A portion of the heart is included in the radiated field with free-breathing radiation

I wish to extinguish some of these flames by emphasizing that we cannot extrapolate the results of antiquated treatment from a decade to over fifty years ago with the results that can be achieved with modern radiation techniques. The invisible high-energy beams of radiation therapy kill cancer cells by damaging their DNA. Radiation beams travel in straight lines, and cannot curve around concave structures. Careful treatment planning minimizes radiation to adjacent normal structures, which may otherwise also be damaged. Scatter of radiation to the heart, in particular the major coronary arteries, increases the risk of ischemic heart disease and heart attack. Radiation for left-sided breast cancers is more likely to cause adverse cardiac sequelae than treatment for right-sided cancer.

There have been considerable advances in the accuracy and targeting of radiation treatment, particularly with regard to heart-sparing techniques. According to Jaymeson Stroud MD, radiation oncologist with Mercy Hospital St. Louis, “Radiation techniques have advanced considerably in the last sixty years. In the 1950s low energy linear accelerators and Cobalt 60 were used. Computerized two-dimensional treatment planning using port field X rays and use of treatment simulators did not come into being till the mid 60s.” He adds, “CT three dimensional planning was introduced in the 1980s, and even more tailored techniques such as intensity modulated radiation therapy (IMRT) a decade later.” IMRT utilizes high-energy beamlets to “curve” the dose to avoid normal structures and thus diminish incidental exposure to the heart. The patients in the Scandinavian study received their therapy before the era of three-dimensional CT treatment planning.

All of the patients in the NEJM paper received external beam radiation. Twenty two percent had breast-conserving surgery and the remainder underwent mastectomy. Accelerated partial breast irradiation (which treats a well localized rim of tissue centered on the tumor bed), can reduce doses to surrounding normal structures depending on the location of the tumor in the breast. APBI can be achieved using external beam techniques, or placing the radiation source within the breast (brachytherapy). Balloon catheter techniques such as Mammosite®, Contura® and Savi® are all designed to concentrate the site of radiation.

With deep breath hold techniques the heart is no longer in the radiation field

Targeted intraoperative radiation therapy (IORT) for breast cancer has been under study since 2000. A single dose of radiation is delivered to the lumpectomy bed while the patient is still on the operating table. The results of the international TARGIT-A trial were published in the Lancet in 2010 and revealed that local recurrence rates were equivalent to external beam RT. Updated data on almost 3500 patients were presented in San Antonio in December 2012; patients in the IORT group had fewer non-breast cancer deaths with a trend towards less mortality.

Kathy Baglan MD, a radiation oncologist, adds that modern external beam heart-sparing techniques such as the Active Breathing Coordinator— which separates the heart from the chest wall during deep breath holds— and treating the patient on the prone rather than supine position, can ensure that no heart is caught in the crossfire of the radiation beam. Please see the attached images showing the heart moving away from the radiation beam during inspiration. These are extra efforts on the part of the savvy radiation oncologist that are not reimbursable. She states, “Not only has radiation been shown to decrease local recurrence rates, but a very large study from Duke University of 112,000 women treated with more modern RT between 1990 and 2004 showed that compared to mastectomy, patients undergoing lumpectomy and breast radiation were fourteen percent less likely to die of breast cancer and nineteen percent less likely to die of any cause. This clearly shows that “good” radiation saves lives, not shorten lives.”

She adds, in reference to the paper by Darby et. al., “To put the Scandinavian results in perspective, for a 50 year-old woman with no preexisting cardiac risk factors, a mean heart dose of 3 Gy (which is high for today’s standards) would increase her absolute risk of dying from ischemic heart disease by age 80 from 1.9% to 2.4% (i.e. 0.5%) and increase her risk of having any major cardiac event from 4.5% to 5.4% (0.9% difference).

As physicians we are all aware that our treatments can cause harm. Every effort has to be made to reduce harm. The authors of the NEJM paper conclude that clinicians have to consider cardiac dose and cardiac risk factors when making decisions about the use of radiation therapy. I suggest that the issue is not whether radiation should be used at all, but whether the radiologist will tailor, customize and individualize the treatment to spare the heart. Patients should discuss with their radiation oncologist what heart-sparing approaches would benefit them.

