Unpredictable variability

There is nothing more predictable than variability in learning in medicine. Largely perpetrated by the type of patient rolling through the door, the learning is based on the patients, their presentations and how those patients are utilized in learning. That variability is expected, understood and often the excitement that is learning in medicine.

But then there is the variability that is nothing but stress, created by the leaders of learning. That stress is caused by unpredictable, variable and ghostly expectations. The ones that largely live n the minds of those guiding the learning. Would it be so damaging to create success paths instead of failure paths at all?

Predictable variability is a God-send.
Unpredictable variability is a night mare

Stand there, just don't do something!

That's the funniest exchange I've heard in a few days. They are so common in this bizarre world.

Anesthesiologist to me: Just don't stand there, do something.
10 seconds later
Nurse anesthetist to me: Don't help. Too many hands are just confusing.

I couldn't do anything at that point due to laughter. I think the anesthesiologist needs more coffee.

Pervasive Burnout

Just read "Pervasive Doctor Burnout" Great to know as I start this wonderful field.

 http://www.jonbarron.org/natural-health/medical-professionals-experience-work-burnout . 

I don't know about the research. It's a little suspect. 

I just left a drinking party with a whole room 

full of interns and residents in medicine and surgery. 

They all were handing their liquor in excess just fine. Happy about nothing mostly.

I'm so sad it's over, it's over

Rotation's almost over, almost over! And I can't believe it's over, it's over. But I'm so glad it's over, it's over. Sad good byes to everyone tomorrow....but not THAT sad!

Wrong stories

Sometimes, when we hear, or tell stories...we just get it all wrong. Even worse? When we try to interpret and provide opinion on wrong stories.

Too Easy

I won't do it. 

It would be too easy to blast someone who asks for constructive criticism who says she's an expert. She did. Told me she knew everything about the topic we were talking about then asked for my feedback. Really? How open. 

The world of medicine is filled with such types. People who will tell you they are open to critique and really constructive critique, who play the game and do the lip service. It's so fake. It's so unhelpful.

I know I don't know anything, so what would I have to contribute anyway? 

What a sham. A rock, I'd be. I'd rather kiss a bloody stone, upside down.

Good morning Siri!

I dream of the perfect Electronic Health Record (EHR). I walk into the physician workroom, sit in front of the computer, enter my user name and password and up pops EHRick....

Good morning EHRick.
Good morning doctor. What can I help you with today?

Were there any admissions overnight EHRick?
Let me check. Yes, there were 3.

List of diagnosis please.
DKA, post stroke dizziness, and intractable nausea and vomiting.

Any missing documentation?
Yes doctor. Admission orders for #3.

Thanks EHRick. Koolphrase, general admission order set.
Done. He's allergic to PCN, percocet, Norco & asking for morphine.

Thank you EHRick. Please print a census complete with map. And take me past the Starbucks stand please. And report patient #3 to the state narcotic database.
Checking.....I have it. I'll print your map now doctor. Landscape print? Reported.
Landscape print will be fine EHRick. Thanks.

Any calls EHRick?
Yes, your accountant, your lawyer, and your therapist. I've scheduled appointments.

Thanks EHRick. Have a nice day.
You too doctor; Don't forget your list.

And doctor, I've ordered flowers for your Mom's birthday.

Sold!

Wish I had a dollar for every time I've heard someone in medicine say "I've sold myself to the devil". It's less an emotion than it is a commentary on the system I think. But it's clearly borne of doing too much with too little for too many.

Out of the mouths of babes

I love it.

Patient said, "you might want to tell your boss [attending] he/she has the bedside manner of a circus clown, goofy smile and all"

HIT Man

It's an ominous sign and finding in medicine. A patient needs to have clots stopped so the clots don't do damage to end organs...stroke in the brain, infarction in the heart, thrombosis to any other organ that needs a blood supply...so you give heparin, a medicine used to stop the blood from clotting.

And then it happens...a rapid fall in the number of platelets with more clotting than even before you gave the heparin. The patient has HIT...Heparin Induced Thrombocyto(platelets)-penia(too few). The heparin has bound with PF4, joined an IgG, formed a complex and then attacks the platelet...marking it for destruction in the spleen or activating it to clot...what you don't want in the first place.

It's essentially an allergic reaction to the heparin and a good thing to know before you go into the hospital as a patient. It's not a good idea to get HIT!

Oh no!

