Poem: 1960s

I have to admit, I struggled a while with this poem. Writers sometimes talk about not forcing a story or poem to go somewhere it doesn't want to go, and this poem really lead its own way (appropriate, given the subject matter). I'm still having trouble with the rhythm and ending but I'll have to sleep on it; that's what revision is for.
-
1960s

Like all women of my generation
I never had a say, never had a voice
but now revived, I look about and cry--
take arms, take pitchfork, burst
from tower and castle and countryside
and hear us--
we will not be defined by birthmark
or congenital curse, will not be defined
by a home of chimney dust or orphanage.
This is not our fate, to wander forest roads
or grow hair in vain or await
handsome cobblers a-knocking.
No--this new century it is time
for those spindle-enchanted women
to cast off that cloak of anesthesia
and slap that costumed buffoon
because we pick our own apples
we defy mirror-talk
we scorn dwarf and prince alike.

Kidneys

For my next rotation, I am teaching in the first year medical student course on the kidneys. I really enjoyed teaching in the cardiovascular block, and so I asked to teach in this block as well. It's really fun, it's very fulfilling, and the first year medical students are awesome. Luckily, I even have some of the same small groups as before. It's also very useful for me to review the kidney, electrolytes, and acid-base problems. I'll be facilitating 12-student sections in physiology, pharmacology, and clinical medicine. I'll have preparation sessions for each small group, but otherwise my time is fairly flexible, and I'm really enjoying that.

Image is in the public domain, from Wikipedia.

The Match

The Match is an odd system of determining residency employment, and I'm not sure if there are any equivalent employment processes for any other fields. After a standard application and interview process, no letters of acceptance or rejection are sent. Instead, each applicant makes a "rank order list" of all the programs she likes in the order of preference. Each program makes a list of all the applicants they like in the order of preference. These lists are processed by a central computer algorithm that then generates a "match list" of the optimal pairings between applicant preferences and program preferences.

It's an interesting system that was historically borne from unequal and unfair residency job offers. In the past, there was little standardization of how to go about obtaining a residency position or how programs were to recruit residents. This led to confusion and apprehension by residency applicants which ultimately may have contributed to applicants accepting suboptimal residency offers. For example, if a mediocre residency offered a position, it might be better just to take that definite job than wait for the better residencies to reply. Now with the Match system, the timeline is standardized and applicants and programs make their decisions with more information.

That being said, I don't know if it's an optimal process. For applicants, it feels as though we've lost an element of control. In the past, rolling admissions have allowed us to accumulate acceptances and/or rejections, giving us a sense of how we were doing and allowing us to "hold on" to an acceptance while we see if we get accepted to higher-desired programs. Here, applicants don't have any certainties and go into the match with a risk of not matching anywhere (leading to a more frantic process called the scramble). This uncertainty in a population of medical students who like assurance can lead to unnecessary costs. We end up applying to more programs than necessary to assure that we will match somewhere. Whereas when applying to medical school, I may cancel a "safety" school once I got in somewhere else, in the Match process, I don't have any acceptances and must keep those safety programs in the case that I don't match at the "harder" institutions.

Furthermore, this process may hamstring job negotiation power. In the past, lawsuits have brought up this issue (but have not been successful). Without knowing if I've gotten into any programs, I have no negotiating power or leverage prior to securing the job. Since I must sign the contract for the program that I match into, I have no negotiating power after the match. This may not be all that important, but it's something absent that is common in other fields.

Overall, we want a method of determining residency positions in a fair, equitable way for both applicants and programs. We want applicants to strive for optimal programs, and we want programs to fill their slots with optimal candidates. A Match process may facilitate that, but whether its optimal, I'm not convinced. Nevertheless, it is here to stay.

Medical Workforce

In the 2009 Residency Match, there are 25,185 positions offered. There are 36,972 applicants registered, and of those, 16,008 are U.S. allopathic medical school seniors and 20,964 are independent applicants (former graduates, osteopathic applicants, and international medical students). How do we interpret these numbers? On the one hand, we have enough positions for all U.S. medical school graduates, and indeed, we have room for more. With the greater need for physicians, some medical schools are expanding their class sizes, and hopefully there will be residency positions for all these graduates.

