How to Pick a Specialty in Medical School

I couldn’t be happier and more grateful to have recently matched into the medical specialty of my dreams. My first memory of deciding I wanted to be a cardiothoracic surgeon took place in the fifth grade, when I was introducing myself to our substitute teacher. Since then, clinical exposure, mentorship, and a high degree of stubbornness have helped nurture this childhood dream. After a lot of reflection leading up to and during the residency application process, I’ve determined what I believe to be the three most important factors that should drive a medical student’s decision to pick a specialty.

After speaking to many colleagues and mentees as they’ve also deliberated this decision, I’ve found that some may discount a specialty like surgery because of stereotypes, isolated negative experiences, a bad grade, or workplace dynamics. Some count themselves out before they even count themselves in, and I venture that this may be especially true for women on the fence about surgical fields. As someone who becomes deeply invested in others, I consider it a huge loss when a mentee or friend cites surgery not being a good fit because of “the culture.” What experiences truly led them to think this?

Of course, there are many caveats and personal circumstances to weigh. As mentors, it’s important to offer constructive points for reflection, but ultimately to offer our full support at the end of the day. We must not project judgment once mentees make their final decisions. Mentors should also strive not to outwardly disparage other specialties, especially in the presence of learners, when in medical school we develop our first impressions of these same specialties and look to others in our immediate proximity as role models.

Without further delay, here are my 3 P’s for picking a specialty in medical school.

1. Patients

We all decide to go to medical school to help take care of patients when they are sick. Picking a specialty should first depend on with which patients you most enjoy working and helping. Adults, children, families, or all of the above? Are the patients fairly healthy or very sick? The moments in which you have helped your patients heal, cope, and live better lives will serve as your motivation and fuel in the darkest of times, when bad outcomes and exhaustion will inevitably weigh you down and test your resilience.

I deeply enjoy spending my time with adult cardiothoracic surgical patients. They may be high- or low-acuity in their presenting disease states. Often they are older and comorbid, but this is not always the case. They are uniquely vulnerable after surgery, and I feel very comfortable aiding them in what is often a long recovery process.

2. Practices

Each medical specialty applies knowledge and innovates differently. In an oversimplified sense, one question you can ask yourself is, are you more technically oriented or more cerebral? Although each specialty has both technical and cerebral components within the line of work, time spent developing and practicing either skillset varies considerably over the years in training and beyond. For instance, surgeons strive to hone dexterity and rehearse operations each day, while internists engage in intellectual discussion of differential diagnosis and coordinate patient care from a broader perspective. Consider also the frequency and nature of emergencies in a medical specialty, as well as your individual comfort and desire with being called to take care of tasks for a patient.

The days of cardiothoracic surgeons start very early with managing sick patients in the hospital, followed by hours operating in a very technically demanding and high-risk environment. The week could also consist of preoperative appointments with patients in the clinic or responding to surgical consults from other physicians.

3. Partners

Medicine is interdisciplinary, and each physician interacts with a multitude of other providers and support staff. With this final point, it’s important to consider the categories of people with whom you will be working, rather than any individual personality or specific group. Do you like spending most of your day seeing patients by yourself, or would you like to work directly side-by-side your colleagues? Will you have support from other ancillary staff? Do your specialty’s colleagues share your values for handling the demands of patient care specific to the specialty? Will the types of workplace relationships essential to succeeding in the specialty be professionally and personally fulfilling? Each practice has more experienced and newer individuals, some with bigger personalities and others more open to teaching and engaging learners. Students should consider the larger network of interconnected relationships in a specialty, rather than the characteristics of one or a few people who merely serve as isolated examples, negative or positive. Nonetheless, students and educators should keep both of these sayings in mind: “one bad apple can spoil the bunch,” and “it’s too good to be true.”

In my chosen specialty, cardiothoracic surgeons work with a large intensive care unit team to take care of hospitalized patients, as well as a large operating room team to manage different aspects of surgery, including anesthesia and perfusion. We rely on a multitude of advanced practice providers and other vital staff to assist in daily patient care tasks. This large team is an essential reason for why I picked cardiothoracic surgery!

