Friday, July 24, 2015

Another day, another shooting


Another day, and another senseless act of gun violence.

I sat down tonight to start writing about my experiences working as a locums primary care physician in the heartland of America and the Indian Health Services.

There's a lot to write about, in terms of the myriad of chronic diseases facing this population and the stressed healthcare services that's trying to care for them.

Cancer, heart disease, diabetes, tobacco abuse, alcohol abuse, obesity etc etc.

I forgot about one particular epidemic until I received a push notification on my phone about the shooting in Lafayette, Lousiana.

Another city, different from where I'm working but still uniquely American, trying to persevere through violence perpetrated by some who believe was just a person. Other's who will attest he's a person who culturually and perhaps legally was allowed to obtain an unneccssary appendage of violence.

In tragedy, the natural tendency is for people to come together.
When it comes to tragedy from gun violence, we seem to grow further apart as a nation, debating the merits of a vestigial amendment. This too, another uniquely American reality.

Another shooting and another night of mourning.



Tuesday, July 14, 2015

"My dad says I'm disabled"

In my last post, I mentioned how I discovered a few things I had started writing before I had this blog. The following is something I started to write after my experience as a part-time disability examination provider for a national company. It wasn't an opportunity that I particularly enjoyed, but with a mountain of debt to repay right out of residency, I decided to give it a try.
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“My dad says I’m disabled”
      Room number 2 was the one. It was worth coming in 15 minutes early just to grab that spot. With 12 hours of monotony from 22 patients getting disability evaluations, the view from that room (and the extra income) made this day worthwhile. In between patients, I would place my palms on the one way panoramic window to channel the warmth generated by the Arizona sun shining down on the black facade of this nondescript office building.  From the 10th floor, I took full advantage of my peripheral vision by taking in the seemingly endless hills, mountains and blue skies. Such mental escapes were fleeting and constantly interrupted by patients trying to make a case to qualify for government assistance.
      I always took the time to review the charts the night before. It allowed me to be more efficient and objective the day of the exam. Whatever skepticism I had about each patient’s claim, I would try not to bring it to the office. I constantly reminded myself that it was my job to make an honest assessment of their medical conditions.  It was up to the government to ultimately determine if they qualified for disability payments. Most of the patients had chronic debilitating illnesses and I knew no matter what I wrote in in my assessment, they would probably qualify.
        When I read Jaina’s file the night before, I felt disappointed but also grateful. I couldn't believe a 20 year old with only depression and obesity would want to and try to qualify for disability. But I also realized this would be an easy visit that I could work through quickly and make up the time spent on more complicated patients. If the day became too long or frustrating, I would try to convince myself that I was performing a public service by helping determine if tax payer dollars should be used to support these patients.
      When I actually saw Jaina my skepticism was unfortunately confirmed. She walked in and sat next to me without any difficulty. My physical exam revealed nothing despite her assertion that knee and back pain limited her capability to work. My conversation with her had clues that her depression is what really limited her. She had a morose look to her face and struggled making eye contact. She was diagnosed by her primary care physician but had poor follow-up with him. She also hadn’t been referred to any mental health services which made me think if her depression was better managed, it wouldn’t be “disabling.” I asked a series of questions in terms of her abilities to do a variety of menial tasks and her answers indicated she could do everything. With each question she must have sensed my increasing skepticism towards her disability claim. At one point she looked away and welled up with tears. I asked her if she was okay when she muttered “I know I can do that stuff, but my dad says I’m disabled.” I paused, unsure what to say. I wanted to delve further but I was running out of time as the proverbial walls started coming up around her. Her answers after that confession was curt and she kept directing me back to her back and knee pain. I eventually had to complete the visit and send her on her way. I felt troubled by what she had just said. I felt even more unsettled thinking about all the things I would never see or understand about Jaina’s life that led to our meeting that day.
In retrospect, as I learned more about medicine and our health care system many things became clearer. I continue to believe she really was clinically depressed. In our perversely broken healthcare system, she probably had difficulty accessing primary care services.  She probably had limited access to mental health services especially ones that could be tailored to patients with specific cultural or language needs. Every day as I continue to see the critical role family plays in both good and bad health, I keep thinking about the injustice Jaina’s father had done to her. A 20 year old physically capable girl should be able to dream big and pursue happiness. Instead, it appeared that her father traded in her self-esteem and hope in exchange for an opportunity to get a few hundred dollars every month from the government. Conversely, I wondered what was going on with the father and his own struggles in our society that would make him take his own daughter down this path.
              It took me only a few minutes after reading her chart to figure out that the odds were against her to qualify for disability. It has taken me years of experience and a single moment to reflect to believe that the odds are against her for a chance at anything at all in this life. 