Ugh, I have to go back to work tomorrow.
I guess things could be much worse, like world destruction, rocks hurling toward me from space, dogs living with cats, mass confusion, madness, mayhem...
Maybe not.

The Most Important

I pass this guy almost every day. He's the guys who rides the motorized floor sweeper, mopper thing all day long. With the hundreds of feet, maybe miles, of corridor in our hospital, it seems to be the most efficient way to clean it daily. And he does, with great regularity, attention and dedication. Day in, day out.

He is a reminder to me every day that even though the business of the hospital is to treat patients, there are many people here who let us do what we do by what they do. Sure the docs, nurses and people in patient are doing the billable work of the hospital, but without the "Sweeper Dudes" and such, we couldn't do what we do. They really create the environment to do this work. They insure the leaks are patched, the air is conditioned, the walls are painted, the spills are managed, the pumps pump, the dispensers dispense and the floors are clean. And for a hospital this size, it's no small task.

I say hi to the Sweeper dude every day. I never forget that he and his comrades create the space, the environment, the world, for me to do what I do.

Leadership

My air conditioner broke the other day. Turned it on and it blew nothing but hot air. I'm no air conditioning expert; I'm a user. I didn't know what was wrong or how to fix it. All I knew, it was broke and I could feel the hot air blowing on me. So is my experience with medicine leadership.

Ideally leaders are forced into position. They take on the role of lead reluctantly with little regard for title or power. They live the idea of bottom up leadership and support, like a bottom foundation, by support, gentle correction and stewardship over those above them...under their lead.

Few have that insight. Even fewer can pull it off.
If force is needed to lead others, it's not leading.

And that is perhaps why medicine is in the condition it is. Too many would be leaders who really can't lead. They create small collections of power and force in groups, departments, programs, and such without really contributing anything to the team at large. Too many egos. Too much struggle for power and control over money, patients, resources, time, rooms, computers...you name it. Little effort to truly lead by example and forge new understanding and territory for the greater good, in service.

I'm so dismayed by this business and the people running it. I'm no expert, and not capable myself of doing what I see needs to be done. I don't have the calling, the brains or the power.

But you don't have to be an expert to see this isn't working. It's just blowing hot air.

So deep

The theater of rounds in academic practice is so silly. It has little to do with reality of the practice of medicine and creates nothing but useless competition, unnecessary banter, misplaced efforts and rounds that last for too many hours.

Chasing the little energizer bunny leader is certainly good exercise. So try to keep up, try not to get side tracked by anything as foolish as talking to the patient, coordinating care with other professionals or to answer a question for the family. You might not want to miss the inspirational and deep commentary of the chief or leader. Everything you say is so, so profound.

"This will be on boards". No it won't and if it was, you'd be in violation of the code of conduct for the boards by telling us that. Besides, I'm not taking your boards anyway.

Dr. Stead, Duke, said that academic medicine had too few who actually could teach. Even fewer who could lead. I really thought he was kidding.

Could be worse

As bad as yesterday sucked, could be way worse. Remembering 9-11.

I suck!

That sucking sound you heard today was probably me. Or maybe it was just "this", as in "this sucks". But I can't imagine a worse day in medical education or care.

After rounds I found myself alone. Everyone else bolted to their respective roles and responsibilities, leaving me to cover the entire service myself. Not a single word of goodbye, support, guidance or anything remotely looking like team work.

Now that wouldn't be so bad if the service wasn't filled with sick folks, if we weren't on call for new patients, if I didn't have to discharge several patients or if I was even remotely interested in this type of medicine. And more important, I'm not even close to being an expert at this. Frankly, I suck at it.

But there I was. Left alone to fend for myself, with little knowledge of the system, the rules that make little sense, the back up that appears to change like the wind or the practice of this type of medicine. On a good day, there would be 5 total folks doing this work. And there I was. Alone.

I've finally finished the day's work after working for 18 hours. I have to be back at 6 AM, less than 6.5 hours from now. The bed beckons. Retirement screams!

Fever, chills, night sweats!

A winner... a patient with a 107 fever. That's a record for me. Actually beats the patient with the over 1000 sugar in "most likely to be unconscious having a seizure" award.



Sun geek...the new sexy

Tragic Loss in Twitterland

I'm sort of numb to this sort of stuff. Too many people have died around me on or around cars and motorcycles. Yet a couple of weeks ago, on a winding road in California, a man from the UK on a rented motorbike was killed. And I felt a great loss.

