Guys Do It All the Time

When I first saw him, I’m pretty sure I let out an audible gasp.

It was love at first sight.

As I approached, I began to get goose bumps.

Could I really be thinking, what I was thinking.

Married, Doctor-moms, in their mid-thirties shouldn’t do such irresponsible things.

But, I couldn’t help it, it just felt so right.

Then his intoxicating scent hit me….a perfect blend of leather and new car smell.

As, I sank into those beautifully stitched seats and took my first test drive, I was officially smitten. He cornered like he was on rails and his torque sent my stomach into a tail spin.

Then I had to break the news to my husband.

Honey, I’m buying a new Camero. A ruby red Camero with leather seats and a kick-ass radio.

Really my husband says? That doesn’t really seem like you?

I know. That‘s why I want it.

Don’t you want a Honda Odessy like all your friends?

No.

We already have an SUV for hauling the kids, so my car essentially drives me back and forth to work which is only 5 miles. I was not even considering buying a new car until mine literally got washed away in a natural disaster*, giving me only days to find a new one. In the past I’ve always carefully researched for months which slightly used car was the proper choice, then proceeded drove it forever. This time, I didn’t have the luxury of months to pour over Consumer Reports, so I just went with my gut.

In the grand scheme of things its not that big of deal what car you drive, so why not have fun with it?. Really, in the words of Mindy McCready, “Guys Do it All the Time.” Most of the Orthopods at my hospital buy a new European sports cars every few years. I spent about a third as much. Hey, I’m just doing my part to help stimulate the economy.

Let me just say that our relationship has flourished. I LOVE my car. It’s a fun escape from my real world. For 15 minutes twice a day , I am no longer a suburban soccer mom, I am the cool kid; the race car driver; the rock star; maybe even the homecoming queen. I am one with the road. I find myself taking the scenic route home , soaking in the sights. Enjoying the purr of the motor as I drive through the country side.

So, I have a new man in my life. Perhaps I am having a little midlife crisis as my mom has suggested.

I don’t really care though, cause my new car is Bitchin’.

*In all seriousness, please take a minute to look through the pictures in this link. Though, mostly ignored by the national media, the Mayday Flood of 2010 was absolutely terrifying to live through.

MiM Mailbag: Post-bac pre-med programs for mom of 3

Hello,

  My name is Crystal and I am currently an undergraduate student at UCLA. I have 3 daughters, 6, 4 and 8 months. I also have a husband. I will be graduating in June 2011 with a double major in Anthropology and African American Studies.

  As a "career changer," I am currently looking for the best pre-medicine post-bac program that will lead me to pursue medical school. I have a deep passion for medicine and currently I cannot find ANYONE who could help me (even here at UCLA). I feel very lost going through this process right now, because to most people that I have talked to (especially counselors), my situation is very unique.

    We currently reside in the family housing at UCLA and my children attend the day care/school here as well. I guess my problem is that I am trying to find a program that offers acommodations to families (housing, preschool, scholarships/financial aid etc...)

  I came across a few post-bac programs (Drew, USC, Temple, Harvard) that I think would be a good fit for me, but I am trying to make sure I can find one that will ultimately be good for my family as well. I don't mind relocating. I just need some direction, especially because I have a family, I will be making this choice for them as well.

Do you know of any resources that could help me with finding the right program?

Thank you very much. Your website inspires me a lot. I had no idea that there were so many women going through the same exact thing that I am facing right now.


Crystal

Homecoming Queen

Some weeks being a pathologist is like being the coolest girl in school. All the docs, guys and girls alike, hang on your every word. They call repeatedly, stop by your office, ask your advice on how to get the most out of their specimen to get the diagnosis for the patient, and actually listen and bend over backwards to follow.

On no rotation is this more true than cytology. Interventional radiology and ancillary techniques developed in the last decade or so - all have been created to maximize knowledge yield from a minimal amount of tissue. Yep, that's my fellowship trained specialty. I'm proud.

It's also stressful, because you want your advice to work. So do they. It becomes frustrating when it doesn't.