On the other hand, we don't have enough positions for all the applicants. If we expanded residency training, the applicant supply would meet those slots, mostly with international medical graduates (IMGs). Indeed, these graduates often go into the fields that need more doctors such as primary care. But whether or not we should be training so many IMGs might be controversial; this often puts a brain drain on the countries supplying those residents. That is, other countries are training medical students that ultimately leave to the U.S. and may not return to their home country. This is a detriment to those countries, and we should not try to exacerbate that problem.

The reality of this situation is that residency positions are unlikely to expand. The funding for resident training comes from Medicare, and in an era with overwhelming healthcare costs and an uncontrollable federal debt, we are unlikely to fund more training spots. But that leaves us with this question: without training many more residents, should we be expanding medical school classes? And what should our attitude be towards independent applicants and international graduates?

East Coast / West Coast

I often hear the generalization that east coast and west coast residency programs differ in attitude. Although obviously every program has its own flavor, there is a common belief that east coast programs are more formal and hierarchical whereas west coast programs are more laid back and relaxed. In visiting different programs, I think some of that might exist, but not to an extent that it should matter. It seemed that more doctors on the east coast wear ties than the west coast, and perhaps there's a greater distance between patient and doctor, but residents and attendings were friendly wherever I went. I think the important parts of the residency atmosphere - a collegial, mutually respectful, supportive environment - don't seem to depend on geography. Yet programs do vary on these factors, and as I consider the things that are important to me in residency, I am trying to find the right balance of independence and support, of formality and informality.

Mentoring

I went to a panel discussion today on mentoring with several amazing faculty members including the new chancellor Sue Desmond-Hellmann. It was a fascinating discussion in which I realized the central role of mentors and role-models in the career progression of fellows and junior faculty. Indeed, all the panelists commented on the importance of both higher-level faculty and peers on their careers, and as they have established themselves in academia, they have taken on the position of mentors for others as well. They talked about the importance of mentoring minorities but also encouraging "cis" and "trans" mentors - that is, relationships between those who are similar as well as those who are different. They talked about the spectrum of relationships, from the very formal to the informal and about fostering these relationships very early on.

In thinking about this, I can identify two Stanford anesthesiologists who were key in influencing me to try research, enter medicine, and ultimately go into academic anesthesia. It always amazed me that they would take the time out of their busy schedule to help an undergraduate focus his life and find a path. They've always been role models of the kind of doctor, teacher, and mentor I would like to become some day. I have really come to appreciate those who've played such pivotal roles in my life.

Revision: Astronaut Love Triangle

Astronaut Love Triangle

Somewhere between the Earth and stars
hovers that maiden of fantasy.
Coercion wisps and whispers her way
into an empty mind, and how could I say no?
In a world with three voices
(one of them my own)
how could I refuse the sister
of imagination and treachery?

You send us out to harvest moon rocks
build satellites, talk to Martians
and soon we realize the only pull in space
comes from ourselves. A year
and we get to know the shuttle hull
pretty well, the air lock between now and after.
In this vacuum closet who could wonder
that three warmths would find each other?

Astronaut love triangle:
discard the laws of our world
discard those sublunary flails in fetters and ideals.
Up here, strip men of jobs, clothes, families, pets,
first loves, last loves, nationalities, alcohol
and what could be purer? Here,
the undiluted emotions perspire.
Envy, obsession, infatuation, murder--
what else could there be
in a world with only Saturn's iridescent rings,
Jupiter's hot spot, all the stars you could imagine.

Eakins

I love the contrast between these two oil on canvas paintings by Thomas Eakins (1844-1916). The first, "The Gross Clinic" from 1875 is dark, with "uncompromising realism," showing a professor lecturing a group of students on extremity anatomy. Based on a surgery the artist saw for osteomyelitis, it captures a sense of foreboding. On the other hand, "The Agnew Clinic" from 1889 is illuminated, with a sense of promise, cleanliness, and control. These paintings are often compared in describing the advancements of aseptic technique and understanding of infection during this period of time.

Both images are in the public domain, taken from Wikipedia.

Preliminary, Advanced, Categorical, What?

Anesthesiology residency, like some other specialties (radiology, ophthalmology, dermatology), has two components: an intern year and advanced training. For anesthesia, we're recommended to do a "preliminary" intern year in adult internal medicine followed by "advanced" training in anesthesia. Some applicants replace the medicine preliminary year with a preliminary year in surgery or a "transitional" year which consists of rotations in many different fields. Other applicants may have completed another specialty and seek to switch into anesthesia; those applicants don't have to redo internship (thankfully). This confusion is compounded by the types of programs out there; some programs integrate the intern year with the advanced training, and these are called "categorical" programs. Most programs have a few categorical positions and a few advanced positions.

