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A proposal for: Queen of hearts

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A proposal for: Queen of hearts

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Content A Proposal for:
QUEEN OF HEARTS
Dr. Alice Perlowski, MD, FACC
Master of Arts, (SPECIALIZED JOURNALISM)
University of Southern California
December 2017

2

Table of Contents

Overview 3

Market 4

About the Author 5

Outline of Chapters 6

Sample Chapter: Androgyny 10

Sample Chapter: Alone 22

Sample Chapter: Alive 31

References 44

3

Overview

“I fix broken hearts.”

That’s my typical response when I’m asked what I do for a living. I am not a therapist or a
psychologist. I’m a cardiologist who actually works on real, beating hearts. That being said, I am
no stranger to heartbreak in a figurative sense. An abusive childhood, painful divorce, and career
rattled by sexism and discrimination has tested my emotional strength every step of the way.

Queen of Hearts is an autobiographical novel that chronicles my path to becoming a physician in
the predominantly male field of cardiology. It provides a personal, inside look into the grueling
life of a medical student, resident, and young physician. The book explores my first experience
with the death of patient, and how I faced my own mortality during a severe illness. It also
describes how, for most of my life, I neglected my own emotional needs, while tending to the
hearts of others.

Physicians, while having a tough outward shell, are often fighting an inner battle. Work related
stress and long hours of intense work in the hospital can lead to loneliness and depression,
causing personal relationships to suffer and fail. As it turns out, most of us don’t have glamorous
love lives like the doctors on Greys Anatomy.

Most assume a doctor’s personal and professional life are accurately depicted in these fictional
programs. This book will prove that theory wrong.

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Market

This novel is aimed at anyone interested in having intimate access to personal and professional
aspects of a physician’s life. Over 53,000 students apply to medical school each year
(AAMC.org), and all are curious as to what their life will be like as a physician. The general
public is also interested in doctors: during its peak season, Grey’s Anatomy had 37.8 million
viewers (“No 6 ‘Grey’s Anatomy,’”...).

The book is also written for young, professional women. Women comprise 47 percent of the
labor force in the United States (dol.gov). Most have faced significant challenges achieving
equality in the workplace. This novel is meant to show women, particularly the 26,000 who enter
medicine each year (AAMC.org), that they are not alone in their fight.

Studies have shown that reading the letter “A” in repetition can have a motivational effect (Ciani,
2010). This is the main reason that every chapter title of the book starts with an “A.” If the book
were published, it would be shelved next to inspiring novels about female scientists, such as
“Lab Girl” by Hope Jahren and “Super Women: Six Scientists Who Changed the Word” by
Laurie Lawyor. Young women must learn about successful female scientists to believe that they,
too, can make contributions to this male-dominated field.

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About the Author

Dr. Alice Perlowski is a practicing cardiologist in Southern California. She is originally from
central New Jersey, and attended college at Cornell University. She earned her medical degree
from Vanderbilt University, before moving to Los Angeles to perform her internal medicine and
cardiology training at UCLA. She then trained in vascular disease at a Harvard affiliate, before
joining the faculty at University of Chicago.

Dr. Perlowski has also held faculty positions at University of California, Irvine and UCLA.
Currently, she is practicing in a managed care organization in Southern California. She is board
certified in six specialties: internal medicine, cardiology, interventional cardiology, nuclear
cardiology, vascular medicine, and endovascular intervention. She is also a Fellow of the
American College of Cardiology.

Dr. Perlowski has been a prolific writer from a young age. In 2015, she earned the Jackson
Fellowship, which funds science writers to earn a graduate degree from USC’s Annenberg
School of Journalism. She is a candidate for a Master’s Degree in Specialized Journalism at
USC. She was encouraged to write this book by her friends, family, colleagues, and patients.

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List of Chapters

Chapter 1- “Alice”- I was a complete surprise to my parents when I came out “normally”- my
older brother was left mentally handicapped by a condition called “Fragile X.” This chapter
discusses what it was like to grow up with a disabled brother, in a family influenced by mental
illness, violence and substance abuse.

Chapter 2- “Anxious”- As a kid, I was a nervous wreck. This was due to my perfectionistic
nature combined with the pressure of being the “normal” child in the family. My agitation
manifested itself as hypochondriasis, which ultimately resulted in my interest in medicine. This
chapter discusses my reasons for pursuing a career in medicine, and how I realized later that my
intentions differed from some of my physician colleagues.

Chapter 3-“A List”- I have always been obsessed with doing well in school. This chapter
covers my years of college and describes the dramatic transition to rigors of medical school. It
also describes my introduction to taking care of patients, including my first experience with a
cadaver and witnessing a patient death.

Chapter 4-“Autopilot”- This chapter explores my years of residency/fellowship training and
my marriage, where it felt like my life was running me, instead of the other way around. During
this period I was completely immersed in my medical career and obsessed with advancing in the
highly prestigious field of cardiology.

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Chapter 5-“Androgeny,”- Discusses my inner turmoil when it comes to being a woman. I’m
clearly a typical female in most ways, yet I have had to focus on developing a more masculine
mindset as part of a male-dominated field. I also describe the perceptions that men and women
have had of me, and how these perceptions were nothing like what I had expected.

Chapter 6-“Alone,”- Documents my initial years as an attending physician, after years of
formal training. Like most highly successful people, I discovered that it can be very lonely at the
top. My impending divorce to my husband of ten years compounded this feeling of isolation.

Chapter 7-“Aggie”- The pet name my father gave me (which was the way I used to pronounce
my own name when I was a baby). Documenting my relationship with my parents, and how they
shaped me as a young woman, and a doctor. The chapter describes how my relationship with my
father dissolved several years before his death, while the bond with my mother became stronger.

Chapter 8-“Annenberg”- Could there be a way to undo the incompetent reporting of a TV
doctor like Oz? A chapter discussing my introduction to journalism, the doors that this has
opened for me, and what I discovered was important about the media/media coverage from the
point of view of a physician. During this time, I also experienced a shift in my career.

Chapter 9-“Alive,”- A surprise illness suddenly strikes, and I am faced with my own mortality
as I fight for my life. Physicians frequently push their own health aside while caring for others,
and I am no exception. I discuss the experience of trading my white coat for a hospital gown.

