I will be a cardiologist with a subspecialty in resilience

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I am writing this as I lay in bed, feverish, sweaty, and persistent dry cough. I have been sick with presumed COVID-19 for the past ten days. I have quarantined myself from my wife and two sons, unable to hug or reassure them that everything will be okay. Additionally, my wife is 39 weeks pregnant. Therefore, I will be unable to accompany her in the delivery room and may not even be able to stay home when the baby leaves the hospital. There is tremendous uncertainty for me personally, medically, and professionally. This overwhelming doubt is the sole subject of my thoughts, yielding a vicious cycle of rumination, introspection, and hopelessness.

As an internal medicine resident in New York City, the epicenter of the current COVID-19 pandemic, I am constantly in awe of the immense sacrifice and bravery exhibited by my colleagues. We are truly on the front lines of this pandemic — a war with a microscopic enemy — and we are the foot soldiers.

When I began feeling ill, I realized how much is still unknown about this threat, and as a physician, I have never felt more helpless. “The virus affects everyone differently, stay home, monitor for any shortness of breath.” I kept hearing this same advice over and over. I have seen patients in their 30s without significant medical conditions on ventilators. What makes them different from me? My wife would come into my room in the middle of the night to make sure I was still breathing, worried that I would be one of the many that developed life-threatening shortness of breath. There is thus far no clinical evidence of documented cure or treatment. I did not take azithromycin or hydroxychloroquine based on the recommendations of my mentors. My only medicine was Tylenol, tea, and television.

Last night, my wife abruptly came to the room I was in and said, “I am having contractions. What should I do?” I froze. I knew I could not help her, and her mother lives more than an hour away. With that said, how do we know her mother is not an asymptomatic carrier? What if my sons are carriers, are they not allowed to touch their new baby brother? We still do not truly know how COVID-19 affects newborns. What if my wife is positive? How would that affect the pregnancy and eventual delivery? Thankfully, she did not have true labor, but that “false alarm” raised many additional questions that deepened our anguish.

In addition to my personal and medical dilemmas, my professional obligations add another layer of complexity to my universe of uncertainty. I will hopefully be allowed to return to work shortly. However, most of our clinical volume revolves around COVID-19.

Everything else, honestly, seems trivial in comparison. Our morning report and clinical conferences have either been moved online or canceled, and our subspecialty rotations have essentially been dissolved.

Everyone is now a COVID-19 generalist.

Most of my classmates have stopped studying for our upcoming internal medicine board exam because they are physically and/or emotionally burned-out, and believe it is pointless to study nuance when we are literally at war.

We have no idea how long this pandemic is going to last, or whether it will decline substantially and re-emerge in the fall. Even though I will be starting my cardiology fellowship in July, will I truly be a cardiologist or an advanced generalist?

The cardiac care unit (CCU) is now a COVID-19 unit. The procedural and imaging volumes have declined significantly, and therefore, there is less opportunity to learn cardiology. If this pandemic lasts another year, will our general fellowships be extended accordingly, as most of that year will almost surely be diluted?

I wonder if cardiology program directors have started thinking about the educational ramifications of this pandemic on incoming fellows as they are preoccupied with the current crisis and the redeployment of their current trainees. Most fellowships have an introductory clinical series, sometimes referred to as a “boot camp,” where core principles and procedures are taught. These procedures include essential fellow tasks such as: echocardiography, transvenous pacemaker and Swan-Ganz catheter insertion, and troubleshooting Impellas and intra-aortic balloon pumps.

What will the “boot camp” look like in this age of social distancing? Lectures could be easily moved online. However, procedural training would be difficult to effectively accomplish remotely. Furthermore, the best training that a resident or fellow can receive is “learning by doing.” How can a cardiology fellow truly practice if there is not a fully-functioning CCU?

The world is changing quickly in the face of this threat. And graduate medical education, as well as medicine as a whole, will never be the same. I discussed this very issue with one of the senior cardiologists at my hospital, whose response alleviated many of my concerns. He stated that he did not know what the future had in store for us, but that he goes to work every day with new-found energy and enthusiasm. He said, “Medicine is not a career; it is deeply personal.”

Honestly, it is a calling. For the past 25 years, I have been doing what I love, but in a sub-specialized silo. We have the opportunity now to drop our labels and just be physicians caring for the sick at the bedside. This is what we went to medical school for. We must battle this together. I am privileged and proud to be in the position to fight.”

Even though many of my questions have no answers currently, I am privileged to be part of such a selfless community of caregivers. I realize that my personal, medical, and professional lives are not actually disparate, and that uncertainty is a foe best faced as a team. Many of us may be burned-out and sick, but this is a time we will never forget. No one knows what will happen next, but I am not alone. I will be a cardiologist with a subspecialty in resilience.

Solomon Bienstock is an internal medicine resident.

Image credit: Shutterstock.com

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