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Implanting the LVAD is a major operation that requires open-heart surgery: It splits the chest open, separates the rib cage, and is not unlike the physical trauma of a transplant. Recovery is tough. As patients often say, they feel as if they're going to “come apart.” You have to relearn to sit up, and to hold a pillow to your chest when you cough. Malcolm is strong and has a good attitude, and he comes through remarkably well. The LVAD appears to be doing its job. Two weeks after surgery, we send Malcolm home, tethered to his power source, able to go out, but certainly not back to work. Given the timing of my rotation and the scarcity of hearts, chances are I won't directly care for Malcolm again.

That's another aspect of the job that's not right—not right for teaching or for treating—but I don't have a solution. Unless you're an attending cardiologist, seeing patients regularly, you don't have ongoing doctor-patient relationships. As Fellows, we often see patients under the direst of conditions, sometimes near death; we diagnose and hopefully stabilize them; we send them home. And then the rest of their life happens, good or bad, and we often never know the long-term outcome. Did she live to be eighty-five? Or a week? Did she have more heart problems? Did she survive? Who treated her and with what? Did she die from an unrelated cause? Was she hit by a car in the supermarket parking lot? We don't know. For doctors in training, it creates a distance between doctor and patient, leaving us removed and perhaps less invested. They really aren't my patients; they're just temporarily under my care.

In some ways, I don't want to like Malcolm as much as I do—because there's some chance of a bad outcome, that he won't survive the transplant, or that he'll die waiting for a heart. If he does survive, for how long? Making rounds with Dr. James, I begin to understand that what appeared to be his disinterest in the average cases might be professional distance. You have to move on. There are always more patients, always more bad hearts.

Two days before my rotation ends, one patient, Mr. Graham, actually receives a transplant. I didn't treat him as a patient. In fact, I barely knew who he was, because he was one of the patients who waits at home, a name on a list until a heart is found. After a year, Mr. Graham has received word that there may be a heart for him, reason for both excitement and extreme caution. Plenty of patients have been called only to be told later that there was an issue with the donor heart—anything from developing arrhythmias prior to retrieval, to not pumping as vigorously as needed, or simply not looking strong enough to the surgeons. Because time is critical, the patient can't live more than two hours from the hospital. Donor hearts can be outside of the body for no more than six hours, so they generally come from nearby—Pennsylvania, Ohio, Delaware, and Virginia—by helicopter, ambulance, or airplane. Theoretically, you could get a heart from as far away as Florida in six hours, but any travel delay can irreversibly damage a donor heart that could have saved a life.

But Mr. Graham arrives at the hospital, his heart arrives, it's a go, and he has a successful operation. I see him in the surgical ICU a day later, and he appears to be doing all right, although
all right
is a relative term. He's tubed into and out of every imaginable place, wires connected, monitors beeping, fluids flowing, IVs dripping, tethered like a NASA astronaut. But his vital signs are stable, and there are no indications of organ rejection. Access to his room is restricted, since almost anything can do him damage during the critical recovery period. His family paces in the hallway, smiling, whispering into cell phones, nervous but happy. Their dad or granddad or uncle or brother has gotten a second chance…if it works. With only twenty or so of these operations in a year at an institution like Hopkins, the event creates a stir even among the most jaded doctors and nurses. Everybody is on high alert. Everybody wants success. We don't want to just do transplants; we want to do transplants that work.

When I finish the rotation, Mr. Graham's transplant is working. After that, who knows? Some other doctors will be there when Mr. Graham returns for his checkups, or with a rejection issue, or to adjust his meds, but not me. That's what's good and bad about the Fellow's role on the heart failure/transplantation rotation. It's intensely interesting, challenging, a chance to make a profound difference in a person's health at an intersection in time…but it is just that, an intersection, brief, random, and then over, disconnected from the person's longitudinal, lifetime care. Later in the year, I'll have another rotation on heart failure/transplantation, another “intersection,” and perhaps that will give me a better idea of whether I could do what Dr. James does as my career. For now, as with Mr. Graham's outcome, who knows? Unlike Mr. Graham, I can put my fate on hold.

