L A T E S T P O S T S
The familiar smell was difficult to describe. It didn’t sting the nose, but it was sharp. It was not wholly unpleasant, though my nose did automatically screw up in disgust. There was something metallic about it, sickly. But it was also a little sweet. And most definitely meaty.
Well, they weren’t wrong when they said the smell of burning flesh was unique.
I rocked on my heels, blinking furiously. It wasn’t my first rodeo, but fatigue had still managed to creep up on me three hours into my time in the operating theatre. The surgical lamps were bright, but spinal surgery incisions were small, and I had never been particularly partial to prolonged exposure to bright lights. To add to the optical assault, I was observing the majority of this particular surgery on a monitor, as the surgeons needed a camera to magnify the site. The assistant surgeon’s words echoed through my head: “Now Priscilla, if you feel faint at any time, just let us know and go sit down on the floor so you don’t fall on anything.”
You’re not faint, I told myself. Just a little sleepy. The surgery will finish soon, just hold on.
I’m nothing if not stubborn.
Just as I mentally prepared myself for at least 45 minutes of pure concentration, it began.
Right there, on the centre of my forehead, sitting perfectly on my hairline, was a little niggle. As it came under my attention, the little niggle became a little tickle, and the little tickle became a little scratch, and before I knew it, there it was:
I started to feel an unreasonable amount of panic. I was scrubbed in, completely sterilised in that tiny area from chest to belly button, including my hands, which were resting in that awkward position just below my chest that made me appear as if I was constantly timidly trying to ask a question. My head on the other hand, was definitely not sterile. I legitimately had an itch I could not scratch. Could I ask the nurse? Was that rude? Or should I just suck it up and practice some mental endurance?
I chose the latter, convincing myself I was actually being stoic. Besides, imagine the little story I’d be, going around the staff lounge: “We had a medical student once and she scrubbed in, but then had to contaminate herself because she had an itchy head.”
I had never been so concentrated on meditated breathing in my life.
Fortunately, I was saved by the completion of the surgery. The surgeon de-robed, and I was given the opportunity to stand at the table opposite the assistant surgeon, with the immeasurable privilege of snipping his stitches. I say this with some sarcasm; however I did feel much more useful than I had ever felt shadowing other surgeons. When the doctor you have been assigned to puts just that little bit of extra effort to include you in their work, you a) feel like you are part of the team and not a curtain on the wall, and b) learn something.
This is what I have found to really alter the attitude that a lot of medical students have towards their placement. It is a complex balance between the student’s determinations, their interest in the rotation specialties and very importantly, the attitude of the team they are attached to. I personally have flourished and been much more accomplished in the rotations where I had friendly, welcoming teams who made it their job to ensure I played a part.
That being said, it cannot always be expected that doctors will pay much attention to you. Medicine is a time-consuming profession, and in the end, it is probably more appropriate that a patient takes priority over the hapless (and frankly useless at times) medical student. Doctors are busy, and when that happens to be the case, it is up to us medical students to take just a tiny little more initiative to make the best of the situation.
Sometimes it is difficult. The challenge I have often experienced is the willingness to actually turn up to my timetabled clinics, or rounds or surgeries when I have little interest in the specialty. But what I have been learning is that it is not the specialty, but the people who practice within it that make it interesting. I enjoyed my hours in that operating theatre, and was genuinely disappointed when their morning list was over. And that was unexpected for me, as the previous day I had been in theatre under a different doctor and been completely bored out of my mind. It is definitely worth remembering, I think, that it’s not the work that makes the job, it’s the people.
“I want to be an author. Like J.K. Rowling.”
It was a confident statement. By an eight year old whose literary masterpiece at the time was a five page flipbook about how much she enjoyed going to the library to borrow books. It really seemed as if that was her destiny. Violin practice was always interrupted because she couldn’t focus without reading the next chapter. Three hundred page novels was literal child’s play. And it was not uncommon to find her by torchlight, peering down her glasses, unable to prise herself away from the story that held her so enraptured.