Friday, July 10, 2015

STICU

Recently, I found a collection of things I had written as a medical student. I didn't have a blog in those days and saved them as Gmail drafts hoping to finish one day. It feels great to discover an old memory, as grim as this one may seem. It’s one of my few distinct memories from my surgery rotation.
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STICU
The alarms forced my body to wake up at 5 AM. By 5:30 AM as day break approached, my body resorted to muscle memory to push the accelerator pedal and turn the steering wheel in order to guide my ugly early 90’s era sedan through the quiet streets of inner city Brooklyn. There was only enough cognition at that hour to determine what color the traffic lights were. Decision making was limited to stop or go. By 5:57 AM, my brain would arrive at 2 rational thoughts. First, I had 3 minutes to make the walk from the parking lot to the STICU. The second completely rational thought was that 3rd year of medical school was making me regret my career choice.
By 6:05 AM, the team collected behind the central counter of the STICU (surgical trauma ICU) and descended upon the resident on-call the preceding night. On this particular night, it was a middle aged, overweight, Turkish anesthesia resident who appeared especially sweaty. From his bloodshot eyes you could tell he was feeling too old to be doing residency all over again here in the United States. Marty, a precocious and social urology resident appearing clean and freshly shaved looked at the exhausted resident and said what the rest of us were all thinking.
“Rough night buddy?”
The on-call resident gave us all a brief look and regretful smile. It was 6:06 AM and although I had been up for over an hour my brain did not register enough of the world to make a reasonable and appropriate response. I wanted to somehow support this resident who had a difficult night but simply couldn’t muster the energy to do anything. In fact, this was as far as I would let my mind explore the emotional realities of being a member of this dungeon. The next 12 hours was not about feeling or learning. It was simply about reacting and doing whatever needed to be done for the 8 occupants of the STICU.
Bed 1: Gastrointestinal bleeding. Draw a blood as soon as the meeting breaks and every 6 hours after that. (I hated drawing blood)
Bed 2: Motorcycle accident: Find out from the pulmonary doctors if he can extubated. (I hoped the pulmonary fellow wouldn’t bark at me for bothering him)
Bed 3: Nasal Bleeder: Ask the ENT doctors if he really needs to be here (More scut work)
Bed 4: Aortic Dissection: Call his pharmacy or family and find out which blood pressure medications he should’ve been on (Even more scut work)
Be 5: Empty. (Mr. Marcellus apparently coded for 45 minutes the night before. The bed looked really comfortable. I didn't care someone had died on it)
Bed 6: Smoke inhalation, Acute Respiratory Distress Syndrome, Sepsis and a deeply pious Orthodox Jewish family. Go to radiology, get a report of today’s x-ray and bring it upstairs. (Apparently, family was in and out of the STICU all night praying at his bedside.) Talk to the family and let them know they can only come inside during visiting hours or if there’s any acute change in his status. (I’m sure a grieving family loved having a 3rd year student restricting access to their loved one)
Bed 7: MICU boarder. Medical ICU patient. Go talk to the medical ICU residents and see if they have a bed available to take her back. (I was sure the answer would be no.)
Bed 8: Liver failure in DIC. Check his labs every 6 hours. (He was a goner, but I knew he’d keep us all busy.)
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Later in the day we coded bed number 8 several times until he died. I remember the final horrific experience of doing chest compressions on his bloated dying body. My arms were tired from several rounds of CPR and my neck became sore from trying to keep my head turned away from his face. After a while, I couldn't stand to see that lifeless zombie stare where instead of words coming from his mouth there was only regurgitated stomach contents. And instead of tears there were only drops of crimson blood oozing from the corners of his eyes, 
Through the entire process, I did what I was told by our code leader. Rather than thinking about what was happening to this poor unfortunate soul, I remember counting the chest compressions in my head wondering how events in my life could've culminated with me bearing witness to this horror.
By 2:30 pm after taking care of some odds and ends, I had the opportunity to go eat lunch. I had to hurry because although Bed #8 was empty now, a replacement for Bed #5 was on the way.

