Perched over the procedure table, dressed in sterile blues, and battling an internal firestorm of anxiety-fueled GERD, I fumbled my way through double flushing a manifold. Never had I imagined there could be so much to the proper handling of a 20cc syringe. But, in fact, there's a right way to it. And, as I learned through trial and error after error after error during my first days on cath, there are a seemingly infinite number of wrong ways to go about it. At 30-years-old and with two decades of school, an internal medicine residency, and an ever-expanding collection of grey hair to my name, I was being taught how to properly hold and maneuver a salt water-filled syringe. That was it. That was the first few days. That was before I ever even attempted to engage tiny blue catheters in equally tiny invisible vessels. And that was just one moment amongst many in the opening months of fellowship that made me question the wisdom of leaving behind the familiar pastures of internal medicine to brave the rocky terrain and tempestuous winds of cardiology.

I'm not one for boasting or bluster, but, in truth, I recognize that by the end of my residency, I was a more than competent internist. Busy, solo night admitting shifts juggling severe hyponatremia, multifocal pneumonia with impending respiratory failure, GI bleeds of various localizations and tempos, chest pain, alcohol withdrawal, and the occasional rapid response hardly phased me. Two years on the job, and I knew enough medicine to safely and efficiently tuck in admission after admission. Just as essential, I had unearthed the core tenants of personal survival on the medicine wards: compression stockings, plenty of water, and a robust stash of NSAIDs, APAP, and TUMS. I had also been around long enough to recognize a friendly face in nearly every hospital hallway that I passed through. I had the confidence and carefree air of a high school senior just before graduation. The work was far from easy, but I was comfortable.

I'm fortunate to never have experienced whiplash. Starting fellowship at a new institution, however, has been a sort of metaphorical, never-ending coup contrecoup cycle of unknowing. Passersby stop me for directions to the closest elevator bank in the old half of the hospital. I haven't a clue. Nurses page me to put in insulin sliding scale orders for post-cath patients. One week into my cath rotation and I'm still unsure which EHR order set to use. Residents ask me for our next steps in managing ventricular tachycardia that has broken through first and second-line antiarrhythmics. I don't know. This unremitting unknowingness is seemingly unshakeable, at least for now.

You would think that all this newness, along with the loss of nearly all institutional and clinical familiarity, would be crippling and overwhelming. And you would be right. It often is. But, to my great delight, I seem to discover and re-discover on a near-daily basis how incredibly fun and compelling the practice of cardiology is. Afterload reduction is fun. Titrating inotropes to cajole reluctant kidneys out of oliguria is fun. And cannulating the radial artery in a single, clean stick is unbelievably fun.

I fully expected that I would spend the majority of my time outside of work this year wallowing in self-pity, moaning and groaning ad nauseum about the hours, the fatigue, and the struggles of the job. Instead, more often than not, I've found myself recounting with gusto the details of an interesting case of the day to polite dinner guests who nod along with feigned interest.

As fun as the start of fellowship has been, I have no doubt that the worries and cracks in my self-confidence will endure. Will I ever again be professionally competent? Can I "have it all"? Will I find a way forward in this male-dominated field? I don't know. But, as the old adage goes: "Success is not a destination, it's a journey." And though I rarely take such bumper sticker wisdom to heart, I'm trying to embrace it for now. Because who knows if I will ever successfully engage a right coronary artery on my own. But the trying is awfully fun.