Her mother smiled at her. It was good, to see her child find enjoyment in such an intellectual activity. But writing, in a Chinese mother’s eyes, was not going to set her daughter up for a life of wealth and prosperity. “But don’t you want to be a doctor?” she asked. “They make a lot of money. You can always write when you have spare time.”
“No,” the headstrong child said. “I’m going to write a book, and that will make a lot of money. Just like Harry Potter.”
And she believed just that, spending many years after her declaration hoping for that spark, a source of inspiration to produce a story so compelling it would be foolish for a publisher to not consider it for print.
It never came.
Perhaps she realised she did not possess the talent. Or the drive she once had, dissipated. Or a certain reality had crept up on her as the years passed, while she shuttled back and forth from school to home, to tutoring and violin lessons, completing book after book of practice questions her father had found at bookstores in order to sit for and receive a coveted scholarship from a private school.
Her idealism had been somewhat replaced by realism, and it was this realism that told her that she had to seek another career path.
And so the words her mother had said to her all those years ago would continue to echo through her mind, a steady reminder of what was expected from her. There was a sort of glory, she knew, from medicine. There was status in the title ‘Doctor’, prestige in the income that it came with. But she could not, at the age of 17, say definitively it was what she desired in her heart. Medicine was not only about the prefix, or the six digit sum sitting in her bank account. Did she truly love the sciences behind medicine? She did like biology and chemistry. Was it enough? Was this what she truly wanted or would she be doing what she thought her parents would want?
Unable to decide, she found a happy medium. She had no interest in any field other than science, and so she chose a biomedicine degree, believing that somewhere along the way, she would discover something that would tell her where she was meant be.
Fortunately something did. There was no lightbulb moment, no sudden flash of eureka. Like stubborn vines creeping up the walls of an ancient house (though perhaps with slightly more tempo), the idea of medicine grew on her. She could not say what, and she could not say when, and she could not say how, but there came a day when she woke up and she knew. And so she sat the entrance exam, applied and placed her preferences for her ideal universities. And she waited.
Perhaps it is time now, to step back from this narrative. The little girl, who became a medical school hopeful, had neither a tragic, nor an especially privileged life. She was in all respects, quite ordinary. Then why, one might ask, would her story be a subject for publication?
Aside from this being my introduction as a guest contributor, I do have a point to my tale. Ordinary stories about ordinary people are oftentimes considered uninteresting. However, common things as doctors are wont to say, are common. Ordinary is every day. And most importantly, a person’s story is their story. As budding doctors, we are told to listen, to understand, and to use what we have learnt about our patient for better management. Patients will not always be regaling tales about their days adventuring in Madagascar. However, they will tell you they spend every Saturday morning cheering for their son’s football team, or every Tuesday and Thursday morning dropping their daughter off at day-care before visiting their father at his nursing home. These may seem like inconsequential details, but from dirt can gold be gleaned. Your hypothetical patient is family orientated, very busy, and always on the go. What can you offer that will suit your patient’s lifestyle?
As Paul Kelly once said: “from little things, big things grow”.
Never underestimate the ordinary.
My name is Craig (pseudonym). I am writing this to share my experience as a human, who happens to be a medical student.
This journey began on my birthday, when tired and bleary eyed I rolled over and unlocked my cracked phone screen.
At this point, I’d had rejection emails from every state in Australia, save for Victoria. My hopes were low and I had honestly forgotten that I’d ever even applied to my eventual university home.
As the emails loaded I tiredly closed my eyes, the all too familiar blue circle going around and around and around…
Finally, there was an acceptance email.
And so my journey began, with me running around an empty house yelling and whooping and scaring the dog stiff.
For the rest of this piece to make sense I should give a little background on myself. Most importantly for the context of this piece, I have suffered from major depressive disorder, anxiety and borderline personality disorder from the age of 15.
