Adieu, Interventional Cardiology: My Journey to a New Ikigai

Jaya Mallidi, MD, MHS

The plain white walls in my new windowless office looked sterile. After months of procrastination, I decided to decorate them with the cards I had received over the years from patients from my interventional cardiology practice. These thank-you cards had been stored in a large box in my car trunk for months. I carried the box to my office and slowly started reading one card at a time, reminiscing about that patient before pinning it to the wall.

"Thank you for saving my life — with all my heart," wrote Mr Kelly, a jovial gentleman in his 60s who had a ventricular-fibrillation arrest when hiking. I remember his son holding his hand in the ICU, patiently waiting for neurologic recovery. The next card was from Shirley. Her husband, Mike, was 40 years old when he came in to the ER with anterior ST-elevation myocardial infarction, cardiogenic shock, and had a v-fib arrest on the cath table. "We can never thank you enough for saving my husband. I write this as Mike is sleeping peacefully, with tears of gratitude for giving him the opportunity for a second life, as he calls it," she wrote. "I never met a more kind, compassionate physician. Please know we will be forever grateful to you!"

When I wrote to my patients to inform them that I was leaving the practice due to personal health issues, even more cards and wishes poured in. Sometimes, I think, all their good wishes helped me get through two lung surgeries and months of painful recovery.

Was Interventional Cardiology My Ikigai?

Ikigai is a Japanese concept of "having a reason to live." Finding one's ikigai is finding that intersection between what you love, what you're good at, what you can be paid for, and what the world needs. For a long time, I considered being an interventional cardiologist as something akin to ikigai for me. Like any job, there were challenges along the way: long years of training, frequent calls, sleepless nights, radiation exposure, and unwarranted microaggressions in the cath lab as a woman in a male-dominated field. My passion for the job, the sincere gratitude of my patients, and the unique privilege of helping people in their most vulnerable state (often in the middle of a heart attack) was the driving force that kept me going.

In the fall of 2020, before a scheduled transcatheter aortic valve replacement case, I was staring at my own x-ray on a computer screen. On the right side, the empty space between the ribs that is normally black was white, three quarters of the way up from the diaphragm. I calmly finished the case, handed over the post-op care to my colleagues, and drove home to call my pulmonologist. Ten days later, after multiple tests, I was operated on to remove the blood that had accumulated in my chest cavity. I eventually learned that I have a rare disorder with no established treatment. It was smoldering in my body for years, and suddenly all the pain and fatigue that I attributed to chronic stress at work made sense.

I recovered from the surgery faster than expected. The soreness on the right side of my chest lessened. The sharp pains that shot up my scapula with every breath became less frequent. I felt stronger than ever before and went back to doing calls and cases. But I was torn between continuing the high-stress job of an interventional cardiologist and cutting back. Did I love it enough to take a chance with my health? After years of fighting through fatigue and pain, without even realizing, my body craved rest. "Just let it be," it screamed.

My mind, though, wanted to go on. How could I give up something I worked so hard for? In the midst of these unresolving conflicts, sleep deserted me. Stillness became elusive.

Lessons From Descartes and Lord Krishna

Like Descartes in First Meditations, I discarded everything I knew or thought I knew about life. Start with a clean slate and go back to the basics, I told myself. I listened to the Bhagavad Gita during my commute to work. In this sacred Hindu text, Lord Krishna narrates the principles of life to the warrior Arjuna, who was conflicted about whether to fight his own relatives on the battlefield. It's a discourse on dealing with our internal conflict or war within us. "Do your duty, in my name, without any attachments to the outcome. You are only an instrument of my doing. The outcome is already determined," God's voice said. Attachments to people, materialistic things, and even non-materialistic things such as ambition, honor, status, and privilege are the sources of conflict. "When there is no attachment to anything, peace will reign in your heart," the voice continued.

I didn't stop with the Gita. I read more. I read about fideism, determinism, and compatibilism. I didn't know what I was looking for. I didn't believe in anything in particular. I had no anchor. I read, learned, reflected, without drawing conclusions. Through it all, I never sought to answer, "Why me?" I was comfortable being someone's or something's random choice.

On February 17, 2021, as I finished a procedure on a patient while still wearing my lead apron, the familiar feeling of not being able to catch my breath returned. An urgent chest x-ray revealed a large-sized air pocket in my lung in a space where it should not be. I knew what was in store: more tests, hospitalizations, chest tubes, and another surgery. That night, I slept hugging a small photograph of Lord Vishnu. I needed to feel the presence of God. Tears of humility rolled down my cheeks. While I was tormenting myself about what choice to make, God had different plans. My internal conflict was an illusion. The storm in my mind subsided. I pictured a rolling green meadow and a calm blue ocean on a sunny day. I knew that I had just spent my last day in the cath lab. Finally, peace and sleep.

Ikigai, Illusions, and Lao Tzu

William Barclay famously said, "The two most important days in your life are the day you are born and the day you find out why." The latter is supposedly when you find your Ikigai. But after that last day in the cath lab, as I read, reflected, and coursed through my own spiritual journey, I found out that I don't need a grandiose sense of purpose. I don't need to feel that I'm changing the world.

Meanings, purposes, ikigais are illusions. That interventional cardiology is my ikigai is an illusion I created. I can create another. It is peaceful to just drift along the waves of the universe, whatever direction they take me. This concept is beautifully described by Lao Tzu, the founder of Taoism, in the Tao Te Ching: Other people have what they need; I alone possess nothing. Other people are bright; Other people have a purpose; I alone don't know. I drift like a wave on the ocean, I blow as aimless as the wind; I am different from ordinary people.

Over the past year, I transitioned to general cardiology at an academic institution. I work mostly in inpatient cardiology service, and I teach medical students, residents, and fellows. I have more time to focus on my personal well-being. Instead of thank-you cards from patients, I now receive thank-you cards from trainees for being an excellent teacher. Maybe this will be my new ikigai; I don't know yet. Colleagues often ask whether I miss the cath lab. Yes, occasionally, when I reminisce, such as on that afternoon while sorting through the box of cards from patients. Otherwise, my life is largely filled with gratitude and peace for what was and what is.

Jaya Mallidi trained in and practiced interventional cardiology for 5 years and now works as a general cardiologist at Zuckerberg San Francisco General Hospital, UCSF. An ardent patient advocate, she writes opinion pieces using patient stories as context to highlight problems in the practice of modern-day medicine. In addition, she enjoys digital sketching and playing tennis.

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