Internal Medicine:

Frederick Ognibene, CC

By his third year in medical school (at Rutgers in Piscataway, N.J.), Aaron Auerbach knew he wanted to go into a diagnostic field—perhaps pathology, perhaps radiology, but the pull to pathology proved stronger. For personal reasons, he also wanted to spend as much of his fourth year in the Washington, D.C., area as possible.

"I also had an interest in research—and what better place could there be than NIH?" Auerbach says, recalling the impetus for his after-hours phone call to the NCI Laboratory of Pathology one evening to leave a message requesting information on the possibility of a rotation during his senior year of medical school. Instead of the answering machine, however, lab chief Lance Liotta, who "happened to be working late that night," picked up the phone. "He asked me what my research interests were, what I wanted to do in the future—and then he said, ‘absolutely’—and the next day it was all set up, and I spent the month of October of my senior year in medical school doing clinical research in Lance Liotta’s department. I was the only medical student. I didn’t know anything, and then I was swept into the science, and I knew that this was where I wanted to do my residency."

During his month’s stint, he did surgical pathology and research on genetic syndromes, specifically the Birt-Hogg-Dube (BHD) syndrome—work that he continued as a resident and prepared for presentation at this year’s Research Festival and the upcoming U.S. and Canadian Anatomic Pathology Society meeting. He and his colleagues reported on previously undescribed colonic lesions in BHD patients.

Auerbach suspended all other residency-selection activities and applied for the NIH anatomic pathology residency program, which does not participate in the national residency matching program. He learned in November that he had been accepted. The following June (of the year 2000), he graduated from Rutgers with his M.D. degree and a concurrent M.P.H. in health-care administration from the graduate school and returned to the Laboratory of Pathology.

Now chief resident, Auerbach cannot praise the program highly enough. "My experience has been excellent; the protocols are interesting, the research possibilities endless. My mentor (Maria Merino) has been great, and I love what I do. The residents here are not viewed as labor for others but are treated as intellectual equals whose input is appreciated and used. I came in a medical student, and I’m leaving a pathologist."

Headed for the Armed Forces Institute of Pathology, Auerbach plans to specialize in GI and liver pathology and to conduct research on medications to reverse hepatitis-associated fibrosis. (According to the website, 143 residents graduated from the program between 1955 and 2001, with approximately 41 percent moving on to nongovernment academic pathology, 40 percent to government positions in academic pathology, 18 percent to community pathology practice, and under 1 percent to industry.)

"NIH is different from anywhere else," Auerbach says. "Not needing to earn X amount of dollars for my laboratory through grants has allowed me the freedom to shape electives and research projects—to create my career—around those things that I want to do while at the same time meeting American Board of Pathology requirements." There is, of course, the pressure to publish—a not-unwelcome pressure that has helped fuel his submission for publication of studies on ovarian cancer metastatic to the mediastinum, Cytokeratin 7 and 20 staining of hepatocellular carcinomas, and solitary fibrous tumor involving the pituitary fossa.

During the last year of her internal medicine residency at the University of Texas Health Science Center, San Antonio, Denise Gonazales spent one day at NIH. She was one of a highly select group tapped by the National Hispanic Medical Association (NHMA) to compete for a slot in one of NIH’s 16 accredited fellowship programs, and she was here for interviews.

Gonzales had not known that these programs existed; it was the chairman of medicine in San Antonio, a former NIH fellow himself and her attending physician during her second year of residency, who had nominated her for an NHMA-sponsored NIH program. Looking through the information on each of the NIH fellowships, she had homed in on critical care medicine. "There was no question. That was the one I wanted," she recounts.

Critical care, Gonzales says, appealed to both of the two strong forces that had propelled her in two directions during her medical school training: surgery because she loved its "pace and demands" and internal medicine because she loved its "intellectual challenges." Her experience in the ICU during her San Antonio residency suggested that it was in the ICU environment that an internist could feel her adrenaline pumping.

And it was that one long day spent at NIH—in February 2000—that convinced her that the Critical Care Department in the NIH Clinical Center was where the action should be for her.

That day started at 7:30 a.m., observing rounds. "I saw a fellow presenting patients to four or five other fellows and about 15 attendings—and those attendings had recognizable faces and names, like Tony Fauci, and they were firing off all these questions. And I asked myself, ‘Can I do this? Can I answer these questions every morning about why I did what to the patients of these world-famous experts?’"

After rounds, the day was spent interviewing with "every single member of the Critical Care Department." Not only the excitement of being at NIH—"where great studies are designed and performed and reviewed"—but the unparalleled freedom to pursue her own interests pushed away any other possible fellowship choice. "Whatever I wanted, I was told, they could find the funds, the space, the time, the supervision. The physical, financial, and intellectual resources were all here—across the board."

With four other fellows, Gonzales started her four-year NIH fellowship in July 2001—two years as an "intensivist" or "criticalist" in training, providing care for critically ill patients, and two years conducting research in critical care.

She spent her first fellowship year caring for patients on protocols at NIH who required critical care, interspersed with rotations through the surgical, medical, coronary, and pediatric ICUs at the Washington Hospital Center, the National Naval Medical Center, and Children’s National Medical Center—altogether five months at NIH and seven months elsewhere.

"I’ve been very pleased with my training. In my rotations through one of the hospitals, I saw that other fellows from other programs aren’t getting such broad exposure—most other programs don’t place their fellows in formal surgical ICUs." As for her critical care experience at NIH, she finds it hard to describe. "‘Challenging’ is not an adequate term. These are patients who have failed conventional therapy and a certain level of experimental therapy. They are here for highly experimental therapy, and if they have reached the ICU . . . ."

Now in her second fellowship year, Gonzales is at the Johns Hopkins Medical Institutions fulfilling the requirements of the pulmonary care component of her dual subspecialty training. The last two years of the fellowship will be spent doing research in the Critical Care Department here—most likely in the area of DNA arrays to identify markers for sepsis. "Anthony Suffredini, a senior investigator here, is doing array analysis in sepsis models, searching for ways to identify the ARDS [acute respiratory distress syndrome] patients who may survive septic shock, who may respond to immunomodulatory drugs or activated protein C."

Beyond that, Gonzalez envisions independent research in the area of noninvasive monitoring of critically ill patients—something that would marry her intensivist training with her interests and skills in biomedical engineering (just one month before entering medical school in 1994, she had completed a three-year Master of Science in Biomedical Engineering program at Boston University, where she had designed a chip resembling the cochlear implant but utilizing a different computer platform).

"If I were ever to use my engineering training, it really should be in an ICU setting," she says, pointing to the desirability of being able to assess hemodynamic status without transport or central lines, without the risk of infection, bleeding, and lung collapse.

In the long-term, Gonzales sees herself in academic medicine, blending clinical care responsibilities with teaching and clinical research. "I could not imagine myself in private practice anywhere. I enjoy working in a research environment."