Doctor's Lounge

I have been working at my hospital for almost seven years. That's a long time.

I walked into the lounge at about 9 something a.m. this morning to get hot water for a cup of black tea.

There were three women sitting at a table by the front door. I introduced myself to one of them two weeks ago - she is a newish PM&R doc. Works mainly at the rehab tower. The other two I didn't know. They looked young and hip - I imagined they were residents. I looked over at another table and saw a woman sitting with a man. Two women were standing at the food station getting some of what was left of breakfast. That's seven women, counting me, and one man in the lounge. Unprecedented.

I felt like climbing onto a table and dancing and singing at the top of my lungs. I didn't. That would have looked crazy. Instead I walked over to the table with the one doctor I knew in the room and said, "I have been here seven years, and I have never been in the presence of this much estrogen in the doctor's lounge."

It is usually an all Caucasian male crowd, with a few exceptions to the former descriptor. Rarely women. I could sit down and chat, but why? To listen to random sports talk I had nothing to contribute to? I usually just get my coffee and maybe a hard boiled egg if I forget my bean burger for lunch while eavesdropping. I leave quickly.

I wandered over to the coffee area to make tea, still resisting the urge to sing and dance something crazy and free and female-oriented. Alicia Keyes was running through my brain. "This Girl is on Fire"

After I made my tea, I walked back over to the table by the door. The PM&R doc said, "I was just telling them who you were." I introduced myself to the other docs by my first name. "I'm Gizabeth." They had super cool first names that complemented their appearances, which were not all Caucasian (I am Caucasian, but of the dark-skinned variety, so I'm not being prejudiced against that. But finally University melting pot in the doctor's lounge!). I learned that they were both new PM&R docs at my hospital. They trained all over the country. I thought of my friend Fizzy, and resisted the urge to say, "So what exactly does a PM&R doc do?" Because I knew. Thanks Fizzy. But I still don't entirely understand. No offense. My job is weird too.

After we chatted and I learned a little about them and they learned a little about me I really had to go. As I was leaving I said, "Looking forward to seeing you around here more often. There has been a dearth of estrogen around here for years. I think we need to create a balance. So that we can initiate our eventual takeover." We all laughed. Kidding. Sort of.

Being tough while pregnant

I was recently talking to a friend of mine who mentioned that another mutual friend was eight months pregnant and he was impressed that she was still walking around. Of course, I was offended because I was still working when I was in active labor.

But then I realized that maybe that wasn't something I should be proud of.

When I was eight months pregnant with my oldest, I totaled my car in a highway accident. I wasn't seriously injured and only required a night at the hospital. The worst thing that happened was I hit my head and had a concussion and a really bad black eye. I felt like with my pregnant belly, I looked like an abused wife. This was pretty much what I looked like:



My chief resident called me and told me he thought maybe I should start my maternity leave early. I didn't. Instead I went back to work only two days later.

When I went back, I was convinced that everyone was angry at me because I missed a call due to my accident. In retrospect, I'm pretty sure everyone felt really sorry for me.

Was it dumb to push myself that way? Possibly. I got through it and made it until my delivery day. And then I got the benefit of my six weeks of maternity leave with the baby instead of home alone.

Your turn. What's the dumbest tough guy move you made as a pregnant lady?

MiM Mail: Pharmacy vs MD

Hello Mothers in Medicine,

I came across your blog while researching whether female physicians could balance a family life as a working mother. Your blog has been very inspiring and I commend all of you.

Regarding my situation, I have just finished my first year of pharmacy school and have job shadowed in both the retail and clinical setting. I found the retail setting to be boring and tedious for the time I was there and figured the hospital setting would be more... upbeat. However, I was disappointed during my time at the hospital.

Now I am faced with the decision do I stick with pharmacy hoping to find some sort of specialty or other path in pharmacy that I will like that accompanies the stability and amount of schooling that pharmacy takes or I was considering a career in medicine.

My parents and friends haven't been very encouraging for the doctor route saying how could I have a life outside of school and then my work. When I bring up the issue in conversation I feel insulted because I have always been driven and decently gifted intellectually (I was Valedictorian) and yet I feel like the only person who believes I could do this, and I definitely have my own doubts, is myself.

I know you posted a blog similar to this, but I suppose the gist of my question is would you choose medicine as the same career path? And what is your recommendation for me between pharmacy and MD?

Thank you for your help!