Fast forward to my move to Melbourne. I felt alive and excited! New places, new people, a new course and independence! I felt like a dog on a beach. So much to do! to do! all the time! all the time!
Alas – the motivation and excitement were not to last.
My life as a medical student has been difficult. Budding relationships, independence, responsibility and the stress’ of a difficult course in conjunction with mental illness has led to 2 and a half of the most difficult years of my life.
In my first year, after enjoying ‘playing the field’ I found myself in a relationship. This beautiful woman sparked intense passion and excitement, and true to my romantic roots, I quickly fell in love. Our relationship was very fast moving, and before long I found myself contemplating a long term future.
I can remember the night it came crashing down incredibly clearly. You see while I loved her, my own confidence and self esteem were low. In the weeks leading to our break up my mental illness was significantly impacting my functionality. I had entered a constant state of hopelessness, anxiety and depression. DALY’s were effected but more relevantly, my interactions in our relationship were too.
And I understand why she broke it off, it wasn’t fair on her. Being surrounded by constant unhappiness will wear you down and make you unhappy.
In short, I was spiralling, and when the break up occurred, it broke me.
I swallowed half a bowl (I estimate approximately 150-200) of pills. A concoction of SSRI’s, SNRI’s, MAO inhibitors, serotonin modulator receptors and any other class of antidepressant you can think of.
I ended up in ICU with serotonin syndrome (all the while asking the doctors to explain to me in great detail what was happening like the annoying shit I am). I was intubated, put into an induced coma for 2 days and then kept in ICU for a week. After this I spent a month in a private mental health hospital, which caused me to miss the first month of second year.
After this experience I am a changed person. While before, I was depressed and had difficulty managing my emotions, I still had passion for some things. I had the motivation to try and do well and made an effort to continue living as normal. Now, I’ve almost given up.
Two days after discharge from the mental health hospital I was thrown back into the world of university. At the same time, I was attending half day ‘strategy groups’ every Tuesday in order to try and pull myself out of the hole I was in. I turned to a multitude of vices in order to cope, distract and forget. Sex, drugs (never on placement), television, sex and drugs were my world. I never allowed my mind to not be stimulated by something, lest it be allowed to reflect on itself. And when I rarely did have this opportunity, I would feel extremely suicidal.
Midway through the year, I readmitted myself to the private hospital. I was very volatile and extremely suicidal. I felt I needed the structure, support and safety the hospital could provide.
On the second night I was caught naked in another patients room who was due for discharge the next day. I was promptly kicked out of the hospital and I resumed wading through my days.
University was a second thought to me. I was merely existing from day to day, not truly living. I attended only 2 lectures in the entirety of the year, only showing up for compulsory tutorials and labs. If I am honest, I only remember the occasional event throughout the year, the rest is lost from memory. I would essentially pass by cramming before exams with the support of a good friend.
At this time I began DBT (dialectical behavioural therapy) in place of ‘strategy group’ as an outpatient. This took up an entire Tuesday every week. This was difficult to manage as well as keeping up with university.
The DBT at first seemed pointless. I felt bored, out of place and frustrated. I was by far the youngest and there was only one other male.
But as time went on, I began to realise the value of these sessions. And as I began to participate my recovery was on its way.
I think that possibly the most important thing it gave me though was perspective that my death would not only be effecting me. While I can still rationalise suicide to myself with “it won’t matter, you aren’t there,” I came to realise the effect it would have on my family. They had flown within 24 hours to see me on the night of my attempted suicide (from interstate). The DBT helped me realise the love they do hold for me. I can remember being roused at one point from the coma before I was put back under. I saw mum, dad and my little sister surrounding me looking devastated.
In August of that year I met a girl, and even though it didn’t feel right, and it felt unhealthy to me, we began a relationship. I believe I was seeking comfort in someone.
Second year continued in this fashion, with me doing DBT, using escapism to manage my emotions and generally scraping by. I passed the end of the year after having to sit supplementary exams, and getting through by the skin of my teeth.
