A View from the Trenches

The line starts forming outside the building around 6 AM. When I walk from the parking lot to the cafeteria to get my morning coffee, I see my patients, crowded under the awning, ready for the monthly ritual of coming to a county cancer clinic. Many of them have bags packed with magazines and snacks. Some are catching up with other patients who have become their friends. Some are holding sleeping grandchildren in their arms. I marvel at how they have adapted their lives to a clunky bureaucracy that doesn’t respect their time. The ones who are first in line may get in before noon, and maybe even get their chemotherapy the same day. The ones in back of the line could be there until 8 pm at night, and then have to return the next day for their treatment. 

Inside the clinic hours later, I am running back and forth between two rooms, seeing patients as fast as I can. I sit down in one room and ask Maria how she is doing. Immediately, she bursts into tears. She lost her apartment this week because she has been unable to work. Her landlord wouldn’t even let her back in to get her clothes. Her nephew was kind enough to take her in, but her chemotherapy schedule has made it impossible for her to get a new job. We discuss how she has been through multiple lines of chemotherapy already, and options are limited. There is no cure and I can’t guarantee that what we are doing now will help. She nods acceptingly. Maria asks only one question: do I have a cell phone charger for her flip phone? The battery died, and her ride’s number is in there. We get lucky in the waiting room and find another patient who has a compatible charger with her. Maria is happy for the small victory.

I see Gloria next. It’s an easy visit. She has completed her treatment. When I enter the room, her husband has his arm around her shoulders, and her sister is holding her hand. They look at me with anxiety and anticipation. I cut to the chase. “I have good news. We don’t see any cancer on the CT scan.” I am pulled into a group hug. “You saved my life!” Gloria exclaims. Her sister cries, and the husband leans back in his chair with relief. I give my spiel about close monitoring. They ask if she can go to the Philippines for vacation. I joke, “Only if you take me with you!” Everyone laughs, as months of blood tests, side effects, and fear momentarily melt away.

I close out my day with Lily and her husband, quiet people who have been coming to the clinic for years; her disease is stable. Her husband tells me that on my recommendation, they bought a new bed. Not only has Lily’s back pain improved, he is also sleeping better. Lily’s wig is askew, and she looks distracted. She shares that her daughter is having a baby soon. I congratulate her and ask her when she is going to visit. She points to her percutaneous nephrostomy, a drain that empties urine from her kidney, and says she doesn’t think she can be around a newborn with that “dirty tube.” I see from her recent imaging tests that the kidney has minimal function, and I propose we remove the tube. Lily laments that it takes weeks to get an appointment with the interventional radiologist. I step out of the room to call; the radiologist confirms that it would take weeks for him to see her, and I ask for instructions to remove the tube myself. When I cut the hidden sutures and the tube smoothly slips out of Lily’s back, she stiffens for a moment, then relaxes. “Ok, I want to see the baby pictures,” I tell the couple. Lily smiles for the first time that day, “You are a good doctor.” Her husband beams at me.

When I chose to sub-specialize in gynecologic oncology, I thought my days would be filled with operating, concocting chemotherapy regimens, and staying up to date on clinical trials. What I found out very quickly was that being a gynecologic oncologist often has more to do with managing the fall-out of cancer, rather than the cancer itself. Patients come wanting you to make the cancer go away, because they think you have the secret to making their lives normal again. Over and over, my patients tell me they will do anything I say. They bring in soaps, fabrics, recipes, and herbs for my approval before use. They want my permission to take day trips. Betrayed by their bodies, they no longer trust themselves to know what’s safe.

The humbling reality is that there is no cure for most cancers right now. We can do everything right and cause harm to the patient; we can do everything wrong and the patient thrives. My job focuses instead on empowering the patients to regain each precious moment of their lives, despite the cancer. I try to convince them that cancer is an aspect, not the totality of their existence. And in the final moments when there is no earthly solution for the suffering, I try to help the families make peace with what can’t be controlled.

In this way, I am comforted that my work serves some good, even though it is far from perfect. In the trenches of the War on Cancer, the small daily battles matter just as much, because so many unique lives hang in the balance.

An Essential Connection

When I first met José, he was already intubated in the ICU, breathing only with the help of a ventilator. Suffering severe pneumonia, he had been found unconscious in his apartment by the landlord. José wore a crucifix around his neck, and had a business card for the local LGBT center and a bottle of HIV medications in his pocket. There were no documents to confirm his identity.