K

Apical Core

I was looking at an apical core a few weeks ago. The surgeons take these cores at the apex of the heart when they are putting the patient on mechanical heart support. Most of the time there is bizarre cardiac muscle nuclear change from hypertrophy. Fibrosis. Iron accumulation. Amyloid. Pathologists look for different things based on the clinical history we read in the chart. This core was clean as a whistle. No fibrosis, tiny box-shaped nuclei. I looked at the patient age - 20's.

I delved into the chart to read about it - a 20 something year old that needed mechanical heart support? Was this viral? Genetic? The history showed no clue. A previously vitally healthy human being had gone downhill to this moment in just a few weeks. She was a student, a daughter, a musician.

A couple of days later I was rushing to finish my cases to leave early for my daughter's fifth grade graduation. I wanted to do something for her - something simple and sweet and manageable. I walked over to the hospital flower shop to chat with the florist. It was under new management and I enjoyed talking to the young energetic successor to the former manager. I explained to her what I was wanting and she pointed to a small basket of flowers.

"I was thinking more along the lines of a single flower. Something that would be easy to carry and give. Maybe a Gerber daisy?"

Her assistant came out of the back room. "What are the school colors?"

That's a good question. I had to reach. "Green and yellow."

"We have one yellow Gerber left."

As the assistant began to package the flower and tie a beautiful dark green ribbon around it I chatted with the manager. She was asking me about what I did at the hospital. The assistant suddenly joined in.

"Do you ever look at hearts?"

"Yes, actually I have an interest in that area. I see lots of explanted hearts and look at biopsies for rejection of transplanted hearts."

"I am asking because I have a friend in the hospital. It's her daughter. We are very close. I'm wondering if you would have seen her pathology. She was just put on support and is waiting for a transplant."

Oblivious, thinking about my schedule and my daughter and my day, I answered, "Oh yes we look at apical cores for mechanical support all the time. I saw one just the other day."

"Oh I wonder if it was hers? She's young, in her twenties, and we are all praying for her. Do you think you saw it?"

I suddenly put two and two together and became hyper-aware of HIPAA in my head. I told her, "Well, a lot of us look at those and we see them all the time. I doubt it was your friend's, but it could have been."

I turned the conversation back to the manager as she was ringing me up. The assistant became increasingly desperate with her questioning. She seemed to really need to know if I had seen her friend's heart core biopsy. She didn't need to know about it, but her entreaties and interruptions into my conversation with the manager were too much for me. I didn't want to violate HIPAA. I didn't want to give out any information. The manager seemed to feel my pain and supported me. "She is a pathologist. She doesn't know the patients, she just reads the tissue." I recoiled in defense.

"Well, that's not exactly true. I read every patient history. I latch onto the stories. Of course I am reading the information to get a better handle on the tissue, but every clinician adds a new piece of personal information to help me see the patient. I don't meet them, but I feel like I know them - some more than others. I'm just a voyeur, but I'm present."

The manager and I started talking again and I did something I'm not entirely proud of but it seemed like the right thing to do at the time and I am glad in retrospect. To placate the assistant I managed to slip in the 20 something year old's musical area of expertise innocuously into the conversation I was having with the manager. Whatever I said or didn't say worked. She relaxed and smiled and interpreted my silent acknowledgement as some sort of reassurance. Suddenly she said, "I have to show you a picture of my friend's daughter. I just want you to see her, even if you weren't involved in her care."

The manager said, "She's busy and she is in a hurry."

I told her to take her time I would wait. I would love to see her friend's daughter. She pulled up a photo on Facebook on her phone and showed me. I was totally unprepared for my response. She was incredibly beautiful, and suddenly and surprisingly tangible in a way so much of the tissue I see isn't. I had seen a piece of her heart just the other day. I never get to see the patient. I read and read and read but there is never a human face connected to the tissue. My eyes welled up and I choked back a sob.

The manager told her assistant, in a loving but chiding way, "Look what you did you made her cry!"

I replied, "No, it wasn't you. I am a little emotional about my daughter." I looked the assistant straight in the eyes as mine were trying to clear of tears. "Thank you."

Guest post: Two points for knowing what you don't know

I’m driving the kids home from school, winding along Dollarton with afternoon sun glinting off Burrard Inlet, and Saskia’s telling me about the Gauss Mathematics Contest she wrote that morning.