Friday, July 3, 2015

The Half-Full Glass

     Its cliché, but I frequently reference the saying “The glass is always half-full.” There are always unexpected twists and turns in life, and that saying definitely helps me keep a positive outlook on things. I look back at sentinel moments in my life that didn’t go as expected and inevitably most of it turned out extremely positive. For example, although I didn’t get accepted to a US medical school, my experience at an off-shore Caribbean school (SGU) was life altering. Besides a great education I came away with numerous lifelong friends, few of whom became like brothers. After residency, I found limited job opportunities around NewYork City and settled on a position in academics. This was despite swearing during residency never to work in academics! But unexpectedly while surrounded by great mentors, residents and students I developed a passion for medical education that changed my career aspirations. After almost 6 years, I moved to Texas to continue my work in medicine and academics. Although I wanted to hit the ground running, I hit a major roadblock in the form of an unexpected 6 month hiatus from my career.
     While in a bureaucratically imposed exile, disappointment naturally set in as the weeks and months went by. But I resorted to my favorite cliché and two incredible things happened. First, I got to nurture another passion; fatherhood. 
     I remember flipping through my phone on my HuffPost app, coming across an article about the state of parental leave in America. It's sad and disappointing. The following infographic shows how we (the USA) lags behind the rest of the world in taking care of our new parents and the children they've brought into the world.


    My unexpected time off has given me the opportunity to watch my youngest daughter grow through her formative infant months. This has been a precious and memorable "paternity leave" that otherwise would be difficult to attain in our workforce. Furthermore, the medical school debt that physicians carry (a whole other topic!) makes extended parental leave for mothers and fathers a rare luxury. Nevertheless, though it wasn't planned, the time off spent with my darling has been wonderful.
     But at some point, I did have to start working again (bills bills bills!)and fortunately the world of Locum Tenens  (temporary contract work) offered plenty of great opportunities. Although it wouldn't be in academics, this New Yorker suddenly found himself in the middle of rural southern Oklahoma, a new resident of the Chickasaw Indian Nation and a physician for the Indian Health Services.
     Once again, my favorite clichè did not let me down. What started out as simply a need to work is rapidly becoming a unique experience that is giving me new perspectives and insight on medicine, the state of our healthcare system, culture, history and my own abilities as a physician. In the coming weeks and months, as I delve further in this experience, I hope to blog all about it!

T.S. Eliot
“We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.”
― T.S. EliotFour Quartets












Wednesday, June 17, 2015

Why I blog

     The best line I ever wrote dealt with grape soda. A shade of fiction, based on real events, I described how during family road trips the cooler seemed to only have grape soda that as an angst ridden teenager, I found it unacceptable. I wrote about this in my 11th grade creative writing english class. It was my first genuine attempt at finding my voice. Learning a variety of writing techniques such as poetry and stream of consciousness I muddled through the semester with a mediocre grade still trying to find a good way to tell a story.
     Over the years life's priorities and the times changed. It wasn't until I got accepted into medical school that this story I had been searching for gathered some substance. The world became smaller and better connected through information technology and it became much easier to find a platform to share that story. And although this blog is only about 3 years old, I always marveled at the incredible world of medicine that I had surrounded myself with. I started to take mental notes about the triumphs and tragedies of patients and the absurdities of our healthcare system. I began to notice the strengths and flaws in our medical education system while opening my mind to envision a better, more technologically fluid world of medicine. And finally about 3 years ago, I took the plunge and started to put my thoughts and memories down on this blog. It has been an incredibly gratifying process ; an important and necessary outlet in a busy life.


“It's like everyone tells a story about themselves inside their own head. Always. All the time. That story makes you what you are. We build ourselves out of that story.” 



"The universe is made of stories, not of atoms." 

Sunday, June 14, 2015

The Good Ol Stuff, Part 2. Guides for new Interns

It's June, and that means as a set of veteran residents cast off into becoming independent physicians, a whole new set of 4th year medical students are anxiously getting ready to begin their journey.

So gather your belongings, hug and kiss all your loved ones and get ready to take the plunge.
You are about to become a real doctor.

Here are 2 posts from last year, to help you interns get ready.