A few months back, I was on cytology and I got a CSF (cerebrospinal fluid) specimen. The patient had a diagnosis of lymphoma, and I saw some atypical lymphoid cells on the SurePath preparation. Tried to run flow cytometry, but cell yield was QNS (quantity not sufficient) to assess the phenotype and prove clonality. I showed it around to a couple of colleagues and they laughed (in fun, of course - we all are elitist about our own areas of expertise). You see, some pathologists think cytology is like voodoo. Smoke and mirrors. "I can name that tune on three notes. I can diagnose that cancer on three cells. No you can't. Yes I can." Every couple of days I got more CSF, two to five milliliters, and every time I got the same complaint from my flow techs. "Not enough cells." Damn it. I saw the radiology. The patient had a diagnosis of lymphoma, and the meninges were lighting up like a Christmas tree, signaling CNS (central nervous system) spread. I knew it was there, I think the oncologists wanted an diagnosis so they could do intrathecal treatment (I'm a pathologist, not a clinician, so don't call me out here), but we weren't getting anywhere.

A couple of weeks later, back on the same rotation, I was saddened to learn the oncologists were still trying to get the diagnosis to no avail. I called one of them up. "Skip cytology. Skip hematology. We've seen the cells, they're scanty but weird, we know what they look like. Draw off more CSF and put it all in for flow." I was trying to get more bang for the buck.

The flow techs were by now jaded and skeptical after weeks of QNS. My hematology trained colleague was scoffing at me. So I was excited when the flow tech popped her head in my office one afternoon and handed me a blue folder. "They're positive for B-cell clonality." Me, the oncologist, hell the PATIENT got their diagnosis so they could begin treatment. I felt like dancing with my microscope.

This week was one of those weeks. I was the most popular girl in high school. My courtiers weren't jocks and stoners - but breast specialty radiologists, oncologists, neurosurgeons, thoracic surgeons, and pulmonologists. My phone never stopped ringing, and some doctors were hand delivering patient specimens to my office. Luckily this week, every effort (sometimes thrice attempted) ultimately yielded good results, and the excitement in each doctor's voice as I relayed the diagnosis gained from their efforts was palpable. They were all giddy with success, armed with knowledge to begin treating their patients. I was heady with the challenge of making tough calls, silently wishing for more straightforward cases, but thriving on each diagnostic dilemma. Poring over my books. Searching for articles on PubMed. Consulting with my colleagues. Thank goodness every week isn't as tough as this one, but I do enjoy them every once in a while.

Who says pathology is boring?? I'm finally the Homecoming Queen. Now I just need a date.

In the Comfort Zone

There are few things I enjoy more than talking about the spine and the brain.

Therefore, it stands to reason that I enjoyed our state neurosurgical society meeting last weekend. I don't like big national meetings, being an introvert at heart. Our state meeting, however, is small; this makes for a more intimate atmosphere and more outspoken dialogue. Colleagues from across the state can exchange ideas, new techniques, and opinions. We also discuss issues of importance to us locally, such as our lack of a motorcycle helmet law (UGH!).

I generally come away from these meetings with a new idea or two to implement in my practice. I fear becoming a "dinosaur," stuck in the rut of old techniques and outdated technology. My patients deserve my best efforts to stay current, as difficult as that sometimes is. Looking back at the last 9 years, I think I've done a pretty good job with keeping up to date, particularly as related to the spine (my professional passion).

This weekend, I sat in that chilly conference room second-guessing myself.

My colleagues are astonishing. One academic cerebrovascular surgeon showed a video depicting the results of the new non-profit organization he founded recently. Neurosurgeons travel to East Africa in groups to train local doctors in basic and emergency neurosurgery. He envisions such a training network all over Africa, bringing ongoing lifesaving care to thousands. They operate on brain tumors without microscopes, power drills, even electric lights. And the outcomes are remarkably good.

Another colleague, a skull base specialist, presented a series of "eyebrow craniotomies" in which he removes tumors through a single eyebrow incision and an endoscope. It's hard to get less invasive than that. Yet another brought me up to date on the neurophysiology of consciousness and the two biological definitions of time, all over dinner.