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Chapter 10-“Amnesia,”- This chapter explores my experience entering formal therapy, where I
discovered mindfulness. I found through inner examination that I had blacked out the majority of
hurtful memories from childhood to protect myself. I also explore how I have used detachment
as a defensive strategy in my career as a physician. Conclusion chapter which describes how I
have developed awareness for the needs of my own heart, while healing the hearts of others.

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SAMPLE CHAPTERS

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Chapter 5

Androgyny

It was a frigid, blustery night in Boston. My Blackberry read half past eight, and I was finishing
my evening rounds in the Cardiac Unit of Massachusetts General Hospital. My fellowship at
Mass General marked my eighth year of medical training after completing medical school. I had
already completed three years of internal medicine residency, three years of cardiology
fellowship, and one year of learning cardiac procedures. This year was for me to learn how to
diagnose and treat blockages in the blood vessels of the legs.

I yawned as I retrieved my belongings from the call room and shuffled towards the elevator. I
wearily glanced outside at the falling snow as I passed a row of tall windows. My gaze shifted
slightly, as my reflection came into focus.

Boy, did I look like a mess.

My long, blonde hair was still pulled back into a messy ponytail; any makeup I had applied
fourteen hours ago was long gone. Blotchy, red lines surrounded my nose and eyes, which had
been covered by a mask and protective glasses all day while I performed heart procedures. My
scrubs were baggy and loose, practically hanging off of my thinning frame. I think I forgot to eat
lunch again. What else was new.

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There is no such thing as “lunch time” in the medical profession. In fact, time, in general,
becomes irrelevant when you work in a hospital- it could be 2PM or 2AM and the sterile,
fluorescently lit hallways look and sound almost exactly the same. No matter what the hour,
doctors, nurses, and staff are bustling about to the rhythm of beeping heart monitors and IV
machines. Breaks for nourishment or rest are only taken when there is a lull in the action, which
is pretty much never. Illness never stops, and neither do medical professionals.

I am often asked why I entered such a demanding profession, which at times has required 90
hour work weeks, interrupted sleep, stress, and immense sacrifice. Especially since I am the only
physician in my family: most of the men in my family are lawyers, and the women are teachers.
Both of these professions are much kinder when it comes to working hours and demands on the
body. At least lawyers and teachers eat lunch.

I found medicine, and medicine found me, because I am crazy. Not crazy like padded-wall
psyche ward crazy, but crazy as in anxious and intensely perfectionistic, with a little bit of OCD
on top. When I was school age, my anxiety often manifested itself with physical symptoms:
stomach aches, headaches, sore throats, you name it. Unfortunately, there was no “Dr. Google”
back then, but there were libraries. Already a voracious reader, my intense curiosity, even fear,
about my symptoms propelled me to read every medical book I could find. After reading about a
hundred of such books, I had cured my hypochondriasis, and was addicted to medicine.

I entered medicine because I consider being a physician the ultimate privilege. It has always been
fascinating to me that complete strangers trust me with their health, and their life. Making

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another human being feel better gives me a rush that I’m pretty sure I could never achieve in
another profession. I’ll just skip lunch for another few decades- it’s worth it!

♥ ♥ ♥ ♥ ♥

I shrugged at my bony reflection in the frost-covered window, and vowed to start taking a
multivitamin. As I entered the elevator, I heard a voice behind me calling my name. I put my
hand out to hold the door, and smiled as I saw Will jogging towards me.

I had known Will for a long time. We had started internal medicine training together at UCLA
nearly seven years earlier. I stayed at UCLA for my cardiology fellowship, while Will completed
his fellowship at another local hospital. We reunited in Boston in 2009, while Will was
completing his coronary intervention training, and I was finishing training in the treatment of leg
and neck arteries.

Will and I were good friends. We had tons in common, namely, both of our spouses were nearly
3000 miles away in LA. We frequently coordinated our weekend flights so that we could go to
the airport together on Friday and enjoy a drink at the airport bar before we headed to LAX.
Being away from my husband was hard for me, but I am sure it was worse for Will, who also had
two kids in LA.

It is not uncommon for spouses and families to separate for a year or more while a physician
completes medical training. Separation from spouses, family and friends can put significant a

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strain on relationships, and can lead to isolation and depression in physicians (Rich, 2016). But
we were talking Harvard here: the opportunity of a lifetime. Will and I had decided it was worth
the risk.

In Boston, I was alone, but I was never lonely. I had been “adopted” by the eight other
interventional cardiology fellows that year. All were, of course, men, which makes sense,
considering less than twenty percent of the nation’s cardiologists are female (Blumenthal, 2017).
That year, it was Brian, Nicky, Pallav, Arnold, Roland, Rahul, Bobby, Will, and me (Ironically,
Bobby is third author on the reference I just cited). They were a fun bunch of guys, who I
genuinely enjoyed working and hanging out with.

Being “one of the guys” had become as natural to me as walking down the street. I liked being
around men. There was no drama, no catty- ness, and, lets face it- guys are just... funny. I smiled
and laughed constantly, as the guys teased me and treated me like their little sister. Although I
was very different, I felt in some way that I belonged more than I ever had before.

I was proud to be somewhat of an oddity, not only at Massachusetts General, but in the field of
cardiology. I felt every day like I was taking some sort of stand for the female gender; I was
earning respect for all women by showing the smartest men in the world that I could be their
equal. I loved showing men that I was as good, or better than they were. I lived for the look of
surprise on a mentor’s face when he saw me do something in the heart procedure lab that my
male colleagues struggled with. I was “one of the guys,” yet I was still me- a thirty- something
woman who liked highlights in my hair, Hello Kitty, and four inch stilettos.

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On more than one occasion, people- even females- expressed surprise at my achievements. At
one annual Cardiology symposium, I had been asked to be a faculty speaker. When I entered the
conference center in Atlanta, I made my way to the “Faculty” booth, and introduced myself.

A poised, well dressed lady behind the desk examined me, then paused, seeming confused.
Suddenly, an expression of understanding strengthened her voice as she addressed me in a thick,
Southern accent:

“Oh sweetie, you are in the wrong place. The pharmaceutical rep check-in is down the hall to
your left.”

I wasn’t annoyed so much as I was caught off guard. I tried to hide my embarrassment as well as
I could, while explaining to the woman that I actually was a cardiologist, and a speaker at the
meeting. I couldn’t blame the woman for making the mistake: there are very few female
cardiologists in academics and the ones who achieve faculty positions are half as likely as men to
be named full professors (Blumenthal, 2017).

