by DANIEL MUÑOZ
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.
5
FELLOWS’ CASE CONFERENCE
My Turn
It’s my second day back, my case conference day, a command performance, Johns Hopkins–style, before my peers and my superiors.
In front of me are thirty-five impressive/intimidating doctors in a space that comfortably accommodates fifteen people. This room is normally a combination of meeting room and cafeteria, and it is littered with old paperbacks, empty soda cans, and worn chairs around a battered table. But on Wednesday mornings, it is also the conference room for the Fellows’ case conference—and today is my day to present.
The conferences are ongoing teaching sessions through the first two years of the cardiology program in which one Fellow discusses a case with the other Fellows and the cardiology faculty. The conference begins with a twenty- to thirty-minute presentation of the case, including the patient’s history, his or her EKG, test results, et cetera. Then come the questions about the patient’s history, symptoms, tests—the whole gamut. The attendings ask and field most of the questions. Opinions fly, sometimes flaring into spirited disagreement. The presenter has to steer the conversation toward a consensus on critical factors, course of action, and prognosis. Meanwhile, since the Fellows are there to listen and learn, both the Fellows and the attending staff are scrutinizing the presenter, judging the case selection, the presenter’s understanding, and his or her diagnosis. It’s billed as a discussion, but you want to look smart, be prepared, and not wing it.
As soon as the case conference dates are set—mine was the second of all the Fellows—you start to consider each patient you meet as a potential candidate for the presentation. Is this case sufficiently interesting? Sufficiently puzzling? Sufficiently multidimensional to generate an hour’s worth of discussion? Conferences are clearly the academic, esoteric side of medicine, in contrast to the pragmatic, deliver-basic-care-to-people-who-need-it-now side I’d witnessed during my time in Colombia. Sometimes I have to remind myself that the academic is what leads to better delivery of the pragmatic.
For faculty, attendance is optional, determined by the particular case and its relevance to their subspecialties within cardiology. For Fellows, attendance is “encouraged but not mandatory.” My being the second and not the first to present turned out to be significant. At the first case, most of the attendings showed up, but only four Fellows did. Dr. Quincy, who oversees the conferences, wasn’t pleased and sent a none-too-subtle email to everyone explaining that when attendance is “encouraged but not mandatory,” it means “Be there.”
So here we are—room packed.
—
The case I chose was that of Mr. Zell, a thirty-six-year-old man recently diagnosed with a serious case of acute lymphoblastic leukemia and currently undergoing chemotherapy treatment. At the tim
e, I was on the cardiology consult rotation, and I was asked to see him because a recent CT (computed tomography) scan indicated there was excess fluid around his heart; he was having difficulty breathing, and his heart rate was increasing. We’d first met on a Friday afternoon in a private room at the oncology center. Mr. Zell had his laptop open, his television on, and he was talking on his cell phone via Bluetooth, like someone in a private airline lounge at an airport. This is a surprisingly standard scene in oncology; refusing to give up the routines and diversions of their daily life, whether work or social media, is one way many patients deal with a devastating diagnosis.
The first thing I observed about Mr. Zell was how fast he was breathing. Lying in bed, doing nothing but tapping computer keys, he was huffing and puffing thirty-five times a minute, nearly double the normal respiratory rate. There were several possible reasons for his breathing difficulties: Does he have pneumonia? Does he have a blood clot in his lungs (a pulmonary embolism)? Does he have congestive heart failure? Does he have excess fluid in the sac that surrounds his heart? Finding the primary culprit was critical: Excess fluid around the heart can be extremely dangerous because it creates pressure on the heart. Enough fluid and the heart chambers can collapse, like what divers’ lungs face in deep, pressurized water. With this in mind, I had one of the echo techs set Mr. Zell up for an echocardiogram, the ultrasound procedure that would reveal whether the fluid was compressing the heart, and force us toward a decision point: Should we go in with a needle and take the fluid out? And if so, should we do it immediately or should we wait? If the patient’s heart rate or blood pressure drops precipitously, or if the patient is unstable or “coding,” the answer is clearly “immediately.” But when the patient’s condition is less obviously dire, there is a chance that the problem might stabilize, or even slowly improve on its own. If there’s any reasonable chance that things will get better without intervention, it’s preferable to sidestep the risk of an invasive procedure, especially in a patient whose immune system and blood cell counts have been weakened by chemotherapy. With his body’s defenses in a compromised state, Mr. Zell would be at higher risk of developing an infection from any invasive procedure. But waiting can be risky, since waiting itself can eventually precipitate an emergency, and any procedure that has the word emergency as a modifier is inherently more risky.
By Friday evening, the tech has performed the ultrasound. Mr. Zell’s heart already shows signs of early collapse in the right-sided heart chambers, the right atrium and right ventricle. It’s not an official emergency yet, but I don’t see the situation getting better. The problem appears to be chemo-related, but Mr. Zell needs the chemotherapy for the cancer. I write up my impressions and present them to Dr. George, and he agrees. Sooner or later, Mr. Zell needs to have this fluid drained, and we don’t want to wait until he “crumps”—medical slang for “fail fast.”