Images courtesy of Dr. Stroud.

As an intern on the heart surgery service I shared the workload with two other interns, David and Rick (all names have been changed). The service was a busy one, one of the busiest in the city. That Monday morning in 1987, David signed out to us at 6am before leaving for a weeklong vacation. Rick and I surveyed the to-do list of tasks for the day; he agreed to be based in the post-op cardiac unit and I went downstairs to assist in the OR.

A couple of hours later, I was completely focused on the task in hand, holding the cannula steady while the attending surgeon, Dr. Harry Brown, tied the purse-string suture around it, the tube to divert the blood while the patient was on cardiopulmonary bypass. A voice behind me said, “Pump’s primed,” the signal that bypass could begin. The RN first assistant harvested vein from the patient’s lower leg, before being sutured to the coronary vessels to circumvent the blockage. I heard the door open and Gary, the fellow in heart surgery (and most senior trainee on the unit), entered the room. From behind his mask, he uttered two words, “Rick’s bolted.”

Both Dr. Brown and I looked up, the words percolating through our respective cortices. “What do you mean ‘bolted’?” enquired Harry. The room was silent otherwise apart for the rhythmic rumble of the bypass machine. Gary answered, “Bolted, gone, left the building, don’t know if he’s coming back.” He nodded to me, “Scrub out, get upstairs and get the scut done.”

Thoughts were racing though my brain as I computed this bombshell of information— Rick gone, David gone. That left only one intern on the service — me, until David returned the following Monday. I’d be able to leave the hospital the evening he came back. Mental arithmetic led to the hard-to-grasp answer, I would be on call for the next 178 consecutive hours. The thought that came foremost to my mind was — I don’t have enough clean underwear with me to last for a week. I’ll have to call home for more.

I’d been in a similar underwear situation before, during my first internship in Glasgow, Scotland in 1981. I should explain that I completed four years of surgery training in Scotland and a two-year fellowship in surgical oncology in Buffalo, NY before commencing more residency training in the US to fulfill requirements of the American Board of Surgery. I was an intern with six years of surgery experience. One of my fellow interns in Glasgow called in “sick” with a migraine one morning when I was post-call. Calling in sick is not generally done in medicine unless one is actually hospitalized or on a gurney being wheeled to the OR as a patient. I could imagine my classmate’s illness though; I knew full well he’d been at the “Roob” the night before. The Rubaiyat was a hostelry on Byres Road, it’s dark interior lined by murals depicting gilded verses from the poem by Omar Khayyam. Migraine or hangover I wondered, knowing his liking for Scotch with a chaser.

Harry Brown looked at me from under his bushy eyebrows, his angular shoulders shrugged, “Off you go then.” I peeled off my gown and gloves, the RNFA moving into my position across the table. Upstairs I set to it, changing central lines, pulling pacing wires, treating arrhythmias, performing history and physicals on the incoming patients for the following day — hopping around from task to task like the scut bunny I was. One patient had dehisced his median sternotomy, the midline incision the length of his sternum, a rare complication of cardiac surgery. He required a dressing change, an intricate task, my hands moving swiftly in and out of the wound as the edges of the sternum opened and closed like a clamshell with each breath.

The following morning, as I contemplated my next night on call, an intern from another service came up to me in the unit while I was making notes in the chart. Matt looked at me with his soft puppy-like eyes, “ I’ll take call with you every other night.” The reason for his largesse — Matt had fallen in love with Mary Beth, one of the night nurses in the cardiac unit. This way he could be near to her.

And so we made it through the week, Matt and I. When David returned I recounted the story. He stroked his russet-colored beard beneath his sunburned cheeks, listening. He just shook his head.

I wonder how it would have been if Matt’s heart had not been pierced by Cupid’s arrow, if I’d been on call the entire week? And what became of everyone? I hear you ask. Matt and Mary Beth married. David and Matt went on to be plastic surgeons. And Rick? I kept thinking we would hear from him, a note, a call, letting us know what happened. But not a word ever came. Every now and then, when I’m rearranging my underwear drawer, I think of him. I hope he’s recovered and has found his niche.