Ms. Southern Drawl looked mortified as she shuffled through a stack of badges to find my name.
As I turned to walk away, the heat of the woman’s humiliation was almost palpable, propelling
me as quickly as possible towards the meeting rooms.

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In a way, I was flattered that the lady was surprised that I was a cardiologist. After all, “pharma
reps” tend to be very attractive, so I took it as a compliment. For my entire career, I have had
patients say I look “too young to be a cardiologist,” which, again, I suppose is flattering, but
sometimes a bit awkward. During such visits, I have learned to artfully make light of the
situation with a joke (“Oh, I am not really your doctor, I just play one on TV”) to ease tension
before I swiftly get “down to business.”

In social settings, I like to have fun with people when asked what I do.

“I fix broken hearts...”

...is my standard response. Of course, most assume that means I am a psychiatrist, or a marriage
councilor, or a sex therapist (yikes). I am definitely none of those, but being a cardiologist does
require similar patience and empathy. The heart is the center of the universe as far as the body is
concerned; without it, none of the other organs can function. Patients are aware of this, and are
absolutely terrified when they find out their heart has a problem. Reassurance that a heart patient
can often live a normal life is a large part of what I do on a daily basis.

I first appreciated the wonders of cardiology as a medical student at Vanderbilt. As med students,
we had access to the rehabilitation center on campus. During lunchtime, or as a study break, I
would get some exercise in on whatever equipment was not being used by patients.

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One day, while running on the treadmill, I noticed a man on the machine next to me with a large
scar in the center of his chest. Noticing my glance, told me that three weeks prior, he had
undergone open heart surgery to bypass blocked arteries in his heart. I was absolutely amazed
with the fact that this man, who had been crippled by a heart attack a few months prior, was now
working out at the gym. I spent the next hour asking him all kinds of questions. Within a week, I
was shadowing a cardiologist on campus in my free time.

The heart was just so cool. So dynamic, so important, so beautiful. And it made sense. Much of
what happens in the heart is defined by simple principles of physics: we make measurements in
the heart using flow and pressure equations similar to the ones that meant nothing to me during
my pre-med studies. I quickly became fascinated with all aspects of the heart: how it worked and
what could go wrong with it. Did you know that a person could be born with the heart anatomy
of a frog (three chambers instead of four) and still survive?

As I studied the heart in the literal sense, I began to recognize why hearts figuratively symbolize
love and adoration. Love drives everything that we do in life, just like the heart drives everything
the body does. When the figurative heart is broken, it can be incapacitating. Just like when the
literal heart “breaks.” The idea of fixing the centerpiece of the human body felt so powerful.

It would be a long road and a demanding career, especially for a woman. Women face extra
pressures in busier medical specialties- there is a constant juggling of family responsibilities and
work (Treister-Golzman, 2016). I never had a doubt I could handle it, and that I would be good

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at it. And I was: I landed some of the top notch residency and fellowship spots in the nation. My
year at Harvard, arguably one of the highest points of my career, was just icing on the cake.

Little did I know that the way I saw myself as a professional, wife, friend, and woman was about
to change forever.

♥ ♥ ♥ ♥ ♥

As the lift descended, Will and I set about bundling ourselves up for the cold, while exchanging
friendly banter about the day. A common pastime for us was to make jokes about our boss,
Kenny Rosenfield, who is not only a legendary interventional cardiologist, but one of the most
hilarious, warm, and caring individuals I have ever met. That being said, Kenny is a complete
mess when it came to stress management.

The fellows, staff, and other attending physicians at Mass General were always joking about
Kenny’s “Activation Stages,” a very scientific (yet hilariously objective) measure of how
stressed Kenny was on that particular day. “Activation Stages” were divided into three
categories: Green, Yellow, and Red. When Kenny was having a “Green” day, he would smile
and laugh, kick his feet up on the desk, and poke fun at his trainees from the cardiac procedure
control room. On “Yellow” day, Kenny could be found running all over hospital barking orders

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and shaking his head with frustration. On a “Red” day, it was best if you just found a place to
hide.

From Day 1 at Harvard, Kenny liked and respected me. He knew that I was one hundred percent
devoted to learning, while helping him take care of his patients (some of which he had been
following for over 20 years). It was an honor for me to help Kenny; not only was he one of the
most famous cardiologists in the world, but his devotion to his trainees and patients was second
to nothing I had witnessed in my career.

On Christmas that year, I was “on call” with Kenny, meaning I had to go into the hospital to help
him with all of his emergency procedures. My mom and brother, who wanted to see me for the
holiday, had flown in from Pennsylvania to spend time with me. A descendant of Polish, Roman
Catholics, I had never missed Christmas Eve mass with my family- in over 30 years.

Except for that year. Kenny, famous for his “Black Cloud,” (or in the medical world- the
propensity towards getting “slammed” with horribly ill patients on call), had drummed up several
cases, and I spent the night taking care of his patients. I didn’t mind. I knew that training under
Dr. Rosenfield was a once in a lifetime opportunity, and I was not about to waste a second of it.

It was well known to my fellow trainees with that Kenny liked me, in the most professional sense
possible. We had a special bond, consisting of friendship, admiration, and respect. This was a
subject of a bundle of colorful jokes with my colleagues, but all in good fun, or so I thought.

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Most of the men respected me as much as Kenny did. Little did I know that I had been blind to
the resentment had been building as a result of my well-earned bond with my mentor.

♥ ♥ ♥ ♥ ♥

As we neared the ground floor of the Elliston Building, Will spoke words that would change my
life.

“Hey Alice,” Will quipped. “Do you know why Kenny and all the bosses like you so much?”

Preparing myself for some stupid, goofy dig, I smiled, glanced at Will sideways and pretended to
accidentally elbow him.

“I have no idea, Will, why?” I laughed.

“Because you are female. And blonde.”

Although we had already reached the ground level, I felt at that moment as though the floor was
still dropping out from under me. I was stunned. Tears welled up in my eyes. It seemed like
hours before I regained my bearings and mustered the strength to storm towards the exit, leaving
Will behind. I could not form a coherent word or thought. I was shocked, sad, and devastated.