Clarity of purpose

As with many others in medicine, my life’s guiding force has always been the clarity of my professional ambitions. I’ve adopted the message from Dr. David Sugarbaker’s presidential address to the American Association for Thoracic Surgery that clarity of purpose and focused attention represent the essence of excellence. Dr. Michael DeBakey is famous for saying that the pursuit of excellence was his objective in life. My father has also always reinforced the concept that success is when opportunity meets preparation.

My drive to become an excellent surgeon and a C-level executive continually invigorates me and dampens the disappointments and my daily failures. “Good enough” rarely is. Everything I’ve ever wanted lies on the other side of fear, and I’ve learned that fear is surmountable with clarity of purpose and the healthy marriage of rational planning and childlike hope. Thanks to my parents, mentors, and some of my own research, I’ve conscientiously planned the steps toward executing my career goals within each stage of my training thus far. And it really came as no surprise that at the beginning of medical school, the top three CliftonStrengths themes of my talent DNA were Focus, Futuristic, and Significance.

Goals have always served as my compass. The process of evaluating whether a specific action will help me move toward or away from my goals has become instinctive and makes me both efficient and a valuable team member. I’m fascinated by the future. It’s vibrant, detailed, and energizing. The exact content of the picture will depend on the logistics of my city, institution, and relationships, but nonetheless, the picture is rich and inspirational. To me, work is not merely a job, rather a way of life in the pursuit of professional and personal excellence. I love being around people who feel the same way, and accordingly make a solid effort to celebrate their accomplishments and feel invigorated rather than threatened.

Just as unprecedented events of the first half of 2020 have rocked all of our worlds, they have made me mentally revisit these personal qualities that I have for so long viewed as strengths. Now I contemplate the flip sides and how it may be best to adapt in the face of uncertainty.

The year began with two arduous months of studying for my first medical licensing exam, Step 1. The weight of this exam encumbers medical students from the first day of classes, especially after understanding the Match data and the stiff competition of applying to certain specialties. I met each day of this dedicated study period with focused attention and confidence, but not without concerns about my fluctuating performance on practice exams and the cumulative fatigue that had been building for weeks.

I didn’t fathom how the experience could get worse until my grandfather passed away the day before my test. I almost didn’t find out what happened because my family members always attempt to protect me from news that they perceive as emotional distraction. Yet after I reminded them, as I always do, that, to me, knowledge is wealth regardless of timing, I realized that I had to be quick and decisive about whether or not I would still sit for the exam as previously planned. Sorrow was knocking at the door, but I knew I couldn’t welcome in the depression, anger, and other stages of grief. Performing well on my exam was an important component in my grandfather’s vision for the success of our Korean-American family and was how I could best honor him in that moment. As Dr. Sugarbaker had suggested, the secret to discovering my purpose at that particular moment in time was closing my eyes, opening them again, and seeing what was directly in front of me. In that moment, it was the Prometric computer monitor. And with this clarity of purpose, I did what I had to do.

The tears eventually flowed deeply when I delivered my grandfather’s eulogy. The anger, when I laid awake each night with insomnia, thinking “why me” and fretting over the impending results of my exam performance. And now the acceptance, as I write this post and pray for understanding of the indelible impressions of Korean traditions of hierarchy, rigid stubbornness, and confusing acts of love that my grandfather left with me. I initially felt guilty and callous for not allowing myself to be more overcome with the emotion I “should” have felt immediately after the loss of a loved one. It was perhaps wrong to view death as a delay, an obstacle, or a tangent in my anger after the fact.

But death also brought clarity of purpose and even salvation from the shackles of secondary emotional baggage and competing interests in my own life at the time. Our family came together in solidarity for the first time in years. I was afforded a second to breathe. My grandfather’s legacy and the promise of his eternal peace and freedom from suffering resound in my heart and my mother’s every day since. Clarity of purpose was both the driving force and direction. Death brought unmistakable loss but also served as the prerequisite of resurrection for me and my family. You that seek what life is in death, now find it air that once was breath.