“I left one question blank,” she begins. It’s a confession: a perfect score is off the table. She doesn’t add up test scores, she works back from 100. She goes on, “But I did that because of how the scoring system worked. You got six points for a right answer, two points if you left it blank, and zero points for a wrong answer. I wasn’t sure about the last question, so I just left it.”

I make her repeat that, making sure I have it right, because I know I’ll be chewing on this for days.

They were rewarded for leaving alone what they didn’t know.
Making a wild stab at an answer was worth less than no response at all.
For once, it wasn’t about doing one’s best, but about acknowledging one’s limitations.

* * * * * * *

I was assigned to a family practice when I began residency in 2000, for several 4-week blocks over the two year program, and callback every Thursday afternoon. It was an established practice on Broadway and Granville, and a good group of doctors, but I dreaded seeing the patients, mostly well-heeled reproductive aged women.

Making a diagnosis and treatment plan on my surgery rotation, or in the emergency room, wasn't a problem, but these women kept presenting with issues that weren’t in any textbook. One couldn’t interpret her baby’s cries; another needed advice on dealing with strangers’ remarks on her child’s birthmark; the next had discovered her teenage son’s porn collection. Working at this family practice was by far my least favourite rotation, and I was doing a family medicine residency. That worried me.

My preceptor and her partners took the entire clinic out for Christmas lunch that first year, between morning and afternoon clinics packed with patients wanting to be seen before the holidays. I remember Sarah pausing during the meal and saying to me congenially, “You know when we knew you were okay?”

I had no idea, but I was relieved they’d arrived at that conclusion.

“Remember that rash?” she asked. “The four-year-old with the vesicles on his legs who’d just come back from camping?”

I remembered. Yet another patient that had had me stumped.

“When I asked what you thought it was, you said ‘I don’t know,’” she went on. “That’s when we knew we had a good resident.”

The other physicians agreed. “We don’t care what you know,” said Joan. “We care that you know what you know.”

* * * * * * *

I teach residents myself, now, and it’s true - I don’t pay particular attention to how comprehensive their knowledge bank is, but to whether they recognize what’s missing. Nothing raises a red flag like a learner who already has all the answers.

And then there are the patient encounters where you can’t turn to UptoDate for backup. Sometimes there really isn’t an answer, in that brisk bullet point way that physicians love. Sometimes the P of SOAP feels terribly inadequate; writing ‘counseled’ or ‘conservative’ or ‘follow’ feels like a fail. Physicians get the God-complex jokes all the time, but from where I sit, we're keenly aware of our limitations. Medicine teaches you how very much is unknown.

That's using the Gauss scoring lens to look at one field in one profession. Imagine if we approached everything from a place of humility.

I read comments on news articles on refugee matters, vociferous ones, that are ignorant of the basic facts of the system. I’ve heard someone predict the eternal destiny of another person’s soul with the same degree of certainty that they state their summer vacation plans. I’ve seen someone with no more than Biology 11 comment with the authority of an immunologist on vaccines.

I can't say that those lessons I've learned in medicine have overflowed into every other part of my life, either.

So how about each of us, the next time we’re in a conversation - with a client, in a staff meeting, on social media or out to dinner - consider whether we truly know the answer to the question at hand.

And if not, take two points for keeping our mouths shut.


Cross-posted at www.freshmd.com and www.mothersinmedicine.com

The Undeprived Child

Two words which could easily describe my sisters and me growing up would be "deprived children." We never went to the beach, the zoo, the park.  We weren't allowed to roller blade.  We didn't have many friends.  We just didn't experience all that much.  Part of the reason for this was that we were just too poor, but the other more important reason is because my dad was over protective and did not allow us to participate in activities that may get us sick or hurt in any way.

Now I'm a parent myself, and I'm proud that in the last month, my husband and I have taken our Doll to the zoo, the city, and the beach!  Which was a serious point of contention among my parents...

"It's too dirty!!" My mother said.

"It's too hot!" My father said.

Even my older sister who has a toddler and an infant refused to come with us.  "He doesn't like big bodies of water," she said referring to her two year old son.

We went anyway and had a blast, and sent pictures to prove it!  Here's to hoping my Doll can really experience this world... Not like her deprived Mama!

Online Mothering Mentor

Her name is Catherine Newman.

I've only commented on her blog once or twice.

I found her when I was pregnant with Cecelia, and she was pregnant with her daughter Birdy. That was 12 years ago.