The result of all of this is that I am applying to preliminary medicine programs, advanced anesthesia positions, and categorical anesthesia positions. In the next few weeks, I have to figure out how to rank these (another post coming soon about rank lists and the match). There are pros and cons to everything. A categorical anesthesia position makes things easy; I don't have to separately secure an internship, I don't have to move multiple times, and I get to know the hospital and attendings earlier. But there are also benefits to doing a preliminary year followed by advanced training; this would allow me to experience multiple geographic locations and play the role of a true medicine intern (as opposed to categorical programs where the intern year resembles more of a transitional year).

I initially thought it would be nicer for programs to all become categorical; this would greatly reduce the number of interviews I go on (I'm doing 10 preliminary programs in addition to my anesthesia interviews). But now at the end of the interview season, I think the flexibility afforded by having this confusing array of mix-and-match programs might actually be worthwhile. In any case, I wanted to write a post on this to clarify for anyone applying to those specialties and to make future posts on ranking and the match clearer.

Advice to Interviewees

As I round out the residency interview season, I figure I should jot down some thoughts about the interview trail and tips I've picked up. Of course, this only helps medical students applying in the future, but hopefully it's useful.

1. I heard mixed opinions on the personal statement. Some people told me to be generic and risk-averse, others told me to try to stand out, and some said the personal statement doesn't matter. I ended up writing a boring one, scrapping it, and writing a more interesting, personal, but risk-taking one. I can't say how important or effective it was, but quite a few interviewers commented on my personal statement; some loved it, others found points of contention but it made room for good conversation.
2. Unfortunately for some specialties, there's no list of the "best" residency programs in that field. Unlike undergrad or even medical school, there's no ordering of most prestigious to least prestigious programs and indeed, such an ordering is probably silly if not impossible. I made my list by word of mouth which was subject to all the idiosyncrasies, biases, and familiarities of the people I asked. I asked both residents and attendings to get a feel of the programs out there that might be a good fit.
3. Scheduling interviews is tough. Schedule them as they come as best as you can. I didn't know this at first, but having multiple interviews in a row is exhausting. I had one week on the east coast where I did four interviews in five days and it was tough (but financially optimized). Also, by the end of the interview season (mid or late January), I was tired.
4. The unanimous advice I got and one I fully agree with is to write down impressions after the interview as soon as possible, when the information is fresh and the gut feeling visceral. Procrastinating on jotting down thoughts will dull the emotions and knowledge and will lead programs to start blurring together.
5. I had some bad experiences with certain airlines. Stick with carry-ons and avoid travel vouchers (or airlines that only give vouchers for cancellations). Cancellations (both by myself and by the airline) have frustrated me quite a bit.

The Curbside Consult

A curbside consult refers to flagging down a specialist or colleague in the hallways to ask an informal question about a patient. Officially, questions are better answered through the process of formal consultation, but sometimes for quick advice or a minor detail, we'll simply ask the people around us.

Medical students often get "curbsided" by friends and family. We get asked what to do with fingers crushed in doors or sprained ankles or a cold that won't go away. To some extent, our friends and family think of us as ad hoc doctors, a source of medical advice when something isn't quite bad enough to warrant urgent care or the emergency department. We hover in this in-between where we know enough to say something, but not enough to solve things confidently. Indeed, ad hoc medical advice, while convenient, isn't the "proper" way to do things (certainly, nothing on this blog is medical advice and the information here should not be construed or used as such). But as medical students, we strive to be "useful," we're proud of what we know, and we have the resources and time to figure stuff out. It's a tricky situation, certainly, and one I know will continue through residency and my career. I'm still trying to figure out how to balance and finesse these situations.