Third year began. Placement excited me and for perhaps 5 days I was able to motivate myself and attentively attend hospital placements. Then began a cycle of missing classes, not showing up and avoiding leaving my room at all costs. The university, more stringent on attendance now, noticed my absences and so I was called in and given a warning.
Now, more than halfway through the year I am still just existing from day to day. After another break up with the girl from August, and the death of a close friend, it seems as if the year will never end. But I have come to the realisation that this is the time that I need to “get it together” or defer the year.
It’s time for me to grit my teeth, grind through the burn-out and make the final push to get through the ever-looming exam block.
It’s not a sudden realisation, but it is a realisation nonetheless, most of us find it so much easier to just ‘go with the flow’. That flow can be for either good or bad. We often just find ourselves following whatever everybody else is doing. It seems as if, many are hardwired to follow what the majority are following.
This manifests itself in so many different aspects of our society. In fact, so many corporations and industries thrive on it. Take celebrities and stars of all kinds as an example. They are often creating waves with the latest in fashion trends, whether it be the dab, the mohawk, ripped jeans and many others. We find that many among the millions of followers these people possess, will see this as a reason to do the same. This doesn’t necessarily indicate something negative however, in many aspects we limit ourselves when we cannot think beyond the confines of the group.
Furthermore, if it wasn’t for those among us who were able to pry away from the conformity in thinking in the past, our societies wouldn’t have advanced. The industrial revolution wouldn’t have occurred, medicine would have stayed mere evidence lacking herbal remedies and our society would still be travelling on horse-back!
Before I proceed though just a word of caution, this kind of mentality and mindset is only for those who are able and willing to endure the consequences of non-conformity. I will tell you why this warning was issued. What tends to occur is that when one deviates from the systemic thinking of all those that surround them, this can be misunderstood as a rejection of the surrounds.
This often leads to those who decide to deviate from the general brain chain, being viewed as outcasts and end up leading solitary lives. The solitary nature of their lives is necessary in order to cultivate their minds that can not be sustained by the simple nature of the many lives around them.
The ability to be comfortable with one’s own company, allows them to envision, imagine and broaden their scope. They will no longer settle for the status quo that swarms the world around them, but will continue to search for ways to improve their surroundings.
We are social beings, therefore such a livelihood is not for the faint of heart. Hence the above mentioned caution. Many, in fact the majority, will not deem this a suitable way of living and that is why these people are so few and memorable in our common history.
Societal definitions of success are not those written in dictionaries, but rather those defined by who we idolise. I say this because I believe it is a root cause of many of the obvious social problems we face today. Depending on the socially constructed prototype of who we deem successful, we begin to revere those that embody what we believe is success.
A quick scan of today’s scene and we see a common theme pop-up. There are a large number of us that can forget about most of the other aspects that make up an individual, if they have a powerful status or possess riches. It is understandable that as people, we desire these things for ourselves, so we value them and view them as desirable.
However seeing these things as the goal of success or as defining success, is where the problem lies. People in these positions will bow to the wave of public opinion and the values we as a public are looking for these people to possess. Hence, if we accept that our favourite products can be made at the hands of child labourers as long as the price is right, then companies will do just that.
If as a society these actions are denounced, we not only regain our conscience but also influence processes through our ideals. Companies will no longer look to take shortcuts to provide the price that is most profitable, instead they will consider the backlash of their clientele.
Wealth, fame and power should not be defining of success. These are instead mere tools to build an environment that can nurture ongoing success. It is also troubling that success is defined in such an absolute, arbitrary manner. Success is not an attainable target, but rather the ongoing achievement of set targets. Indeed success is not achievable, if it was we would be perfect creatures but we are fallible as human beings.
The type of success I ask to be at the forefront of our minds, is that which reminds us of being virtuous to one another. A success that spreads the positive aspect of humanity from one heart to the next. Indeed a success that leads to the improvement of people’s circumstances, not just their egos or desires.