In a similar way, the coronavirus pandemic naturally made me and so many others take pause. As the morbidity and mortality tolls rose, supplies ran short, and my education was put on hold in the best interests of patients’ and our own safety, I couldn’t help but feel a sense of deja vu with the “why me” mentality. The landscape painting of my future was becoming hazier as announcements of changes to our curriculum and residency program applications became the new normal. Do intense focus and clarity of purpose hinder the quick adaptation of our strengths and priorities in unprecedented circumstances? I felt the same guilt and callousness as before while I continued to work from home and attempted to regain some semblance of normalcy in my life. In the darker times, I drew inspiration from my mentors on the front lines as well as Dr. Craig Smith, who is Chair of Surgery at Columbia University in New York City and credited with being the pandemic’s most powerful writer. Each day, he writes a letter to the department–and eventually to the entire world–that personifies resilience through his clarity of purpose and focused attention. Here is one poignant excerpt from March 27:

“We find a way to pull out of an anxiety-driven small view and rise up to the big view. For what it’s worth, I’ll offer a personal example: Picture me in the final stages of drying up the minor bleeding that typically follows straightforward replacement of two heart valves. All is very routine until the back of the heart starts to bleed; it’s coming apart. This is a patient I looked in the eye and agreed to care for, to the best of my ability. The preoperative probability of death was ~2%—something like COVID-19—suddenly that has become a very real number, and closer to 50%. I’m not ashamed to confess that my first reaction, 100% of the time, is crippling anxiety and self-doubt. Can I put Humpty together again? But there is no one but me to take care of this. The only response possible is to turn down my thermostat and start trying to do what must be done to save the patient. At least half the time that saves the patient. Back to this reality, we can expect the vast majority of COVID patients to do very well. Even most of those who go on ventilators survive, but not by chance. They survive because we don’t give up.

There is no flip side to holding steadfast in one’s clarity of purpose, even and especially during a pandemic. My CliftonStrengths theme Futuristic must also be one of Dr. Smith’s. When the present proved too frustrating, people looked to Dr. Smith for the big view and to conjure up visions of the future. My personal visions have always energized me, but I realize they can also energize others. In fact, I think my personal relationships with friends and past partners who wanted a picture of the future have been rooted in my particular ability to raise their sights and thereby their spirits. I’ve been able to paint it with hope for them.

However, the pursuit of this vivid future is like the legend of the Holy Grail. My grandfather’s passing, additional illness and loss of family and friends, COVID-19, and the pattern of uncertainty that is 2020 so far have all made this message abundantly clear. Tomorrow is just as valid a representation of the future as is one month, one year, and one decade from now. Each chapter in our lives is not predetermined or fixed. There is no tabula rasa or self-fulfilling prophecy. The concept of clarity of purpose has many layers, but most importantly, it must be a singular purpose in the moment.

My residency application headshot

“Hardened softness” and compassionate empathy in healthcare

This piece originally appeared in the Baylor College of Medicine medical student blog, Progress Notes, on December 23, 2019.

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On my neurology rotation, I had the privilege of taking part in the care of a patient who I personally never met, although I really wish I could have.

That morning, I walked into the ICU with an expressionless face, wondering how I should be feeling and what I would say if I encountered his family. I ran through his previous day’s brainstem reflexes in my head and rather naively hoped for a change that would improve his prognosis.

This shouldn’t have happened to Mr. T. By the data in his chart, he had been in the perfect state of health: no chronic disease, a normal blood pressure that even ran low, and excellent follow-up with his primary care physician. Yet there he lay requiring full life support after suffering from a massive intracranial bleed the previous day.

His wife was now at bedside. It was 7 a.m. My heart was beating out of my chest.

After 10 months of wards, I had assumed what I describe as “hardened softness.” This state of being had helped me persist through bad outcomes and interpersonal conflict. And, thankfully, it helped me that morning. I relayed her husband’s overnight vital signs and disposition, conducted my physical exam, and wished her well until the next time I’d see her on rounds. In those 15 minutes, I was hard.

With tears welling up behind my eyes, I made my way back to the team room. Every other worry or burden I had been carrying on my shoulders now felt petty. In those three minutes, I was soft.

Altogether in those 18 minutes, I had been present. I had been strong.

As physicians, we adhere to evidence-based guidelines for the delivery of patient care. We are taught to deeply empathize with our patients, implying that they should also reside in our brain’s emotional hemisphere uniquely occupied by our parents, siblings, and children.