St. Ninian’s Episcopal Church, Troon, Scotland

There are two churches I know celebrating anniversaries in 2012. They are entirely different in location, size and age. St. Ninian’s Episcopal Church in Troon, on the windy west coast of Scotland, celebrates 100 years. Its red sandstone walls framed my christening, confirmation and early years of worship. In my earliest memories of it, I sat in the miniscule wicker children’s chairs when we shuffled in from Sunday school, to an-all-too-prominent position in the front of the nave.

In later years and adulthood, I sat in the larger wicker-seated chairs of the pews, and knelt on the embroidered individual kneelers. It was from one of those kneelers that I keeled over into the red-carpeted aisle in a dead faint, suspending the service. It was into that same aisle that my mother leapt and sprinted back to pull on the heavy carved arched door, and then high-tailed it out down the path to our house on Bentinck Drive a hundred yards away. I learned later that she had a chicken “roasting” in the cooker but had forgotten to turn the oven on.

Visiting the church recently, I saw the same small chairs and the same conjoined chair backs of the pews. The sunlight streamed through the leaded glass windows illuminating some of the plaques commemorating those lost in the Great War. In the church hall we found the stone donated by Mrs. Townsend who lost both sons, their sacrifice in 1917 twenty-two days apart. It was a somber moment as we contemplated her grief.

Sidney and Margery, St. Ann’s Church, Manchester, England

Over 200 hundred miles away, in the center of Manchester in the north of England, stands St. Ann’s Church, three hundred years old this year. Its imposing façade is also sandstone, not the Mauchline stone of St. Ninian’s, but red Collyhurst stone. As the soft bricks required repair, sandstone was brought in from other parts of the North country—yellow-grey stone from Darley Dale; pink from Hollington, Staffordshire; dark red from Runcorn in Cheshire; and pale brown from Parbold, Lancashire—each repair adding to a jaunty patchwork.

The black and white images in my parents’ wedding album do not reveal to me the varied hues of St. Ann’s façade, but they do capture the size and grandeur of the church. Inside, at the far end of the aisle is the renowned large curved apse beneath three huge panels of stained glass. It was a chilly day in October 1946 when they stood on St. Ann’s Street with the wedding party. Dad had recently been demobilized from the RAF after flying in over seventy sorties in WWII; mother had saved up her clothing coupon ration for her wedding dress. Although the Luftwaffe heavily bombed the city of Manchester during the Blitz, St. Ann’s sustained little damage. In 1996, however, an IRA bomb in the city center blew out the upstairs windows.

St. Ann’s has stolidly commanded St. Ann’s street for 300 years. The grand old church has seen three hundred years of weddings and funerals, of joy and tragedy. Three hundred years of prayers of the people. Three hundred years of prayers for peace.

There is an increasing awareness about the quality of life of the cancer survivor. The Commission on Cancer has listed as one of its goals for 2012 that each patient be given an individual care plan, detailing, among other things, their plan for survivorship. Emphasis is placed on optimizing function, and complete healing, recognizing that care does not cease when the surgery, chemotherapy and radiation have ended.

As a breast surgeon, I know that lymphedema is a complication dreaded by patients. Lymphedema, swelling of the arm due to disruption of lymphatics, can occur following removal of lymph nodes for staging the disease, and to control recurrence in the axilla. Historically, a full axillary dissection was performed, removing an average of 10-15 nodes from the underarm. The sequela of that surgery was a lymphedema rate of up to 35%. In the late 1990s the technique of sentinel node biopsy was applied to breast cancer. In this elegant procedure, the potential pathway of the metastatic cancer cells is reproduced, leading the surgeon to the nodes that stand sentry (sentinel) to the rest of the axilla.

Usually 2 to 3 nodes are removed, with consequently fewer cases of arm swelling, in the range of 2-5%. The dogma was always however, that if those nodes contained deposits of tumor seen with standard staining methods, then additional nodes had to be sacrificed. A landmark paper published February 2011 in the Journal of the American Medical Association, detailed the results of a trail conducted by the American College of Surgeons Oncology Group (Z0011). Just under 900 patients who had breast conserving surgery (lumpectomy) and no more that two positive nodes found at sentinel node biopsy, were randomized to have either no more surgery or excision of additional nodes.  At a median of over 6 years of follow up, there was no significant difference in overall survival or recurrence rates. The authors of the JAMA paper concluded that implementation of this practice change would improve clinical outcomes in thousands of women each year by reducing the complications associated with axillary lymph node dissection and improving quality of life with no diminution of survival.