I had looked forward to seeing the only other woman neurosurgeon in our state, but she wasn't there. She was in another state doing a fellowship in interventional neuroradiology, learning to coil aneurysms. She already has a fellowship in neurotrauma, and she is laying the groundwork for a new residency program at her hospital system.

Driving back across the state, I tried to envision how my colleagues do all these marvelous things. I don't know how they find the time and energy. I admit that I struggle just to keep juggling all the basic balls: raising a kid, running a practice, taking care of a house and husband, the things we all do as routine. I am doing my dead-level best to just stay current in my field. Professionally, I am inspired by all the possibilities out there; I would love, for instance, to learn to do an eyebrow craniotomy. I probably should learn. Practically, I can't imagine taking time for more training or an overseas mission trip, or anything on top of my current load. I understand Bilbo Baggins when he said, "I feel thin, sort of stretched, like butter scraped over too much bread."

So, this week, despite my glimpse of the shining frontier, I feel myself inevitably settling back into my comfort zone. My familiar routines embrace me like a warm, cozy bed. Just as it's hard to get out of bed in the early dark, it's so hard to contemplate changing the patterns of my practice and my life in a dramatic way. I'm actually alarmed at how much harder it is as the years go by. Maybe it's time to push myself out of the zone and see how much more I can do.

On the other hand, perhaps it's wiser to stick with what I do best, as opposed to scraping myself over even more bread. How important do you think it is to keep stepping out of the comfort zone?

Fee for advice

I used to love my daughter's first pediatrics practice. Then they went and totally BETRAYED us. (Sort of.)

Some background:

I'm not one of those mothers who calls the pediatrician for nothing. I would say that in Melly's first year of life, I called a total of twice, one of which was for simultaneous fever of 102, diarrhea, vomiting, and bilateral ear infections. (For the record, I had to beg for an appointment that time, which the nurse only grudgingly gave me. Should have been a warning.)

When Melly was about two, she woke up one Sunday morning and one of her eyes was swollen. This had never happened to her before and I was concerned, so I called the pediatrician's office. I was met with the following message:

Due to the high cost of after hours phone calls, all calls to the advice nurse after regular business hours will be charged a $20 fee.

At the time, I was a resident and my husband was a student. I thought about the $20 and decided her eye didn't look that bad and decided not to pay the $20.

I can understand why they might do this. Even if you're not a physician, if you've ever read Dr. Grumpy's blog, you'd see the ridiculous, trivial, non-urgent things people call about in the middle of the night. I bet parents are even worse than neurology patients.

But I also think it was horribly unfair. I can understand charging parents who call excessively a copay, but I don't feel like it's fair to put a parent in the position of deciding if their kid's swollen eye is worth the $20. And what if my kid had a health problem that required more monitoring? Would I just be screwed and have to keep paying $20 every time my kid got sick and I wasn't sure whether to go to the ER?

I've used two different pediatrics practices since then and neither charged a fee for after-hours advice.

What do you think? As physicians or mother or patients, do you think it's wrong to charge for after-hours nursing advice?

Nightmare on Nanny Street

Things had been going well, as well as could possibly be expected, ever since my husband moved down to N.C. a few months ago. My dramatic post about becoming a single parent seemed almost silly in retrospect, since here I was, having a ton of help and support all the time, between my parents, my in-laws, my husband on almost every weekend (yes, driving the 6-8 hours each way), and our live-in nanny. Yes, I pulled more double bedtime duty than I had been accustomed to M-F, but it was hardly the hardship I imagined.

Tempeh, who has been through multiple deployments, and who is quite possibly The most supportive friend in the history of supportive friends and who has made offers weekly to help in some tangible way, joked a couple of months ago that I was overdue for a major appliance failing, a fate that befalls almost every newly-alone spouse of a deployed servicemember.

My appliances, thankfully, are all in good working order (I am furiously knocking on wood right now), but my once-rock-solid nanny situation disintegrated before my eyes.

I will save you all the gory details, but even before the sordid events that unfolded over the course of a couple of months, we had certain reservations about her as a childcare provider. Namely, that while she was perfect for an infant: loving, warm, patient, calm, she was highly ineffective with a toddler and a kindergartener:  entirely passive, indulgent, and without a limit-setting bone in her body. Yet, we were willing to ride it out until the new baby came in a few months and her primary focus would be, again, a newborn. The older two kids would be at school all day.