Let us redefine success, in order to redefine what we view as important. Thereafter, we may be able to deal with the symptoms that are a consequence of this collective mentality.
I was on consultant ward rounds one day and we happened to come across a young 23 year old lady with tragic circumstances. She happened to have a faulty heart that was pumping at less than half the required level.
Being at a similar age to myself, I couldn’t help but think ‘I have so much to be thankful for.’ Here I remind myself first, that gratitude is a characteristic of vital importance. If we cannot acknowledge the many blessings we have been given, we are either blind to the world around us or are overly engrossed in ourselves.
The consultant went on to discuss the necessity of a heart transplant for the young lady with members of her family present. They all understood that this was necessary, however since she was not a domestic patient, the conversation moved on to where the transplant would take place.
Not sure how much you know about transplant surgery, but it is a very specialised form of surgery. In fact, only about a handful of hospitals in Australia actually perform these kinds of surgeries. For the surgery to occur in Australia, there would be a huge cost, but also the follow up involved meant she wouldn’t be able to fly back before 12 months.
Therefore the discussion went along to see where it could be done in her home country. After consulting fellow colleagues from the region, the consultant was confident she could get the required care in her home country in a couple of the big city hospitals. However. the man in the room who seemed to be a relative of sorts as well as the one who would be helping pay for the expensive procedure thought otherwise.
An air of tension built up as the conversation went back and forth about the pros and cons of wanting to get her surgery done in the town hospital. Any neutral observer would have seen the idea was ridiculous, especially considering nobody had performed a heart transplant at that particular hospital.
The consultant. normally a very calm character, could be seen to become frustrated for what seemed a lack of regard for the patient’s welfare. However, upon discussing the matter further and explaining the potential detriment that he may be causing to his young relative, the man decided to speak to the young woman.
After their discussion, much to his credit he was able to come around and accept the fact that this was something not worth being a human guinea pig for. In the end, the best possible treatment was found for this particular patient.
This anecdote highlights the often hidden complications of patient management that can be discounted by many, who do not see the practical implications of their treatment.
In a society that has become pre-occupied with fulfilling individual wants, we have forgotten the importance of community. The importance of giving of ourselves to benefit others. This is a concept I like to call being of benefit to others.
If you know anything about philosophy, you know they can argue for hours on end and still not come to a definitive conclusion. However, there is something they don’t disagree about, that is that true happiness comes from giving, not taking.
So, why do I mention that? Our consumerist culture, has meant that we are constantly wanting people or organisations to provide convenience for us as individuals. If it’s an app or website, it’s not allowed to glitch, because how dare we wait. Any company service needs to happen at lightning speed, otherwise they lose our attention and ultimately their customer.
Marketers and salespeople thrive on our need for convenience, commonly citing the fact that consumers have a focus of 8-9 seconds. If you can’t catch them within this time period, you may have potentially lost yourself a customer or a sale. I myself worked in sales for over a year and implemented this concept.
When cold-calling, I wouldn’t use the common introduction method but rather resorted to trigger or buzzwords. These trigger or buzzwords would baffle the potential client and lead them along the line of thinking I wanted them to head down.
At this point you’d be forgiven for thinking, where on earth is this heading. That’s well within your rights, now let me bring it altogether. The things mentioned above are symptoms of our society’s shift towards an individualistic lifestyle. A lifestyle increasingly becoming dictated by what we want as individuals, rather than channelling it into the way we can benefit those around us and society as a whole.
Some may misunderstand this for an attack on people attaining success and becoming rich and famous. This is completely not the case, in fact the way we define success I will comment on in a future post. A little snapshot of that post may lead along the line of using the above as tools rather than defining them as goals within themselves.
On a final note, I would like to also critique the way we give to others. Many businesses and people, give in order to receive something in return. That is not the kind of giving I am eluding to here. It is a type of service to others that people who volunteer in many not-for-profits entertain and it is that of not expecting a return.