Poem: Haiti

To be honest, I'm still trying to understand e.e. cummings, but imitation is the sincerest form of flattery. This is also the most punctuation I've ever had in a poem.
-
Haiti

reckless,mind you,earth in rebellion
a circumference cracking at seams
&discortation by desolation;but
if you thought,you were wrong were
wronged to find solace
among chimney spent ash rent
dourness widowed&childless,pitchfork-weld
bones harvested through rent skin
&gurneys of white,flashes&photographs
tell of earth(quaken and crumple
pits of homelessness/echo
in rains today,everywhere but
silence in spondees,hesitations--
);

Paper

Though this is likely of no interest to you, my previous lab from undergrad just published a paper on a study I jumpstarted about six years ago. For a long time, I've been interested in microarrays and gene expression (even before it became such a hot topic) and so with the Patterson lab at Stanford, we began studying gene expression of a mouse model of heart failure. It was only in its nascent stages by the time I graduated, but now after quite a bit of work, we published in Critical Care Medicine. Congrats to Jim and Christine! Hooray!

Normal

Where do normal values come from? Any time we have numerical data such as a blood pressure or lab value, we compare it to a normal range. But how are normal ranges determined? For example, normal heart rates are between 60-100, but certainly well-trained athletes have a physiologic bradycardia (pulse less than 60) and exercise-induced tachycardia is normal. Who decides these numbers? Weirdly enough, people don't think about this question even though every time we present a patient, we rattle off "chemistries were normal" and "liver function tests are elevated."

One method of determining normal values seems reasonable: test a lot of "normal" people in the population and graph the distribution. If it falls into a normal distribution, a reference range can be set based on standard deviations. Indeed, blood tests like "calcium" are set according to this methodology; each lab tests "normal" people in the community and calibrates its reference range based on the statistical outcomes. That seems reasonable, but in some cases, it doesn't work very well. For example, pediatric growth charts were initially developed in 1978 by the CDC in this manner. However, the "normal" population used was from Fels research institute data which studied white formula-fed middle-class infants living in southwestern Ohio between 1929 and 1975. Although it was the best data at the time, it's hardly representative of the U.S. population. Nevertheless, growth charts became widely used, and nobody questioned this "normal range" until 2000 when the CDC updated growth charts to be better representative of the population.

Another method of determining normal values is using clinical outcomes. For example, clinical studies have found that fasting glucoses of 126 or greater have associated medical conditions like retinopathy. As a result, the cutoff for diabetes is set at fasting glucose >=126. In the same way, hypertension is defined not based on a normal distribution of blood pressures, but rather when we start seeing the clinical effects of high blood pressure.

Although on a day-to-day basis, it may not be crucial to know where normal values come from, I think having a sense of how they are determined is an important part of being a well-rounded physician.

Image of a female growth chart shown above is in the public domain, from Wikipedia.

Haiti

My deepest prayers to the victims and survivors of the catastrophic earthquake. My sincerest wishes for timely, effective, and well-organized humanitarian and medical aid.

Telemedicine

Telemedicine is a relatively new field that utilizes technology for doctors to take care of patients remotely. Recent advances in video and internet communications have allowed this field to blossom. Now, radiology studies are read by physicians in India, teledermatologists consult on patients based on computerized images, Kaiser physicians have secure email with their patients, and doctors can monitor arrhythmias with the patient's cell phone. But even more, traditional patient encounters are being transformed into telemedicine; some doctors do "home visits" by webcam.

This has lead to a novel and perhaps dangerous proposition of ICU telemedicine. A good portion of intensive care involves sophisticated monitors, frequent laboratory tests, and daily radiology studies. Some of the clinical decision making each day depends on the blood pressures, ventilator settings, electrolytes, and chest X-ray. All this data can be easily computerized and transmitted to physicians remotely. Conversely, the history and physical exam are given lower priority in the ICU setting - whether this is right or not is a different question. But this has allowed ICU telemedicine to gain traction; a physician remotely monitors many ICU beds, possibly at several different hospitals. This is usually done at night when each hospital may not have the resources to have overnight physician staffing.

To me, the advantages and disadvantages of ICU telemedicine need to be considered carefully. There is one compelling reason to do it: it brings care to places that don't have it. Whether rural community hospitals or the third world, technology can bridge some of the health care disparities we see. However, I don't think telemedicine is a solution to geographical physician maldistribution, and we need to continue trying different approaches to bringing care to those who don't have it. On the other hand, I don't think telemedicine is ideal medicine. How can you take care of a patient without ever meeting him or the family? How can you reduce a person to a series of numbers, and how can the practice of medicine simply be a routine of correcting abnormal laboratory values? I know there's some burgeoning evidence that telemedicine produces comparable results (in mortality and length of stay) as having full-time on-site physicians. I also understand the economic pressures to move toward this model and I am aware of the shortage of intensivists, but I'm resistant to it. I think there is a real and tangible role to the face-to-face patient-doctor interaction that computers and phones simply cannot provide. While technology evolves quickly and things may change, I think ICU telemedicine's role at this stage should remain minimal.