But, then, the sordid events happened, involving a quite-possibly mentally unstable boyfriend to nanny who would not stay away from our house or our children despite our many requests, and to top it all off, reports from the school that she and said boyfriend picked up our  two-year-old son from half-day pre-school and put him in boyfriend's car, without a car seat and sitting on her lap in the front passenger seat.

Stress? Yes, hello, it's me again. This all went down on my birthday, of all days, and right before a month for me that included 3 work conferences, including 5 presentations and being attending on wards.

We fired her immediately. My parents moved in temporarily. It was all very sad since she had been with us for over 2 years and was very much a part of our family. She had taken care of my son since he was 9 months old and he was/is very attached to her. When she moved out, she cried and hugged me for at least 10 minutes straight, telling me how very sorry she was and how I was like a daughter to her.

This has all highlighted for me how tenuous having a nanny can be. Great one minute. Disastrous the next. I can't tell you how many times my husband and I have told each other how lucky we were to have had our nanny over the past 2 years. Up until recently, it was truly great and made our lives many times over easier. And now, we're/I'm starting all over again. No one is going to be perfect, I know. But, it's scary how far from perfect they can be.

Sick Days

Recently, there was a post I ran across on Kevin M.D. that argued that doctors who are sick should just stay home, for their patients.

I'd post the link, but it was a while back, and I don't feel like searching for it.

Calling in sick is antithesis to our profession. I know of neurosurgery and anesthesia residents, dehydrated and drained from GI illnesses, who hook up their veins to a bag of normal saline to keep working through the night. As a pathologist I thought - lucky that they had the resources and know how to be able to do that.

I called in sick once during residency - it was the night before my rotation at the State Crime Lab. I had been up all night vomiting due to God knows what bug and remember laying on the bathroom floor at one point with my arms drawn up in a semi-state of paralysis, probably induced by a dearth of electrolytes. I could not face my first Monday morning of bodies swarming with blowflies - knew instinctively that it was a bad idea. I felt horribly guilty, and showed up on Tuesday apologizing profusely.

Although I have been sick in my three years in private practice (I have two kids - they bring home lots of bugs), I haven't once called in. This decision probably caused illnesses that might have lasted a few days with some good old fashioned R&R to drag on for a couple of weeks unchecked, but there was really no precedent that I could find making "calling in sick" acceptable. Not that I begrudge this aspect of the M.D. work ethic - it had been set up in residency and even on clinical wards as a medical student.

To be fair, a pathologist doesn't really see patients that often, and I think the crux of the article I read had to do with not exposing your patients to the bugs you yourself are suffering from. But it made me curious. The only partner I know (of my 13) who has called in sick in the last three years was in the ER with perforated appendicitis. And one of my senior partners once went to the ER with heart issues, but we all covered him for a few hours and he was back at the end of the day to finish his work.

So I wonder - how many people out there feel justified in taking sick days? Have you ever taken one? If you are a clinician, or anyone in the medical field, how do you feel about exposing your patients to your own illnesses?

Working weekends

I don't like working weekends.

Well, who does, right? I mean, there are probably a few people who like it for some reason. But I'm guessing most people don't enjoy working weekends.

But I really, really don't like working weekends. When I have to get up to work on the weekend, I usually spend much of my time at work on the brink of tears, accompanied by a steady stream of resentment toward all the people who don't have to work that day. Then I usually come down with a cold the next day. So I feel like I might dislike working weekends more than average, but I could be wrong. That could be average.

Sometimes weekends on call aren't as painful as regular days. But sometimes they're much more painful. Sometimes they involve rounding on every patient on everyone's service with an attending who doesn't seem to understand that weekend rounds are for emergent issues only and judiciously uses the phrase, "Is there anything else?"

I suppose that there are several jobs that also involve working weekends (policeman? chef?), but there are also many that don't. My husband, for example, has never worked a weekend. And he has a good job with a good salary.