The first one, is from a former colleague at Stony Brook School of Medicine.
A terrific doctor, blogger and social media aficionado,  Dr. Garcia published this great article on Medscape!

The " July Effect " Tips for New Interns


This second post, was written by yours truly!

The Calm before the storm. Tips for New Interns

Hope you enjoy reading both and find it helpful!
Good luck newbies :-)




Wednesday, June 3, 2015

A Muslim doctor gets on an airplane...

     The recent events of Tamera Ahmed on a commercial airline and the alleged discrimination and Islamophobia she endured, got me thinking about my own experiences in the air. Fortunately, I have never experienced anything as blatant as the events described by Ms. Ahmed. But as a Muslim-American, I've become too keenly aware of the growing specter of Islamophobia across the world. Whether it's at a TSA security checkpoint, sitting at a terminal or falling asleep inside the plane, I have to admit I sometimes wonder if someone is watching me, thinking I'm capable of committing harm. To those that continue to subscribe to beliefs that all Muslims on an airplane are a potential danger, I offer my own personal experiences that are the opposite.
     I've had the privilege of twice responding to a request for medical assistance on an airplane at over 30,000 feet. The first time, I was a senior resident flying home with my wife from a well deserved vacation. The flight attendant requested anyone with medical training to assist a passenger who had collapsed near the forward bathrooms. Without hesitation, I looked at my wife and headed to the front of the plane in my jeans, t-shirt and baseball cap looking nothing like a physician or a stereotypical dangerous Muslim for that matter. I ended up converging at the front with a nurse and a radiologist on the flight. Without access to a CT scanner on the flight, the nurse and I quickly took charge of the situation :-).  We came to the conclusion the the elderly lady had a vasovagal episode brought on by a lack of sleep, and the effects of alcohol at high altitude on a body altered by gastric bypass surgery. The flight attendants were understandably worried and repeatedly asked me whether the flight needed to be diverted for an emergency landing. I reassured them and gave my blessing to press forward towards our intended destination. After the flight I caught up with the lovely lady outside in the terminal while paramedics assessed her. She was extremely gracious in expressing her gratitude. In addition to her, several random passengers expressed their appreciation. One gentleman was particularly thankful that I didn't divert the plane and take away vacation time with his girlfriend.
     A second and similar episode occurred on another flight a few years later. This time, a passenger that was battling a stomach bug, vomited and subsequently also passed out. I once again marched to the front of the plane to assist the passenger. But this time, as I spoke to the passenger, his sister  next to him started to feel ill and weak. She too almost passed out from a vasovagal episode triggered by watching her brother heave. Fortunately, both passengers were ok as I reassured them and the flight crew that everything would be fine. And once again there was an outpouring of gratitude from a variety of people.
     As physicians, we are reminded early in our training and throughout our careers to treat all patients equally. I certainly did not ask who or what those passengers were on my flight. They were  people in a vulnerable situation who needed some help. Perhaps they even harbored the same biases and fears that plague the bigoted passengers on Ms. Ahmed's flight or the policy makers of the airline she flew. It wouldn't have mattered. What matters is that the vast majority of proud Muslim-Americans like myself continue to advocate unity and peace while in service of everyone in our communities regardless of sexual orientation, race, religion or any other identifier. We are your teachers, lawyers, waiters, engineers, plumbers, mechanics, nurses, doctors and all others. And occasionally we are also your guardians in the sky.
 
 

Thursday, May 21, 2015

The Good Old Stuff

Looking back, I've written many posts on this blog and some have gotten a bit buried.

So I thought I'd give a little bit of love to some of my favorite old posts.

This one is from 12/2013 and still very relevant today

Top Ten Reasons I use Twitter in Healthcare

Enjoy!