I followed her weekly "blog" on babycenter.com before blogs even existed.

I read her book, even though I didn't need to because I read all those posts.

I followed her when she left to start her own blog.

She now writes on Dalai Mama, among other things.

She is a fantastic cook. She posts recipes, and when I try them once or twice a year when I have time they are fantastic.

Her crack broccoli is a fave go to at my house for a veggie on a school night. Her fried eggs with sizzling vinegar is one of my most beloved dishes.

I occasionally read what she is reading. Buy the games she is playing with her family. Recommend them to my friends.

I am still catching up on blogs from when I did not have internet on vacation last week. Catherine has been writing articles for New York Times on Motherlode over the last year or so. I read one today that brought me to my knees. It's not the first of her articles to do this to me.

That's why I'm writing this post. To share this fantastic article. Give kids your undivided attention - Or no attention at all. I'm taking an evening weekly six week parenting class from a highly experienced social worker based on a book her husband co-wrote - Parenting the Strong-Willed Child.  She trained in urban Atlanta and rural Mississippi and has two grown children. Catherine's article reminds me of what I am learning there to supplement my own awesome but lacking in some areas (aren't we all?) parenting. Strategies to gain control of your relationship to your kids and help them prosper and grow with capability and responsibility and love. I've got fountains of knowledge from this class from both the social worker and other parents despite only being halfway through it.

Thanks for everything Catherine. You don't know me but I love you!! Thanks especially for all the substitute mothering.

MiM mail: His sacrifice or hers?

Hi everyone,

I've been reading this blog looking for pearls of advice and wisdom ever since I was accepted to medical school just over a year ago (in Canada).  When I interviewed for medical school, I was actually 8 weeks pregnant with my first daughter.  I decided to defer for the first year to stay home with my daughter.  Now the time has come to decide whether I indeed do go back to school and become a doctor. This situation is complicated, and I need some advice from some women/mothers who have been there.

A little about me: I am a 32-year old (will be 33 after 2 months of school) family nurse practitioner.  I have a great job and work with an amazing team, but no I have no flexibility in terms of hours.  I have decent pay (but no real opportunity to grow). And the nurse practitioner role is still developing in Canada so there are many other "issues" with the profession as well, including barriers to practice, funding/remuneration issues, and scope of practice limits.  Not to mention that most people in Canada don't even know what a nurse practitioner is.  When I tell people, they think I am training to be a nurse. That aside, I know I would love a career in medicine.  I've been in the healthcare field myself now for over 10 years, and I think I have a pretty good idea and sense of the role.  My daughter will be 9.5 months if/when I start school, and I do want/plan to have 1 or 2 more kids.

The situation is complicated because I was accepted in a different city and province from where we live now.  My husband is working at his dream job and has NO desire to leave it.  He feels (and has been told) that he is on a great trajectory with the company, and has already been promoted a few times in the 2.5 years that he's been with them.  There is no office for this particular company in the city we would have to move to.  There is no family of either of us in the city that we have to move to (but there isn't now either). We just got into an AWESOME brand new daycare on the campus of my current job (for which I am still on mat leave), but we have to pay the monthly fees as of now in order to hold her spot until I go back to work in October.  This is pricey, plus if we end up moving, a huge waste of money. But if we stay, it is super convenient, as I would just have to bring my daughter to work with me and could pop over between patients and see her!

Essentially, it has come to either myself or my husband sacrificing for the other.  He has his dream job with great future prospects.  I can have my dream job in medicine, but not for another 8-ish years (I would probably specialize). Plus, we will go from a two-income family living a comfortable life, back to going into debt and living a student lifestyle. Also, I don't really know how much time I will have for my kids during all of this training. And is that what is best for them? I really don't know what to do.  I feel so guilty about uprooting and making him quit his job if we go.  He doesn't have any prospects in the new city as of yet either, which makes it hard for him to visualize being there.  I can visualize myself there because I know I would be starting school etc.  We have decided that we need to do what is best for our family (daughter and future children). But we can't seem to figure out which path is "best." I wish I had a crystal ball to look into the future and see how each path would turn out.  I really really want to go, but he really really wants to stay.  We both said we would sacrifice for the other, but that still leaves us with a decision to make, and we are having such a hard time.  Any thoughts or advice or wisdom would be MUCH appreciated.

Signed,
Confused

What Does "Lean In" Mean? Whatever You Want It To.

