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A tribute to an unforgettable mentor
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“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” — William Osler, MD
“Judge a man by his questions rather than by his answers.” — Voltaire
“Mel’s playing with soap bubbles again.” — Mary Ellen (Mel) Avery, MD
I hope you excuse me a personal moment. Mary Ellen Avery, MD, died this winter. Best known for her pivotal work on surfactant, she was my chief as a resident at Children’s Hospital in Boston in the ’80s. Dr. Avery graduated from William Osler’s Hopkins and became the first female physician-in-chief at Children’s; the first woman to head a clinical department at Harvard Medical School; the first woman to be chosen president of the Society for Pediatric Research; and the first pediatrician to lead the American Association for the Advancement of Science (AAAS).
Dr. Avery was my attending on the infant’s ward (Division 27, Team A) in mid-winter, when I was both an intern and senior resident, and I am honored by her choice of me as a chief resident. Those were still the days of hospital whites, every third night call without hour restrictions and “crib-side” attending rounds. As is fitting of an infant ward in winter, between bronchiolitis and rule-out sepsis, there was never a lot of down time on the floor. Dr. Avery’s approach as an attending was respectful, but quite formal. She never questioned our dedication or commitment to patient care, nor seemingly suffered our work load. She expected excellence without complaint. I always thought of this as her expression of a Hopkins’ ideal.
Lessons from a mentor
There are three clear memories of Dr. Avery that still resonate with me that I would like to share with you as they still echo — as Osler’s quote above still motivates. As an intern on rounds, I presented yet another 2-month-old patient with respiratory syncytial virus (RSV) bronchiolitis that I admitted overnight. Dr. Avery’s question to me had nothing to do with fluid management, oxygenation or use of antibiotics pending culture results. Instead, she asked me why this patient’s illness required admission — how this baby’s biology could be understood as an explanation for disease severity. I’ve long forgotten my answer, but I still remember her question and applied a different metric that afternoon as I admitted another 2-month-old with bronchiolitis whose additional finding of persistent jaundice led to the diagnosis of biliary atresia. I’ve always felt her approach to clinical findings was motivation for her asking why ICUs at different institutions had better outcomes, leading to the acceptance of permissive hypercarbia in infant ventilation — an early victory in outcomes research.
A second example from my time with Dr. Avery on the infant floor was her questioning of how we managed infants with “failure to thrive,” a term she never cared for, but was a leading reason for admission at the time. While we all understood the social context of most of these admissions, there were, of course, examples of malabsorption, metabolic disease and even Munchausen by proxy. Our standard of care was typically to bring the children into the hospital and feed them, or observe the mother feeding them, and then see if they would gain weight before embarking on a much more involved workup.
Looking beyond what you see
Generally, questions of attending physicians were directed at the history and physical exam to determine any clues to a specific diagnosis that would lead to a narrowed evaluation. After a month with Dr. Avery, I assumed as the admitting intern I would be asked to explain the physiology of weight gain in infancy, rather than a prolonged discussion of family dynamics. I was surprised when she asked what similarities this infant’s condition had with an infant who was on service 3 weeks earlier, whose mother also was not able to care for the infant because of maternal illness. Again, I’m glad my memory of my answer eludes me, but her question proved prescient because the patients and their mothers went on to die of an immunodeficiency we would only understand more fully in the following years with the discovery of HIV.
My last thoughts are much more personal. The end of my first night on call as a senior resident on July 1 was marked by the beginnings of my wife’s premature labor with my second son. At the dawn of the HMO era in Boston, my wife had four different attending obstetricians and the full battery of new obstetric residents, some of whom asked if I could make sense of the fetal m-mode ultrasounds. Born several days later on the 4th, looking like Ali and Frazier had been battling him with forceps, Jacob fortunately had an uneventful NICU stay. Later that week, as I walked in to the Children’s Hospital Boston lobby to begin my rounds, I heard my name in greeting. Dr. Avery stopped me and asked how my family was doing and informed me that we were now members of the same club. I don’t know which surprised me more, that Dr. Avery knew my first name or that somehow we were members of the same club. The club was the “I hate Obstetricians Club,” which I think at that time was honorary for any neonatologist.
My last memory of Dr. Avery was from her stint less than a decade ago as president of the AAAS, when I attended its annual meeting in Boston with Jacob, where she again surprised me with a greeting, acknowledgement of Jacob’s no longer premature status, and support for me as a fellow pediatrician member of AAAS.
We owe so much to those who taught us, teach us and learn from us.
William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. Disclosure: Dr. Gerson reports no relevant financial disclosures.