Friday, May 15, 2015

When the Bells Tolled for Me

     Empathy is a big topic in medical education. How do we teach and nurture it in the next generation of doctors? Personally, I've noticed that students and residents with personal experiences as a patient often "get it."
      I've had a few personal experiences as a patient and I think it's helped me gain perspective. Fortunately none of my experiences were life threatening, but one them did leave a big impression.
     In the fall of 1991,  I woke up on one morning with a strange sensation. I had difficulty speaking and drool was intermittently falling from my mouth. I wasn't in any pain and I remember finding the experience unusual and funny. My father had already left for work and with the situation unclear, my mother sent me to school with an appointment for our family physician later that day. I was happy to go and didn't want to miss school early in the year. I remember later that morning, despite how my mouth felt, I volunteered to read a section of my social studies text book. I always considered myself an adept reader, but that day I sounded incomprehensible. I even remember the quizzical look on my teacher's face after my attempt. I quickly realized I would have to hold back my enthusiasm for education for 1 day until my doctor could fix my ailment.
     My family practice doctor was a nice Indian gentleman with silvery grey hair. I remember vividly that his office was also his only examination room. Right next to his large, expensive wooden desk and leather chair, was an examination table, up against a wall lined by his innumerable degrees. It felt like I was being seeing in his home rather than in the sterile exam rooms I've grown accustomed to. I don't recall the details of the visit, except that he had diagnosed me with Bell's Palsy, given me "steroids," and a consultation with Neurology. As a teenager, I found this amusing but my parents were extremely concerned. They were so concerned that any run of the mill neurologist wouldn't do. We had to find someone affiliated with one of the major teaching institutions in New York City.
     We were lucky to get an appointment the following day. After an hour long subway ride, we were in front of a neurologist who was affable, intelligent but also eccentric with hair that only had chance encounters with a comb.The details from this part of the story are foggy. All I really remember is the concern on my father's face after the doctor advised that we immediately go to the emergency room. For reasons that I don't recall, my neurologist was concerned about meningitis.
       My inpatient story began like many others in the ER. The most vivid memory had to do with lumbar puncture (LP). My father consented for me, as a pleasant male ER resident explained the procedure and how pain would be minimal and to expect some post procedure headaches. I remember laying on my left side facing a wall 6 inches from my face with my arms clutching my knees close to my chest. With my bottom and back exposed, I felt the warm anesthetic burn its way through my back, while the rest of me shivered in the cold room. My father had to wait outside for what seemed like an eternity. The resident was talkative and friendly but I found it hard to focus on anything else besides my fatiguing arms and lower back. I recall several attempts at him guiding the needle to find the sweet spot. It didn't hurt but the repeated pressure and prodding of the apparatus was unnerving. After several minutes, the physician proclaimed success and asked me what color did I think the fluid was. I guessed red. To my surprise it was serenely clear.
      I woke up the next morning with a terrible headache and nausea. This was definitely much worse than the actual lumbar puncture. I couldn't enjoy the view from my window overlooking the East River while the smell of the hospital food made me that much more ill. Despite that, I was happy to see my eccentric neurologist who walked in like the Pied Piper with several medical students in tow. They stood around me, in a semicircle with their shiny white coats, smiles, enthusiasm and words of encouragement. The neurologist demonstrated his cranial nerve exam to the students with my Bell's palsy playing a central role. The student's marveled and I felt really special. I wish I could say this was that sentinel moment in my desire to be a physician and medical educator. But honestly, at age 13 although I fancied being a doctor one day, my real priorities in life were baseball cards and video games.
      The days that followed were less about my Bell's Palsy and more about a nasty pathogen. Although the results of my lumbar puncture were negative, the Varicella Zoster virus (Shingles) reared its ugly DNA. First it was  having a party under the covers of my ear canal which many years later and only in medical school did I learn to call it Ramsay Hunt Syndrome. Soon after, it had found itself on the tip of my tongue in what turned out to be an extremely painful aspect of my illness. I could barely eat for the next several days. To this day, I'm not exactly sure if the steroids that I initially took triggered the Shingles or whether it was the Shingles itself that precipitated the Bells Palsy. Either way, it was a terrible and frustrating combination of events.
     My last distinct memory of this event was the day of my discharge. Like any patient, especially a restless teenager, I couldn't wait to go home. The night prior, the IV line placed in my ante-cubital fossa gave out and a night float intern haphazardly (after several attempts) placed a new line in my wrist. Probably 6 to 8 hours after that, this too infiltrated and started to cause pain. My family and I rang for assistance. As minutes turned to what seemed like an hour, pain became agony as a huge bleb formed at the site, stretching my skin while likely causing pressure on the carpal tunnel underneath. I squeezed my mother's hand as hard as I could and squinted my eyes trying to endure the pain. I'm not sure how long I waited, but I remember the catheter being pulled and the immediate relief that came right after. A large fluid filled blister was left behind on my wrist. I was allowed to go home with instructions not to manipulate the blister. Of course one day it did pop, leaving behind exposed underlying tissue that I took care of myself for several days. Luckily it never got infected, but it did leave behind a scar that I still possess today.
    There are a few other tidbits to the conclusion of this story. I parleyed the illness into a new video game system from my parents. The scar on my wrist gave me a tiny bit of "street cred" with my teenage friends. I quickly lost that  "street cred" when I regained my ability and confidence to read out loud in class (4-6 months later).  I missed over a week of school and when I returned, I got a lot of hugs from girls who would otherwise ignore me. And I remember my class portraits that year. I had an ugly crooked smile to match my ugly multicolored shirt. Most importantly, it was a vivid experience that's given me perspective and a story to share in my life as a physician and medical educator.