Genmedmom here. You'd think that as a doctor and a mother and a blogger with a focus on work-life balance, that I'd have been psyched to read Sheryl Sandberg's Lean In. Truthfully, I dreaded reading it.

I figured I'd have to read it sooner or later, given what I do, and I wasn't looking forward to it at all. From the bits and pieces I'd heard about it, I assumed that it must be a pushy, finger-wagging manifesto designed to make me feel more guilty that I already felt.

But I felt guilty NOT reading it. So one day, when I ordered a bunch of books on Autism (our son is autistic) and a few Barbara Brown Taylor essay collections, I also ordered Lean In. It sat on my bedside table for about a month. The other books got read (I read a lot), but Sheryl's smiling face looked up at me night after night, book closed, waiting.

Finally, one night, after the kids were down and charts were done and my brain needed some book reading for an hour or so, I realized I had nothing else to read but smiling Sheryl. I very reluctantly opened it...

And she had me at the second paragraph of the introduction.

She describes how she gained seventy pounds in her first pregnancy, and suffered from brutal nausea the whole time; how she struggled with simply walking, and realized that Google needed to have pregnancy parking close to the building, for all pregnant employees. So she made it happen. Wow.

Flashback to my pregnancies, where I gained, yes, seventy pounds, and felt awful, and struggled with simply walking... Like many employees of my big city hospital, I park at a garage about a mile away, and walk in. For my first pregnancy, my manager gave me a handful of parking passes that I used in the last ten days. That was great, but it was the last ten days, and there weren't any for my second pregnancy. I remember waddling painfully to and fro...

The point of her sharing the anecdote is to illustrate that she didn't realize how helpful pregnancy parking would be until she experienced it for herself. She wondered how no one brought it up before:

"The other pregnant women must have suffered in silence, not wanting to ask for special treatment. Or maybe they lacked the confidence and seniority to demand that the problem be fixed. Having one pregnant woman at the top- even one who looked like a whale- made the difference".

The book continues in this style, outlining the significant challenges women face in today's workplace, dotted with personal anecdotes and shared stories, humor, and problem-solving suggestions. There's plenty of data, but it's not boring. I was surprised at the praise, validation and encouragement for women at all angles of leaning in, including those who work part-time or stay at home. There is very little by way of exhortation; actually, I had to search for anything:

"I have written this book to encourage women to dream big, forge a path through the obstacles, and achieve their full potential. I am hoping that each woman will set her own goals and reach for them with gusto."

I actually enjoyed this book, and strongly recommend it to any woman considering a career in anything.

So, why did I dread reading it? Why did a book described everywhere as "an inspiring call to action" sit gathering dust on my bedside table for a month?

Well, as an internist who works part-time and mother of two young children, I've been exhorted, invalidated, even attacked. So, I assumed Sandberg's book would be another attack. It's not every day, but I'm sure I'm not the only part-time physician who has encountered this, the face-scrunching and "So, how does THAT work?" or a "Don't your patients get frustrated that you're not fully available?" kind of thing.

The attack most famous came from a senior female physician. I remember how sick I felt when I read anesthesiologist Karen Sibert's Op-Ed "Don't Quit This Day Job" in the New York Times (June 2011). In this essay, she doesn't just frown upon women working part-time in medicine: she crushes them. Worse, she crushes the aspirations of those considering medicine as a career:

"I recently spoke with a college student who asked me if anesthesiology is a good field for women. She didn’t want to hear that my days are unpredictable because serious operations can take a long time and emergency surgery often needs to be done at night. What she really wanted to know was if my working life was consistent with her rosy vision of limited work hours and raising children. I doubt that she welcomed my parting advice: If you want to be a doctor, be a doctor....You can’t have it all."

The death blow, however, was to people like me,

"Patients need doctors to take care of them. Medicine shouldn’t be a part-time interest to be set aside if it becomes inconvenient; it deserves to be a life’s work."

The... what do you call this? It wasn't an implication or an accusation, it was a sound dismissal of MY life's work. I have a small panel of patients, commensurate to my four clinical sessions per week. I work in a warm, nurturing environment, in a group practice of all part-time female internists. We have excellent clinical support staff. We enjoy great flexibility in our hours. We also are also regularly evaluated and rated by our patients, as well as our hospital, on various criteria ranging from patient satisfaction surveys to outcomes data comparisons between practices, and we perform extremely well.

