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and is an avid gardener.
    I ask the surgical team to order an echo (done by the in-house tech). The ultrasound can reveal critical information about what region of Midge’s heart might be injured. If Midge has a new blockage or clot resulting in a decreased blood supply, then a part of the heart wall wouldn’t work as well and the ultrasound would indicate that. From that standpoint, her echo images are reassuring, showing the heart squeezing as it should. I also ask the surgical team to check cardiac enzyme levels every six hours, since a blockage or clot can also cause enzymes to leak into the bloodstream. A day later, the results come in: Midge’s cardiac enzyme levels were mildly elevated but fortunately now seem to be trending down.
    This news is good but not definitive, and the surgical resident needs a conclusion. I explain that I do not think Midge is having a heart attack, but rather is experiencing postoperative cardiac stress. For the time being, all we should do is keep a careful eye on Midge.
    Over the next several days, the immediate evidence seems to confirm my judgment. It turns out that pneumonia was the likely stressor. When I visit Midge later, she is no longer hooked up to as many tubes and monitors and, now surrounded by her daughter and grandchildren, appears the image of a strong, resilient matriarch. Although Midge later develops other complications, which require two more trips to the operating room, her heart functions well under the strain. I had made the right call: Because she was never put on blood thinners—as she would have been if there had been a clot or blockage—she was able to have these surgeries without additional risk.
    I survived my first real test. Unfortunately, Midge has a particularly awful form of liver cancer. Statistics say she has only eighteen to twenty-four months to live. Even though I made the right call, and even though we fixed the heart problem, we cannot fix the cancer. It’s not a victory—just a delay.
    My attending, Dr. George, is a reassuring, hands-on mentor, who guides me through each case and outcome, including this one, showing me what I did right and what could have been done better. He’s always there with the safety net, just in case. Working with Dr. George, I feel as if I’m doing well, although I see so little of the other Fellows that I have no point of comparison (as is usual in fellowship).
    Weeks three and four are another story. My new attending is Dr. John, a sharp contrast to Dr. George; his approach is to let me find my way. I’m on my own, almost being dared to fail. Over the next two weeks, I see patients throughout all parts of the hospital—as many as six or eight a day. Each time my pager beeps, I run a mental drill of what I will do: Take a deep breath, clear my mind, and then call the doctor back (urologist, surgeon, gynecologist, ENT [ear, nose, and throat] specialist). I listen to the case, ask key questions, and examine the patient. Then I process all the information and determine the next steps in diagnosis and/or treatment. But before implementing a plan, I call Dr. John, who listens to my summary as if he were preoccupied with something else, waits for my assessment, then grunts “Uh-huh,” and hangs up. His near silence is his form of approval. Working with Dr. John is cardiology without training wheels.
    Case after case after case: I’m on a roll. A woman coming out of labor with a fast heart rate. A young man with a drop in blood pressure after a bowel resection. Several elderly patients with swelling that might be due to congestive heart failure. The closest Dr. John comes to “input” is one case in which I conclude that the patient’s post-op arrhythmias warranted a transfer to the cardiac intensive care unit. This time, I’m surprised to hear him say “You sure?” I double-check the data and realize that I
am
sure, and go ahead with the transfer.
    It’s my last week on cardiology consults when I am called by