Alpha Docs (3 page)

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 order 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.

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.

Almost. I still have some things on my mind. I'm visiting my roots, and I want to see how my family has contributed to who I am, and what I am trying to be. How did I get here? Who and what made me this way? I've spent so little time here that while my Colombian family are loved ones, they can sometimes feel almost like strangers. I'm trying to connect, to find out what habits or values or DNA they added to the chemical mix that made me into me.

I am staying with my father's mother, the matriarch of the family, who still lives on her own. My father is currently a professor of epidemiology in the United States, but he grew up in Medellín as one of three children. It's home, and while one of his sisters lives in New York, the other lives in the building next door to my grandmother, with her husband and their twenty-three-year-old daughter. Their father—my grandfather—was a successful local attorney in Medellín, who also served for two years as the city's mayor. As a result, the family placed a high value on education. After my father graduated from the university here, he went on to Stanford for his doctorate in mathematics, and from there to Harvard. My father's family may value education in faraway places, but their roots in Medellín are deep.

My maternal grandmother is in an assisted-living facility nearby. My mother is one of ten siblings, and she is the only one no longer in Colombia. Her father was a navy pilot, and he and my grandmother made sure that my mother and her brothers and sisters were well educated—a lesson that my mother clearly took to heart, as she is now a professor of ophthalmology. But what I admire most about my mother is her remarkable inner strength, a quality that I don't yet know if I inherited from her. I want to see for myself whether this resiliency perhaps comes from growing up in Colombia as part of a strong family, able to deal with loss, but possessing an ability to move on.

As I settle into family life here, it seems that the best way to foster a connection is not to ask deep, searching questions but to participate in the international, time-honored tradition of being overfed by your grandmother. Between all these meals with various aunts, uncles, and cousins, I run miles every day in a futile effort to stay even with my calorie intake. I eat and I talk. I run around the courtyard of my grandmother's building and I think.

The house is full of relatives, telling stories, reminiscing, but mostly talking about me and asking questions. The family likes the idea that I'm a doctor. They like the service aspect—that I can help people, and that they will have someone who can listen to them and maybe fix their ailments. But they wonder why becoming a cardiologist takes so many years. As long as they can remember, I've been in school or training of some sort. I often think the same thing. When do you actually get to be what you're training to be one day? When are you done? Yes, when? Although I came here for answers from my relatives, it is their questions that linger.

They're less impressed with credentials, with titles or prestige or names. They're impressed with reality, with whether or not I can help the sick. You're a doctor? That's good. You can make people well? That's good. You went to Johns Hopkins? Or Harvard? Or Stanford? So what? The name of the university doesn't seem to carry the same weight that it does back in the United States. Residency, fellowship, chief of this, or head of that? Titles don't matter. Here in Colombia, they're just the means to the all-important end of healing people.

As the days go by, I find myself venturing outside of my grandmother's neighborhood. I start to explore Medellín itself. I don't always know exactly where I am or where I'm headed, but the more I run, the more I learn my way. Similarly, the more I talk to my relatives, the more I realize that the essence of cardiology is not a competition, a series of victories or losses against heart disease. There's no race.

Their attitude is a dose of humility, and precisely the kind of perspective that I need. Don't take your fancy credentials too seriously. Sick people don't see your grades, or your diploma, or care where you were ranked to match. My relatives say it lovingly, but their message is unmistakable: Get your priorities in order. You have been given special opportunities. Don't waste them. Use them well. Their simple message is like a cold shower. The real challenge is to become a good doctor and learn how to help others. My questions about who I am, my inherited qualities and shared characteristics, appear increasingly irrelevant next to the forthrightness of my Colombian family.

When every day consists of studying charts, diagnosing, prescribing, and staring at EKG lines, it's easy to start thinking that the world revolves around Johns Hopkins and its metrics of success. But the evaluations of the attending doctors, the number of papers published, and even the titles earned are cold and quantitative and often superficial ways to measure progress. Focusing on accolades—even though you work with patients every day—is just another way of placing yourself on the opposite side of the glass.

Thousands of miles away from my fellowship, my relatives assessed me by other gauges—human gauges, values, and worth. After Colombia, I feel cleaner, as if I have washed off some of the superficiality and returned to what mattered, to why I became a cardiologist. On the plane ride back, I think that I've regained the balance I lost. Now the trick will be hanging on to it.