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My colleague- my supposed “friend”- had just suggested that the affection I had won from my
male bosses was related in some way to my gender and appearance. I had never, had anything
but professional exchanges with any of my mentors or male colleagues. I never dressed
suggestively, wore heavy makeup, or flirted. I had completed the same degrees, training
programs, and board certifications. I was doing the same job at the same level or better. For
years, I had considered myself “one of the guys”... and genuinely thought that was how they saw
me, too.

I think I had missed the signs indicating that Will and the other guys were envious of my
relationship with Kenny, and my success. I had assumed when the guys joked about me being the
“favorite” and “Miss. Perfect” and “apple of Kenny’s eye” that they were just trying to make me
blush. Will’s “blonde” statement, which had been made with a completely straight face,
confirmed that a certain amount of resentment had been packed into those otherwise whimsical
comments.

I never spoke to Will again (despite the fact that he, to this day, works a few miles from where I
live in LA). He realized his mistake, and did try to apologize, but I was so furious I couldn’t even
look at him. I found out later that many men resented my success- Will was just the first one to
make this obvious to me.

Learning to cope with misogynistic men was the first of the many serious challenges I would
face in my career... and in life for that matter. Will’s words had provoked a deeply painful

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realization that I had been sheltered for decades; guarded from such harmful and sexist
confrontations by strong, adoring men like my father, my husband, and my mentors.

As the men who truly respected me began to leave my life, one by one, my protective shield
would vanish with them.

♥ ♥ ♥ ♥ ♥

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Chapter 6

Alone

At last. After over a decade of training after medical school, I was a full fledged interventional
cardiologist. An interventional cardiologist, or IC for short, is a heart doctor who has done more
specialty training to perform minimally invasive heart procedures. These heart procedures
involve placing microscopic balloons in the heart arteries to open up cholesterol blockages. After
the blockage is expanded, tiny scaffolds called “stents” are placed to help keep the blockage
open. To put it simply, I was a glorified “plumber” of the heart.

I had trained seven years to learn everything about the heart and how to fix it, plus two additional
years to learn how to open up leg blockages and fix heart valves as well. I was arguably one of
the most well trained ICs in the country. And I was a woman.

In the US, women make up less than five percent of ICs (Grines, 2015). There are are a few
important reasons that women avoid this field. First, the hours are long and grueling, and not
conducive to having much of a family or personal life outside of work. There are many days
when I worked over 16 hours, and the majority of these were completely on my feet. I worked
nearly every day of the year. I missed holidays, weddings, and funerals.

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Another deterrent for women entering IC is the radiation exposure. Heart procedures are often
done with fluoroscopy, which is X-ray equipment that allows us to see heart arteries that have
been filled with contrast dye. Obviously, for a woman of childbearing age, radiation exposure
can be a serious concern. To protect us from the X rays, we wear special suits and googles that
are made of lead. That being said, several parts of our bodies, such as our heads, face, and lower
legs and feet, are not protected. It is a well known fact that practitioners who work in radiation
have a higher risk for cancers; there are several reports of physicians dying at young ages of
cancers related to prolonged exposure (Roguin, 2013).

So why did I choose a specialty where I have no life and could get cancer? Simple: I am an
adrenaline junkie. Not really in the sense of jumping out of planes or swimming with sharks; but
more in the medical sense. I was the crazy one during internship who would sprint to every
“Code Blue,” or emergency resuscitation of a patient. While those who went into less intense
specialties like dermatology were more often seen walking away from the Code, I wanted to be
there first, so I could lead the resuscitation effort. I literally become high on crisis; extreme stress
brought a strange sense of calm and euphoria.

Crisis and chaos felt familiar; almost comforting. This stemmed from growing up in a turbulent
household. My father, a corporate attorney, was a raging alcoholic. Many nights when he came
home from work, he had already had several drinks at a local bar. Some nights, the alcohol
pacified him. Other nights, the booze fueled his anger. This led to heated, violent arguments
between he and my mother. When his rage was directed at me or my brother, it usually resulted
in a whipping with a leather belt.

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Growing up in a violent home, I had two choices. I could become distracted, mess up in school,
and get into drugs. Or, I could bury it, shut it out, and not let it affect me at all. And that is what I
did. I was in constant denial about what was happening at home; the worse it got, the harder I
studied. As a child, I had learned to suppress my emotions for self preservation. As an adult, the
ability to detach myself from my emotions made a career in medicine the perfect choice.

It is well known that physicians must be emotionally detached. A physician who displays her
emotions when faced with the death and despair of their patients can be viewed as
unprofessional. This contradicts the desire to show empathy towards patients, which is what
drives individuals to medicine in the first place. This conflict, along with unresolved emotion,
can lead to depression and physician burnout (Kerasidou, 2016).

I was nowhere near burning out as I gleefully started my first job as an attending interventional
cardiologist at University of Chicago. It was a prestigious position: I was an Assistant Professor,
involved in teaching students, residents and cardiology fellows. So, I was constantly followed by
a gaggle of trainees, seeing patients and doing procedures. I absolutely loved the teaching part of
it. Being a professor filled a void that was left by never having children- I felt like I was making
a difference in the next generation- creating a legacy.

I was one of four interventional cardiologists at U of C. The other three of my colleagues were,
of course, men. I was actively recruited to the position by a physician I knew from a decade ago
when I was training in Los Angeles. He seemed genuinely interested in me joining the group,

25

almost giddy about it. Before I started the job, we communicated frequently and even went out to
dinner a few times. I welcomed having a friend there as I navigated my first year as an attending
physician.

Our real relationship was defined my third day on the job, when I dealt with my first “STEMI.”
STEMI is short for “ST Elevation Myocardial Infarction;” basically a patient who has come in
for emergency treatment of an artery that has been completely blocked by a blood clot. The goal
of an IC and her staff is to get the patient into the catheterization lab emergently, perform an
angiogram to identify the blockage, and then use small catheters and stents to treat the blockage
and prop it open. The time it takes to accomplish this process is closely monitored: when the
patient crosses the threshold of the emergency department, a clock starts. The IC has ninety
minutes or less to open the blockage.

Due to the time-sensitive aspect of a STEMI case, there is a lot of pressure to gain access to the
patient’s leg or arm artery, string catheters into the heart, identify the problem, and fix it. Any
case where the physician does not meet this benchmark will result in administrative review, and
even disciplinary action in some cases.

