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the trauma surgery team to see a fifty-two-year-old man, Mr. Rosen, who has been brought in by ambulance following a car accident. After his lacerations are cleaned, Mr. Rosen reports feeling chest pain. His EKG looks normal, apart from a couple of small vagaries. The trauma team is worried about acute coronary syndrome, which is a catchall for clinical symptoms of acute myocardial ischemia (insufficient blood supply to the heart), which can come in varying degrees of severity.
    On my way to the ER, I call Dr. John with a run-through of the case. He says, “Tell me how it goes afterward.” He doesn’t ask anything more about the patient’s condition. He doesn’t ask for my take on the situation. He doesn’t tell me to call if I have a question. He just assumes I’ll know what to do…or I’ll call if I need him.
    In the ER, I check on Mr. Rosen’s electrocardiogram. It appears to be normal, which is reassuring—the “vagaries” don’t mean anything unless there are other indicators. I examine Mr. Rosen and see no signs of congestive heart failure, no fluid backing up into his lungs.
    What he does have is profound wheezing, very labored breathing. I look at his X ray with the surgeons: no punctured lung, no obvious fractures, no evidence of pneumonia. The one notable finding is the degree to which his lungs are hyperinflated (expanded), a telltale sign of a smoker’s lungs or COPD (chronic obstructive pulmonary disease), most commonly known as emphysema. I decide to administer steroids and a series of nebulizer breathing treatments. Mr. Rosen relaxes, and his breathing and chest pain get better. I report this to Dr. John. He grunts his “Uh-huh.”
    I did this cardiac consult solo, and it went fine: It turned out that Mr. Rosen’s possible angina was just a breathing issue related to smoking. The Dr. John method worked. That night I find myself thinking about which attending’s style is better—hands-on or hands-off. The answers, for patients or for young doctors, are almost diametrically opposite. Before this rotation, I would have said the hands-on method is better, the safety net for patients being obvious. But then doctors such as me would never learn to do what we have to do. And now that I’ve succeeded without a net, I realize that maybe a little fear is a good thing. For learning, anyway.
    Perhaps the net was there all along—I just didn’t see it. And because I didn’t see it, I learned to rely on myself, to trust my judgment even when Dr. John second-guessed me. Maybe Dr. John knew that I could push myself further and handle the pressure. Maybe. But doesn’t a patient deserve more than a young cardiology Fellow hoping that he or she has made the right call? It’s a trade-off, teaching versus treating. The answer is clear. You have to teach…but, as popularly paraphrased from the Hippocratic oath,
first, do no harm.
    Okay, I’ve made it through cardiac consults—an onslaught of cases, questions, diagnoses, and decisions, almost eight weeks of hours packed into four—a total immersion. Still, I am no closer to knowing what kind of cardiologist I will be, but, I rationalize, this is only the first rotation. And I’m learning some key lessons—how to perform an ultrasound, to “consult” on what may or may not be cardiac issues and know the difference, to trust my instincts a little more each day, and, as in the case of Midge, accept that even when we win a heart battle, sometimes another illness trumps and we lose the war.

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ROTATION: NUCLEAR MEDICINE, PART I
Anything “Nuclear” Sounds Impressive
    My next rotation is in nuclear medicine, which sounds impressive but just means reading stress tests. And even “stress tests” sounds more impressive than the reality: putting people on treadmills to see how fast and far they can go without pain. These tests are prescribed for patients who might have abnormal blood supply (ischemic heart disease) or who need a prognosis for recovery from a