It's the middle of October. On to Cardiac ICU at Johns Hopkins's Bayview Medical Center. I'd like to say today is a crisp fall day with the leaves changing color, but I have no idea. I go from one sealed enclosure to another—hospital to car to home to car to hospital. I'm tired. I am also a little edgy going into this particular rotation. While I'd done cardiac intensive care unit rotations as a second- and third-year resident, this is my first time there as a Fellow, which means carrying greater responsibility for decisions. This time, I'm more doctor than student.

A few words about Bayview. Among medical residents and Fellows, Bayview carries a certain stigma. Although it's actually a newer facility, in many ways with better technological equipment and good staff, these are details that traditionalists like to ignore because it feels like a community hospital—a satellite, and not a clone. If Hopkins is the headquarters, this is the branch office. A friend from my residency says, once you choose to train at Hopkins, you can find something wrong with just about anywhere else. We're taught state-of-the-art medicine by great attending physicians. We see the hospital ratings every year, and Hopkins keeps coming out on top. We go home exhausted every night, or morning, and figure the exhaustion was worth it. Our tolerance for anything else becomes low. We develop an elitist pride—exactly the kind of attitude that I don't want to have.

A practical difference between Hopkins “downtown” and Bayview is that many of Bayview's medical residents are just doing one year of internal medicine before going on to a different field, such as psychiatry, neurology, or ophthalmology. All of these specialties require a year of general internal medicine so that a psychiatrist can tell the difference between an anxiety attack and epilepsy. That's the good part. The downside is that part of my role as a CICU Fellow will be to make sure that, for example, the first-year psychiatry resident who correctly diagnoses a patient with mild depression doesn't happen to miss the patient's decompensated heart failure that is also present.

There's a sharp difference too in the way the patients are treated. Downtown, we are more aggressive about treating sick patients on non-ICU wards. We will move patients to the cardiac ICU when and if there is an emergency. At Bayview, the drill is to send the patient to the ICU first and ask questions later. As a Fellow on ICU, this can be frustrating when an ER doctor calls and says, “We're sending the patient to the ICU just to be safe….” If one always followed the just-to-be-safe rule, all patients could be sent to the ICU because, technically, it is never absolutely possible to predict everything that could go wrong. Instead, you have to apply your medical knowledge and make a reasoned judgment. The fact is, between “take everyone to the ICU” and “take only the sickest to the ICU,” there's probably an appropriate, wise middle ground.

Then there's the difference in patient population. Downtown is split between two extremes: international VIPs (Hollywood celebs, Wall Street moguls, Washington power brokers, European gentry, Saudi oil barons, coming to Hopkins for the best medicine) and the hospital's next-door neighbors (struggling families, single mothers, fatherless kids, drug sellers and users, urban casualties).

Bayview's constituency is somewhere between those two. The hospital is located geographically within the city limits, at the edge of Dundalk. It's a blue-collar/no-collar neighborhood, with a lot of second-generation Eastern Europeans, Poles, Greeks, Estonians, Latvians, Slavic diners and bars, and a Baltimore accent that can be almost unintelligible to outsiders. And that's a good description of one of my first Bayview patients a couple of weeks ago.

I'd been covering for another cardiology Fellow when I was asked to make the call on a larger-than-life character named Ray Jay. Ray was a forty-six-year-old, pony-tailed, busted-toothed contractor from the Highlandtown neighborhood. A heavy drinker and a red voter in a blue state, Ray cheered for the football team that he called the “Bawlamer Ravins.” After a typical Friday night of gambling, cigarettes, and a few lines of cocaine, Ray had decided to check in to Bayview because of “weird” chest pains—caution that was completely out of character for Ray, who later revealed that when he broke his arm, he didn't go to the hospital until the next day, when his arm was bright blue and wouldn't move.

But by the time he got to Bayview on Saturday morning, Ray could barely walk without leaning on the wall. His EKG was abnormal, and his cardiac enzymes were slightly elevated and still rising. Ray had been taken to the cath lab, where we had found a tight blockage in his right coronary artery. What now? A decision had to be made, and the cath attending and the cardiac ICU attending decided it was time for the Fellow—me—to step into the real world and make the call.