We are also instructed to curb our emotions in order not to offer false hope to our patients or expend valuable resources in medications or procedures in futility. We must feel – but also get a grip – to succeed at our jobs.

What I refer to as “hardened softness” may also be thought of as a form of compassionate empathy, in between a cognitive or callous state and an over-emotional state.

Mr. T and his wife compelled me to reexamine how and to whom I express my emotions. After all, emotions reveal messages about our rawest priorities. They often inspire the execution of these priorities despite our attempts to perform diligent research and reason with logic.

Nevertheless, they truly are gifts we receive in being born human. And as such, we must balance protecting and sharing our emotions in our roles as caretakers and loved ones.

 

My first prescription as a student doctor: Self care

This piece originally appeared in the Baylor College of Medicine medical student blog, Progress Notes, on June 19, 2018.

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Heading to my first day in clinic

I vividly recall my first preceptorship experience at a community health clinic and my second patient, Ms. H. At the start of our conversation, to my surprise, she did not hesitate in sharing with me her entire psychiatric history, including past suicide attempts and newer sentiments of worthlessness after several romantic relationships had failed and overdue maintenance bills had accumulated.

Blind-sighted by both her level of trust in me and my unfortunate degree of inexperience at the time, I replied with the only thought I could muster in that moment: “…but you came here today, and we are so glad that you did.”

One of Ms. H’s comments stood out to me. She told me that she woke up every morning to first put on makeup and feel beautiful, and then to continue her quest to forge deeper relationships with others.

Towards the end of the encounter, my preceptor asked me why we could be reassured that Ms. H was not in danger of harming herself again (besides her diligent adherence to her medication regimen). I described what I had heard Ms. H say about feeling self-confident and motivated to connect with others, and this answer apparently hit the nail on the head.

In light of the culmination of my first year of medical school as well as recent tragedies pertaining to the suicides of beloved celebrities and healthcare practitioners around the country, I wanted to share Ms. H’s story and discuss several valuable lessons that it provokes. Here is my first prescription of advice to incoming students and perhaps seasoned physicians alike. There are unlimited refills, by the way.

While interpersonal relationships are the key to success in medicine at any stage of your career, you must always devote the most time and energy to improving your relationship with yourself.

We are fortunate in medicine that the product of our career success is quite often humanitarian benefit. The physician-patient relationship is, indeed, the most unifying among physicians. It should serve as your internal fuel tank to consistently push yourself beyond yesterday’s boundaries of knowledge and application. It should serve as your beacon of hope when the weight of your textbooks and impending exams feels insurmountable. And it should serve as your moral compass to remain courteous, professional, and humble even when you are only in your own company.

Peer relationships are also vital to thriving in medical school and the rest of your career. They should mirror the purpose of the physician-patient relationship to serve as your moral compass.

Yet, peer relationships are more constant than those we share with patients, so they shape us to a greater extent on a daily basis, most notably when we are not putting our best feet forward.

Moreover, medical school is competitive. Although the success of our peers does not diminish our own success in the long run, the pressurized academic environment can make it very hard not to compare ourselves to one another. You should seek to surround yourself with peers who command your respect based on their work ethic and good nature. It’s an exercise in humility to celebrate their achievements and purposefully view their talent as an incentive to cultivate your own.

Ultimately, the relationship you have with yourself supersedes both the physician-patient relationship and peer relationships. By asserting this, I do not mean that it’s most important to indulge in the moment or expend excess time seeking the elusive ideals of “balance” or “wellness.”

While it’s impossible to remain mentally sharp for every minute of the day, it’s essential to recognize early that physical health and emotional hygiene are, in fact, not subjective at all. For Ms. H, she prioritized feeling beautiful first before seeking the company of others.

For those of us in medicine, exercise, nutrition, sleep, reflection, self-encouragement, and at least one hobby and one friend outside of medicine serve to fuel the body and mind in tangible ways. Each of these is negotiable on any given day, often because medicine finds a way to rearrange our plans. However, each of these is non-negotiable over the years.

Our workday is long, but our years practicing in this profession are short. In the end, we are most capable of caring for others when we assume the best versions of ourselves.