For weeks, my medical team and I meticulously watched over José’s physical health. Twice, his lungs collapsed and we put in several catheters to re-inflate them. Five times he went into respiratory failure despite being on maximal mechanical support. We spent hours manually pushing air through his breathing tube to keep him alive. A multitude of continuous IV medications and blood products maintained a semblance of vital signs. Drains in his bottom kept him clean and dry. We could not feed him because he had persistent bloodstream infections. Every week, the quality assurance team came by to ask: What are your care goals?

This is usually a question my medical team and I would discuss with the patient or a patient’s family. But José could not be woken up and no one ever came to see him. Fingerprinting turned up no leads. No missing person’s report had been filed fitting his description. We called the doctor who wrote José’s prescriptions. He gave us the number for an emergency contact; however, that man said he had not seen or heard from José for months and knew no personal information about him.

José’s profound disconnectedness troubled me. Every day, his nurse and I evaluated all his tubes, medications, and machine settings with extra care, trying to compensate for his loneliness. I would squeeze his hand for a moment before I left, though I wondered if he was still with us in this world. The immensity of his solitude weighed on me. He could pass away without anyone who had ever mattered to him having a clue.

How did José become so cut off? Was it because he was gay or HIV positive or both or something else altogether? Working in a safety net hospital, I have cared for many people like José, who are hanging by mere threads in the margins of society. What kills them, and often in heartbreaking ways, is not their medical illness. It’s their social isolation. Stigma is the cultural stress that ultimately extinguishes their lives.

When academics talk about “vulnerable” populations, they are usually referring to people who have no money, no power, or need public assistance to thrive. Health care disparities are defined along demographic factors like ethnicity, income, employment, education, and marital status. Ultimately though, what makes certain groups more vulnerable than others is not the category they identify, or are identified, with; it’s how connected they are to other human beings. Poor people can belong to strong communities that will take care of them in times of need, and thus be resilient. The same goes for people who are unemployed, disabled or uneducated. People only end up on the street when they don’t have anyone at all.

It is in this light that I have come to appreciate marriage equality as an important and relevant policy issue for our society. Beyond civil rights and basic human dignity, marriage creates a connectedness that is protective against life’s unknowns. When crisis strikes, it is a buffer that prevents people from ending up like José, who essentially became a ward of the state. What cause does the public have to deny equal benefits to consenting adults who want to make a lifelong commitment to each other? Why do we still quibble over gender when so much collective good is at stake?

The same month I took care of José, I met Oscar and his “cousin” Eddie. Like José, Oscar also came to the hospital with severe pneumonia, but Eddie was with him, and brought him in in less critical condition. I was able to counsel both of them about intubation when breathing became too difficult. Oscar designated Eddie as his health care proxy. As long as Eddie was there, Oscar did not require much sedation and pain medication. We could see how quickly his heart rate and blood pressure improved with Eddie by his side. One quiet night, I finally asked Eddie why he introduced himself as Oscar’s “cousin,” when it was obvious that he was his partner. Eyes to the ground, Eddie muttered that he was afraid we’d kick him out if we didn’t think he was “family.” I started to apologize if we had made him feel uncomfortable in any way, but he interrupted and said, “It’s not you. It’s Prop 8 that’s been hard on us,” as he laid his head on Oscar’s chest. “When will you be able to take this tube out, Doctor?”

As a whole, we have enough intractable conflicts to contend with, without wasting valuable time and resources to set up more stumbling blocks for ourselves. The ultimate goal of government is to provide an infrastructure for diverse peoples to live peacefully, happily, and freely together. Marriage equality on this level isn’t about interpretations of religious text, historical precedent or legal technicalities. Moreover, it is not about whether or not the private sex lives of two people make us feel “icky” or not. As far as our elected officials are concerned, marriage is a simple civil construct to bolster beneficial human connections that spill over into all aspects of our lives - at work, in schools, in hospitals, in neighborhoods and beyond. Pride can overcome individual shame, but it takes all of us together to remove stigma. It’s time to end the unnecessary suffering.

Achieving Physician Autonomy

The American Medical Association and the American Association of Medical Colleges reported recently that increasing numbers of medical students are seeking dual degrees. The most popular combination was the MD/PhD for physician-scientists, followed by MD/MPH for physicians with public health interests, MD/MBA for physician-entrepreneurs, and lastly MD/JD for physician-lawyers. Despite the extra time and money, MD candidates believed that additional training would lead to a more sustainable, and perhaps, more productive career.