The publication of the Z0011 data has used a change in surgical management of breast cancer patients across the US. In August 2011, the American Society of Breast Surgeons (ASBrS) issued a position statement on the topic. They emphasized that routine axillary dissection should no longer be required for patients undergoing lumpectomy who met the following criteria: invasive tumors up to 5cm in size; no more than two positive sentinel nodes with no extension of cancer beyond the confines of the node; completion of radiation treatment to the entire breast; and compliance with additional medical treatment.

In December 2011 the International Breast Cancer Surgery Study Group presented their data for a similar trail in which over 900 women were evaluated. Their conclusion aligned with the results of the American College of Surgeons Oncology Group results. The National Cooperative Cancer Network (NCCN) changed the national guidelines for breast cancer treatment for 2012 to reflect the gathering evidence supporting less surgery to the axilla. Surgeons can change. Research presented at the 2012 ASBrS annual meeting showed a change in practice patterns of surgeons at MD Anderson Cancer Center following Z0011 — rates of full axillary dissection have plummeted from 85% to 24%.

CaduceusOur care should be evidence-based, and the evidence is accumulating in favor of less axillary surgery for appropriate patients with breast cancer. And that’s good news for the 226,870 women estimated to be diagnosed with breast cancer in the US in 2012. When I graduated from medical school we pledged a covenant with our future patients. We made a promise — the Hippocratic oath. An oft-quoted part of that oath is primum non nocere — above all do no harm. As surgeons, we harm our patients by making an incision, although the ultimate goal is a good outcome. Perhaps the surgeons’ pledge should also be deinde minui nocere —then minimize harm. Minimize harm by causing fewer complications.

Sidney Radford, tailor.

We all worked with our hands, we just had different tools and worked on different materials, be it fabric, leather, or human tissue. Our basic tools, however, were a needle and thread. When I was growing up in Scotland, I remember studying my dad as he worked at his tailor’s bench. In the yellow light he bent over the fabric, lips pursed in concentration, dividing the tweed with huge shears. Around his neck was his measuring tape, by his side his tailor’s right angle, nearby his triangular chalk.

Against the wall in front of him were arrayed row upon row of bolts of cloth —flannel, light wool, heavy wool, silk, satin, pin-stripe, check, and houndstooth. Proudly displayed were his framed awards from Tailor and Cutter magazine, the medal for Ladies’ Couture, and the Donegal Trophy for craftsmanship in Ladies’ Suits. His hands were nimble, whether he basted a hem by hand with Coats® cotton or machine-stitched using his trusty Singer®. I was fascinated, transfixed.

His dad, the saddler, sewed with thicker beeswax-coated thread— the beeswax to waterproof the thread and ease its passage through the thick leather. Among his tools were a half-moon blade to incise the leather, whalebone to make the leather tight around the edges of the saddle, and a stitching awl. He first became a saddler during the Boer War. Then served the same role with the Welsh regiment in World War I. He kitted out the war-horses, the steeds of battle.

Sergeant Saddler Alfred Radford

My tools, as a surgeon, are the scalpel, the forceps, delicate and precise; my thread is not cotton but prolene, monocryl, and vicryl. We cut, and then we sew. Those are our common denominators through three generations. I heard as a surgeon-in-training, during my apprenticeship (as it were), “Cut well, sew well, get well.” All of us Radfords had to be exact in our craft or the suit would not fit, the saddle would be uncomfortable or the wound heals improperly.

On this Father’s Day, I appreciate those skills inherited from my father and grandfather and all the generations of artisans before me.  Cut well; sew well.

Author Bio

Heather Smith is an ex-nanny. Passionate about thought leadership and writing, Heather regularly contributes to various career, social media, public relations, branding, and parenting blogs/websites. She also provides value to hire a nanny by giving advice on site design as well as the features and functionality to provide more and more value to nannies and families across the U.S. and Canada. She can be available at H.smith7295@gmail.com.