Given Ray Jay's personal habits—cigarettes, cocaine, and general machismo—monitors, medicines, and watchful waiting is the cautious option. A stent might save Ray from a bigger heart attack, but the patient must take medications every day to keep it open. And Ray didn't seem to be someone who always acted in his own best interests. But after a short conversation in my head, I decide to take a chance on Ray. I explained to him that a stent could fix the blockage, but if he doesn't take his aspirin and clopidogrel—platelet-suppressing medications—he could clot off the stent and the whole artery could shut down, potentially bringing on a massive heart attack. “If we stent you and you snort coke, you're going to die. I promise you. Your call, Ray.” He swears he'll be good. Of course, I wasn't sure whether to believe him. The cath team then stented him successfully. But for me, making the call myself was very different from observing and second-guessing someone else's decision.

Having met and treated Ray means that I feel as if I have a slightly better grip on this patient population. From the sixty-year-old former steelworker who has smoked two packs of Camels since the seventh grade to his reasonably healthy younger sister who eats a bag of Doritos every afternoon while watching her soaps, Bayview patients tend to be more of an American cliché. These patients come in with shortness of breath, or fluid in the lungs, or pain radiating down an arm, not because it's a world-famous hospital but because they're sick and Bayview is in their neighborhood.

The first week of cardiac ICU is stressful. After the initial day one, week one introductions to the nurses, techs, and attendings, the focus is on making rounds with the team, seeing patients, and getting used to the cardiac ICU routine. The nature of CICU is stress. Nothing unexpected may occur…but it could at any time—the stress of potential stress.

I spend most of my time working with the residents, figuring out their quirks and foibles, who's good, who might panic, and who won't. Every night a resident is on call. If it's one you trust, you sleep. If it's one you don't, you're up all night with the pager dilemma. As the CICU Fellow, a quiet pager can worry me as much as a loud one. “What if they don't know when to call me? What if they don't recognize they need help? What if they're not relaying critical information?” My job is to prep the residents so they don't panic, so they do page me when they should and (preferably) not when they shouldn't.

I want to be a good teacher, and I know that the best learning takes place in the urgency of the moment, not just by watching but by doing. And that is one of the stresses I'm managing—that intersection of teaching and urgency, or clinical treatment. This first week, that's the toughest challenge for me—seeing things that need to be done now, knowing I could do them fast and right, whether it's a femoral central line or a central line into the chest or neck, yet knowing I have a responsibility to try to pass the knowledge on to someone else, but without heightened risk to the patient. So, I teach. It's stressful.

The stress is compounded by the fact that I am trying to be the teacher I would like to have as well. My attending for the first week is an excellent practitioner, but not an excellent teacher. And attendings need to be both. They need to know how to talk without being pedantic; to keep us interested; to question; to tease out our curiosity; to encourage but not allow a wrong conclusion; to make the case intellectually challenging, a Rubik's Cube we can solve; and to create a tutorial learning atmosphere. This particular attending is all about detail—sometimes germane, sometimes not—and not a natural teacher. At the first case presentations, he almost immediately interrupts the resident during her or his presentation. Rather than cutting in to point out where the resident's assessment is off or to contribute a relevant fact, he delivers an expansive footnote on exactly what the resident was saying, a minilecture on a point already made. Interrupting at the right time can be a great teaching technique. At the wrong time, it stops the momentum and undermines trust. Ideally, the residents should work their way through the potential scenarios, and find the answers on their own if possible—with the Fellow guiding and the attending providing an invisible safety net.