For my first STEMI, I was both excited and terrified. I knew I was good, and that I would have
no issues with the procedure; I had performed thousands of cases at this point and could
practically work on a patient’s heart with my eyes closed. The patient arrived, and we went to
work. Of course I was focused on the procedure, but I had a weird feeling I was being watched. I

26

was. Out of the corner of my eye, I could see all three of my colleagues standing in the control
room, arms folded, examining every move I made.

I am not sure if they were waiting for me to completely screw up, have a panic attack, kill the
patient, or cry. Maybe they were waiting for a combination all of all three. Little did they know I
was...as I would come to be known by my fellows...an “Ice Queen.” No matter how hot the fire, I
kept cool and collected, and no amount of intimidation could distract me. Plus, I was completely
determined to prove myself to these guys.

The case went well; my time from patient arrival to me opening the blockage was 57 minutes. As
soon as the procedure was complete, my “audience” dissipated. I saw the “friend” who had hired
me smirk, turn, and walk away without saying a word. I think he was angry that I didn’t fail. Had
he hired me to try to prove that a woman couldn’t do what he did, and had I already disappointed
him? We would never speak again other than in formality.

The men I worked with soon started the alienate me. They talked about me and my cases behind
my back. They tried to egg on physicians in other specialties to believe that I had not followed
standard of care, or managed a patient inappropriately. It is almost like they were angry that a
young female physician was as successful and talented as they were. The resentment was
palpable.

27

The better I did, the more alone I felt. I didn’t dare ask for help, or even advice from the guys-
they were waiting for me come crawling to them- and to fail. I promised myself and my patients
that I was never going to give them what they wanted- ever.

My call schedule became impossible. I was on call two weekends a month, while the rest of them
took one or less. One week, all three of them took off to a meeting, leaving me to manage the
entire coronary care unit, do all the heart procedures, and be on call for a week straight, with no
break. At the end of the seven days, I was having trouble seeing straight, was nauseated and
dizzy, and, at one point, was laying on the floor of my office drinking Coca Cola, praying I did
not pass out.

The year I joined the faculty, Division of Cardiology at University of Chicago was composed of
35 physicians. Six of us were women; all of them very accomplished. Several of them were
highly acclaimed, nationally known researchers who had won large research grants for the
institution. Half were considered world experts in their field. Most had over a decade of
experience.

Yet, if one voiced an opinion in a faculty meeting, they were silenced, humiliated, and ostracized
by the male majority. Despite the fact that all of us put in the same, and sometimes longer hours
than the men, we were considered invisible and insignificant. I came to find out later that all of
us were grossly underpaid compared to our male colleagues, sometimes by as much as twenty-
five percent. This was not unique to University of Chicago: recent data from Journal of

28

American Medical Association showed the average female physician in the US is paid 50K less
per year than her male counterparts (Jena, 2016).

Sitting in these faculty meetings, watching women I admired get silenced, corrected, and
dismissed by the men made me physically ill. Every one of those women had worked just as
hard, or harder than me, and all they faced was abuse and disrespect. None of us really talked
about it- I guess we all felt embarrassed and despondent in a way.

This is what I had worked so hard for for almost twenty years? This is my life now? That is what
I will be in ten years? I had this conversation with myself after every faculty meeting. Soon, I
started dreading them weeks in advance.

The only way I came through that year and a half unscathed was due to my old friend “survival
mode.” Early in my childhood, I had learned to push my stress and worries aside- I had learned
how not to feel anything, so I could get the job done. And I excelled- as long as I maintained an
emotionally numb state.

I eventually lived up to my “Ice Queen” nickname. The frost that preserved my concentration
and demeanor eventually began to seep inward. The warm heart that had loved the people in my
life became lifeless and chilled. Sadly, I began to neglect my family, friends, and husband of ten
years.

29

As my heart became colder, my marriage went on life support. My husband Jason tried very
hard to understand what I was going though. He offered as much comfort and support as he
could. I was just at capacity. I could no longer could handle the stress of trying to keep a
marriage together while I was trying to save my career. The immense pressure I constantly felt
was all-consuming.

I started to avoid my husband, even during time off. I tried to give him every excuse possible to
leave me. I felt tremendous guilt over the fact that I could not love him anymore. I felt he
deserved children, if he wanted them, and a wife who could focus on what he needed, instead of
just her career. Finally, I suggested that we should get a divorce.

Jason was completely crushed. At one point, he called my mother in tears, asking her what he
had done to deserve this. He felt completely rejected, and alone. He didn’t know what to do to
make it better. I am not sure there was anything he could do.

When Jason’s father was diagnosed with lymphoma and died a few months later, something
snapped. Jason knew his parents had been in a loveless marriage for several decades, and I think
he started comparing their situation to our own. He somehow felt the stress of his parent’s
marriage had contributed to his father’s demise. The very next week he agreed to the divorce.

And so, just like that, I lost my best friend of 15 years. Daily phone conversations were replaced
by formal texts, curt email conversations and messages from his lawyer. Each heartless
communication melted away a layer of ice around me.

30

Losing the man who loved me more than anything in the world would revive me from the
emotionless coma that had consumed me for over two decades. And when I opened my eyes, all
I could feel was pain.

♥ ♥ ♥ ♥ ♥

31

Chapter 9

Alive

Ever heard that doctors make the worst patients?

You would think physicians would be an advertisement for wellness. Kind of like those creepy
ones on TV, with the shiny hair, perfect teeth, and wrinkle-free faces. In reality, the majority of
doctors I know completely neglect their own health, devoting every waking hour to patient care.
In a recent survey, 83 percent of physicians admitted routinely going to work on days they were
significantly ill. The most common reasons doctors gave for working while ill were not wanting
to disappoint colleagues, not wanting to let patients down, and fear of being ostracized by
coworkers (Szymczak, 2015).

Ignoring the body takes its toll over time; in fact, the majority of doctors I trained under have major
health issues. I find it particularly ironic when their medical problem turns out to be an illness they
have treated for years. For instance, I know several cardiologists who have had massive heart
attacks and strokes. I know a general surgeon who had to have major abdominal surgery for
diverticulitis. I know an ObGyn who had to have a double mastectomy for breast cancer. I know
doctors who know that their blood pressure is dangerously high, yet refuse to take their blood
pressure medication. Doctors who are overweight. Doctors who smoke. Doctors who drink
themselves into oblivion. Doctors who take illicit drugs to “party.” Doctors who sleep two hours
a night.