Dr. George and I go to see Mr. Zell, now with his wife at his bedside. There seems to be some sort of traditional machismo in play, as Mr. Zell is still insisting that he’s “fine” despite his constant gasping and panting. We explain to him that his condition is not life-threatening at this moment but that it could be soon. “The chemotherapy, which you have to have for your cancer, is the most likely cause of the fluid accumulation around your heart. It won’t get better on its own. We think it’s time to consider having the fluid drained.” We carefully explain the procedure—pericardiocentesis—which involves inserting a long needle through the chest wall, into the pericardium, or sac that surrounds the heart muscle, and then withdrawing fluid from the pericardial sac until the pressure is relieved. Mr. Zell listens calmly, as if we were suggesting it might be time to get a haircut.
After we finish, he says, “I’ll wait.” We’re stunned. Dr. George says, “Our recommendation is to do it today, but we can watch you closely to try to avoid this becoming an emergency.” Mr. Zell nods and we exit.
But his wife follows us out of the room, saying, “Is it dangerous?” Is she asking whether his condition is dangerous or whether the procedure is? Or both? If she’s like most people, Mrs. Zell heard “long needle,” “through the chest wall,” “into the heart muscle”—and it sounded dangerous. In fact, it’s not a needle into the heart; the interventional cardiology team uses ultrasound and X-ray guidance to place the needle into the sac around the heart, an important distinction in terms of potential harm. The procedure carries risk, but it’s often done without incident in the cath lab, where the team watches every second of the needle’s insertion on a monitor to make sure that the needle’s path steers clear of the heart itself. But in an emergency, the pericardiocentesis can be done at the patient’s bedside, and we have to go in “anatomically”—which means that the team is aiming for the fluid collection without the video assistance of ultrasound or X rays. Mr. Zell’s decision to delay potentially makes his situation more dangerous.
Saturday passes. Before I go home, I find the intern on call and tell him to check on Mr. Zell throughout the night and alert me if anything occurs. The intern’s reaction is to wonder why anyone of sound thinking would wait. I can’t help but agree—I’m fully prepared to get a 2:00 a.m. page that reads, “Mr. Zell is crumping.”
But when I return to the hospital on Sunday, it seems that Mr. Zell has changed his mind and is ready to have the procedure. Maybe he saw the light. Maybe his wife convinced him. Maybe he felt worse. Or maybe being asked “Are you okay?” every few minutes by a nervous intern on call rattled him. Nothing does more to convince you that you’re not okay than someone constantly asking if you are.
I show both the “before” and “after” echocardiograms at the case conference. I want my audience’s opinions as to whether Mr. Zell’s heart chambers were in partial (i.e., early) collapse or full (i.e., more advanced) collapse. Neither answer is great, but one is definitely worse. Then, depending on their conclusions, what would they have done? Would they have pushed as hard or harder to tap him earlier? Would they have labeled it an emergency? Was the fluid around the heart the direct result of the chemo? Would they have presented the situation differently to Mr. and Mrs. Zell?
As I lay out the facts of the case, I am nervously trying to gauge the reaction of my audience. Basically, there are two nightmare scenarios for a case conference: Nightmare A is when you present to total silence, not because you’ve stunned the listeners with your brilliance but because your case is so obvious that there’s nothing to discuss. In that nightmare, one of the attendings says, “Simple, straightforward, and no reason to be here at this early hour.” Nightmare B also ends in silence, but this time it’s because your case is a statistical outlier, highly unlikely to recur, and therefore of little or no value. In that version, one of the attendings says, “Fascinating. Ellis–van Creveld syndrome, traced to a rare autosomal recessive trait, found in Amish people, resulting in atrial septal defects, sometimes manifesting in extra digits and dwarfism. That should be very helpful should a case come along again in this century.”
I open the discussion by fielding questions from some of the Fellows, and then the faculty members weigh in. After scrutinizing the films, some faculty members see this as an open-and-shut case—the procedure should have been done immediately. Others think you could make a case, albeit a thin one, for waiting. The nuances of reading the films have proved, once again, that these tests are not yes/no data points but rather pictures subject to interpretation. What is “collapsed” to one set of eyes is “almost collapsed” to another. What is “a lot of fluid” to one expert is “too much fluid” to another. What constitutes an emergency is sometimes a matter of opinion. It is our job to make the subjective as objective as possible, to try to turn art into science—but even a roomful of experts cannot always reach a consensus.
Still, there is widespread agreement that we gave the patient and his wife an accurate picture of the situation and, if anything, would have been justified in being more dramatic. Success: The attendings and the Fellows believe that th
e case was handled appropriately. One attending even cracks that the patient’s denial reminds him of the scene in Monty Python and the Holy Grail where the Black Knight has limb after limb hacked off by King Arthur in a duel. Even when the knight is nothing but a head and a torso on the ground, he still insists, “It’s just a flesh wound!”
We all laugh, and the group files out. Good questions. Good answers. No nightmare scenarios. I survived. Then I remember Colombia and the conversations I had with myself on priorities and realities. In the real world, no one cares about your who’s-smarter-than-who meetings or fancy credentials or elite hospitals, only about being sick and finding someone to help you get better. Yes, I made it through Fellows’ case conference, but what about Mr. Zell, his cancer, and the fluid around his heart? Whose outcome is important here? A Fellow’s or the patient’s? How do I keep my perspective as I continue through more rotations, more training, and ultimately more years of practice?