Hand

Image of this X-ray of a ten year old male with polydactyly is shown under GNU Free Documentation License, from Wikipedia as one of "Wikipedia's featured pictures."

The Great Teacher

The great teachers teach a way of learning: critical thinking, problem solving, deductive logic. They help the student work out the answers on their own. Instead of imparting bits of knowledge and facts, they open resources and doors that allow the learner to traverse those fields of knowledge independently. When students work out problems or answers on their own, those solutions are more likely to make sense and solidify in the mind in contrast to low-retention memorization. Thus, the great teachers must give their students room to think; they give their students independence to try different approaches, even if they know that those choices could be wrong. They strike a balance between hand-holding and independence, sometimes nurturing, sometimes watching from afar, always supporting and guiding. Great teachers know how to finesse that balance between facilitating a student's critical thinking so they work something out on their own and guiding them away from potential pitfalls and problems. Clinically, these teachers will give their students the right balance between responsibility and supervision even in situations that are emergent, challenging, and novel. They resist stepping in prematurely but also know how best to help the trainee do everything correctly and efficiently. Not only that, great teachers have a particular attitude. They consider their students peers, they welcome challenges to their ideas and teachings, and they are constantly learning.

Nurses and Team Structures

I don't fully understand hospital structures and all the competing interests when setting them up. But the setup for MDs and RNs are fundamentally different. The medical team of doctors, residents, medical students, pharmacist, and social worker admit patients to their service. The patients go to different "wards" (physical locations within the hospital) based on bed availability. Certain "wards" specialize in various things; some may be neuro-oriented or have intensive care abilities or allow cardiac monitoring. So on a medical service, patients can be in many locations throughout the hospital, and each morning on rounding, we figure out the most efficient way to see everyone.

On the other hand, nurses are based in defined wards. Since most of nursing function requires physical proximity (patient assessment, medication administration), this makes sense. Nurses also get to know how certain wards run; nurses who like more intensive care stuff can work in an ICU or step-down/transitional ward. Nurses working in surgical wards get familiar with surgical dressings; nurses on the neuro floor have a more fine-tuned neurologic assessment.

The problem with this set-up is that there is less integration between the MD and RN providers. Since each patient on a medical service may be on a different ward (and even patients on the same ward may have different nurses), doctors often do not know which nurse is caring for which patient. This can be compounded by the unfortunate hierachy of MD and RN. The communication isn't ideal, and patient care can suffer.

To remedy this problem, some services have begun incorporating nurses on rounds; when the medical team stops by each ward in the morning, they track down the nurse taking care of the patient. This allows them to address nursing issues as a team (rather than the nurse paging the harried intern later) and to discuss the plan of action (so the whole care team is on the same page). Furthermore, some hospitals are trying to admit patients on the same service to the same wards; this way, the medical team gets to know that ward and its nurses. I think these changes improve patient care, but we should continue to develop ways of improving communication and integration of the whole care team.

Technology

Yes, I got an iPhone. After playing around with it for a few days, I started looking at medical applications and realized smartphones are a really powerful technology. In the last two years, I carried around a pharmacopoeia, antibiotic resistance chart, pocket manuals, and other assorted paraphernalia. But with a smartphone loaded with applications and access to the Internet, much of that becomes unnecessary.

I think many in the medical community (especially older practitioners) are "late adopters" - that is, they don't try new technologies until they've matured. And indeed, the iPhone is by no means "new." But I think there's a good deal of potential to unlock with smartphones. For example, what if laboratory results could be "pushed" to the iPhone? On the one hand, physicians would receive results much faster (rather than hunting for a computer and constantly refreshing to see when new results are up or calling the lab repeatedly). On the other hand, how does that fit with patient privacy laws? In the same way, can the iPhone be used to take a picture of a patient's rash and then forward it to a dermatologist? Or would that be an imprudent use of technology? How about an application that identifies pills taken by the iPhone's camera? When patients come in with unmarked pill bottles, we could figure out what they are. One can even imagine more extreme cases; perhaps smartphones may be able to listen to patient's hearts and determine the rhythm or be used to send in prescriptions.

