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This is followed by checked and a sample sent to transfusion for group real-time radiography buy cheap metoclopramide on line gastritis and ulcers. Hepatitis B and C surface antigen sta- Further diagnostic and therapeutic manoeuvres: r tus should be known purchase generic metoclopramide pills gastritis diet ходячие. Percutaneous aspiration of an abscess is approximately 1% order metoclopramide with a mastercard gastritis drugs, but this rises with any therapeutic occasionally performed. Haemorrhage and perforation occur less cedure the patient should rest on their right side for 2 commonly. Ascending cholangitis may be prevented by hours in bed and should gently mobilise after bed rest antibiotics, which are given prophylactically to all pa- for a further 4 hours. However, in many cases of Percutaneous transhepatic cholangiography is used to malignant tumours only complete removal of the liver image the biliary tree, particularly the upper part, which and liver transplantation is curative. Localised metas- is not well outlined by endoscopic retrograde cholan- tases may also be resected. For example in obstruc- The liver is composed of several segments, as dened tive jaundice with obstruction of the upper biliary tree by the blood supply and drainage, this is important in and when malignancy of the biliary tract is suspected liver resection. Prior to the procedure the clotting have a left and right branch and these supply the left and prole is checked and the patient is given prophylactic righthemi-livers respectively. The im- comprises of the remainder of the right lobe and is also age can be followed by real-time radiography and still further divided into four segments (see Fig. The T-tube allows drainage of Right lobe Left lobe bile and also allows a cholangiogram later. Laparoscopic cholecystectomy requires three or four cannulae inserted through the anterior abdominal wall, Caudate and for visualisation and access with operative instruments. Open cholecystecomy often requires quite a long stay Gallbladder Hepatic artery and in hospital, possibly a week or more, whereas laparo- portal vein scopic cholecystectomy may be conducted as a day case. Laparoscopic tech- This means that right hepatectomy, left hepatectomy nique reduces the incidence of respiratory problems and and extended right hepatectomy (right lobe plus cau- surgical site infection. The appropriate vessels for the segment(s) Disorders of the liver are ligated and divided before the segment(s) are dis- sectedawayfromtheremainderoftheliver. Carefuliden- Introduction to the liver and tication and ligation of biliary ducts and smaller vessels liver disease is required to reduce blood loss and therefore morbidity and mortality. Drainage is required postoperatively, to Introduction to the liver prevent bile from pooling intra-abdominally. It has two blood supplies: 25% of Cholecystectomy its blood originates from the hepatic artery (oxygenated) Surgical removal of the gallbladder and associated stones and 75% originates from the portal vein that drains the in the biliary tract may be by open surgery or laparo- gastrointestinal tract and spleen. Cholecystectomy is also considered in The functions of the liver are carried out by the hepa- younger patients with asymptomatic gallstones in or- tocytes, which have a special architectural arrangement. Blood enters the liver through the portal tracts, which Carcinoma of the gallbladder is treated by wider resec- contain the triad of hepatic artery, portal vein and bile tion, including neighbouring segments of the liver and duct. The lobule is classically used to Open cholecystectomy is usually performed through describe the histology of the liver (see Fig. Cholangiography may be used to The hepatocytes in zone 1 of the acinus receive well- visualise the duct system. The gallbladder is removed oxygenated blood from the portal triads, whereas the with ligation and division of the cystic duct and artery. The liver has multiple functions, which may be im- Aetiology paired or disrupted by liver disease: The causes of acute hepatitis: r Carbohydrate metabolism: The liver is one of the ma- r Acute viral hepatitis may be caused by the hepa- jor organs in glucose homeostasis under the control totrophic viruses (A, B and E) or other viruses such as of pancreatic insulin. Excess glucose following a meal Epstein Barr virus, cytomegalovirus and yellow fever is converted to glycogen and stored within the liver. The liver is also involved in the breakdown of amino acids producing ammonia, which is converted Pathophysiology to urea and excreted by the kidneys. Cellular damage results in impairment of normal liver r Fat: The liver is involved in synthesis of lipoproteins function: bilirubin is not excreted properly resulting in (lipid protein complexes), triglycerides and choles- jaundice and conjugated bilirubin in the urine, which terol. Swelling of the liver results in stretching of the liver capsule which may result in pain. However,itissometimesdiagnosed may be an enlarged, tender liver, pale stools and dark earlier than this. Stigmata of chronic liver disease should be looked for to exclude acute on chronic liver disease. Aetiology The main causes of chronic hepatitis: Microscopy r Viral hepatitis: Hepatitis B virus (+/ hepatitis D), Acute viral hepatitis has a histological appearance which hepatitis C virus. Complications Clinical features Fulminant liver failure, chronic hepatitis, and cirrhosis. Patients may present with non-specic symptoms (malaise, anorexia