I'd never actually met Ian, but I've been following him, literally, for several years on Twitter. He and his friends posted some very witty observations about life and social media. I stumbled upon he and his friend Corrine one day, searching for motorcycle tweets. They were enthusiasts, like me. They were living life and chatting to each other and friends about upcoming plans for a great adventure on a bike to Northern Africa. I was hooked.

I began to take great interest in their lives and how they figured out work, school, moving, dissertations, social media, politics, cigars, drinking beer and fine liquor, foods, motorcycles and a host of other topics...just living. I felt a bit like a voyeur when I'd catch @Peregr1n chatting with @PolarIceQueen. I felt every ache she felt when they wrecked their bike in Africa and broke her wrist.

And I suspect that my attraction and fascination is not unusual on Twitter for others as they view other people's lives on Twitter or other social media.But what made this unique, I think, was the candor and unique perspective Ian had for social media as a user, and as an IT professional in Europe. His wit, intelligence, humor and sophisticated perspective oozed from the tweets and made me chuckle regularly. I particularly appreciated the love and real friendship between him and his friend Corinne, something many never achieve and only yearn for.

I've been so, so busy, that I've not been on social media much. It's been a challenge to get to the grocery store let alone keep up with Twitter. But I had a break to do just that and check in with Ian and Corinne. And that's where I found out about Ian's death, and Corinne's loss and devastation. The last thing he wrote about was trying to figure out the gas and gauge operation of his rented bike. 2 weeks ago, Ian (@peregr1n) wrote:

"Oh if someone could tell me how to view the fuel gauge on the Ducati Monster 696's digital display I'd be very grateful!"

He must have been hit by that pick up truck right after that tweet. I hope it wasn't a stupid tweet distraction that got him killed.

I read later where she had to fly to California to "bring him home". I can't imagine the loss Corinne feels, but actually felt a little part of that myself. And the irony is not lost on me that I was just looking at Ducati motorcycles in the cycle trader the other day, thinking about it. But worst will be the loss to his friends, colleagues, and Corinne. I know nothing can remove the pain and shock of this, but I hope that there comes comfort and great knowing how Ian affected others. RIP @Peregr1n , RIP. I for one, will miss you.

Brains to Brains

It's that time of the month again. That time when residents generally move from one service to another. Nothing less so for me. Onward from specialty surgery to general medicine...the antichrist, the polar opposite. I guess you have to fill those potential surgical hours with something. Might as well be hours and hours of rounds, discussion, and rounds again.

But this will be a good time to study for the next round of boards bound to be just around the corner, as they always are. Step 3 is the next "step" and the one "must do" before getting licensed in the U.S. as a physician. There are many 100's of folks in my same position, looking forward with great awe and nausea toward that next exam. I'm sure there is a tonic for that ailment.

If I learned anything on the brain service it is that there is a tonic for everything. And for everything that doesn't have a tonic, there's surgery. A chance to cut is a chance to cure.

Batteries Not Included

There are so many reason not to swallow batteries. Beyond the local irritation, they can get jammed and cause obstructions. The little watch size batteries can eat through the lining of the gut easily. All and all, it's just a plain nuisance.

But when you are schizophrenic, it's just plain fun I guess.

Hurricane Andrew

I can't believe that it's been 20 years since Hurricane Andrew hit South Florida. Has it really been that long ago? Incredible how time seems to be flying by and moving at the speed, well, of a hurricane.

That was a surreal time but one of those events that marks the passage of time and activity of life. One of those event where you know exactly what you did, where you were, how you reacted.

I hope Issac moves through this week with little damage or mayhem for Haiti, Cuba, West & Panhandle Florida and New Orleans.

Suprise!

Rarely are there real common things presenting in medicine. Although I've heard it said that common things present in common ways, when considered with the unique characteristics of the human sitting, standing or lying in front of you is rarely common. Ponder that.

Exception: If someone rolls in with a large metal object sticking out of his face. An uncommon thing in a common place (his face) perhaps, but uncommonly uncommon none the less. Now I've confused myself.

Neurosurgery is like that. The shock of the presentation wears off into the activity of the care taking, surgerying, ordering, x-raying, and a host of other ings. I think it's the proximity to the head that makes this stuff so unbelievable. Nothing should be that close to the head, unless you are making out with it, or eating it. Rebar belongs embedded in cement, not in a skull. Pretty uncommon.

Mistakes

Ever contemplate...wish I'd married a Virgin.

Now, let me get this straight!