Interestingly, my dual degree, the MD/MPP was not discussed in this article. MPP stands for Master’s in public policy, a hybrid between an MPH and an MBA with a dash of public administration. My fellow MPP classmates included healthcare providers, state officials, presidents of foreign countries, military leaders, and directors of nonprofit organizations. I was drawn to the program because it allowed me to learn from my classmates, as well as experts who taught in the law, education, public health, and business schools of the university. When a number of my teachers and classmates left abruptly to return to government service after the 9/11 tragedy, I felt even more thankful for the richness of knowledge and influence that was expanding my view of the world.

Many people over the years have asked me why I chose to take this detour. Being a nontraditional candidate doesn’t win you many points in what remains a conservative application process for medical school. I was frequently asked during residency and fellowship interviews why an aspiring doctor would waste time dabbling in public policy. I told the truth: I wanted to learn how to protect my patients from the system. I never wanted to feel helpless in the face of laws, regulations, and bureaucratic red tape. My interviewers liked how I emphasized the primacy of physician autonomy.

Sit down with any group of doctors and you will hear that we want people to stop getting in our way of taking care of patients. Just last week, Dr. James Breeden, the president of the American College of Obstetricians and Gynecologists, wrote an impassioned letter to the editor of the New York Times, demanding that politicians “get out of our exam rooms.” The letter struck a deep chord within the physician community. Throughout 7+ years of education, we were preparing to combat disease and to hold the doctor-patient relationship as sacred. Then, we graduate into the world of clinical practice, and realize that the U.S. health care infrastructure was not created to support our mission. Doctors lose hours on the phone trying to convince insurance agents to approve indicated treatments. Scheduled surgeries are cancelled last minute due to nurse under-staffing. Uninsurable patients with pre-existing conditions go to emergency rooms for routine care. Hospital financial managers tell families that their unconscious loved ones in the intensive care unit have to go elsewhere because they have the wrong insurance.

In pursuing a dual degree, my colleagues and I wanted to guarantee our independence in an often-dysfunctional system. Autonomy should naturally develop from greater self-sufficiency and competence, and we would have more letters after our name to confirm it. Yet, 12 years into my pursuit for autonomy, I find myself going back to a lesson learned early on during my public policy years -- team players get better results than lone wolves. When faced with serious problems, professional collaboration usually trumps single expert opinions in getting things done.

I especially remember the Spring Exercise in graduate school, a class-wide activity in which 130 of us were expected to organize and produce a detailed solution to the issue of HIV/AIDS in Africa, using real-time data. We had one week to prepare the report and presentation for faculty members. I still recall the stunned pause in the auditorium when my classmates and I wondered how we could possibly complete this massive assignment, not knowing each other’s names, much less worked together. Then, we rose to the occasion. We formulated objectives and assigned them to committees based on our majors and interests. We made contact lists and set up a strict schedule of meetings. We had daily check-in times when every committee shared their progress with the entire class. We debated, negotiated, walked away from the table, came back to the table, and ultimately drew up an extensive policy brief with graphs and figures, a budget, and a political strategy for execution. Who knew a ragtag collection of people from all over the world with various backgrounds could pull together and accomplish a common goal in 7 days? During our final presentation, we found out that our work would be given to the Secretary of State for review. It was exciting to hear echoes of our efforts in subsequent government briefings.

I didn’t appreciate the true power of the Spring Exercise until years later, after I have stayed up nights wondering why our health care system is so inadequate. It was a success that continues to remind me of what’s possible. Medical training encourages lone wolf behavior, but health care reform needs team players. Doctors want to be left alone to do our work, but sustainable autonomy won’t happen until we let go of our siege mentality and look for solutions outside our comfort zone. I had originally set out to equip myself for independence, but instead, I’ve learned that our problems are too big and too complicated to tackle alone. I hope that what our country is experiencing now is that pause in the auditorium before the action gets underway. 

Choosing to Practice Good Medicine

“We need you to counsel a pregnant patient about getting an MRI.”

In my public, inner-city emergency room, when the medical student calls requesting an OB/GYN consult, I know it’s been a bad night down there. Heading over, I could already envision the rows of patients shivering in half-open gowns, waiting hours to get answers to the emergent reasons that brought them to the hospital.