Still, letting the residents find their own way doesn't always pan out, as I learn after working with Pat. She's going to be a psychiatrist—and probably a good one, because she displays empathy, is smart, and can deal with me at my most impatient. One day, Pat tells me that she wants to learn to put in a central line. A central line (that is, a central venous line, also known as a central venous catheter, or CVC) is a catheter put into a large vein in the neck, chest, or groin, used to administer medication (such as vasopressors to treat critical hypotension), to get blood for tests, or to determine central venous pressure. Even with a topical anesthetic, the insertion can be painful. Wanting to learn such a delicate procedure is good, but on the other hand, it's unlikely that Pat will ever have to do it again in her career. There is a real, live patient who needs one. I've put in many CVCs, and in most situations, I can insert one in minutes. Pat is going to have to know all about compulsive behavior, Oedipal complexes, anxiety, schizophrenia, and bipolar disorder. But after this year, she'll never have to put a venous catheter into someone's neck. Am I doing the patient a disservice if I allow her to do this one? Would I want my mother to have a central line put in by a psychiatrist in training?

Still, I want to be a good teacher. Pat and I spend forty-five minutes setting everything up, prepping the patient, me prepping Pat. We even step outside the room for a rehearsal because I don't want the patient to hear me whispering instructions—“Okay, the next step is…”—and wonder, “Am I a lab rat?” I can't let Pat flail around, just bruising the patient's neck, and I need to give her a reasonable amount of time in which to try, whatever that means. How far should I let her go before stepping in? I wonder, why couldn't she say, “Hey, I'm going to be a shrink. You do it and I'll watch”? But she didn't. She asked to do it. And I don't want the lesson to be, “Don't bother to learn outside of your field.” Instead, I find myself just wishing she weren't so earnestly interested.

We're gowned, in the room; the patient is comfortable that two good doctors are at his bedside, and I'm guiding Pat through it. To her credit, she's not too aggressive, the unintended by-product of overenthusiasm, and she's not too tentative, the result of first-time trepidation. So far, so good. But despite following the ultrasound pictures, she can't seem to get the needle into the blood vessel. I flex my fingers as if I had the line in them. I lean in, clench my teeth, and mimic the gesture of putting the line in. After her second and third attempts, I try hard not to say “No, let me.” I have to loosen my grip on the reins. It isn't easy. But I know that others did so for me, and stay quiet.

The patient doesn't know there's a problem, but Pat does. After about twenty minutes, my mental time clock runs out. Calmly, professionally, so that the patient remains unalarmed, I say, “I'll take it from here,” which is academic code for “You're done. Give me the f—ing needle.”

Within forty-five seconds, I have the needle in the vessel, the wire threaded, the catheter inserted along the guide wire, and the central line in—a relief. You don't want to take over and then struggle while the resident watches, nor do you want the patient to be the victim of two fumbled tries. (But you do mentally rehearse the failure speech to the resident, just in case. “This one was tougher than it looked….” And you hope the resident doesn't think you're a pompous jerk. There are already enough of them in medicine.)

I can tell that Pat feels lousy. On the way out, I pull her aside and reassure her: “You did everything right. Your technique was good. Your pace was good. It was bad luck more than anything. It gets easier with time.” I want her to feel better, but at best, she's going to feel less lousy. And she's probably not going to get better at it with time; she won't get enough practice. Having a basic understanding helps her as a doctor, no matter her specialty, to see the procedure in action, to know what it is, how it works, and when it's called for…just in case. But the reality is that she doesn't have to be good at doing it.

The next day, it's the end of week one. We do case presentations again, and again, the attending interrupts with minutiae. I think about how I've been teaching, how I've tried to be tolerant and gentle. I tried not to overlecture. But when I have to decide between letting the student fly the plane and taking the controls, I hear myself saying to Pat what I never wanted to hear as a student: “I'll take it from here.” Is my approach better than the attending's or just different?

Fortunately, I am working with a different attending during the second week, Dr. Martin. I had worked with him for a few days back when I was a resident, so I know that he is a good diagnostician and clinician. Unusually, he also has a PhD in economics: While practicing cardiology full-time, he went to grad school at night because of his interest in health policy and the healthcare system as it relates to socioeconomic issues. And Dr. Martin has another intangible going for him: He's effortlessly cool. He doesn't try to seem young or hip; he's just a naturally appealing guy who is happy with himself and what he does every day—practice cardiology exceptionally well.