“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.”
“Mel’s playing with soap bubbles again.” — Mary
Ellen (Mel) Avery, MD
William T. Gerson
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
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
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.