The “C” word is one of the scariest words that a person can hear. Cancer is a crushing disease, and one that claims more lives than it ever should. Unfortunately, a lot of cancer can be prevented – or at least drastically reduced – if we just take the necessary precautions. Here are five ways you can help lower your risk of getting cancer:

1.     Shade yourself from the sun – Skin cancer is one of the most frequent cancer culprits, and it’s one that we can readily avoid if we take preemptive measures. Wear sunscreen every day, don’t fall victim to tanning beds, and always keep a hat handy. Being out in the sun doesn’t have to be deadly – but it will be if we don’t actively protect ourselves.

2.     Get moving – Keeping our bodies and hearts healthy by regularly participating in some form of exercise keeps us stronger so we can better fight off different types of cancer. Work up a sweat for 30 minutes a day and you’ll reap the benefits of a reduced cancer risk as well as toning up and fighting off several other diseases.

3.     Kick smoking to the curb – We all know the consequences of smoking so why are we still doing it? Smoking is the leading cause of cancer and it’s completely preventable. There’s no better time than the present to kick this habit and clean out our lungs. An added bonus? We’ll also be protecting our throats and mouths from cancer as well. Just say no.

4.     Limit or eliminate alcohol consumption – Consuming any more than one or two glasses of alcohol daily means that you’ll start to raise your risk of contracting throat, liver, larynx, colon, rectum, and mouth cancer. That’s a lot of potential places for cancer to hit. On top of that, even just one glass of alcohol daily increases your risk of breast cancer. The solution? Drastically limit alcohol consumption, or even just completely eliminate it, to play it safe.

5.     Get checked regularly – Early detection is the best way to ward off any serious rounds with cancer, so get checked regularly. It’s such a simple step to take, and one that can do wonders as far as prevention and early detection. The earlier cancer is caught the higher the success rate with eliminating it, so schedule regular screenings.

While not every case of cancer can be prevented by doing everything the right way, taking as many steps to prevent it as possible can drastically reduce the risk of getting it. With more and more people falling victim to cancer every day it’s imperative to do whatever we can to ensure that we have as low of a risk as possible.

Dr. Diane Radford and Professor Sir Kenneth Calman, Alpha '81 reunion, Glasgow, Nov. 2011.

I remember it as if it were yesterday, the spacious auditorium in the then-new Boyd Orr building at the University of Glasgow. The oncologist, young to be the Chair of the department (but so wise), lectured to us about the importance of touch in patient-doctor communication. Not salacious touch of course, but touch for support, empathy, and reassurance. It may be holding a trembling hand, or a gentle squeeze to the elbow. It may be a hand laid on a shoulder. He talked about how physicians can be “touchers” or “non-touchers,” based on their personality. But all could be taught to be touchers.

The hands laid on the body have always been part of the physician’s actions. As students, we learned that it was essential to the physical examination; feeling the “thrill” of turbulent blood flow, palpating the thyroid for nodules, pressing on the abdomen to feel the guarding indicating peritonitis, and of course, the breast exam to detect masses.

In the era of extensive imaging, the physical exam may be in jeopardy. There can be too much reliance on a negative imaging test even when a physical finding is present.  I have been a patient myself, of course, and I remember the feeling of betrayal as I sat there covered only in a gown as the doctor left the room having failed to perform a physical examination. It had been forgotten. I had undressed for my yearly “physical” only to have a discussion of my lab results. Touch in patient communication is more just than the exam however. It is part of the whole interaction.

The oncologist was Professor Kenneth C. Calman, who was also the honorary president for my graduating year, 1981. He went on to become the Dean of Postgraduate Medicine at Glasgow University, Chief Medical Officer for Scotland, Chief Medical Officer for Her Majesty’s Government, Vice-Chancellor of the University of Durham, Chairman of the Calman Commission and Chancellor of the University of Glasgow. He was knighted in 1996.

2011 marked the 30^th anniversary of the Alpha ’81 club. Professor Sir Kenneth attended and I had the chance to tell him what a profound effect his “touch” lecture had on me all those years before. I put his words into practice every day in the office and operating room. I am so grateful for his teaching and the chance to thank him personally.

The other day, when I was in the recovery room talking with a patient post-op about her negative axillary nodes, I squeezed her toes as I said goodbye. Touch is part of what keeps us together as humans. It binds us.