It spilled from my mouth before I could even stop myself. It was one of those "trigger" after and long day of really sick folks. And I laughed all the way back to the truck.

My boss doc had me go down to interview a patient prior to admission to the hospital. I asked the usual questions about the who, what, where, when and how's of his complaint. I discussed the what were were going to do and the medications he was one, and those we would give him.

And he said, in a thick, Southern front-porch rocker drawl...
"Doctor, ain't there nothing I can take?"

And I heard myself say...
"Now let me git this straight"

And then started singing under my breath...
You put the lime in the coconut and stir them all together,
Put the lime in the coconut and you feel better,
Put the lime in the coconut...

All Knowing, I Surrender

ca·pri·cious (k -pr sh s, -pr sh s). adj. Characterized by or subject to whim; impulsive and unpredictable. Synonyms at arbitrary.

Any semblance of control in the process of medical education is purely accidental and largely a mirage. There is no control placed in the hands of the student. This is a great exercise in surrender, acceptance and releasing all vestiges of control.

Just wish it wasn't so arbitrary and carpricous bordering on abusive. Traditional medical education is as broken as the system itself. And that may be a whole chicken or egg first discussion all by itself.

I become more and more understanding of what Dr. Stead was fighting at Duke all along. It's an entrenched way of doing things that prevents any real progress without threats, rules, regulations and outside scrutiny. Medicine has brought this upon itself and I, along with my colleagues, are paying the price for 100's of years of bad habits.

I surrender, once again.

USA!

Nicely done ladies! Great redemption gold medal win v. Japan!

Adding Years to Life 2.0

Wish there was a way to just upload the basic information and skills people need to get healthy. It's so simple, but so hard:

Sleep more,
Less work,
Brain thinking activities,
Best air quality / Quit smoking,
Less caffeine,
Aspirin daily,
Less tanning/sunburning,
Floss/brush more (less heart dz),
Lose weight,
Less fast food (salt, sugar, fat),
Less iron supplement,
Physical activity

Ready, set, go!!

Evaluation

I really don't know why we waste our time and effort in medical education with summative evaluations on clinical rotations. What a crock of clostridial waste.

Let's review: Effective evaluation is both summative and formative with timely feedback based on established learning objectives with unbiased, objective and constructive educational correction.

With none of that present, the result is pure manure, wasted paper, time and effort with absolutely no ability to learn or improve.

That was fun.

Medical Types

I've become, in my old age, a consumer of watching people. I really listen now, really absorb who is right in front of me, and try to seek understanding of who they are. And in a teaching hospital, it is quite the array of personality types.

But I think I've distilled it down to it's basics at this point. It seems there are three "types" of people involved in the practice of medicine.

Dr. User
They seem to always want something from you to assist what they are doing, but rarely (if ever) offer something to you. They reach out when they identify your strong points, to augment their weaknesses. But they are the first to run for the hills if you need them or you demonstrate weaknesses yourself. If you are in trouble, these folks can't be relied upon or even trusted with your issues. They certainly aren't bad people or clinicians. But they are fearful, insecure, self-centered and driven to achieve little beyond what serves them best and first.

Dr. Standby
I'd say most of the people I encounter in medicine are "standby" folks. They wait in the wings. They don't come forward in hard or easy times. If you get into a jam, they wait silently close by and watch to learn from your mishaps, but are willing (although not excitedly) to assist if you ask. They aren't easily made friends of, but once they do accept you, they are all in. They are good people to know and have access to, but they aren't very committed to you or anyone else.

Dr. All-In
These folks are totally committed to everyone and everything around them. They don't hide in self serving practices and aren't shy about committing to you if you are open to it. They are accepting of everyone, every patient, every situation without a whimper. They are there for you when you need in hard and good times. They seem to approach more readily when they sense distress. They never appear burned out or disturbed by the people we live with or serve. They stand by you in good and bad times. They are likely the best friends to have in the long run and have the potential to be totally honest with you when you need it most.

I'm a Standby right now, a bit cautious. I strive to be an All-In. I think it's all about moment by moment focus, stress management, being there and approachable in good and bad times for colleagues and patients. It's about daily renewal and openness to the possibilities. Paging Dr. All-In, Paging Dr. All-In.

Cocaine

"Cocaine can constrict blood vessels in the brain, causing strokes. This can happen even in young people without other risk factors for strokes."