32

Physicians neglect not only their physical health: they also fail to seek treatment for mental health
issues such as anxiety, depression, and suicidal ideation. A survey of over 2,000 female physicians
found that 50% of women believed they met criteria for mental illness but had failed to seek
treatment (Gold, 2016). Fear of being stigmatized and stripped of their medical license are the
reasons these physicians gave for suffering in silence. Unfortunately, untreated mental illness
results in almost twice the suicide rate in physicians compared to the regular population
(Schernhammer, 2004).

Stigmas aside, doctors simply don’t want to be patients. We become very uncomfortable in this
role, even when in the familiar surroundings of a clinic, or a hospital. Finding ourselves on the
other side of the stethoscope makes us feel as though we have given up control, even let go of our
identity. It would be like a jail warden finding himself the other side of the bars.

Most of us don’t even get yearly check ups; in the US, one in three physicians report not having a
family physician (Gross, 2000). I mean, who can take time off from our own patients to bother
another physician with our problems? Besides, do we really want to even know what might be
wrong with us? What kidney stone might be forming after years of not having time to hydrate or
pee when we needed to? What brain tumor might be growing, thanks to all of the radiation
exposure and stress? No, thank you. Like most physicians, I would rather eat a denial sandwich: it
is much easier to work, all the time, and worry about our health later.

33

When I began to have abnormal menstrual spotting soon after my fortieth birthday, I ignored it. I
figured it was probably stress, or from starting a new running program, or from getting “older.” I
let it go for several months, relying on my own self diagnosis skills, until I got annoyed enough
with my perma-period to make an appointment at the ObGyn.

My usual ObGyn was on leave, so I was assigned to “Dr. May” at one of the most reputable
hospitals in Los Angeles. My new doctor was young; a year out of training. But she seemed
competent enough. She was confident, and had trained at decent places. Who was I to challenge
the qualifications of a young female doctor? I had been in her position once, and depended on my
patients to trust me, despite the fact that I was relatively inexperienced.

A week after the visit, Dr. May called me to tell me that my pap smear showed abnormal cells,
and I required a biopsy of my cervix. A week after the biopsy she called me to say I had cervical
precancer. A couple weeks after that, I was scheduled for a “LEEP,” or a Laser Electrosurgical
Excision Procedure. Sounds like modern day torture; it’s pretty close- it is a surgical excision of
the portion of the cervix affected by the abnormal cells.

The LEEP went fine; it was done under general anesthesia in the outpatient surgical center. A
couple of weeks later, I was asked to return to Dr. May for a checkup. I took a day off from work
and complied.

What happened next remains a mystery to me. After exchanging pleasantries with Dr. May, I found
myself with my feet up in stirrups, as she peered at my recently lasered cervix.

34

“I don’t like this scar tissue that is forming here, so I am just going to push it aside,” said Dr. May,
from her perch halfway into my vagina.

Before I knew it, I felt a severe pain in my abdomen, which ran like electricity throughout my
entire body. The cramp lasted about a minute, and caused me to sweat and become nauseated. Dr.
May didn’t seem too concerned. She told me I might have a little spotting from what she did, but
that all was well and I should return for a pap smear in a year.

The next morning, I awoke with severe pain that radiated from my pelvis all the way through to
my lower back. It felt like someone had taken a 45 caliber handgun to my vagina and the bullet
had gone right through me. I called Dr. May’s partner, who was the covering physician for the
weekend. She didn’t seem concerned, nor did she seem to think the pain was in any way related to
the manipulation that had been performed the day before. She told me to rest and take ibuprophen
(duh, I’m a Doctor. I know about ibuprophen).

Conflicts can occur between the physician-patient and her treating physicians; even if our medical
opinions are different, we both think we are right. After all, our egos that got us here in the first
place, right? As a result, both the patient-physician and the treating physician can become
frustrated, and distrustful of each other. This can lead to mistakes in medical care.

To make matters worse, physicians can suspect physician-patients of seeking pain medication to
feed a drug habit. This is not surprising: physician substance abuse is a widespread problem in the

35

United States: 10-12% percent of physicians will develop a substance abuse issue at some point in
their career (Berge, 2009). Alcohol accounts for over half of physician abuse, while narcotic
medications run a close second. High stress levels and easy access make the frequency of substance
abuse in physicians higher than the “normal” population.

I am not a junkie. In fact, the last time I had taken narcotic pain medication was five years prior,
when I had sinus surgery. So, when I asked Dr. May’s partner for “a couple Percocet” when I
called her back that afternoon, the last thing I was thinking about was hopping on a flight to Vegas
to party. She reluctantly prescribed a few pills. That evening, my pain was worse. I started to feel
feverish, and began to sweat through my bed sheets.

Shit. I have an infection, were my thoughts that Easter Sunday at 5 AM in the morning, as I tried
to figure out who I could get to drive me to the ER. I called a friend, who picked me up, and we
sped down the 10 freeway towards Beverly Hills (of note, Sunday morning at 5 AM is basically
the only time one can actually speed down this normally packed Los Angeles freeway).

The doctors in the ER were unimpressed. After eleven hours of lab tests and ultrasounds, I was
told that my symptoms represented a “normal period.” When I heard this, I actually started to
weep, begging for antibiotics, insisting I had an infection. The physicians responded by giving me
a large slug of Dilauded (a very powerful intravenous narcotic), and discharging me from the ER.

Three days later, I woke up with a temperature of 102.7. I had such severe rigors I could barely
stand. I managed to drive myself to the ER of another tertiary care center. When I got there, I

36

nearly fainted in the foyer, requiring a wheelchair. My heart rate in triage was 130, and my
temperature was 103 degrees.

Those vital signs are what is referred to in medicine as “toxic.” Meaning the patient is severely ill,
with a serious condition that is overpowering the body. The normal resting heart rate is 60-100
beats per minute (BPM); thanks to years of exercising, mine was between 60-70. 130 BPM is my
typical jogging or running heart rate. So, my cardiovascular system was working overtime to cope
with the severe infection that was spreading though my blood stream.

At that instant, I felt a rush of panic. I had seen cases like this before so many times in my career;
young people with severe infections who walked into the hospital like this, only to leave either
severely disabled or in a body bag. My only thoughts were: 1) I need urgent antibiotics and 2) I
need to get my mother here as soon as possible. My biggest fear was ending up in a coma, unable
to communicate, leaving my mom to make difficult decisions about my medical care.