The medical student led me to the patient, asleep and huddled under her coat. “Her temperature is normal, but her pulse is on the high end and she has vomited 2 times. We think she has appendicitis. The ultrasound shows an 11-week pregnancy, but couldn’t visualize the appendix. Surgery team hasn’t seen her yet, but recommended an MRI.”

I flipped through the chart as the medical student spoke. The patient had been driven in by a co-worker, who found her vomiting in the bathroom at work. Since her arrival to the ER, she has been given intravenous fluids and a single dose of nausea medication. Her care had now passed on to the next shift. The new team wanted to do further testing.

“Why do you think she has appendicitis?”

“She came in with abdominal pain, hasn’t wanted to eat and has a slightly elevated white count.”

“That can be normal in early pregnancy. Tell me about her chief complaint and initial exam.”

The medical student sheepishly admitted that he didn’t have the details. The patient spoke minimal English.

A surgeon by training, I tend to tread carefully when it comes to medical interventions. My mentor taught me early on that I should think through every history question, physical exam element, and diagnostic test, as judiciously as I would for major procedures. His mantra was: What is the indication? Clinical decisions should be focused on doing the appropriate thing for the specific individual. “Every patient is your grandmother, mother, sister, or daughter,” he liked to say. I took his words to heart.

I set up the translator phone, and gently tapped the patient’s shoulder to wake her up.

“Can you please take out this tube?” She winced and pleaded, pointing towards the catheter that led from her bladder to a bulging bag of clear urine on the floor. Sympathizing, I took out the catheter, figuring this would build rapport. She exhaled with relief and gratitude.

“How are you feeling? How’s the pain, the vomiting?”

“Much better now.” She elaborated that she always had terrible morning sickness with her pregnancies. But because she didn’t want her new boss to know she was pregnant, she had allowed herself to be taken to the hospital.

Finishing up my evaluation with an abdominal exam, I concluded that the patient probably didn’t have appendicitis. What she needed was not an MRI, but prenatal vitamins and a prenatal appointment. I gave her the obstetric clinic’s business card and told her to follow-up within 2 weeks, or call if her condition worsened. She nodded and said, “I need to get home to my kids. What time is it?”

My ER colleague was hesitant about my plan. “The MRI is already ordered. We don’t want to miss anything.”

I understood that my colleague wanted to be thorough, though critics may call it defensive medicine – performing additional tests on the patient primarily to protect the physician from potential malpractice claims. In my mind, appendicitis was not likely enough of a diagnosis to warrant extra hours in the emergency room and an uncomfortable, hi-tech imaging study. The MRI would contribute little to our therapeutic decision-making, especially since the patient has improved already. Moreover, we could find ourselves trying to explain physiologic cysts, pelvic fluid, and other routine incidental findings, causing undue distress for the patient.

That, in a nutshell, is my problem with defensive medicine. The weight falls disproportionately on the patients. They and their families lose time, money, and sleep for no health benefit. Over time, this phenomenon erodes the essential trust between doctors and patients. It gets harder and harder for patients, already in a vulnerable state, to differentiate when their doctors are advocating for them, versus when their doctors are fearfully responding to a mix of real and imagined pressures on their reputations and bottom lines. This only adds fuel to the fire.

Malpractice litigation is a hostile, inefficient, and sometimes unjust process in our society. Most suits are dropped and most plaintiffs never get any money. Defense costs are high whether or not there is a payout. Existing laws try to pin the blame for failures of a broken health care system on individual physicians. My OB/GYN counterparts working in underserved areas get sued more, not because of bad outcomes, but because the patients are poor enough to become easy targets for solicitations on TV, public transportation, or the hospital doorsteps.

Despite this harsh reality, defensive medicine, or shifting the burden onto the sick, is not the answer for anyone involved. The solutions are tort reform, better communication, and meticulous documentation. While doctors push for change, we can’t budge on our responsibility to make the tough judgment calls that match the right tests to the right patients. It’s not acceptable to create an illusion of excellence by doing more; we have to provide actual, evidence-based, clinically rigorous quality care. More is just more, not better.

In this case, I chose the diplomatic path. “I don’t think your approach is unreasonable. Given my observations, I think she is safe to be discharged for outpatient management. Here is my full consult note. I won’t be offended if you don’t use my recommendations.”

