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Saint-Cloud had one of the best-known alcoholism treatment programs in France, and I sometimes admitted patients when they arrived to enter the program. They all had a similar look, pale and grim, that I later saw among my fellow patients in detox wards and rehab centers in the United States, not to mention when I looked in the mirror during binges, after I became an alcoholic.
    What puzzled me as a young physician, however, was that the criterion for admission was a minimum period of abstinence from alcohol. It seemed there was only help for those not in the most immediate need of it. I wondered about those alcoholics who were in even worse shape. But I never stopped to question the requirement of abstinence before treatment and its implicit assumption that alcoholism was largely a question of willpower.
     
    After much debate, I decided that cardiology was the medical specialty for me. France had a strong tradition of research and training in cardiology, and I did a cardiology residency in Paris. But I wondered how the field looked from an American perspective. Ever since I had seen the Statue of Liberty at the age of fifteen, I had harbored a dream of spending at least a year in America, and my heart was set on New York, the city of Woody Allen, Leonard Bernstein, and Carnegie Hall.
    I arrived in October 1983, for a fellowship in the cardiology division of the department of medicine at New York Hospital–Cornell University Medical College, where I worked under and with Drs. John Laragh, Jeffrey Borer, and Paul Kligfield. Laragh was the head of the cardiology division and had recently been on the cover of Time magazine for working out some of the mechanisms of hypertension. This cover story popularized the concept of hypertension as “the silent killer.” Jeff Borer and Paul Kligfield were also enormously talented and productive people, and Jeff headed up the hospital’s division of cardiovascular pathophysiology.
    The research project that Jeff Borer and Paul Kligfield were running, and which I joined, was an effort to refine the accuracy of the heart stress test. False normal results were common with the stress test, meaning that serious heart disease was routinely being missed. Over time we developed a new form of the test that took the individual’s heart rate into account, and we published a number of papers on the ST/HR (ST segment/heart rate) slope. This innovation enabled very precise differential diagnosis of mild, moderate, or severe coronary heart disease.
    As part of this work, I often read EKGs and twenty-four-hour monitors known as Holters in a windowless room in the heart station. The room had only one door, and I sometimes experienced a rising sense of anxiety as I sat there. It wasn’t claustrophobia. Rather, if someone came in suddenly, there was no way for me to dart out without being seen. That was a problem not because I was avoiding work, but because I felt subject to scrutiny without notice and I was always ready to think that I would then be found inadequate. I was sure that the only reason people were nice to me was that I was a novelty, the French guy.
    One day Paul Kligfield came around with a woman from the Payne Whitney Psychiatric Clinic and said they were interested in heart rate variability in people with panic attacks. It was the first time I had heard the term panic attack , which was not yet widely used. When they told me the diagnostic criteria for susceptibility to panic attacks, I realized I fit the bill.
    To calm stage jitters before a talk, some of my colleagues used beta-blockers, which reduce symptoms such as heart pounding and shakiness. Beta-blockers did nothing to ease my anxieties, however. Valium and Xanax worked somewhat better. But I never liked how I felt on benzos, and it is best not to take them too much because they induce dependency and impair memory and other cognitive function. The result was that I sometimes paged myself out of meetings in order to avoid possibly