I also have two small children, ages two and three, a working husband who is a wonderful partner, and family close by. I'm almost always home for dinner, and enjoy most weekends with my family. Yes, we carry pagers and are on call for ourselves Monday through Friday, with weekend calls shared, and there are occasional calls at less opportune times (bathtime, bedtime..). And, with the advent of the patient portal, where patients can communicate with providers online (kind of like email), they can send me a message basically anytime. But overall, clashes between work and family are few and far between.

My gut sense is that what I have going works. Most of my patients are working women, and I'm open and chatty about being a working mom (can you tell?). My kids' photos are up in my exam room, regularly updated, and patients eagerly ask about them, just as I inquire about their families. We trade stories. I receive solidly positive feedback from patients and colleagues alike. (I feel weird putting it on paper, all this positivity, but isn't that what we women do, is downplay our achievements?)

THIS is my "leaning in". I do not aspire to be a department chair, to publish in the peer-reviewed literature (though I have), or to have my own office with puffy leather chairs. I have made the considerable achievements of graduating from medical school, surviving residency, and thriving in a highly regarded primary care practice. I want to be a good doctor and a good mother (and to write about it!) I believe that you CAN have all this, because I do.

That is the beauty of the message from Sheryl Sandberg: "leaning in" isn't a one-size-fits-all formula. As in the quote above, she hopes that women set their own goals and reach for them.

Sandberg also talks about how women need to help other women achieve their goals. I agree with that, and it starts with pregnancy parking! It also includes calmly ignoring even senior female docs like Karen Sibert when they try to force a one-size-fits-all, my-way-or-the-highway approach onto a career path as variable and malleable as medicine. Sandberg discusses the phenomenon of senior women not only being unhelpful, but even hindering the progress of the up-and-coming women:

"Critics have scoffed at me for trusting that once women are in power, that they will help one another, since that has not always been the case. I'm willing to take that bet. The first wave of women who ascended to leadership positions were few and far between, and to survive, many focused more on fitting in than on helping others. The current wave of female leadership in increasingly willing to speak up. The more women attain positions of power, the less pressure there will be to conform, and the more they will do for other women."

So, read the book, and either make your way up, or reach a hand down. Set goals and "lean in" any way you choose, because only you know what is right for you, and if it's right for you, it's all right.

And I'm interested to hear what others think of smiling Sheryl's book.

evolution

I've been a practicing oncologist for all of seven months, and so was surprised when my chief asked that I take part in our quality review panel. The quality review panel is an internal group that is tasked with the responsibility of looking into allegations that a patient's care was not in keeping with best practice or what is generally considered the standard of care. Cases (often in the form of a complaint) can be submitted by patients or the nursing staff, but more frequently come from other physicians.

Cases are reviewed and scored individually by each member of the panel, and the composite score is used to determine whether corrective action should be taken. Although physicians whose cases are repeated scored "P2" - in which the standard of care was clearly violated - can be forced into remediation, the purpose of the review panel is didactic, not putative. And to that end, the standard is different than that of a legal proceeding - there need not be a bad outcome in order to determine a case P2, only that the expected level of care was not that which was delivered.

Obviously I can't go into the specifics of the cases or the physicians, but what I've been impressed by so far is the recurrent sin of omission. The incidences in question didn't involve the wrong therapy, intended deception, or malice, but the accumulation of small omissions - documentation, timely follow up, etc that morphed into a larger problem. Data management and communication also came up as frequent offenders. 

In one or two cases I felt the problem was that the physician - a few of whom had been practicing medicine while I was still in grade school - couldn't or weren't able to evolve with changing expectations. We are expected to be transparent, thorough, and accountable for what the patient does and does not understand. There's an astounding amount of information to be managed, including but not limited to the electronic medical record, patient email, open notes, and the near-entirely of uptodate and pubmed.  I can speak better to what is happening in my own field - where fifteen years ago there were about that many different types of chemotherapy. Now there's fifteen new drugs coming out every year. 

I started thinking about what it means to evolve and what its going to look like for me over the course of my career. I've found the review experience hugely instructive in that I understand better how physicians get themselves in trouble, but I've also found it unnerving. Twenty years from now the central tenets of"being a good doctor" might be entirely unrecognizable when compared to today. 

I wish I had a note of conclusion on which I could end this post, but I don't. I am just beginning to see how important professional evolution will be, but I have no idea what that really means.