I think with emerging technologies, we need to be aware of the ethical implications and risks. But there's an untapped potential to improve patient outcomes through efficiency, accuracy, and decision support.

Image shown under Creative Commons Attribution 3.0 License, from Wikipedia.

Internal Bleeding

When we first came to UCSF, we were all given the book Internal Bleeding by Robert Wachter (chief of medicine, shown above) and Kaveh Shojania. Although I read it as a first year, upon rereading it recently, I've found it to really resound with my experiences in the hospital. The book discusses medical errors in the hospital setting from all perspectives. It takes the reader through a comprehensive and compelling story of medical mistakes, discussing how things as absurd as wrong-site-surgery or treating the wrong patient actually happen. The book draws the often-cited comparison of medicine and aviation. It brushes on topics like doctors' handwriting, medication errors, teaching hospitals, long work hours, patient handoffs, and problems with teamwork. Each chapter begins with a real patient case and the root cause analysis in each chapter is convincing. Not only that, Drs. Wachter and Shojania go further to propose solutions to this epidemic problem. They take a systems approach, looking at reporting of mistakes, how to tell patients what happened, medical malpractice, and accountability. I think this is the crux of the book; while all practitioners are aware of the problems in medicine, few solutions are proposed. For those interested in hospital management, systems-based practice, patient safety, and health care policy, this is a must-read.

Images shown under Free Use, from biblio.com and ucsf.edu.

Revision: Birth Day

I actually pulled two separate poems together to write this. I wanted to capture a certain tone, flow, and pace.
-
Birth Day

The world's sonorous music calls
and within the insulation of a cocoon
waters swell and mature
tides that began before you or I recall
summoning a small din of calamity
blue coattails flying
breaths in rushes, heaves, spurts
words you'd never said before
contracts and promises and confessions
to any deity who will listen
seeking atonement or absolution
almost a restitution of sorts
broken by a cry taking breath, breathtaking
a slippery warmth like a fish
wriggling a dance you and I learned
so many years ago, a breath
which takes in all at once
love, misery, dream, deception, joy, being
with great devotion, the stuff of philosophers
a lease out of amniotic confinement
into this new world
a world with as many types of mermaids
as there are fish, mermaids who teem
in schools, flocks, fortunes
flitting from one island to another
driving down the street, attending schools
shopping at grocery stores
shedding fine little scales like dandruff
wading constellations across the sky
idling by the river, pole in hand, hook in mouth
lounging on New Year plates
mouths stuffed with Chinese fortune
darts and swords, jellies and mantas
plumes through the water
until we can't tell fish from mermaid
from baby, a magic that intoxicates and charms
teaches us that beauty of metamorphosis.

Complacency

The greatest danger to the fourth year medical student is complacency. Done with the bulk of our "hard" rotations, and perhaps a little burned out too, we're coasting to the finish. Indeed, most of us view fourth year as the well-deserved break after the grueling first three years of medical school. We choose electives partially based on the hours, and we spend our free time getting to know San Francisco. It's a welcome relief, but it can also lull us into a sense of complacency. Much as I like the freedom and vacation time, I also need to remind myself that I'm still paying tuition and I ought to make use of the flexibility we have in our education. So now that winter break is over, I must do away with laziness and senioritis. After all, by now, I ought to know the etymology of that word makes no sense.

Resolutions

This year harbors big changes. It seems that my life can be partitioned into packages of four years: high school, college, medical school, and now residency. Each transition is intimidating and exciting, but this one may be the biggest yet. Finally, I will be stepping out of the student's shoes into the gray area of trainee, balancing learning with patient care. After being in school for 20 years, I'll actually have a job - and for someone like me who hasn't taken any years off of school, that's a big deal. In six months, I will take upon the rights, responsibilities, and privileges of this profession. I'm sure when the time comes, I'll ruminate on it much more.

But for now - resolutions! Though it's quite general and perhaps generic, I think this coming year, I want to achieve balance. On the one hand, the people I'm caring for must come first; patient care is always the priority. These four years of residency will build the foundation upon which the rest of my career rests; I must take advantage of every opportunity to learn. On the other hand, the long hours and emotional trials of internship are taxing. I have to maintain my own health, cultivate my personal interests, and pursue growth. I must take care of myself along with taking care of others. In residency, the work-life balance must tip towards work, but I don't want my job to consume me. I hope that I will be able to find a balance between myself and others, work and play, growth and service in the coming year.