I've read that statement in countless books in school and journals studying the use of cocaine. I've always had a interest in the effect of drugs on the body growing up in South Florida where it's always been available. I've been interested in the effects since my days working in trauma and seeing the aftermath of use and abuse. I've seen people try to fly off balconies on LSD. drive into walls on alcohol and drive too fast for the curve on coke.

But nothing is more devastating than a deep brain bleed in a young person from a snort. It leaves the person alive but with greatly reduced function, with bills they can't pay, rehab that will never get them close to the way they were, and loved ones taking care of the rest. So sad.

Heros All Around

My new hero, Kayla Harrison ,78 kg of "kick ass". Great lesson; Don't get mad at the past, just GET GOLD! Awesome, amazing performance after years of total bullshit in her life. Way to go Kayla!! Absolutely inspirational.

First Month Done

Oh thank God it's August! I can finally sleep in my OWN bed... the simple pleasures of life.  The first month of residency is officially over and I've broken the ice on the "rest of my life". Beyond the cognitive decline of an aging clinician, I think I held up pretty well for an old guy.

Still the yungins are really, really sharp and I can tell already it's going to be a challenge to make the grade and keep up in some respects. We shall see. It's one day, one patient at a time. But for now, it's (I hope) a realy good nights' sleep in my own bed.

Ready for the End

This is the last weekend of my first block. It was challenging. 319 hours in 4 weeks, just one short of a violation. Over 400 pages for services to the floor. Untold number of scut monkey activities and moments of potential humiliation by upper class folk and attendings sprinkled with a solid 1/2 dozen moments of amazing connections with family and/or patients.

And it's those few moments that fuel my love for what I'm doing and yearning for more. I think I can put up with almost anything as long as those moment continue. And I know that that part of the equation is up to me. Because I know I have little control over any of the rest of this madness and mayhem they call residency, filled with strange rules, hours, notions, myths and activities.

Yet at the end of any brutality is the notion that one can survive almost anything. And then onward to the next block of work, education and hopefully more time for me. Remarkably, I am about to survive and this is my last weekend. And, I think I'm ready!

Let the games begin

I think medical education is constant search for diversion and distraction punctuated by the complete lack of sleep. Let the games begin!!

Love the Ralph Lauren USA garb, made in China :)

Dragon Speaking

"ice on a dill" = lisinopril

Voice recognition dictation can be so so entertaining

Loving what you don't like

It's inevitable. Experiences in medical education, or in life for that matter, that you file away in "I'm sure I don't like that". And then you set about a way to avoid it, to the best extent possible. But still staying politically correct, snuggling to the correct person, and stating the most obvious sarcasm you can muster... "I love this [thing you really hate]!" Although hate is a strong word, certainly something you will try to avoid. It just feels wrong.

But somewhere in the political correctness, the lies about what you say you like but don't, is a spiritual nirvana and real message in the "hate". We learn what we don't like but still take away a greater knowledge, experience and appreciation for that thing or experience.

And so is the life of an intern. Moving through the motions of learning so you can be a working physician, figuring out what you like and what you don't like, but still learning...always. Every skill, every nuance, every opinion, every fact; Adding to the knowledge base that is your toolbox for the future practice of medicine and patient care. Always with the knowledge that there isn't anything that they can do to me in one rotation that I can't get over. But a positive lesson on something, even if it's negative, every single day.

------------------------------------

There is no way possible to fix the current medical system quickly and easily as long as it's core is made up of professionals that believe that the old way is the only way. Sadly it's those old ways that have brought us to this broken, unenviable place in U.S. medicine.

Cost of doing bad business

She said "I ran out of my medications" and couldn't afford to get them.

Cost of medications for the month not covered by insurance, $85

Cost of the Emergency room visit for the hypertensive crisis plus the ambulance ride in, $2800

Does this make any sense to anyone?

It's not mine

There are few things that are more disturbing than to hear those words from physicians who are in the business of attending to and working with patients..."It's (referring to a live, breathing patient) not mine"

Let me get this straight. The patient needs your services, but "it's not yours?" And the it, ...that's Mrs. Bernstein. I know you are tired, so am I. I know your reimbursement won't be maximal, but who's is. But she is yours. You are a neurologist with expertise in meningitis, you are on call, and she does have meningitis.

So it, her brain and it's surrounding meningeal structures, are yours.

Healing in the modern era

This has gotten so complicated. Financial issues prevent or alter access. Why not use the ER for your primary care. They can't turn you away, even if you don't have the co-pay. So, so broken...

