Alpha Docs: The Making of a Cardiologist

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CARDIOVASCULAR FELLOWSHIP

The Match Process with a Twist

July, one year later. I’m standing outside Johns Hopkins again, at an hour when most people are heading home from work, about to begin the first rotation of my cardiovascular training. Each rotation is an immersion in a subspecialty. Most run four weeks, some two, some repeat with two segments. By the end of the fellowship, not only are you supposed to be educated and proficient in every area, but it’s assumed that you’ll know what kind of heart doctor you’d like to be. Will you go to work in interventional cardiology, with caths and stents? Will you end up reading stress test films in nuclear? Will you be in preventive, changing patient lifestyles, or working in the more dramatic area of transplant? Fellowship is a countdown to yet another decision day.

Unlike residency, which is a form of group learning, fellowship builds individual relationships, one Fellow working closely with one or two attendings on each rotation. And unlike residency, the other Fellows aren’t likely to become our friends and surrogate family. We’ll see one another only occasionally, in meetings, in hallways, at a case conference.

Still, we’d all briefly met and sized one another up yesterday, during the cardiology fellowship orientation. Clasping our packets of information about the basics of parking, health insurance, campus map, phone numbers—­papers we’ll likely never look at again—­we had smiled and shared small chuckles about our contracts. These papers state our salaries, benefits, et cetera, and we’re supposed to read and sign them. The fact is, there’s no reason to. We’ve been winnowed from thousands to hundreds to nine. We all want to be Hopkins cardiologists. We’ve already signed up for this deal.

Rotation order is mostly random, but sometimes the faculty can change it up and make judgment calls. I’m starting with cardiology consults, considered one of the most demanding rotations of all. I won’t have total medical responsibility for any of the patients, but I will have cardiac responsibility for patients whose issues can range from a routine inquiry on the dosage of a beta-­blocker to a postsurgical weekend jock who goes into cardiac arrest in recovery. I’m pretty sure I got consults first because of a Hopkins prejudice—­that a Hopkins-­trained resident is more ready for trial by fire. We know our way around the hospital, and that’s no small thing whether you’re looking for the SICU (surgical intensive care unit) or a bathroom. Other than that, the biggest difference between me today and me two days ago as a senior resident is the word Fellow stitched above my name on my white coat.

I look up at the dome on the roof of the old hospital building, the icon that says, “This is Hopkins—­the best,” and think back on how I got here. I’m almost thirty years old, pursuing a career that often feels like a distant mirage: No matter how close I get, it always seems a little further away, and when I haven’t slept for thirty-­six hours, I wonder if my profession will ever start or if I’ll forever be “in training.” I went to Princeton for four years, Johns Hopkins Medical School for four years, interrupted by a year at Harvard for a master’s in public administration, then a Hopkins residency in internal medicine for three years, and now a Hopkins cardiovascular fellowship for three or four more years. Plenty of doctors choose not to do a fellowship in a subspecialty. After years of training, and after seeing their peers rise through the ranks in nonmedical professions, they want to get started. Many of my friends have earned hundreds of thousands of dollars in the time I’ve run up loans for nearly as much. But, after the impact on me of the events with Randy, I knew I wanted to keep going, to extend my training and pursue a fellowship in cardiology.

That meant entering the annual “match” last year. The match is the computer-­assisted mating dance, which narrows applicant pools to on-­site interviews before assessing the ranked preferences of the final applicants and the programs. Acceptance is based on a combination of clinical work during residency, evaluations of residency attending staff, research the candidate may have done, and a personal statement, the closest thing to a wild card or tiebreaker—­what you’ve done that could set you apart from the hundreds of overachievers vying for the same few slots.

There is something called the rule of 10 in selection processes. It maintains that being chosen gets exponentially harder each time you take another step up the ladder, whether it’s from the county beauty pageant to the state pageant, or from a high school team to Division I. If getting into the most selective colleges, on a 1-­to-­10 scale, is 10, then getting into the best graduate or medical schools is 10 × 10, and getting into the best residency is 10 × 100, and getting into the most selective fellowship is 10 × 1,000, or 1 in 10,000.

I still remember my interview day at Hopkins. After all the applicants were treated to an ironically high-­cholesterol breakfast spread, Dr. Fitzgerald—­the head of the program—­walked in. He not only knew all of our names and where we went to school, but he created a story, in one endless sentence, weaving in our individual interests, hometowns, talents, siblings, foibles, everything. “Sara, we’re glad you were able to travel all the way from Barcelona, especially since you’d probably rather be helicopter-­skiing in the Andes, which Amit could appreciate, having just returned from Pakistan’s K-­2 summit, which he first climbed as an undergrad at Oxford, coincidentally where Maya studied Old English poetry before switching to premed (our gain, their loss), and the same could be said about Dan since he’s divided his time between medicine and Washington health policy for the past three years, a far cry from Raj, who locked himself in a room to finish a book about . . .”

It was more than an entertaining performance or a stroking of our young egos. It also sent a message: “We know you. We put time into this because we will put time into you. Of all the candidates, we think you will become the best cardiologists if you come to Johns Hopkins.”

After a tour of the facility came the individual interviews with faculty members, each a medical version of a police interrogation. Where’d you grow up? Play sports? Travel? Where’d you go to college? I see you had a rocky year first year of med school. What happened? Too demanding? Why do you want to be a cardiologist? Why Hopkins? What makes you think you can make it here?

I went on nine of those tours and interviews: Johns Hopkins, Brigham and Women’s Hospital (Harvard), University of California at San Francisco, Duke, Northwestern, Columbia, Penn, University of Virginia, University of Maryland. Then I submitted my order of preference to The Match process and the institutions did likewise—­and where the two rankings intersect, the matches would be made . . . all very objectively, very algorithmically.

But not always. Sometimes, institutions can unofficially make direct human contact with candidates to signal their feelings.

I had one of those conversations when the same Dr. Fitzgerald asked me to stop by his office. One of his tasks was to target two or three Hopkins residents to stay at Hopkins for their cardiology fellowships. He was very up front with me: “Dan, you’re at the top of our list for the cardiology fellowship program.” I was a little stunned. I’d hoped to match with Hopkins, but “the top of the list”? It wasn’t easy to tell him I’d mentally ranked Hopkins and Harvard in a tie for first place, but I did. He said he respected my thinking, told me to take my time and then decide. In other words, come to Hopkins.

A couple of days later, I got virtually the same call from Harvard. Choosing between these two was a great problem to have, but not one I could share. Hopkins? Harvard? No one would sympathize. In the end, I made a rational-­emotional decision. I’d chosen to become a cardiologist that day with Randy at Hopkins; Hopkins is where I’d see it through.

I called Dr. Fitzgerald and told him. He didn’t seem surprised.

That was December. Now here I am.

I walk back inside. It’s five o’clock. As of this moment, the system considers me a cardiologist. After all, I have a white coat that says so.