The name on my boarding pass was Mrs. Frederick Quick (Jane Richards), a 33-year-old mother of two daughters, Winifred and Phyllis, aged 8 and 2. She was traveling with her children back to her husband in Detroit, after visiting relatives in her native England. Jane and Fred had been married ten years. Fred adored her. He had pinpricked the words I love you on a leaf, a leaf she was carrying with her on the voyage.

The events of the cold, starry, moonless night of April 14^th 1912 have been well recorded. At 11.40pm the largest ship in the world, the practically unsinkable RMS Titanic, struck an iceberg. Water gushed into six of her watertight compartments. She could not recover from such an injury. Two hours and forty minutes later she sank to the depths. If fewer compartments had flooded she would have been able to stay afloat. Many have speculated on what might have happened if circumstances had been different that night. If the moon had shone, illuminating the berg; if the water had been choppy, frothing around the base of the ice, making it visible; if she had hit the ice head on perhaps fewer compartments would have flooded; and if the key to the cabinet containing the binoculars had not been taken off the ship, sequestered in a crewmember’s pocket. We know that the lifeboats were not full to capacity. We know that a coal strike caused some passengers to be rescheduled from other vessels to the maiden voyage of the Titanic.

The tour revealed many aspects of life on the ship, the Versailles-like opulence of first class; the marble faucets, the porcelain and other table wear, different for each class. Vignettes about various passengers taught us about these individuals, their backgrounds, their purpose for travel. We saw the leather case containing 62 of 65 perfume samples carried by the perfumier Adolphe Saalfeld. The aroma of the mixture of scents could be detected through the fenestrated plexiglass.

In the last room of the exhibit listed on the wall were the lost and the saved. By now I had bonded with Jane. I was rooting for her. I found myself thinking what did she say to her children, how did she comfort them? My eyes scanned the list of the lost from second class, she and her children were not there. I breathed again. Jane, Phyllis and Winifred were among the saved. I found out later that she was one of the lucky on lifeboat number 11, the third lifeboat launched. Jane was the last person to board the lifeboat. She was reunited with Fred, and went on to have two more children, and died aged 85.

Before we left the exhibit, I bent down and gently placed my rose beneath Jane’s name. I said a prayer for the souls of the lost and for those who were saved, 100 years before.

Mothering Sunday in the UK follows the Anglican Liturgical calendar, and falls on the fourth Sunday in Lent. The Nigerians and Irish also celebrate Mothering Sunday on that day. Easter is a moveable feast, thus the date of Mothering Sunday will change from year to year. For example, in 2011 it fell on April 3^rd, in 2013 it will occur on

Margery Radford

March 10th, and in 2014 March 30th. But it is never, never, not ever in May. Not once, never. So it never coincides with Mother’s day in the US; basically I was toast as far as remembering Mother’s Day was concerned.

We’d be on our usual Sunday afternoon transatlantic call from St. Louis to Troon (I called by 2pm on Sunday afternoon, as that was 8pm in Troon. I wanted to call before her bedtime). After the chitchat about our week she’d say,

“Have you forgotten?”

Well obviously, whatever it was (and I had a twinkling of a notion what it was), I had forgotten, but I tried to feign ignorance.

“Forgotten what?”

“Mother’s Day, you forgot Mother’s Day.”

Once again, I was in deep kaka.

I countered, “Mother’s Day isn’t until May, I have your card already, ready to send.”

“Well, we had Mothering Sunday services at St. Ninian’s today, so it’s today.”

There was no good recovery from this one, but I thought I had nothing to lose.

“As far as I’m concerned, it’s Mother’s Day every day.”

Now there is some truth to that, when we look at how Mother’s Day is celebrated around the world, because it could always be Mother’s Day somewhere: in Norway, it’s the second Sunday in February; in early March (the eighth), Mothers are recognized in Albania, Macedonia and Serbia, to name a few. The vernal equinox, March 21, is the day motherhood is celebrated in Egypt, Lebanon, Saudi Arabia and many other Arab countries. The Armenians choose April 7^th. On the Iberian Peninsula, it’s the first Sunday in May. In Mexico it’s May 10^th. In Paraguay Mothers are celebrated on May 15^th, the same day as Dia de la Patria. The French honor Mother’s Day on the last Sunday in May, or the first Sunday in June, depending on when Pentecost falls. In Kenya, it’s the last Sunday in June. In Thailand it’s August 12, the birthday of Queen Sirikit. The Argentines have Dia de la Madre on the third Sunday of October, the Russians honor motherhood on the last Sunday in November, and the Indonesians December 22^nd. So I did have a point, in retrospect.