and weight loss) or with the compli- Investigations r cations of cirrhosis such as portal hypertension (bleed- Serum bilirubin and transaminases (aspartate ing oesophageal varices, ascites, encephalopathy). Asymp- Ultrasound may be needed to exclude obstructive tomatic patients with chronic viral hepatitis may be de- jaundice, if applicable. This includes careful uid balance, which is likely to progress rapidly to cirrhosis with adequate nutrition and anti-emetics. Where possible re- chronic inammatory cells inltrating the portal moval of the causative agent, e. Patients require se- to central veins or central veins to each other (bridging rial liver function tests (including clotting) to follow the necrosis). Pathophysiology Complications All the liver functions are impaired (bilirubin meta- Cirrhosis is the most common complication. Femini- Investigations sation in males and amenorrhea in females are common Chronic hepatitis is diagnosed by a combination of per- in alcoholic liver disease and haemochromatosis due to sistently abnormal liver function tests and the ndings alterations in the hypothalamic pituitary gonadal axis. Other investigations are aimed at diag- Reduced immune competence and increased suscepti- nosing the underlying cause and providing a prediction bility to infection also occur. Patients may present with complications such as bleed- ingfromoesophagealvaricesorencephalopathy. Patients Management withactivechronichepatitismaypresentwithfeaturesof r Symptomatic management includes adequate nutri- chronic liver disease before cirrhosis is established. The liver is usually enlarged, rm and irregular, but is shrunken Aetiology in late disease. The spleen may be enlarged due to Cirrhosis results from continued hepatocellular necro- portal hypertension. The cut surface shows nodules of liver tissue, r Alcohol accounts for more than 80% of cirrhosis in separatedbyneorcoarsebrousstrands. Other rare but impor- Grading system 1 2 3 tant drug-induced causes are halothane, isoniazid and rifampicin. Hepatic time (seconds encephalopathy is thought to be due to failure of the over control) liver to metabolise toxins. Serum amino acid levels rise Child Pugh grade A = score of 5 6; Child Pugh grade B = score affectingthebalanceofcerebralneurotransmitters. Hep- of 7 9; Child Pugh grade C = score of 10 15 atic dysfunction also results in renal failure (hepatorenal syndrome).
In 1999 buy generic metoclopramide online gastritis remedies, a preservative-free formulation of (R)-albuterol metoclopramide 10mg discount gastritis diet gastritis symptoms, called levalbuterol purchase 10 mg metoclopramide fast delivery gastritis ibuprofen, became commercially available for nebulized administration. Clinical studies have evaluated the safety and efficacy of levalbuterol in adults and children. A multicenter randomized study in 362 teenagers and adults with moderate to severe asthma reported that 0. Because of the flat dose-response curve, this study failed to show a significant difference with regard to efficacy between levalbuterol and racemic albuterol. In this study, levalbuterol use was associated with dose-dependent side effects similar to those seen for racemic albuterol. In a smaller study of levalbuterol and racemic albuterol in children, lower doses of levalbuterol were as effective as 2. Other investigations have not confirmed this finding (65,66), yet regular treatment with (R)-albuterol and racemic albuterol results in partial loss of bronchoprotection after methacholine challenge ( 66). Despite the use of controller therapy, some individuals may develop breakthrough symptoms or acute exacerbations of their disease. Rapid-acting b agonists are recommended for the relief of mild or severe symptoms. These guidelines also suggest that the frequency with which b agonists are needed for symptom relief serves as a useful marker of asthma control and of the need for adjusting antiinflammatory therapy. Rapid-acting b agonists may also be used to confirm the diagnosis of asthma by establishing whether reversible bronchospasm exists ( 67). These agents are also effective therapy for the prevention of symptoms, such as exercise-induced bronchospasm, when used 5 to 15 minutes before exercise ( 69,70 and 71). Given their short duration of action, rapid-acting agents are not well suited for the prevention of nocturnal symptoms. The regular daily use of these agents is generally not recommended, but this has been a source of controversy for many years. Although some reports maintain that routine use of b2 agonists is safe and effective (72), other studies have reported detrimental effects. Although some prospective studies of regular inhaled b-agonist use failed to demonstrate deterioration in asthma ( 82,83,84 and 85), other studies have shown deleterious effects in as little as 3 weeks (86). Because there has been no evidence that regular use of rapid-acting b agonists improves long-term asthma control, their regular use is not advised. Consensus panel reports clearly state that antiinflammatory treatment should be considered when b agonists are needed on a frequent, regular basis ( 67,68,71). In light of their slower onset of action, long-acting b agonists are not recommended for relief of acute symptoms (87). These agents block exercise-induced bronchoconstriction ( 88,89) as well as cold air induced responses ( 90) for up to 12 hours. Given their onset of action, they should be administered 30 to 60 minutes before exercise ( 91). Despite the ability to prevent such symptoms, long-acting b agonists should be used