Mom was nearly 3000 miles away: 6 hours away by plane, in the Pocono area of Pennsylvania. I
had called her on the way to the hospital, telling her I was very sick. She booked the next flight to
California. As I waited to be seen by the ER physician, I managed to pull out my phone and send
mom one last message:

Please hurry. I feel this could be the end.

37

As I look at this text now, it seems pretty dramatic. But, I was terrified. I felt like I was experiencing
deja-vu: I had cared for patients many times who were this sick, and in most cases, it did not work
out well. Was this really it for me? At 40 years of age? After all of that school and training? Was
this really the last chapter?

No. It won’t be.

With the determination that had propelled me for twenty years to accomplish nearly everything I
set my mind to, I decided to survive. From that point forward, my battle can only be described as
an out of body experience. Panic had been replaced by fight, and I was going to win.

The doctors at this hospital were amazing. I was seen by a physician shortly after arrival to the ER,
and immediately diagnosed with endometritis, or an infection of the uterus, which had been likely
caused by the scar tissue removal a few days before. The infection had spread from my uterus to
my Fallopian tubes, to my ovaries, and had spilled out into my abdomen, infecting my intestines,
liver, spleen, and pancreas. My small intestine was paralyzed, obstructing passage of food or water
from my mouth to my colon. As a result, my abdomen was distended, hard as a rock, and intensely
painful.

Several strong antibiotics poured into my veins, as the doctors tried to control my infection. A
parade of health care professionals came to my bedside, including a surgeon, infectious disease
doctor, ObGyn, and a general internal medicine doctor. Between visitors, I stared at the wall clock,

38

counting down the hours until my mother made it. I willed myself to hold on for her and not to get
sicker.

I did get sicker. After being admitted to the hospital floor, my blood pressure plummeted to
dangerously low levels. My fever raged on. My heart raced faster than it ever had while laying
motionless in a bed. I stopped urinating completely, as my kidneys began to fail. I began to drift
in an out of consciousness.

My general surgeon, a veteran doctor of nearly thirty years, was urgently paged and drove in from
home, arriving at my bedside at almost midnight. He declared that I required urgent transfer to the
medical intensive care unit. More doctors and nurses flooded my bedside, placing catheters in my
bladder, drawing blood, performing ECGs, and taking X rays.

I knew I was, what we call in medicine, “crashing:” the medical lingo for “trying to die.” Yet, I
was completely calm. I had been in this situation (in the role of a doctor) so many times over the
course of my career that it almost seemed natural, even comfortable. Maybe I stayed calm because
I accepted my mortality. Or because I understood what was going on. Or because my blood
pressure was so low I wasn’t receiving enough blood to my brain.

Mom arrived a few minutes after my surgeon did. She was taken aside and told I was “very, very,
very sick,” and that there was a chance that I might not make it. I give mom a lot of credit for
keeping herself calm enough to fly 3,000 miles and see me in the state I was in. She, too, was in
survival mode.

39

A severe bacterial infection had taken over my entire body, and placed me in “septic shock.” That
means that my blood vessels had become dilated and leaky, and could no longer sustain a blood
pressure that was compatible with life. As fast as intravenous fluids poured into my body, they
leaked out of my skin, making me swollen and bloated. The mortality rate for patients with sepsis
can be as high as 60 percent (Linde-Zwirble, 2003). The odds were against me.

There are intravenous medications that can artificially elevate the blood pressure during sepsis that
are called “vasopressors.” These are used in intensive care unit patients frequently, to support the
patient as their body tries to fight off the infection. The medication the doctors ordered in my case
is called “levophed,” or norephinephrine, the same chemical in the body that mediates the
infamous “fight or flight” response.

As a medical intern, you learn that the other name for levophed is, “leave ‘em dead.” Levophed
constricts the large blood vessels of the body, which improves the blood pressure. However, it also
constricts the small blood vessels found in the hands, feet, and skin. It is not uncommon for a
patient on levophed to lose blood flow to their hands and feet, which can result in multiple
amputations of fingers and toes, sometimes entire limbs.

My ICU nurse’s name was La Shonda. Here she was, receiving a new patient in the middle of the
night, who happened to be young woman trying to die. While a natural reaction would have been
to become anxious, La Shonda was as cool as a cucumber. She reminded me of myself when faced
with a crisis: the worse it got, the calmer she became. My eyes toggled between the monitor

40

displaying my vital signs and the supplies being brought into my room: more antibiotics, a
defibrillator, a ventilator, and a bag of levophed. I remember looking La Shonda straight in the eye
and saying:

“My blood pressure is going to be 100 by morning.”

I saw her nod, as she placed the silver bag of toxic, amputation juice on a shelf.

“Its for just in case, sweetie.”

I spent the next several hours staring at my vital signs, and explaining to my mother what all the
equipment was in the room, and what was going on in my body. I naturally fell into my familiar
roll as teacher, my mom the student, with my failing health the topic of the lesson.

La Shonda and the doctors gave me and my mom privacy, but I know they were close by,
monitoring my vital signs on the monitors outside the room. My blood pressure hovered in the
90’s systolic (“systolic” is the top number of a blood pressure reading. Ideally, this should be over
100). As I drifted to sleep, my systolic blood pressure drifted down to the 80’s. That is about the
blood pressure that becomes dangerous, where blood flow starts decreasing to the kidneys and
brain. Although I couldn’t hear them, I knew the doctors outside were discussing the next step:
starting “leave em dead.” If my blood pressure were to fall any further, my heart could stop.

41

La Shonda, acting quick on her feet, performed a simple, old fashioned maneuver, which probably
saved my life, along with my fingers and toes. She calmly entered my room and tilted my bed so
that my feet were 15 to 30 degrees above my head. This is called the “Trendelenburg position,”
named for German surgeon Friedrich Trendelenburg, who practiced in the late 1800’s. This
maneuver is used for patients who have low blood pressures or are losing blood, using gravity to
promote blood flow from the feet to the head.

My next blood pressure reading was 92/50. Over the next several hours, I stared at my monitor
and willed for my body to fight. Antibiotics trimmed my IV pole like ornaments on a Christmas
tree; medical appliances were hooked to my every appendage. My mother sat vigil in a reclining
chair next to my bed, praying for my survival.

By the next morning, my blood vessels became less leaky, my blood pressure improved, and my
fever disappeared. The dangerously high acid levels in my blood started to go down, and my
kidneys started to work. I had turned a huge corner. I was still alive.