It bothers me that becoming a physician requires this commitment of working weekends, at least during training (which, as we all know, lasts for freaking ever). Especially when you have young children at home, this requirement ranges from annoying to heartbreaking. I'm sure lots of people will comment and say that they have a job that doesn't require any weekend responsibilities, but I don't think that's the norm for physicians. People get sick 7 days a week.

There's a part of me that wonders if you're the kind of person who really, really hates working weekends, and really, really hates waking up early, if maybe you shouldn't consider a different career based on that alone? Sometimes I wonder if I should have.

Maybe I Need to Clarify

I feel the need to defend my daughter here, before I expose her. And I get the chance to boast a little.

When I went to her second grade parent-teacher conference a couple of weeks ago, I learned she made the honor roll. Here are a few other things the teacher said,

"Your daughter is very smart."

"She is a leader, not a follower."

"Boy can she tell a story! She will go on and on, and if she's not done before recess she'll come back in and pick right back up where she stopped. Her level of detail and vocabulary are impeccable for her age. She's going to be a great writer."

"Your daughter and son are some of the sweetest children in the entire school."

OK, I'll stop. But when you've been through all we've been through in the last year, and believe me - the sibling infighting does increase a little during rough roads, and it takes extra effort to try to keep everyone level and sane during all the change surrounding divorce. So to get this level of praise was extra rewarding, and relieving.

I was going through my daughter's weekly work that comes home every Tuesday just now. I always learn amazing things - like that she knows what the word antonym means and can apply it on worksheet questions or that she is getting more complex understanding of math word problems. This week, on one section of a worksheet she had to choose verbs from a word bank and fill them in to sentences with missing verbs. Here's one mix up she encountered that made me laugh out loud:

Mom examines us home after school.

My doctor drove me carefully when I have a checkup.

I guess she's got the whole mom/doctor thing mashed up in her head. What on earth do I do that makes her feel examined? Sure, I scrutinize her bumps and rashes at night on occasion, but that's at her request after bedtime is long over - I think it's one of those "what can I think of to continue to engage mom as long as I possibly can" tactics. Or is she thinking of my incessant and sometimes pleading questions about her day and how it went and "tell me something good" and "tell me something bad." I'm not always so insistent but I just love hearing about her day, and try to create questions around bedtime and dinnertime to get her going. Maybe she feels overly scrutinized. But isn't that what we mom's do? Hold up the magnifying glass under the bright sun and hope your kid's head doesn't start smoking?

She's quite healthy and with her mom and dad both being doctors, she hardly ever goes to one. So she was probably really stumped on that one.

Anyway, I can't wait for breakfast. I'm thinking maybe I need to clarify.

I am 22 years post partum and still worried about mood

I just came back from a research conference put on by the Marce society on the topic of perinatal mood disorders. It was great—the science is growing rapidly, and there are lots of clinical programs that are trying to promote recognition and treatment for women across the social spectrum, here and around the world. The human genome project is really bearing fruit.

Even as I got fired up (again) on this subject, I felt my usual sorrow and frustration that most pediatricians and obstetricians don’t screen for these disorders, even though they see the women (and their fetuses and then children) at risk, repeatedly. Today, many more obstetricians and pediatricians are now mothers themselves. Yet the demographic change in those professions doesn’t seem to compensate for the dis-incentives, blindspots, and confusion that discourage psychosocial pregnancy care.

I hope I am wrong, and that this area has just become so routine that my younger colleagues address it well and take it for granted. Is it?

PS: PLEASE VOTE ON NOV 2

scary doctors?

...for Halloween, that is. Anyone's kid dressing up as a doctor? Girl (6) is choosing to be a veterinarian (close!) and boy (4) is choosing to be a, well, Michael Jackson (who shall we say, had enough doctors). Any Halloween plans? We happily hay-rode and picked and carved our pumpkins way too early, kept them inside on the countertop safe from squirrels, hence the mildew and caving in on themselves, before we donated them, alas, to said squirrels. All in advance of 10-31.

Socks on Stairs

by Dr. Shoes

(The latest in patient educational materials, written after one too many such injuries came through my office...)


I like my socks.
I have 12 pairs.
I wear my socks
Upon the stairs.

1 step, 2 steps...
That's not all!
3 steps... Oops!
I slip and fall.