as adjunctive therapy to inhaled corticosteroids and should not be used as monotherapy (67,87,91). Moreover, these results are superior to those seen after increasing the dose of inhaled corticosteroids. Although all groups improved, a similar study in children failed to demonstrate an additional benefit for salmeterol after 1 year of treatment (99). Based on the benefits demonstrated in these studies, long-acting b agonists should be used in conjunction with inhaled corticosteroids for the management of asthma that is inadequately controlled (100). Levalbuterol has been approved for use by nebulization in patients aged 12 years or older for treatment of asthma. It may be administered every 6 to 8 hours, but, similar to the other rapid-acting agents, levalbuterol should not be used for maintenance therapy. Levalbuterol may be a suitable alternative for patients who experience unacceptable side effects from racemic b agonists, but further studies are needed to clarify the position of levalbuterol in the management of asthma. It is important to note that most of the adverse effects associated with b agonists are reduced when these drugs are administered through inhalation. Given the widespread distribution of b2 receptors, many organ systems may be affected. The most common complaint is tremor, which is due to stimulation of b2 receptors in skeletal muscle (103). Often associated with oral or intravenous administration, tachycardia and palpitations are much less frequent when usual doses are administered through inhalation. Mediated by b vascular relaxation in skeletal muscle, cardiac stimulation occurs as a result of decreased peripheral resistance with resultant sympathetic output. Isoproterenol use is associated with alterations in coronary blood flow that may lead to subendocardial ischemia ( 105). Transient decreases in PaO2 may occur when vascular dilation and increased cardiac output enhance perfusion to underventilated areas of lung ( 106). Abdominal complaints are sometimes seen in children receiving aggressive therapy for management of severe, acute asthma. Metabolic effects include hyperglycemia (due to glycogenolysis) and reductions in + + serum potassium and magnesium. Intracellular potassium shifts occur as a result of direct stimulation of the Na -K pump. Magnesium also moves in this fashion, but increased urinary excretion further contributes to the reduction in this cation. A review noted that despite the low frequency with which this occurs, these reactions may be quite severe, even life-threatening (107). It has been suggested that a lack of efficacy to b agonists may also be attributed to this phenomenon. Contamination of nebulized solutions, particularly from multidose bottles may also contribute to this problem. Finally, recent investigations suggest that the detrimental effects of (S)-albuterol may account for paradoxical bronchospasm ( 109). Short-term loss of effectiveness, or tachyphylaxis, occurs for b agonists as it commonly does with agonist cell surface receptor interactions. Whether clinically relevant tachyphylaxis to bronchodilatory effect exists remains controversial ( 1). Tolerance occurs after as little as 3 weeks of repeated use and appears to affect the duration rather than peak response ( 110,111,112 and 113). The first epidemic occurred in the 1960s, when a 2- to 10-fold increase in asthma mortality rates were noted in six countries, including the United Kingdom and Norway ( 115). Initial evaluation did not find the rise to be related to changes in diagnosis, disease classification, or death certificate information (116). A high-dose isoproterenol forte preparation was in use in the affected countries at the time ( 115), and the epidemics occurred only in those countries. Case series analysis revealed that many of those who died of asthma used excessive amounts of this high-dose product ( 117).
Descripcion y plan curativo de la epidemia que ha reinado en Queretaro desde fines de junio de este presente ano purchase metoclopramide 10 mg visa gastritis snacks, hasta la fecha en que esto se escribia [Description and treatment plan for the epidemic that occurred in Queretaro in June of this year best 10 mg metoclopramide gastritis diet options, until the date of this writing] metoclopramide 10mg mastercard gastritis diet ханука. Arzneybuchlein von mancherley bewarthen und erfahrnen Arzneyen, fur allerley Zufalle und Krankheiten des menschlichen Leibs dienstlich. Manuscript with title in a language other than English with optional translation De la grippe et de son traitement par le sulfate de quinine: 2 e partie. Manuscript with translators and other secondary authors Berengario da Carpi, Jacopo. Manuel des operations de chirurgerie par monsieur De Puys premier medicine du Royal Hopital de la Marine de Rochefort [Surgical operations manual of Monsieur De Puy, chief of medicine of the Royal Hospital de la Marine de Rochefort]. Manuscript date with month or month and day provided Kansas Legislative Council, Research Department. Relations of the war to medical science: the annual address delivered before the Westchester Co. Descripcion y plan curativo de la epidemia que ha reinado en Queretaro desde fines de junio de este presente ano, hasta la fecha en que esto se escribia [Description and treatment plan for the epidemic that occurred in Queretaro from the end of June of this year, until the date of this writing]. Apparently written by a military doctor providing a concise history of the origins and progress of an epidemic of 660 Citing Medicine measles and scarlet fever