Luxury

Nothing too good for our residents. I have the luxury top floor penthouse suite

Letting Go

Medicine is a strange training ground. So much pressure to compete. So many lost opportunities for real collaboration and real team work. Mix that with sleeplessness & stress and you have a potential challenge.

Letting go of the tendency to hold ourselves up to other people’s standards, and letting go of the belief that we need to compete and win, doesn’t mean we don’t believe in doing the best job we can.

I love baby Pandas.
But I digress.

Reality

The hospital ED has a way of dealing reality to both patients and providers.

Reality: that which you were formerly clueless on, becomes clear as a bell.

Value

Without good teaching and teachers the process of learning in residency can become disheartening and destructive. But with good mentors and teachers, it holds promise and value to be both gratifying and productive. We shall see.

First Days of Residency

The first days of work were a little challenging with the hours, demands and (most of all) the reactions of the patients. Do you think it had anything to do with my shirt?

Survived

First of anything are usually a challenge. It certainly was my first night on call as an intern. They said it wasn't too busy, but it felt like an avalanche to me. Fortunately all the patients did well and the only faux pas on my part...walking into a "isolation" room without a yellow gown. I learned to read door signs more carefully.

Of course the patient load/calls were compounded by not knowing how to get places, how to use the electronic medical record, or the "norms" of the hospital and staff. It was challenging to integrate medical school and my experience into the work of getting through the night. But I survived. Barely. I fell asleep after my 14 hour shift during morning report before going home.

And so it begins. The residency learning process in the face of overwhelming responsibility, not enough time, not enough staff and a learning curve as steep as Mt. Everest. But I'm determined to make the climb, one step, one day, one patient, one decision, one new EHR skill, one nap, one admission, one order at a time.

July Effect

July 1 each year is the start of residency for several thousand medical school graduates. That is the where the term "July Effect" arises. I am, starting July 1, part of that effect.

My colleagues in law, and business get so excited when they speak of internships. Companies with big names and even bigger reputations are discussed freely. Visions of suits, handshakes, networking breakfasts, long hours and potential job offers to follow usually accompany those discussions.

But for those of us in medicine, internship is more akin to a form of indentured (or edentulous) servitude. It is that first year when you have no sleep, no very little, have high amounts of activity, and no opinion (at least none that matters to anyone). On the food chain, even medical students are treated better (they go home early usually). It is a very different look and feel.

So now it's my turn to become part of the productive, or dangerous, time called internship. For the next year, beginning on July 1, I will become part of the 1000's of first year, PGY (Post Graduate Year)-1, residents... aka Interns. I'm scared, excited, worried, elated and I'm hopeful to be at least able to find my way around this massive medical center.

I am also going to become part of the "July Phenomenon", that time when experts have said to stay healthy and avoid the hospital due to up to a 10% rise in medical error. That is the first month that "we" are there, doing our doctor thing, in the very first month of our training practice. There have been arguments over the years if the effect actually exists, but from the looks of the PGY-1 class around me, I think the world is safe... as long as they are continually hovered over and supervised.

And so it begins. The years of medical school have led to this point in time. You really can't do much with a medical school diploma so this is where the rubber meets the road so to speak and we translate our knowledge into real, tangible patient care.

I'm scheduled for a opening schedule of 160 hours over the next two weeks with only one day off in the next 14 (not a violation of the new GME hours rules).

Ready or not hospital, patients and staff,

HERE WE COME!

Longevity: 4 Years and 1/2 way

It's really been a long gestation, but I birthed the credentials that I've been working toward for the past 4+ (depending on how you count the years) . In no particular order:

1. M.D. diploma
2. ECFMG certification of education
3. Residency match offer/acceptance
4. State M.D. resident license

It's a slow, slow delivery with much frenzy in the last year, but the "quads" have been birthed. And as I start my unpaid orientation for residency, I'm excited to be at the 1/2 way point "finish" of my education and training as a physician.

Throw on top of that a new hospital I.D. card, some new embroidered coats, and it becomes an "ahhhh" (like right after the baby delivers) moment

This point in time was a distant dream when I first got accepted to medical school and began this trek. And I say 1/2 way because given a 4 year (maybe 5) residency/fellowship course of study to follow, I've literally only completed 1/2 of the necessary hurdles to full medical practice licensure and board certification.

The process to get to this point is truly amazing, on so many levels.  It's been a cascade of emotions, effort, trials, schedules, deadlines and processes. It's hard to believe sometimes that anyone actually completes this process, but with one day at a time, enjoying every single moment, it is possible and feels great.