By: Alan S. Tenerife, M.D. (Class 1998)
Posted: January 2, 2007

     I wrote this a few days after our recent graduation ceremony at UP-PGH. For all graduating fellows, it was the price of hard-earned work marking the transition from a trainee to a consultant. While a fellow works under the watchful eyes of his consultants, he now has to depend on his own knowledge and experience to make rational decisions for his patients. He also assumes the role of a teacher to younger aspiring doctors.

     Three years ago, I was a young internist starting a medical practice. Confident and idealistic, I felt that I could cure the world. But even then , I felt that something was still lacking. Knowledge and experience are endless pursuits and I was thirsting for more. Further training would take a few more years and many established practitioners had already scrambled at the opportunity of going abroad. Was I going in the right direction? I wrestled with the thought for several weeks.

     I thought of my Mom whose years were cut short by heart disease. Maybe it was a big factor that helped me decide. But more importantly, it was my love for cardiology that made me pursue fellowship. Since residency, I’ve seen the most exciting cases in cardiology. It was always physically and emotionally taxing – “toxic” as most doctors would term it, but the self-fulfillment of cardioverting a malignant arrhythmia to sinus rhythm, decongesting a patient with pulmonary edema or reversing a cardiogenic shock always kept me on high.

     Thus, I started my journey to be a cardiologist. Every arduous day was a struggle to cope with the demands of never-ending rounds, conferences, and other clinical tasks. Our patients came from all walks of life, but most were indigents who more often were already “toxic” before they sought medical attention. For the next three years I was preoccupied with clogged coronaries, scarred valves, and heart failure. And as any young cardiologist will soon realize, behind the murmur that he often encounters is a frightened soul shattered by some of life’s most brutal truths - the soon-to-be mother with congestion from mitral stenosis or the father with a massive myocardial infarct whose life and family’s future hangs in the balance.

     For the budding cardiologist, much is learned at the bedside. Countless of hours is spent listening to a patient’s story and formulating differential diagnoses even before his stethoscope touches the chest. Then he listens to the heart and hears the various murmurs – the harsh sound of a scarred stenotic valve or the swooshing sound of a regurgitant jet. The fellow then interprets hundreds of ECGs per week until it becomes almost a second nature to him. He turns his attention to echocardiography and soon marvels at the images of a dilated cardiomyopathic heart, a ventricular aneurysm or a massive pericardial effusion with tamponade.

     In his senior years, a fellow is exposed to the more invasive world of interventional cardiology. He assists in performing coronary angiograms, angioplasties and stenting , balloon valvuloplasties, and permanent pacemaker insertions. By that time he is also adept at inserting a temporary pacer or a central line and doing a pericardiocentesis . He likewise plays a dynamic role in the postoperative care of open-heart surgery patients. His sphere of interest covers almost every aspect of medicine such as strokes, lipids, blood dyscrasias, hypercoagulable states, and immunologic entities like vasculitis affecting the entire cardiovascular system. If a fellow is patient enough , studies and works hard enough , he will be a cardiologist.

     But more than the textbooks and mentorship of consultants, the many patients I’ve seen for the past years have taught me what I needed to know. I remember one of my most toxic patients in first year: a mother in her 50’s who was admitted for unstable angina and was having severe, persistent chest pains despite maximal medical therapy . Her angiogram revealed severe multivessel coronary stenoses necessitating urgent coronary artery bypass graft surgery (CABG). However, she couldn’t afford it so I had to present her case in our preoperative conference and convince the consultant cardiologists and surgeons that she needed urgent surgery and financial assistance. Fortunately, she was granted full assistance on that same day. An intraaortic balloon pump was inserted followed by CABG. Weeks later, I saw her at the clinic and her warm smile showed that everything was okay.

     Mrs. E was a 70-year old woman who developed myocardial infarction and stroke on the same admission. She developed cardiogenic shock and sensorial changes. Almost all my co-fellows and consultants were involved in her case in one way or another. Though her coronary anatomy necessitated bypass surgery, she was deemed too high risk considering the multiple associated stenoses in her cerebral circulation. After several consultations with interventionists and neurologists it was decided that she was better off undergoing stenting of her left internal carotid artery and left anterior descending and circumflex coronary arteries. I thought we were losing her, but after several more weeks of medical care, she was discharged improved. Last week as I saw her coming to the clinic on her own for the nth time, I spent most of the time recounting to her how she miraculously survived that ordeal three years ago.

     Mr. I brings to mind the wonders of medical therapy for heart disease. He presented with heart failure symptoms and on work-up was noted to have 3-vessel coronary artery disease and severe mitral regurgitation. Because his left ventricular function was already very poor , he was not amenable for surgery. For the next several months, I had to draw every evidence-based therapy to control his failure symptoms. To this day he has gained healthy weight and has marked improvement in functional capacity.

     I mentioned these cases because they remind me of some of the best memories I have of my fellowship and they inspire me to go on knowing that I have been an instrument in God’s healing grace. Fellowship had been a grueling and humbling experience with the seemingly endless duties and responsibilities and the realization that much is still there to be learned. But every effort was worth it because I know that any small good deed can make a big difference in other people’s lives.

Feedback: comment on this article at the Forum (registration required) e-mail the author at alan_tenerife_md@yahoo.com