Alpha Docs
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I confess to a prejudice right now in favor of the disadvantaged, or at least in favor of pushing for a level playing field in how we treat patients. Maybe that will erode over time and I will become callous. I hope not.
—
It’s 11:45 a.m., Wednesday, June 10, and I’m driving to White Marsh clinic, mentally replaying an incident yesterday at the diabetes clinic. Senior endocrinologists run the clinic, but the role of cardiologists there is to get people better from a diabetic standpoint, which, in turn, can help get them better from a cardiovascular standpoint. Diabetes, along with high blood pressure, smoking, and a few other villains, is at the top of the list of risk factors for development of coronary artery disease. Treating a root cause can, to some extent, treat the entire equation.
But the case I see is emblematic of why, in many patient populations, preventing cardiovascular disease before it happens is an uphill battle. The patient, Ms. Bailey, is sixty-two, not old by today’s medical standards, African American, lives in East Baltimore, has children who bring her groceries, but is otherwise on her own (a sharp contrast to the VIPs). When I walk into her room, she’s in a wheelchair, best guess about five foot six, 250 pounds, talking with her forehead in her hand, eyes closed. After missing several appointments with her primary care doctor, she had mounting calamities by the time she saw him—high cholesterol, high blood pressure, plus diabetes, and sleep apnea due to obesity—and he sent her to the clinic.
My one mission is to talk about Ms. Bailey’s diabetes, not her other problems, and it takes discipline to keep her on point. No matter the question, she talks about her chronic pain—which is understandable, but not what we’re here for. I ask how often she takes her insulin. “Twice a day. In the morning and after lunch.” Not good. It should be in the morning and evening. I ask, “What time after lunch?” She says, “Actually, it’s before dinner.” I ask, “Is it closer to after lunch or before dinner?” She holds her head and says, “I don’t know, maybe before dinner.” I finally learn she takes her insulin at 9:00 in the morning and around 6:00 in the evening, give or take. That would be okay because it’s a twelve-hour formulation, but I get the strong sense she is hardly consistent. She’s on a long list of other medicines, but similarly, we don’t know if she’s taking those regularly or not. I ask her directly, “How often do you forget to take your insulin?” She says, “Oh, a lot…a real lot.” I say, “Ms. Bailey, this morning did you take your insulin?” Her answer is “I don’t remember.” She has no diagnosis of dementia; she’s conversing; she got herself to the clinic. She’s just not capable, from a cognitive standpoint, of taking care of her own illnesses.
I have to wonder what we can do to lower Ms. Bailey’s risk of long-term damage from the disease when she’s having so much trouble in the short term. She is a statistical case study, one patient with multiple risk factors that add up to comorbidities, or potential ways to die. The system hasn’t totally failed Ms. Bailey. In fact, it is trying to reach out to her, but in doing so, it has overwhelmed her with a long list of medications and directions that she can’t keep straight. She lives alone, on government disability, likely to be increasingly debilitated, with almost no social support in the way of family or friends to help with her meds, her weight, and life’s other challenges.
It hits me hard: Despite all of the high-tech tools at our disposal, it takes a willing and capable patient, plus outside support. Without those components, nothing works. Preventive cardiology? Preventive anything? How about just staying alive? There are countless people in urban America, like the locals in Colombia or Costa Rica or anywhere else, who need a basic doctor and basic support more than they need any specialist, cardiovascular or otherwise.
That’s what I’m thinking as I pull into the parking lot of the upwardly mobile, suburban White Marsh clinic. The average patients here aren’t average at all. They’re aware and have families and access to Googled information and insurance, and they’re generally motivated to get better. Another study in contrasts.
The last day of the preventive rotation, Dr. Franklin gives a lunchtime talk to the Fellows. He says his goal is nothing less than to change human behavior so that heart disease happens less. A challenging and noble goal. Realistic? Highest priority? I’m not so sure. Not nearly as sure as I might have been twelve months ago.
19
365 DAYS A FELLOW
What I Learned
After preventive, I have one more rotation, part III of echocardiography, a return to the sequestered caves of echo, essentially a repeat of parts I and II—venerated but narrow practitioners, nuanced/vague interpretations of pictures, via imperfect technology—a reminder of a highly specialized field I do not wish to pursue.
Echo is followed by a weekend in the cardiac ICU, featuring a refresher course in “the groin hold.” An eighty-two-year-old frail but fleshy woman has had a cardiac catheterization via her femoral artery, and the entry point now threatens to leak. This low-tech treatment involves applying almost thirty minutes of sustained physical pressure, doctor’s fingertips to patient’s flesh, over the incision to manually stave off massive blood loss.
