Alpha Docs (19 page)

This woman told us she had taken a diuretic, but she didn't tell us the dosage had been reduced, nor did her sister. And she didn't mention the potassium at all. But in our search for whatever we didn't know, what might not have been told to us, her sister did give us the name of Bunny's primary care doctor and had his office send us her records. There was a note saying, “Diuretic likely causing dehydration and lower kidney function. Cut back diuretic.” Attached was also a list of medications, including the potassium, but no notation to lower the potassium dosage. And we found that she was also on a blood pressure medicine that can, in the event of kidney failure, make the patient more likely to have high potassium.

Mystery solved. Good outcome for the patient; good learning for me and for the resident. Even in situations where I don't immediately have the answers, I'm developing a set of skills that enable me to cope with whatever presents itself. I have a sense of being outside myself, watching myself handle a challenge. And I'm pleased. That may sound cocky, but it's not. It's a relief. It's good to know that the clinical training we're getting is working.

Early Monday morning, I do the return handoff to the CICU Fellow, after my two-day cram rotation in the Bayview CICU, and go back to finish up cath.

I'm ready to start preventive…but it turns out preventive begins with me. After a two-day break for mountain climbing in a New Hampshire hailstorm, I report to my rotation hacking and dripping. A nurse spots my symptoms and sends me to the ER for a flu swab, which means sitting and waiting like any other patient, which is a good empathy experience, but I wouldn't mind being taken to the front of the line. Finally, I'm released with a diagnosis of a “cold,” and instructions to try not to sneeze on anyone.

With almost a year of fellowship behind me, I'm a different doctor on my second preventive rotation than on the first, but one thing is the same: the attending, Dr. Franklin, the preventive guru.

I meet him at Hopkins downtown at 8:00 a.m. in the outpatient center. We hit the day full throttle with a packed panel of patients. I see five; he sees my five plus another six of his own. The morning is vintage Dr. Franklin. In three and a half hours, he talks to every patient, adjusts his or her cholesterol medicine, checks the patient's progress, and does whatever he can to prevent a heart attack, all the while marketing himself and his field.

In preventive cardiology at Hopkins, he is the brand. The world knows it and comes to consult him. This morning we see a sitting member of Congress, unnamed but of
Meet the Press
level; then the chairman of the board of trustees at an Ivy League school; then the former chair of a medical department at Hopkins, now head of an international healthcare consulting firm (Franklin is a doctor's doctor); then the founder/CEO of a defense-contracting conglomerate in northern Virginia. The CEO is sixty, responsible for a billion-dollar enterprise; his board and shareholders are betting a lot on his body and heart, so there's only one guy to see. The list goes on. Some people are famous, some are rich, some both, but what they have in common is Dr. Franklin, the master. He doesn't ask just about their heart; he asks about their business, or the government, or their golf game. It's a studied but effective form of personal interaction. And the celebrity aspect can't help but be enticing.

Personally, I find it a little uncomfortable dealing with patients who think they're important. But Dr. Franklin seems to be able to shoot the breeze and yet maintain attention, focus, and objectivity. Not everyone can do that. These people are used to being treated differently, and that can be dangerous, even affecting the quality of service. We're all human. If Bruce Springsteen walks in, we're going to say, “Holy shit, it's the Boss,” and want to text everyone we know. Even Dr. Franklin is a bit of a stargazer, but he also seems like a star himself. His office is a photo gallery of Dr. Franklin and Somebody Famous.

Monday of week two, our first patient is a venture capitalist who splits his time between Silicon Valley and Maryland's Eastern Shore, travels two hundred days a year, meeting clients and making deals, but doesn't take time to stay in shape and now gets winded going up a flight of stairs. His primary care doctor discovered he has high blood pressure and high cholesterol and tells him to see a cardiologist. Who else but Dr. Franklin?

At lunchtime, I walk outside and am reminded of the Big Contrast. In East Baltimore, people are living marginal lives, some with drug problems, some working hard but barely making it, most with little or no health insurance. And all the while, shahs, politicos, and honchos are being escorted through Hopkins's doors. The contrast is stark. And unfair.

I ask myself, if I attain some level of success professionally and financially, will I maintain the compassion to care for the person whose life is unlike mine? I can do it at thirty, but could I still at fifty? I see colleagues—with good values—who seem to grow callous, or at least resigned to realities they can't change. The system has made it harder to take care of the disadvantaged, uninformed, uninsured person. It may be spiritually fulfilling, but there's little upside, and plenty of downside—financial, time, prestige—for the hospital, for doctors, for the healthcare system. Is the poor person less deserving of good care than the affluent? Of course not, but it's a challenge. And it's amazing—and revealing—how grateful people are when they're treated with dignity, having gone through much of life without it. It's equally amazing, and upsetting, how often the overprivileged may take good care for granted. I try to be as understanding of the tanned, rich scion as of the average Joe. Both have the same physiology inside, the same heart disease. Both need the same tests, the same drugs, the same stents or surgery. One of the takeaways from preventive is to ask the identical questions, try to react the identical way, stay focused on the medical issues, not celebrity, golf games, or airplanes. There's a credibility you gain by not treating patients as if they're special, but by going right to matters of health. Treat them all as patients—the average guy, the poor, the rich, the star—all just people, sick or worried about getting sick. They are people who are scared and want care.

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.

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 important 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.