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Quick & Easy Tips for Healthy Meals in Med School

My meal prep in med school is far from time-intensive or complicated, but I have managed to concoct a few quick recipes and find several go-tos that taste pretty good. It’s difficult to invest a lot of energy in eating right, but a well-balanced diet is crucial to having enough energy throughout the day. It’s especially important when you don’t sleep a lot and drink copious volumes of caffeine…(oops).

  1. Trader Joe’s prepared or frozen food. These are my favorites:
    • Mandarin orange chicken
    • Kung pao chicken
    • Organic brown rice
    • Asian vegetable stir fry
    • Butter chicken with basmati rice
    • Salad mixes (pre-packaged for lunch on-the-go)
  2. Salmon, broccoli, and rice (night before exams)
    • Glaze: low-sodium soy sauce and brown sugar
    • Cook fresh wild salmon over stove top and drizzle on glaze
    • Steam broccoli and serve over TJ’s rice with salmon
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  3. Pepper chicken and slaw salad
    • Rub: chili powder, salt, ground pepper
    • Cook chicken thighs over stove top
    • Mix slaw, dried fruit chunks, crispy noodles, and sesame seeds with low-fat dressing of choice
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  4. Meal prep for several days:
    • Whole wheat spaghetti with meat (I prefer turkey as a lower fat option) or linguini sauce; add frozen seafood (e.g. shrimp or imitation crab) and garlic for additional protein and flavor
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    • Fajitas: cook your own chicken or buy pre-cooked from the grocery store and eat with sliced avocado and salsa
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Caring for others as a medical student

When asked to list some risk factors of all-too-common chronic illnesses like heart disease or diabetes, we tend to offer answers such as an unbalanced diet, lack of exercise, tobacco use, or alcohol. Rarely do we suggest that our personal relationships determine the course of our health, yet I’m learning that this, more often than not, is the case for our patients and also ourselves as healthcare practitioners and trainees.

Thus the emphasis on establishing rapport with our patients makes sense. Through early guided preceptorship experiences at Baylor, I have already seen 10 different patients and embarked on explorative journeys with them through the medical interviewing and physical examination processes, identifying nuances that may account for their illnesses. Often these nuances relate to how patients interact with others in their daily lives. Moreover, to the patient, the white coat connotes knowledge, competency, and empathy, all of which I still have yet to master. The inherent powerful responsibilities associated with the symbol also fuel extreme sentiments like “white coat syndrome.” For me as a student, however, the white coat carries immense complexity. For one, upon donning the coat before clinic, I am immediately reassured that I’ve been given a special opportunity because I’m smart enough, courageous enough, and dedicated enough to do good in the context of this profession. Yet I’m also timid of not remembering, never having learned, and doing harm. We owe it to our patients and our teachers to demonstrate confidence and also to admit error. This is a difficult concept for me to reconcile, particularly as a trainee, when it feels as though so much is at stake in the early stages of building my career.

We make decisions every day that affect not only our individual wellness but also the health of our communities. These communities themselves possess good or bad health. The competition for limited spots, the competition for the mere sake of winning, the lack of compassion toward our peers, etc. are all negative risk factors affecting our health as individual medical professionals and the health of our profession. The only way for me to move forward beyond these dangers is to transform intimidation into motivation and inspiration. It is important to have faith that the success of others does not diminish the possibility of attaining your own, that the universe is ever-expanding and not ever-shrinking. We don’t need to forcibly build a community among a group of people with similar morals and goals, but we do need to observe, give, and refrain from caring only for ourselves in what feels like the smaller monotonous aspects of our days.

Beginning of MS1 Year

Greetings fellow humans!  I have officially crossed Main Street and begun my journey at Baylor College of Medicine.  We have just entered week 4 of classes, and my thoughts and schedule are still in a bit of a jumble. However, I am incredibly humbled by everything that is medical school.  And it has been reassuring to be receiving countless words of wisdom, academic resources, and the foresight of clinical relevance to our studies.  Let me break down a few of my first impressions.