that swept through the city of Queretaro, Mexico, during the summer and early fall of 1825. Chabert came to Paris where he taught at and, in 1780, took over the Royal Veterinary School. In two sections: the first is mainly Greek Orthodox Christian prayers for clergy members for the benefit of sick laypersons in their care; the second half contains recipes for medicines and directions for therapies, also written for clergy. Original manuscript of the printed article found in the Indian Medical Gazette, June 1920. Sample Citation and Introduction to Citing Manuscript Collections The general format for a reference to a manuscript collection, including punctuation: Examples of Citations to Manuscript Collections A manuscript refers to any type of work, either handwritten or typewritten, that is not published. Titles for collections of manuscripts are unusual in that they are assigned by the library or other Manuscripts 661 archive housing the collection. Although they are thus constructed titles, they are not placed in square brackets as are constructed titles for books. If a manuscript collection is not available in any public archive, most authorities recommend placing references to it within the running text, not as a formal end reference. Place the source information in parentheses, using a term or terms to indicate clearly that the citation is not represented in the reference list. For example: material gathered from a collection of papers of Harold Jones (private collection; unreferenced, see "Notes") that The rules below apply when a manuscript collection is included in a reference list rather than within the text as described above. Note that most of the examples for citations provided in this chapter are taken from the Modern Manuscripts Collection of the National Library of Medicine. Citation Rules with Examples for Manuscript Collections Components/elements are listed in the order they should appear in a reference. Box 35 Other surname rules Keep prefixes in surnames Lama Al Bassit becomes Al Bassit, Lama Jiddeke M. Box 42 No author can be found If no person or organization can be found as the author but a compiler is present, begin the reference with the name of the compiler. Follow the same rules as used for author names, but end the list of names with a comma and the word compiler. Manuscripts 667 If no person or organization can be identified as the author or compiler and no translators are given, begin the reference with the title of the manuscript collection. Box 47 Names for cities and countries not in English Use the English form for names of cities and countries whenever possible. Manuscript collection with items not in English Type of Medium for Manuscript Collections (required) General Rules for Type of Medium Indicate the specific type of medium (microfilm, microfiche, etc. Manuscript collection in microform Secondary Author for Manuscript Collections (optional) General Rules for Secondary Author A secondary author modifies the work of the author. Box 52 Secondary author performing more than one role If the same secondary author performs more than one role: List all the roles in the order they are given Separate the roles by "and" End secondary author information with a period Example: Jones, Albert B. Box 53 Non-English names for secondary authors Translate the word found for editor, translator, illustrator, or other secondary author into English whenever possible. Manuscript collection with author and compiler Date for Manuscript Collections (required) General Rules for Date Give the date range of the items in the collection Enter the earliest date of the items in the collection, a hyphen, and the latest date of the items. Manuscript collection with dates estimated Extent (Pagination) for Manuscript Collections (optional) General Rules for Pagination Give the total number of the items in the collection End with a semicolon and a space if Physical Description is provided; end with a period if there is no physical description Specific Rules for Pagination Collection bound in volumes Number of items unknown Box 58 Collection bound in volumes A collection of manuscripts may be bound in volumes rather than being placed in boxes or other containers. When this occurs: Express extent as the number of volumes Abbreviate volume to vol. Box 59 Number of items unknown A collection may be so large that an exact count of the number of items in it has not been made. Manuscript collection with extent estimated Physical Description for Manuscript Collections (optional) General Rules for Physical Description Give the total number of containers holding the collection and/or the total number of linear feet of shelf space the collection occupies Follow with the type of container or the words linear feet, such as 3 boxes or 10 linear feet End with a period Give information on the total number and physical characteristics of the items in the collection if they reside in a microform, such as 26 microfiche: black & white, 4 x 6 in. Typical words used include: color black & white positive negative Manuscripts 679 4 x 6 in. Box 61 More than one type of medium If a manuscript collection is in a microform such as microfilm or microfiche, place the name of the type of microform after the title in square brackets Alchemy collection [microfilm]. Manuscript collection with physical description Availability for Manuscript Collections (required) General Rules for Availability Enter the phrase "Located at" followed by a colon and a space Give the name of the library or archive, preceded by any subsidiary division(s), and