“You are such a chancer, Diane Radford, a real patter-merchant.” She used the Scottish idiom for one with the gift of the gab.

I knew we were reconciled then, I was forgiven. She chuckled.

Over the years, I tried; I really tried to remember the correct day. There were years I sent cards for UK and US Mother’s Day, there were years I sent cards that arrived in between, late for one and early for the other. There were years I sent only cards for UK Mother’s Day (when I had UK calendar at home), and there were years I sent cards for US Mother’s Day. I have to say, I really got the most points when I sent a card for the UK date and one for the US; it was Mother’s Day in stereo.

Father’s Day falls on the same day in both the UK and the US, thank God. It is the third Sunday in June.  However, if you live in the Antipodes, in Australia and New Zealand it’s the first Sunday in September. It was easier for him. I’d send a card, make a phone call and say, “I love you Dad.”

“I love you too, poppet,” he would reply.

So advice to all, Mother’s Day in the States is on May 13^th 2012, and Father’s Day is on June 17^th. Send cards. Oh, and call too.

Diane: You are the founder and driving force behind the annual course “Improving Healthcare Leadership, Communication and Outcomes through Writing and Publishing” (formerly “Publishing Books, Memoirs and Other Creative Nonfiction”).  What was your motivation for starting the course?

 Julie: Nearly every day doctors and other professionals email me and ask how they can get their work published.  What I found was that not only was it far too time consuming for me to try and respond to these emails individually, but it wasn’t very effective.  Publishing can’t be explained in an email or a short phone conversation.  It’s too dynamic and complicated.  However, what I realized is that these individuals were really positioned well to publish if they had more information.  So, I decided to develop a course at Harvard Medical School which would be open to all professionals–not just people at Harvard (www.HarvardWriters.com).  The course would move them quickly along the path to getting their work published in all sorts of ways–books, magazine articles, blogs, op-ed pieces and so on.  This has really worked, and I have a very long list of past attendees who have done incredible things with their work, including publishing many award-winning books and appearing on national TV.  Every year there are different speakers who come from all parts of the publishing world, so the faculty and the attendees learn a lot!

Diane: What advice do you have for the aspiring writer?

Julie: The publishing industry is changing very quickly, and in order to be successful most people need to really understand what is happening now.  Reading a book about how the publishing industry works doesn’t help that much, because it has changed considerably, even in the past few months.  Also, it’s nearly impossible to publish without being connected to professionals in the industry, especially editors and literary agents.  Very few editors and literary agents respond to “cold calls” from aspiring writers–even if they are physicians.  Coming to a course really helps you to “fast track” your publishing.  Writing in a vacuum doesn’t work for most people.

 Diane: You have authored and edited many books, how do you balance your time between writing, teaching, patient care, leisure and family?

 Julie: Like most people, my life is rarely balanced!  There is always something more that I should be doing in one or more of those categories.  However, one thing I’ve learned is not to struggle too much when there are better ways to do things.  I really try and avoid spending time on things that I don’t have true expertise in.  Instead, I’ll collaborate with a colleague or hire someone to help me or attend a course.  Basically, I practice what I preach!

Diane: What is your daily writing routine?

 Julie: I like to write early in the day when my mind is fresh.  That’s when I do most of my creative writing.  Later, when I’m tired, I’ll tackle email and other correspondence.  I don’t write every day.  I like to take breaks.  However, one thing to remember is that in order to publish, one does need to write.  It’s very hard to limit yourself to writing only when you feel highly creative.  Most writers write even when they don’t feel that creative.  It’s often a chore, like any other part of your work.

 Diane: How do you protect time to write?

Julie: By getting up before anyone else!  Everyone has their own strategy, and mine works well for me.

For more about Julie Silver MD please visit www.juliesilvermd.com