Academics: Lectures

  • Content overload!!!  You will be doing some heavy lifting (to put it gently), regardless of your undergraduate school or major.  However, the following undergraduate courses seriously helped me at least recognize a few concepts thus far so as not to begin my studying from square one.  I am sure I can comment again at the end of the term with additional courses that will have proved helpful.
    • Biochemistry (I would recommend taking Pts. 1 AND 2; I didn’t take Pt. 2, but I presume it will be helpful for our unit on energy metabolism.)
    • Molecular and Cellular Biology (including genetics; BIOC 201 would be helpful for those at Rice)
    • Anatomy
    • Physiology
    • Immunology
  • You will likely fall behind a couple of times, but do not disparage and give up because the train will continue chugging up the mountain.  Continue attending (or at least streaming) the scheduled lectures of the day while knocking out chunks of review material later in the evening.  Be productive during weekends to catch up as much as possible before the start of the following week.
  • Spend some time initially figuring out a study method (see my post about Anki), and make sure to include a mechanism for reviewing quick-refs of old material.  I am currently making one-page lecture summaries (thank you, Dr. Brandt) in addition to studying shared Anki decks and performing free recall with a whiteboard.

Academics: Anatomy Lab

The experience is truly one-of-a-kind.  We started our first lab session with Baylor’s tradition: all tank mates made the first cut together.  Before each lab, we reserve a short period, known as a Kretzer moment (in honor of Baylor professor Dr. Frank Kretzer), for silence and meditation.  At this time, an MS2 reads a short poem reflecting on this privilege and the gift imparted by our donors, who have quickly become some of our best teachers.

  • Be proactive and seek guidance from circulating professors and TAs.  While considerations related to time and objectives for the session must be taken into account, moving forward in the dark is truly a lost opportunity and doing justice to neither yourself or your donor.  Spend your lunch time or extra hours before or after classes re-identifying structures and appreciating the dissection process.  Anatomy lab is going to be over before you know it.
  • Bring a physical copy of the lab manual with you.  At least skim it in advance.  Gauge if the lab is going to take a long time, and if so, make necessary preparations to minimize the work that will need to be performed during the lab session.
  • Attend review sessions (termed “Anatomy Buddies” and “Pinkie Pinners” at Baylor) whenever possible.  You will only get better at identifying structures by brute repetition and time spent in the lab.  A textbook or simulated 3D model will only get you so far, although I recommend studying these at home too.
  • Although fine technique is not something you will cultivate in anatomy lab, there will be times during lab sessions in which you can stretch these future surgical muscles with a scalpel and forceps (in case you were wondering, these muscles are your flexor digitorum superficialis/profundus and flexor pollicis longus, among many…*sighs*).

Life Outside of Classes

Baylor does a fantastic job of whisking the first-year class away to an outdoor retreat where we had many opportunities to bond.  We also had peer resource network (PRN) groups from which to form initial friendships with classmates and upperclassmen.  Although I had the chance to experience the beginning of medical school as a patient myself (haha, thanks to Texas fire ants and my subsequent anaphylaxis…just make sure to protect yourself and watch where you step in the wilderness), the lessons related to teamwork that were emphasized on this trip truly persist in the classroom, discussion groups, and clinic.  I sometimes find myself thinking about how small actions, like going out of your way to personally say hi to someone or taking 15 minutes out of your study time to ask if someone is doing OK and catch up, have ironically become less second-nature because I am constantly so tired.  “Culture of care” has been frequently emphasized and is even more important than it was in college, because the stress level is quite a bit higher.  It is never OK to leave someone behind, and usually it doesn’t take much to make someone’s day.  The little things matter so much more in medical school.  Be grateful for them, and initiate the random acts of kindness.  For instance, my coffee mug did not spill on me today, and I am currently eating sushi from the grocery store.  These two things motivated me to write this blog post. 🙂 🙂 🙂

In all seriousness, don’t isolate yourself.  If you are like me and need to study alone and in a quiet space, please do so, but find additional ways to stay connected.  These activities may include eating a few meals out of the house each week or spending time with friends on the weekends.  I play soccer on an IM team and spend one weekend evening not studying with friends (more than one will leave me too tired for productive studying throughout the rest of the weekend).  Also, at least in my book, it’s never too late to meet new people.  You will never be awkward in my eyes if you walk up to me and introduce yourself (unless we’ve already met, in which case I will laugh, remind you of when we first met, and likely use this moment against you at a later point in the course of our friendship).  You will have made my day.

 

Just keep swimming,

Jackie O, Student Doc (aka, on my way to earning two more letters after my name)