I later learned that I had entered what is called “multisystem organ failure.” The infection had
affected my kidneys, liver, lungs, and blood clotting ability. My body was left covered in bruises.
I was grossly swollen all over, and my abdomen was three times the size of normal. My lungs were
full of fluid and I was short of breath. My gut couldn’t tolerate anything more than ice chips. But
I was alive.

42

I stayed an entire week in the hospital, receiving strong antibiotics and learning how to eat again.
The fluid eventually drained out of me over the next several days and I shrank down to normal
size. It took several weeks for me to regain enough strength to remain awake for eight hours
straight, and a month to be able to return to work.

In an ironic twist of fate, I had spent 20 years obsessing over the safety of my patients, only to be
severely harmed by members of my own profession. I consider myself victim of the “VIP
syndrome:” where “special” care of an ill physician-patient can result in bias and deviation from
protocol, and lead to poor outcomes (Schneck, 1998). Would “Dr. May” have removed scar tissue
on my cervix (presumably trying to prevent a complication) if I had not been a physician? Would
my symptoms have been taken more seriously if I were not a doctor? Who knows.

All I can hope for is that the physicians who ignored my infection learn from my case. That another
young woman’s life can be saved as a result of my misfortune. That the next physician-patient
coming to the emergency room with legitimate symptoms is taken more seriously.

As a physician, there is a delicate balance between confidence and humility. On one hand, doctors
must be secure enough in their knowledge and skills to respond to emergency situations. On the
other, we must realize that we are not God. That there is so much about disease that we simply do
not know or understand, leaving us to depend on our instincts with certain patients.

43

In my case, the physicians who missed my diagnosis were overly cocky. They ignored several
signs of my serious medical condition. They did not take the time to channel their instincts, which
should have told them that a physician has to be practically dying before they seek medical care.

The doctors who saved my life used their intuition. To them, I am a tremendous success. And to
me, probably for the first time in my self-deprecating life, I am a tremendous success. Fighting
that illness was the hardest thing I have ever had to do. I will never take another day for granted,
nor will I minimize the pain and suffering of my patients. And I will never, ever, underestimate
the strength of my body and mind.

Becoming a doctor is like climbing a mountain. Becoming a patient is like landing on the moon.

I am glad I am still around to help my patients defy gravity.

♥ ♥ ♥ ♥ ♥

44

References

Berge, K. H., Seppala, M. D., & Schipper, A. M. (2009). Chemical Dependency and the
Physician. Mayo Clinic Proceedings, 84(7), 625–631.
Blumenthal, D, Olenski, A, Yeh, R, DeFaria, Y, Sarma, A, Stefanescu, A, Wood, M, Jena, A.
(2017). Sex difference in faculty rank among academic cardiologists in the United States.
135(6): 506-517.
Ciani, Keith D.; Sheldon, Kennon M. (2010). A versus F: The effects of implicit letter priming
on cognitive performance. British Journal of Educational Psychology. 80 (1): 99.
Grines, C. (2015). Few women choose a career in cardiology. Is that about to change? Cath Lab
Digest. 23(10), (no pp).
Gold, K., Andrew, L., Goldman, E., Schwenk, T. (2016). “I would never want to have a mental
health diagnosis on my record:” A survey of female physicians on mental health diagnosis,
treatment, and reporting. General Hospital Psychiatry. 43,51-57.
Gross CP, Mead LA, Ford DE, Klag MJ. Physician, heal thyself? Regular source of care and use
of preventive health services among physicians. (2000). Arch Intern Med., 160:3209-14.
Jena, A, Olenski, A, Blumenthal, D. (2016). Sex Differences in Physician Salary in US Public
Medical Schools. JAMA Intern Med. 176(9):1294-1304.
Kerasidou, A, Horn, R. (2016) Making space for empathy: supporting doctors in the emotional
labour of clinical care. BMC Med Ethics. 17:8.
Linde-Zwirble WT, Angus DC. (2004). Severe sepsis epidemiology: sampling, selection, and
society. Crit Care, 8(4):222–226.
“No. 6 ‘Grey’s Anatomy,’ 38 million viewers.” baltimoresun.com.
http://www.baltimoresun.com/zap-top-episodes-greys-photo.html (Accessed August 4,
2017).
Rich, A, Viney, R, Needleman, S, Griffin, A, Woolf, K. (2016). ‘You can’t be a person and a
doctor:’ the work-life balance of doctors in training- a qualitative study. BMJ Open.
6(12). e013897. doi: 10.1136/bmjopen-2016-013897.
Roguin, A, Goldstein, J, Bar, O. (2013). Brain and neck tumors among physicians performing
interventional procedures. Am J Cardiol. 111,1368-72.
Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender
assessment (meta-analysis). Am J Psychiatry. 2004 Dec. 161(12):2295-302
Schneck SA. (1998). "Doctoring" Doctors and Their Families. JAMA, 280(23):2039-2042.
Szymczak JE, Smathers S, Hoegg C, Klieger S, Coffin SE, Sammons JS. Reasons Why
Physicians and Advanced Practice Clinicians Work While Sick A Mixed-Methods
Analysis. (2015). JAMA Pediatr., 169(9):815-821.
Treister-Golzman Y, Peleg R. (2016). Female physicians and the work-family conflict. 18(5):
261-6.
“US Medical Applicants and Matriculants by School.” AAMC.org.
https://www.aamc.org/download/321442/data/factstablea1.pdf. (Accessed August 4, 2017)
“Women in the Labor Force.” dol.gov.
https://www.dol.gov/wb/factsheets/qf-laborforce-10.htm
(Accessed August 4, 2017).

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Asset Metadata

Creator Perlowski, Alice Anne (author)

Core Title A proposal for: Queen of hearts

School Annenberg School for Communication

Degree Master of Arts

Degree Program Specialized Journalism

Publication Date 09/21/2017

Defense Date 09/21/2017

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag autobiography,cardiology,Medicine,OAI-PMH Harvest,physician,women's equality

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Cole, KC (committee chair), Bustamante, Peggy (committee member), VanHerle, Helga (committee member)

Creator Email calirunnerdoc@yahoo.com,perlowsk@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-430072

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Legacy Identifier etd-PerlowskiA-5733-0.pdf

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Document Type Thesis

Rights Perlowski, Alice Anne

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

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