My ER colleague sighed deeply. “Ok. I hope you’re right. Sometimes, I feel like we’re playing Russian roulette.”

“I hope I’m right too. I have a large bottle of Pepto-Bismol in my office if you need it.”

“Don’t worry. I’m prepared.” He showed me the package of Tums in his pocket.

We laughed. It takes guts and a very strong stomach to practice good medicine.

From Laboratory to Patient; From Theory to Cure

Less than a year ago, I packed my belongings into my MINI and drove towards the Pacific Ocean to begin a three-year fellowship in gynecologic oncology. I passed through the diverse landscapes and cultural environments of the South, Midwest and West to arrive at my final destination – a cancer research laboratory.

Cancer 1, Doctor 1 (Part 2 of 2)

I left work after my dermatologist broke the bad news that I did indeed have cancer. He had said that my type of cancer wasn’t so deadly that I should drop everything and find the nearest qualified surgeon; however, he added he wouldn’t wait too long. He gave me two names to look up, experts he’d trust with his own face. I appreciated how he fed me the information in digestible bits, and then gave me a straightforward task. It distracted me from thinking about how we don’t really have a cure for cancer.

At home, my partner and I set to work decoding our insurance coverage. We searched through hundreds of network physicians and learned that none of them performed the surgery I needed. In fact, none of the health plans available through my employer – HMO, PPO, POS, union-run – would cover the treatment. So, we called up the two specialists recommended by my dermatologist and asked for quotes. Would it be hundreds, thousands, or tens of thousands of dollars?

At the university hospital, no one could answer the question. One friendly nurse philosophized that our hospital should be offering comprehensive insurance for its own providers. I wish one could assume, but I wasn’t in the mood to ponder the capitalist, for-profit nature of our health care industry. Imagine going into a store and being forced to buy something for the sake of your life. What incentive do suppliers have to keep products accessible and prices low, when consumers have to make a purchase regardless? I just needed to be cancer-free, ASAP. I didn’t have time to wait for health system reform.

The private office we called next connected us to their billing person, who briskly listed the costs, line item by line item. Encouraged by the office’s efficiency, I requested the earliest available appointment...four weeks away. A good friend of mine confirmed from people who had worked directly with this surgeon that he was among the best in his subspecialty. My parents agreed to help me with the bill.

I attempted to relax as I counted down the days. In preparation for my treatment, I reviewed the latest literature on my cancer and informally consulted colleagues to make sure I was making the right decision. I wrapped up loose ends at work. I purchased a wide-brimmed hat. The weekend before, I stocked the refrigerator with fruits, vegetables, and ice cream, and cooked a large pot of chicken soup. I bought the recommended list of wound care supplies. All in all, I was ready. The goal was to stay in control, keep everything predictable. My cancer didn’t have to be any more disruptive than getting my car washed.

My surgeon good-naturedly obliged my need for order. While I laid stiffly on the operating table, he gave a detailed timeline of how the surgical site would change over the next weeks. Even when the affected area turned out to be much larger than expected, he explained that the gaping wound could be hidden with a special skin closure technique. I stole glances at the vital signs monitor and was pleased to see my blood pressure and pulse remain normal. My surgeon finished by commenting with satisfaction that my case was done on time. I liked him precisely because he was a skilled technician who didn’t get too caught up in the emotional messiness of illness. He affirmed my desire in that moment to believe in “magic bullets” – cancer => cut => cure.

My cancer experience thus far had been running like Swiss clockwork. So, it was an unwelcome surprise when my methodical façade broke down only hours after the procedure. At home, resting with an ice pack on my face, I found myself spooning rum raisin ice cream into my mouth as if I were in an eating contest, all the while fighting back tears. What is going on, my brain raced in confusion. The cancer is gone. Everything went smoothly. Why the drama now?

I replayed the events of the day in the doctor’s office. At one point, a nurse had come in, put her hand on my shoulder, and stated that my surgeon was confident he had gotten all the cancer. I should do “just fine.” Her smile was warm and sincere. I wanted to believe her, but I had seen healthy women almost bleed to death from routine vaginal deliveries. I had dealt with minor office procedures that turned into ICU stays. I have had to admit to patients that we have no explanation for their diseases. Doctors can’t give guarantees. Most of the time, we don’t have cures, just symptomatic remedies. Rather than comfort, the nurse unwittingly reminded me that science, technology, and medicine have more questions than answers.