Bump! Bump! Bump!
I bang my head.
Thump! Thump! Thump!
Ouch! "Help," I said.

I wish my socks
Were not so slick.
My low back hurts.
I'm feeling sick.

I have to see
My surgeon now.
My spine's messed up.
Those socks, that's how

I hurt myself.
I couldn't wait
To put on shoes.
Now I'm prostrate

Upon the floor
Below the stairs.
My vertebrae
Will need repairs.

Be more cautious
Than I have been.
Those socks on stairs
Will do you in!

Join me in my journey to 50K!

So once again, November is almost upon us and once again, it is almost time for National Novel Writing Month (NaNoWriMo)!

In case you didn't read my post last year, NaNoWriMo is "a novel-writing program for everyone who has thought fleetingly about writing a novel but has been scared away by the time and effort involved." Yes, you too can write a novel that will never be read by anyone ever.

I think it's especially aimed at us workin' folk, who are too busy to write most of the time. This kind of forces you to sit down and write. And it's FUN. All the cool kids are doing it, including yours truly.

I would love to have more "writing buddies" so that we could have some fun competition. If you want to friend me, go here to read my brilliant title and the compelling description I wrote.

I "won" (= finished 50K words) last year, but this year is going to be a much bigger challenge. First, I've got a real job instead of a "research" "fellowship". Second, I'm losing an entire weekend to a conference. Third, Thanksgiving is gone because I'm going to relatives. And fourth... well, you don't need to hear my whole life story, but trust me, I've got stuff going on. But I'm determined to stagger in at the finish line.

Will Fizzy succeed? Can a mother/physician write 50K words in a month? Friend me to find out!

AWOL: Waiting for baby

I left work four days ago. Standing waiting for the elevator I felt tears well up in my eyes. Pushing back the emotion I turned my thoughts away from reflection and toward my next move.

A 38 week and 4 day little boy. Inside my uterus threatening to make his big arrival. Oh the places this little guy has gone (conferences in distance cities, organ procurement midnight travels) things he has seen (dying patients, miracle recoveries) and the drama overheard (dying great-grandmother, father unexpectedly unemployed). I could feel the strain of the pregnancy. In my hips and pelvis. On my mind. Being the wholesome expectant mother was inconsistent with my reality of 12 hour work days, two week blocks of call and Saturday and Sunday rounds.

It was time for me to move on. To move away from my office. To enter the parking garage and drive away. To pick up my two year old at day care in the middle of the afternoon. To arrive home in time to make dinner.

Really I had made it. Worked beyond emotional and physical pain. Accomplished professional milestones that I felt would justify my absence for maternity leave. But on that day instead of high fives on my way out- I felt a strong sense of disappointment. Despite all that I had done. Despite my sacrifices of health and happiness. To my (mostly male) colleagues at the end of that day I was still leaving. Taking a three month "vacation" where my work would need to be done by someone else.

Is it simply a scenario of wanting the cake and to eat it too? (And let me tell you I have indulged in my share of cake eating over the past nine months.) Honestly it would have been my preference to continue working up until my due date. To ease out of the most grueling work and ease into my transition home. Ultimately I had to call it quits. I needed a physical separation. I needed a vacation.

In my first days home I completed my patient charting, painted/organized the nursery, caught a matinee and napped in the mid-morning (and afternoon). It has been an active process of turning off my role as doctor, grappling with this guilt of desertion. What I have been able to do is sit and find my voice (hence the blogging). A week ago I feared that labor would come too early- leaving me to scramble and find a replacement for my hospital duties. Now I find myself, thank goodness waiting patiently, staring over at an empty bassinet as I type.

What I also found is strength. Strength that I was using every day, but somehow managing only to get by. Following a day at work too exhausted to climb the stairs to bed and overwhelmed to the point of tears. Now physical strength to attend a fall festival and join the family for a hike in the woods. Emotional strength to participate in the hospice care of my grandmother occurring five states away. Finding myself in the quiet and recognizing that there is plenty of me for this baby, my son and my husband.