followed by a comma and a space. Bibliotyeka, Rossiiskaia Akademiia Meditsinskikh Nauk [Library, Russian Academy of Medical Sciences] or [Library, Russian Academy of Medical Sciences] Translate names of organizations in character-based languages such as Chinese and Japanese. Manuscript collection with availability Language for Manuscript Collections (required) General Rules for Language Give the language of the collection if not English Capitalize the language name Follow the language name with a period Specific Rules for Language Collections with items in more than one language Box 62 Collections with items in more than one language If the items in the collection appear in more than one language, give all languages found, separating them by a comma and a space Examples: von Diringshofen, Heinz. Box 66 Collections with restrictions on use A library or other archive may place a variety of restrictions on the use of manuscript collections, or the donors of the manuscripts may restrict use. Gertrude Henle required to quote, cite, paraphrase, or publish any of the unpublished material during her lifetime. Box 67 Other types of material to include in notes Notes is a collective term for any type of useful information given after the citation itself. Examples include: Explanatory information on the content of the collection Bailey, Zachariah. Manuscript collection with other notes Examples of Citations to Manuscript Collections 1. Manuscript collection standard citation with full name for authors Calderwood, Howard Black. Manuscript collection with organization as author Association of Military Surgeons of the United States. Manuscript collection with no author or compiler Collection concerning health resorts. Manuscript collection title not in English Fonds du Conseil de Recherches Medicales. McFarland collection in aerospace medicine and human factors engineering [microfiche]. Fonds du Conseil de Recherches Medicales [Collections of the Medical Research Council]. Manuscript collection accompanied by material in another medium American College of Cardiology. Gertrude Henle is required to quote, cite, paraphrase, or publish any of the unpublished material during her lifetime.
Educate residents spouses about the physician the confict between the demands training and home-life purchase genuine metoclopramide on-line diet during acute gastritis, and health resources available to their families (e discount 10mg metoclopramide otc gastritis chronic. These individuals are often the frst to in both parental and marital satisfaction order metoclopramide overnight delivery gastritis symptoms bloating. Adequate vacation time, fexible Case resolution work hours and equitable part-time work are conditions of The program director organizes a day-long retreat for the employment that are conducive not only to improved family residents and their signifcant others. The program director life and mental well-being but also to greater job satisfaction brings in a well-known speaker to discuss issues surround- and productivity. Physicians are most satisfed as parents when ing physician health, including work-lifebalance, ways to they have a supportive spouse and when the work home con- maintain healthy intimate relationships, and recognizing ficts of both partners are minimal. The resident body fnds the expe- medical practice can also affect physicians relationships with rience very useful and decide to make this an annual event their children. For instance, Armstrong s group, found that to help prevent family stress related to residency training physicians who worked for a salary were more fulflled in their and to help recognize the roles that each of their families parental role than physicians who worked on fee-for-service play in their own residency program. Finally, the employment status of one s spouse seems to play a role in parental satisfaction. It is also im- medical families, and portant to value the work and other pursuits of one s partner, explore challenges specifc to those relationships. Case As seductive as the practise of medicine can be, Michael Myers A resident requests a meeting with their supervisor over reminds us to say yes to the relationship and practise say- coffee. The resident becomes distraught while disclosing ing no to other offers (Myers 2001). Spend a minimum of that she miscarried her frst pregnancy three weeks ago twenty minutes alone with your spouse each day and plan a and that her partner, a more senior resident, is preoccu- date together every week. The resident acknowledges that her partner has tried Monica Hill and Nancy Love quote the novelist Henry James to be supportive, but feels that he just doesn t get it. For physicians as for anyone else, this means having population, domestic violence and abuse occurs in medical time together to develop the essential advantage of such rela- families too. Confict between work and familial roles is inevitable at times, whether one or both partners are physicians. Classically, role Work and family life strain has been more frequently noted among female physi- The issue of deferring intimacy in favour of medical work has cians, but in reality male physicians experience it as well. Half been described in the literature on medical marriages (Myers of married women physicians are married to other physicians 2001 and Gabbard 1989). Dual-physician relationships bring sional advancement over the nurturing of intimate relation- certain challenges, such as complicated schedules and career ships, working long hours at the expense of their home lives. Careers