We want very much for patients in health care settings to speak up for themselves and get their needs met in situations where staff members are less than helpful. I commend Kathy and Jon for being able to do so. But after years of working in acute care settings with seriously ill children and their families, I can understand how difficult it is for many people to do this, especially at a time when they feel very vulnerable, frightened and often in pain. I was struck by the fact that sometimes families of children in for a one-day "minor" surgery or procedure (like having tubes put in ears, a hernia repair, or eye muscle surgery) seemed far more overtly frightened than families of children facing major illnesses like cystic fibrosis, cancer, or repeated surgery for congenital defects. Part of this, I believe, is that those with major illnesses had had a chance to become familiar with the hospital system and the way things worked over time. They knew the staff, who would be most helpful, what things had worked to their benefit in the past, what (and who) to avoid. They could build on past experiences and had developed trusting relationships. Newcomers to the system haven't had a chance to do this, and may easily be too tense and overwhelmed to try. This certainly applies to couples coming in for childbirth. All the learning from childbirth education class may be tested when they encounter something unexpected or when they experience the intensity of real labor for the first time. They may agree to anything just to get out of there alive. This is where a birth attendant or doula who is a familiar person can make a real difference. As a nurse, I always felt defensive when the subject of patients' advocates came up, because I want nurses and doctors to be able to truly be the advocate for patients and families. But the reality is that families have to deal with multiple caregivers, each with slightly (or sometimes drastically) different messages and approaches. It is very confusing and distressing, and it takes a long time for people who are vulnerable and scared to learn how to work the system to meet their own needs. My father used to joke that hospitals would be great places if it weren't for the patients coming in and messing up "The System." I guess we all need to continue to do our best on all fronts: to have all staff work to be caring, sensitive to individual needs, and consistent (we need to communicate with each other, too); to help patients and families be as clear as they can in letting staff know what they need, and what is helpful and what is not; to make "The System" work for meeting the needs of real people rather than just smooth operating; to continue to get as much preparation and skills as we can ahead of time (breastfeeding education as well as childbirth preparation); and to really listen to people afterwards so that we can continue to improve the way we provide care. And of course, all along the way, to encourage people to support families staying together. (Than goodness we are no longer in the era when parents were restricted from visiting their hospitalized children!) Anne Altshuler, RN, MS, IBCLC and LLL Leader in Madison, WI