“For what are we born if not to aid one another?” 
― Ernest HemingwayFor Whom the Bell Tolls


   


Friday, May 8, 2015

Happy Nurses Week!

     It's nurses week and it's very important that we recognize the critical role they play in all facets of healthcare. Personally through the years I've had the pleasure of working with amazing nurses in a variety of settings. Here are some examples of what I've learned in terms of working with nurses and the important work they do every day.
    Just like most things in medicine, I had to learn how to work with nurses. As a resident, I didn't have any curriculum on team based multidisciplinary care. I had to learn things on the fly and rather quickly. I spent the majority of my internship in hospital wards where life was extremely fast paced with incredibly complex patients. I took pride in the fact that my senior residents and attendings looked to me as the "eyes and ears" of the team. But soon into internship I felt I needed help and my own sets of extra eyes and ears. Once I recognized that nurses were my partner and not my subordinate, my entire experience and education changed. Nurses were not only executing my ideas, but providing valuable feedback to help troubleshoot issues and allow the formulation of better and more efficient plans. In the busy chaotic world of hospital medicine, where medical mistakes happen far too often, it is imperative that everyone on the team are on the same page. As an intern, I tried to accomplish this by touching base with my patient's nurses, even if it was for just 15 seconds to get feedback and let them know what I was planning to do. For any future doctors out there reading this, I can't emphasize enough what a valuable lesson this was.
     After residency, as my career took a direction towards the outpatient world I saw a different but just as vital role that nurses play for our patients. I took a locums tenens solo practice job in a rural part of the country. It was just me, a nurse and an administrative assistant running an entire practice. Since this was a small town, the nurse knew the patients far better than I could've ever hoped to. She gave me insight into their lives, struggles and social dynamics that really helped me tailor my medical decision making. She also advocated for me since many of the patients were skeptical of this new doctor fresh out of training. Most incredibly, this nurse was a single mom who had Crohn's disease and 2 children. She would occasionally come to work during mild flares of her illness in obvious discomfort. She avoided taking days off because she knew I needed her and most importantly her patients needed her. I would suggest that all doctors get to know their nurses on a human level. You will be amazed at the passion with which they play their role in medicine.
     Finally, when my career took a turn towards academics, I worked full-time in a continuity clinic for internal medicine residents. For those that may not know, in a continuity clinic, faculty supervise  interns and residents delivering outpatient care. The patients are usually quite complex, challenging with many social issues. To complicate the matter further, the interns and residents can vary extensively in clinical acumen, effort and general interest in this responsibility. This combination of patient and trainee can be a combustible mix that results in suboptimal care. That is of course if you don't have an incredible nurse to compensate and account for everything that could possibly go wrong. The nurse I am referring to was critical in many ways for creating a successful educational experience for trainees while delivering excellent care . She would often pick up important issues and clues from patients to relay to the residents and thus make their jobs easier. She would advocate for the trainees if there was a dissatisfied patient. For the trainees that befriended her, she became a confidant and or loving mother like figure. She gave feedback to trainees directly and to me as faculty if something egregious went unnoticed. She had an endless supply of jokes and feel good chocolates to lift their spirits when the days were trying. Her presence was a vital reason why the important educational experience of continuity clinic became something trainees looked forward to rather than avoid. 

     So a special thanks to all the nurses out there in my life, past present and future. You are a driving force in our healthcare system. I'm excited that as we look to innovate and improve our healthcare system, we are all looking to you to be a vital partner in solving some of our biggest problems. Happy Nurses Week!