As I remove my numb, stiff fingers, bleeding stopped, I’ve completed my first year in fellowship, with apologies to T. S. Eliot, not with a bang but with a look back….
—
I take inventory of what I think are the lessons of the year. First and foremost, fellowship is not heroic. It’s not 365 days of testosterone. It’s not war. The value is in the pure learning. In residency, the education can be something of a brutal rite, the medical equivalent of One L, Scott Turow’s revealing look at law school. The process taxes you, overloads you, tests you—physically and mentally—demanding that you learn the basics of so many disciplines, fast, and under pressure.
Fellowship is hard in an almost opposite way: all about focus—intense focus. We learn a great deal about one thing—cardiology and each of its facets, but all still cardiology. It’s not an endurance test. It’s a chess game, taking in the whole picture, seeing where danger lurks, finding paths through the maze, reckoning with the ramifications of each. If X happens, I do Y, but if Z happens, I absolutely do not do Y. Fellowship zeroes in on the subject and mines it, and leaves us with a greater depth of knowledge. It’s analytical. It’s distilled. It’s pure.
Fellowship is solitary, to a large extent, up to the Fellow. The rotations are predetermined. The attendings are who they are. But once in a rotation, I have a lot of control over what I do each day and whom I learn from. I can skip over things that are a waste of time and immerse myself in the areas I like, and I can, for the most part, pick my mentors.
Fellowship, despite the literal meaning of the word, is not a team or group experience, not “we” as much as “me.” When I started, I thought the other Fellows would be my world, the people I’d live, breathe, eat, or stay up all night with discussing cases. That’s more residency than fellowship. In fact, I hardly know the other Fellows. I know the attendings better because the learning has been one-on-one, me and an attending. I miss the collegial aspect, but the reality is, now it’s not about how well you play or work with others; it’s about making you as highly trained as possible in each particular skill.
But, as a result, after a full year of fellowship, because we work solo, I don’t really know who, in my class, is a good doctor and who isn’t. Unlike residency, there’s no opportunity to see their performance, style, or knowledge, save the rare glimpses in case conferences.
Has fellowship made me a better doctor? In some ways yes, in others maybe, in still others the jury is out. I’m not smarter than I was a year ago, because, at this point in life, I don’t think you suddenly get more intelligent. But I am better at what I do. I’ve seen and experienced a lot. And absorbed it. There’s value in pattern recognition and in having mysteries demystified. It’s about generating sufficient experiential data regarding certain things to be able to responsibly make decisions for patients. People say there is an impo
rtant difference between intelligence and wisdom. Intelligence is limited. You go as far as you can go. Wisdom continues. I am hoping to get wiser.
Have I gained any wisdom? Am I wiser? The confluence of events that closed out the year—the end of preventive, part III of echo, and the groin hold—resonate with me more than any single rotation, procedure, doctor, or outcome. Too often we think medicine is about heroic dreamers chasing miracles such as Dr. Franklin’s Don Quixote–like quest for extended life by way of prevention, or the futuristic but flawed wizardry of devices that purport to “read” the body and tell us just what is wrong and what to do. Then we get the sobering reality check that, for Ms. Bailey or the elderly woman who needed a literal human tourniquet on her groin or most people with most illnesses, for that matter, it’s simple measures that heal, or try to, keeping patients alive another day. Medicine is not one, but all of these—lofty, technological, and primitive—although we often forget it.
It’s an appropriate segue into my next endeavor. Rather than going straight into year two of fellowship, I’ve been asked to be a chief in the internal medicine residency program. At Hopkins, the chief year does not directly follow the completion of your own residency. Hopkins believes that the chief should perform the function after having gone on to a fellowship, or research, or into practice, to bring more perspective and experience to the job. It’s physically far more taxing than fellowship, and adds another year to my endless training, but it’s an honor and a teaching/learning/mentoring opportunity.
On Monday, when I begin, I’ll take a page from Dr. Fitzgerald’s welcome to fellowship, in which he noted something meaningful or distinguishing he’d gleaned from each of our backgrounds, by doing likewise with my new group of mentees. I hope to show them, as he did, that beyond GPAs or résumé credentials, their human individuality is of equal or greater importance in caring for people. I hope to bring them some wisdom.
EPILOGUE
What Kind of Heart Doctor Will I Be?
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 a
nswers, 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
—Daniel Muñoz
To Ellen, as usual, as always
—James M. Dale
Acknowledgments
DANIEL MUÑOZ:
As I hope this book has conveyed, there are many physicians who have influenced my personal development and my fondness for the practice of medicine. Naming them all is not practical, but a few stand out for the lasting impressions they have made and for their powerful examples of how to care for patients: Steven Schulman, David Thiemann, and Phil Buescher.