The Cave: Reflections on Nephrology Fellowship

  • 1 Nissreen Elfadawy, MD, FASN, is assistant professor, Case Western Reserve University, and a nephrologist with University Hospitals, in Cleveland, Ohio.
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Nissreen Elfadawy

Citation: Kidney News 12, 2

I recently started practicing nephrology and wish to share a few reflections.

To start, when I am going about my duties during the week, I often begin thinking about my fellowship. My heart beats faster and I can’t keep myself from looking at the time. This is exactly what I used to do while on consult service as I tried to budget the time I had with the work yet to be done.

I also remember the dark, small room, nestled between just a few other rooms on the bottom floor of the old hospital building, where we fellows used to end our long and exhausting days, wanting to make sure each of us had survived. I used to call that room the “cave” because when you are there, you are disconnected from the outside world. You cannot tell if it is day or night or dark or light outside. If we could only leave our pagers outside, the cave could be a paradise.

On first sight, the cave looks ugly and feels cold. But over time, you get used to the cave and the cave gets used to you. The longer you stay in the cave, the warmer it starts to feel.

There, I spent most of my time looking up charts, answering pages, and typing as fast as I could to finish my endless notes while arguing with residents over the phone that my kidney failure patient did not need urgent dialysis after receiving computed tomography of the chest with contrast.

I cried in the cave when my 35-year-old patient died in his wife’s arms after all the antibiotics under the sun failed to treat his hemodialysis catheter–related sepsis. I got excited in the cave when I was the first to hear from my dialysis patient that he had received his first call about an available deceased donor.

I read most of the Primer textbook in the cave when the days approached their end and my pager fell dead after a full day of buzzing and beeping. We used to hide in the cave and discuss our rare cases, laugh at jokes that did not sound as silly as they do now when I recall them, and brag about our success in diagnosing that tough case or getting the core from the second poke while doing a kidney biopsy.

In the cave, we used to support each other and remind ourselves there was “light at the end of the tunnel.” When I was a junior fellow, my senior’s job was to walk me through the tunnel and try to show me the light. Before I knew it, I found myself talking to my junior fellows about the tunnel and the light at the end.

The light at the end of the tunnel fairy tale became the happy ending to any conversations we started in the cave. I could not wait to leave the cave and see that light at the end of the tunnel one day. But that day felt like it would never come. By all objective indicators, I would never miss the cave when I got to the end of the tunnel and saw the light there.

Fellowship passed more quickly than I thought it would, and soon I graduated and started practicing on my own. For the first time, I came up with the plan and didn’t have to run it by my attending. That felt wrong, very wrong. What if my plan was incorrect? What if I was missing something?

As I muddled through, memories from my fellowship started to pop up in my mind: Dr. X once told me this, and I learned that from Dr. Y. I felt them around me in my mind. I heard them whispering in my ears to do this and check that. I felt like a baby taking the first step and walking away from their parents, thrilled about finally being independent but anxious about falling. I used to check my notes several times before I signed them. Gradually, I felt more comfortable and confident. I found myself talking like Dr. M, and telling my patients the same jokes as Dr. Z.

I started seeing that light at the end of the tunnel I’ve always looked forward to.

But guess what? I really miss the cave.