shorter days. When I ask another Fellow, “What are we supposed to do with all of our downtime?” he looks at me as if I’ve lost my mind. “How about sleeping late? How about relaxing? How about nothing?”
I take his advice, and fill my extra time with jogs in the July–August heat and humidity. I catch up on Meet the Press and The New York Times, and the political figures vying for attention. I plan a trip to see my extended family in Colombia, and I make an effort to see old friends.
I admit to myself, I’m a little bored.
Even though it might be peaceful and relaxing, I realize that hunting for arterial buildup on computer screens is not for me. If anything, this rotation feels too calm, too much like being on the other side of the glass again. It’s clear to me, I need to be closer to the front lines, with the patients, despite the sleep deprivation, anxiety, and stress that entails. I need patient interaction. In a more cynical or selfish moment, I recognize that’s a costly realization. Too bad I don’t like nuclear. It is considered one of the more lucrative areas of cardiology. Every test costs a lot, is reimbursed by an insurance company, and brings revenue to the hospital, the testing service, and the doctor who reads it. But a lucrative career where I never meet a patient, never become one of the doctors who actively work to impact a patient’s life…that’s just not for me.
As the days go by, I find myself itching to get back to bedside medicine. I remind myself that nuclear is a fundamental diagnostic skill. It is supposed to be pure science, and there’s a part of me that is drawn to the scientific side of medicine, to the clarity that a diagnosis provides. But the more I study the blots and blobs, the more nuclear feels like a rudimentary version of a videogame, where a series of fuzzy pictures can mean something…or nothing. Nuclear perfusion imaging may sound high-powered and impressive, but anything sounds more important if you put the word nuclear in front of it. The reality is that the quality of the images is variable at best. It turns out that nuclear is less of a pure science, and more about subjective interpretation.
While we call medicine a science, a good deal of it is the art of reading between the lines, of piecing together clues, of seeing patterns, like squinting at the stars and recognizing dogs and bears and calling them constellations. Even the best doctors, the ones who can practically sense a blockage, rely on intuition and related clues—such as chest and arm pain, shortness of breath, and enzyme elevation—and not just the images. One attending will say, “There’s an abnormality,” and another will say, “Maybe.” They each send their readings to the treating physician, who then has to decide on the next treatment steps.
I would never tell a patient or a relative not to have the test, or to discount the results. In general, I’d recommend it as useful in the right situation. And I’d pay attention to the results. But to me, nuclear feels like fancy guesswork, an assessment that fails to take in the overall picture. This is my biggest issue with nuclear, and also what makes it the easiest rotation for the doctors: It’s a vacuum.
In my final week of nuclear, I come face-to-face with what I find most problematic about these tests. It’s not their subjectivity, or the money they bring in, but that their interpretation can be almost totally disconnected from the patient.
—
It’s my last Wednesday on nuclear, which means that today is my day for continuity clinic. Once a week, every Fellow works for a half day at an outpatient clinic connected to the Hopkins system, where we practice cardiology like a fully qualified practitioner. It’s a chance to treat people on an ongoing basis and develop a longitudinal, therapeutic relationship with patients over time, all the while improving our skills with pros looking over our shoulders.
I’m assigned to the White Marsh clinic, which presents a stark contrast to the downtown hospital neighborhood. White Marsh is a stereotypical suburb—SUV-driving middle-class families in cul-de-sac developments, ranch homes with granite countertops and big mortgages, upwardly striving people, whose heart issues are perhaps their only commonality with the East Baltimore population.
Two of the patients I see are candidates for nuclear stress tests. The first is Jennifer, a forty-six-year-old woman who seems enviably healthy. She works out five days a week, with no apparent medical problems. Recently, she has developed a pain in the right side of her chest, which comes and goes at random intervals. If she rubs her shoulder, the pain seems to get better. Still, her friend insisted that she see a doctor, so here she is. The attending physician and I take her history and conclude that there’s nothing seriously wrong. But, since this assessment does not satisfy Jennifer’s anxiety, we order a nuclear stress test to reassure her. Jennifer has the test at the clinic, and it is sent digitally to Hopkins for reading the next day.