Yes I do have a problem with work/ life balance. Partially to blame is my chosen specialty, but also to blame my own ambition. Achieving a sustainable effort is something I will continue to pursue- but for the time being I am the wholesome expectant mother. Hmmm, I wonder if there will be time for a pre-natal massage before my OB visit tomorrow afternoon?

Maternalism

I attended medical school from 1996 to 2000. At that time HMOs were on the rise, Google was being born and a strong emphasis was placed on patient autonomy. Although no one recognized it at the time, we would become the next generation of physicians. We had already been advised by old wise doctors to choose another profession. That we would never make any money. That MDs were no longer respected by society, and everyone (insurance companies, litigators) were out to get them.

We enrolled in med school anyway. We would become the physicians that knew nothing other than evidence based medicine, that would trade in our pharmacopias for epocrates, and see a work hours revolution change how patients are cared for in the hospital.

As an impressionable first year medical student I had a wonderful course called Medical Humanities. In a series of lectures we explored the philosophy of doctoring, and received our assignment. To preserve our humanism despite the rigors of training. To see each patient as an individual. To ask open ended questions. To respect cultural and racial diversity. To evolve beyond the paternalistic model and embrace the world where the patient is a partner.

I took this assignment on as a mission, reminding myself as years went by that smart and skilled was only part of the equation. That acting patient and compassionate was ultimately important. Years later I find myself in a field caring for extraordinarily ill patients, where astronomical efforts are made to save a life. Where more often than not this falls short and the best we can offer is a good death.

Over time I sense something that is just not right. It began with overwhelming frustration as a patient arrived with a ream of "medical information" downloaded from the Internet. Later it turned to disbelief as I found that my patient who cannot afford their rent is buying $100 per month of vitamins and supplements. As I find myself explaining why their information and supplements are bunk I find myself tip toeing in order not to offend and alienate. With so many new sources of medical information I think perhaps the grumpy old physician was on to something, the role of the physician has changed. Not necessarily a lack of respect toward doctors, but certainly a fair dose of skepticism that perhaps is deserved.

In my opinion the partnership model became derailed as the physician embraced the evidence and at the same time grew fearful of litigation. Informed consent then became central to the patient- physician relationship, a legal document. The conversation turned to odds of this and that, alternatives A and B, and finally the decision is up to you. The physician no longer answers the age old question, "If I were your mother/ child/ spouse what would you tell me to do?" Instead the doctor deflects a personal stake in the matter and ensures that in case of a bad outcome it will all be supported by the evidence, guidelines and paperwork.

Emerging from my medical training I began to feel an alienation at the bedside of my sick and dying patients. Witnessing their struggle with fear and uncertainty I felt like the care was falling short. The paces of a typical hospitalization includes selection of the proper evaluation, declaration of the correct diagnosis, and the discussion of treatment (with risks and benefits)- by the book. All of this done with the physician as the advisor and patient as a partner. When tackling the toughest issues- for instance at the end of life this series of discussions and decisions became just too much.

Grandma is too ill to speak for herself and there is a 80% chance that she will die. Would you like for us to do? Continue to try to save her? Should we treat the renal failure/ pneumonia/ UTI? Place a feeding tube? Continue lab work? Continue IV fluids? Turn off the ventilator?

My attempts to impartially advise and educate about all options grew in conflict with an urge to protect. To comfort. To spare whatever suffering could be spared for the patient and their family. But to step in and dictate what should/ could be done would be adopting the age old Paternalism we were raised to leave behind.

Perhaps there is a better way. May I be bold and call it "Maternalism". A way to provide compassionate care and resume part of the burden that we were taught to deflect. Partnering not as an equal but as a nurturer and comforter. For dying Grandma, first to help the family understand the situation, then to articulate what Grandma would have wanted. If that is go down fighting, they get a fight. But prevent the fight gone awry where Grandma suffers years as a vegetable with a feeding tube. If Grandma wanted to die naturally, then we allow nature to take its course. But spare the family from the agonizing series of discussions, where the family feels that at each step they are actively bringing the death of their loved one.

I find myself in a struggle to practice with excellence but also to sleep at night. Perhaps what we need is a sound clinical trial- or perhaps a meta-analysis to investigate the most effective role of the physician- in the post-Paternalistic era?