postpone their investment in the emotional bank account of can be shaped, reshaped and salvaged more easily than rela- their families or in some cases, avoid admitting that they in fact tionships and families. For example, while physicians of female physicians being the primary or sole income earner are accustomed to their role as experts and expect to be in in their households. In contrast to Protecting and nurturing our intimate relationships may require most physicians experience of medical education, marriage is a re-examination of our professional responsibilities and work non-competitive. John Gottman, a respected re- Does your group discuss shock-absorber systems for searcher in marriage and relationships, stresses the importance parental leaves and urgent family issues? She had speculated that a child would keep geographical triangle: home, school and workplace. Keeping her relationship together, given her partner s attraction to logistics as simple as possible will beneft your marriage and more medicine and achievement. He expresses fear of giving in Raising children together to his feelings lest they derail his career focus. With the For many women physicians, the question of when to plan counsellor s help, they review their priorities with regard childbearing is especially challenging when training demands to career plans and the timing of child-bearing. Supportive sessions lead to a better understanding of their mutual colleagues and training programs are nearly as important as a objectives, and of the supports available to them to help supportive partner. Furthermore, resi- dency training directors never accompany graduated residents impact on your family, whose sleep is being disturbed by the to the infertility clinic. The concept that it takes a village to raise a child applies to medical families, too. Women physicians are particularly aware Vacations are one of the non-urgent but important elements that the more they work, and the greater number of children of time management. Vacations in which play and fun and they choose to have, the greater the chance that they will need not perfection are modelled, where being rather than doing to rely on child care arrangements beyond the family. Many are valued and pleasure for its own sake is enjoyed, are healthy women physicians and dual-career couples fnd live-in help with for the whole family (Maier 2005) regard to child care invaluable. External assistance with regard to other household duties can also be a time-management tool Summary that benefts everyone. Managing the expectations of our partners and others can be problematic in medical relationships. Some of these expecta- Two points to remember when your medical relationship is tions may be fnancial, arising from assumptions about what blessed with children are these: the lifestyles of physicians will be. You do not have to be perfect, but you can be good pectation of concierge service within the health care system. All deserve Although little has been written about the children of physi- refection, good communication and attention to maintaining cians, we do know that children want and deserve their parents appropriate and ubiquitous boundaries. Depending on their stage of development, this may mean breastfeeding for the recommended time, taking Relationships go through cycles. Should your medical marriage the maximum possible parental leave, delaying a career move, run into challenges, remember you are not alone. Even if you cannot Myers, through his book Doctors Marriages, shares his wisdom always be there, it is important to work with your partner and that face-to-face couples therapy works best. Seek professional to communicate with your child so that you are emotionally help through your community resources or your physician involved and up-to-date with what is going on in your child s health program. In addition, more men than ever before are taking This chapter will advantage of parental leave policies. Thus, traditional gender describe some of the challenges commonly faced by phy- roles in Canadian culture are clearly undergoing a healthy evo- sician parents, lution. Medical students are watching this transition and may choose not to Case engage in specialty medicine if it is perceived to be adverse to A second-year resident has recently adopted an infant their family-related values and expectations. However, several residents in the year are In the meantime, academic medicine has not been particularly off on parental leave, and the frequency of call is higher kind to physician parents who have typically enjoyed less insti- than usual. In fact, the resident is perceive a slower progression of career goals, and have lower planning on taking leave, but is now dreading approaching levels of career satisfaction. Children add a dimen- sion to life that is unique and delightful, and the parental role Unique challenges of parenting provides opportunities to know ourselves better. That being Physician parents are in an unique position as they promote said, parenting can add to the complexity of managing busy and monitor their children s health and development. Where some may argue that knowledge about health is valuable and helpful, but as is the physician parents lack full professional commitment, others case with any parent their objectivity is limited. Issues that they ensure their children have a primary care provider confronting physician parents are many, and their complexities who is skilled and comfortable working with the dynamics concern both professional and personal roles.