Later in the afternoon, I meet Albert, a walking ad for heart disease. During our examination, he rattles off a litany of risk factors: He’s fifty-seven years old, obese, has poorly controlled high blood pressure, poorly controlled diabetes, poorly controlled cholesterol, smokes two packs of Marlboro Lights a day (having proudly switched from regulars to lights), and often meets his buddies for lunch at the Burger King near his office. If he walks more than a block or two, he gets a “squeezy pain” on the left side of his chest, which, right out of the textbook, runs down his left shoulder and arm. Amazingly, he isn’t too worried, because, “If I sit still and put out my cigarette, it goes away. Then I walk slower.” The reason he’s here is that his wife nagged him into seeing a heart doctor. In Albert’s case, we order a very justified nuclear stress test.
Since I happen to be doing nuclear readings the next day, I actually know something about the people behind the tests. Usually, the test readers know almost nothing about the patient, so this is a fluke. For me, Jennifer isn’t just a name on a readout. I know something very important about her: that she’s pretty healthy, and there’s a low probability of coronary disease. And the test shows nothing. But if I hadn’t personally examined her, if I didn’t know something about her, then it’s possible that she would have been recommended for all kinds of risky, expensive diagnostic procedures to confirm, or reconfirm, that she’s a healthy forty-six-year-old woman whose shoulder sometimes hurts.
Now it’s Albert’s turn. Again, by chance, I know him as a patient, not just as pictures of radioactive dye running through vessels into his muscle cells. I know that he’s at the top of the charts for likelihood of coronary diseases. With that knowledge, I study his stress test very carefully for any abnormality. If I didn’t know about his deplorable eating habits, his smoking, his “squeezy pain,” his method of relieving his arm pain, I would have no understanding of the whole picture. Would I be as suspicious? Would I look as hard?
Tests are tests. They don’t have eyes or ears. They don’t know background, habits, perspiration, or attitude. They examine openings and flow. They don’t talk to people. A test without a conversation, without an understanding of the patient’s humanity, seems incomplete to me. Conscientious doctors make the assessments and send patients for tests, but then test readers call an abnormality, or miss it, in a relative vacuum.
As I drive home, I’m relieved to be done with this rotation. Nuclear seems not only a little dull, but frustratingly myopic and inhuman as well. Still, I haven’t wasted the last two weeks of my life: Now I know there�
�s no way I’m going to be a nuclear cardiologist.
4
DISTANCE AND PERSPECTIVE
Sometimes You Have to Get Away from Medicine to See It Clearly
I have survived four years of med school, three years of residency, including one year of preparing and applying for fellowship, but after two months of living and breathing cardiology, I realize that I am drained and exhausted. Fellowship is not harder than residency, but it is more intense. Instead of getting a broad overview of a discipline, the point is to immerse ourselves in every detail of cardiology, to understand the minutiae, and then be able to apply it all. This is what it means to be a cardiologist. To be a cardiologist at Johns Hopkins, though, means being steeped in the culture, customs, and language of the hospital. It’s easy to forget that there is a world outside of the hospital at all.
I’m hoping that a visit to my family in Medellín, Colombia, will provide the grounding and perspective that I need. It’s a trip that I’ve made several times, usually with my parents and my sister. This time, it’s only me. That’s okay. I’m glad to be alone, just me and my medical and personal ruminations.
Both of my parents are originally from Medellín; most of our family still lives there, including my grandmothers (both of my grandfathers have passed away). But because I was born and raised in the United States, Colombia was always the place I traveled to, not the place that I came from. When my sister and I were younger, Colombia was the place where we saw our grandparents at Christmas. Some people went to Florida; we went to Colombia. When we got older and heard the news stories of drugs and crime, Colombia seemed like a scary, dangerous place. Now, Medellín is just another big city. It’s true that there is rampant hardship in Medellín—too many people trying to live on too little. But the only difference between the drug business in Medellín and in the United States is that in the United States, we can compartmentalize it, or live well in spite of it. I choose to live in Baltimore, a city that a show such as The Wire depicts as far more threatening than anything in Medellín. In reality, I have nothing to fear. Visiting Medellín feels like coming full circle, as if I’m leaving my stress and anxiety behind, almost like being a kid again.