So, it was not in the doctor’s office, but at home when my healing truly began. Twice a day, I cleaned and dressed the incision that started in the middle of my forehead and ran into my hairline. I carefully washed over the small stitches with saline, applied antibiotic ointment, and taped down the large white bandage. The wound started off angry and inflamed, causing swelling down to my cheeks until I looked like the cross between a Klingon and Frankstein. I hid from the outside world, mortified by the blatant sign of illness on my face.

But in the quiet and in my embarrassment, I slowly came to acknowledge my physical limitations. I sought calm in daily rituals. I sipped nourishing stews and ate fresh fruit. I napped on the couch with my dog at my feet. I replied to emails and texts from family and friends. I took medications as prescribed. I listened to birds chirp and watched the sun light stream through different windows throughout the day. I took deeper breaths and just closed my eyes from work whenever I wanted to. I started playing with Twitter. I let myself cry.

The vulnerability was awkward, but therapeutic. I thought about the disconnect of expectations that can occur between doctors and patients. I think most doctors realize the shortcomings of our craft. We have a set of tools that sometimes work and sometimes don’t, and we try our best to do some good. In the end, we are not someone’s parent or best friend or spiritual guide. Many patients, though, demand more. They want to be healed. They seek meaning, connection, and hope, when they are sick.

I didn’t ask my own doctor for such existential reassurance. But then, my illness has a defined, effective treatment. The cancers I deal with at work are usually mysteries, filled with uncertain disease courses and treatment responses. They cause patients to question their essential womanhood and values. Who am I if you take out my uterus? Will my partner still find me attractive? Am I more afraid of never being a mother or dying of cancer? I listen to the stories patients tell about themselves, because in there, are the clues to how they see their bodies, how they make sense of their lives, and ultimately how I can best contribute to their healing experiences, if they want me to.

I think my doctor picked up on my pragmatism and knew intuitively that I just wanted to get out of there as soon as possible. He mumbled during the initial consultation that doctors have a hard time being patients, that illness is extremely humbling. I have not made peace with illness, but I have gained a new respect for the process of healing. There are no magic bullets.

My Two Cents

February has been a hectic month for women’s health issues. First, there was a fall-out and reconciliation between the Susan G. Komen Foundation and Planned Parenthood. Then, religious organizations fought back against the Obama administration’s plans to mandate free contraception coverage through employers. Now, the news cycle has turned to controversial legislation in Virginia and Alabama requiring transvaginal ultrasounds for women choosing abortion. I have followed each of these discussions with interest, but what has really bothered me was another story that got relatively little attention yet indicates a troubling trend in health care politics – the “doc fix."

Cancer 1, Doctor 0 (Part 1 of 2)

The doctor leaned in to study the lesion on my forehead. I could see his easy demeanor fall away into a frown, his brows now tightly knitted in concentration. The air was suddenly sucked out of the room. I was afraid I’d vomit on his pristinely ironed white coat. I recognized the expression on his face. It was the same one I’ve worked to control before breaking bad news to my patients. I took a deep breath, bracing for the doctor to substantiate the diagnosis I had already suspected.

Redefining Success

My Monday morning belongs to “Tumor Board.” In this weekly meeting, gynecologic oncologists, radiation experts, radiologists, pathologists, nurse managers, fellows and residents join forces to develop treatment blueprints for our cancer patients. Crowded into an old conference room, our collective mission is to tackle the challenge: “What can we do for our patients?” Pathologists scrutinize slides of tumor under the microscope. Radiologists show images to elucidate the extent of cancer invasion. Researchers critique the merits of the latest clinical trials. Radiation experts evaluate the opportunity for radiotherapy. A senior clinician summarizes the action points, and the fellow meticulously documents the discussion in the chart. Then, the residents get their marching orders to execute the strategy. We are a fiercely technical and data-driven army, churning out evidence-based recommendations for 20+ patients in under 2 hours.

What I Learned from Standing in Your Shoes

Last week, I flew to Milwaukee to witness the long-awaited birth of my niece. I’m happy to report that mother and baby are doing just fine…and this OB/GYN aunt – who knows too much about the birthing process for her own good – survived the experience as well. I have never been one to mix the personal and the professional. In fact, I compartmentalize to cope with the stresses of my work. But in this case, it was impossible to avoid being both a sister and a doctor.