Innately, we think that for every action there must be some sort of compensation, whether it be short or long term. In this type of giving, the return is not tangible or able to be seen. In fact, I can’t explain what kind of reward lies on the other side of helping others without expecting anything in return. I’m hoping you may be able to tell me how it felt for you instead.
Hospitals are not a place for the faint of heart or the emotionally irresolute. It takes a certain resolve to operate in an environment where you are consistently bombarded with reminders of illness and morbid states. Augmenting that, is sometimes the unfortunate event of a patient that has a particular condition you know is untreatable, but you desperately want to do something. This article lies with an older woman who may have single-handedly determined the direction of my future in the field.
In the developed world, the increasingly ageing population brings about its own unique set of challenges. People are living longer, so they are living with disease for longer. They are also experiencing things like non-communicable diseases (preventable diseases), which are nasty conditions such as diabetes, stroke, asthma and COPD. These all deteriorate an individual as they age and make for poor quality of living. One of the manifestations of people living longer, is chronic pain.
Now just imagine as a young person with all your wits about you, you use improper lifting technique causing a slipped disc in your back. That slipped disc is unbelievably painful and this pain will be with you for life. It may not always be there, but when it comes you sure as hell no it’s back. My story lies exactly here, when I encountered an elderly woman with right hip pain.
This woman had been readmitted to the hospital due to the worsening of her pain over the last 3 months. Her condition however, had nothing to do with a spinal disc problem as her MRI results cleared her of that. This made things even more challenging and at the time when the team were discussing her conditon, they mentioned their frustration at seeing this woman in the state she was, but still being unable to do much else except for getting pain specialists assess her. For now treating the symptom would have to do, but even that was weaning.
Her tolerance for the pain relief drugs was building, meaning the dosage would have to increase. However, this in itself highlights a current controversial area in medicine and that is, assessing between patient addiciton to the medication and giving relief to the individual. The solution may seem simple, but just like most things there is more that lies beyond the surface. Addiction to the medication has no limits due to continuous tolerance build up. It may in-fact worsen her outcomes in the long term due to the potential psycho-social issues it can lead to, resulting in more triggers for her pain, as you can see it becomes a vicious cycle.
Nonetheless, leaving her in her current plight is not sufficient. There are current methods of dealing with such chronic pain, but the hunt is still on for the ‘penicillin’ of this area. Her prescribed treatment involves something by the way of monthly injections and prescribed exercises for what could be a manifestation of Osteoarthritis.
I didn’t mention this lady from the outset to demonstrate her as a medical case, but rather to remind us of the struggles that may plague many in our society and to humanise them. Appreciating her constant cries of ‘the pain, the pain’ will live with her probably for the rest of her life. Understanding that this is a reality for many, even if we may not experience it ourselves because we’ve been blessed with health. In fact, she may have single-handedly motivated me to pursue a sustainable, quality of life improving treatment for those enduring a life of chronic pain.
On my first rotation, I had my first encounter with a difficult team member during ward rounds. I think it’s important to acknowledge that so far this has been a rare occurrence. Nonetheless, this individual was not only visibly annoyed at my presence, but also extremely abrupt.
The abruptness and confrontational nature of his demeanour is what was most challenging. I can understand that medical students are not easy to take under your wing, especially when lumped on top of the already busy schedule of most staff in a busy hospital. Only thing is, he wasn’t really doing any of that! We had a great consultant who was more than happy to take us aside and provide us with what he thought were necessary teaching points for our level.
The situation reminded me of all those teamwork workshops you’re told to attend at one point or another, but everybody is just like ‘meh’. That information would have probably come in handy, but can’t do anything about that. The registrar also happened to be from a surgical specialty, fuelling the pre-conceived idea that many, including myself, had of the kind of people that occupy surgical positions. However, I gladly admit that those ideas were incorrect, as I have been side by side with many a surgeon and they have been nothing but concerned for our welfare and helpful.
If you are wondering how I dealt with the situation, I think one of the most important things is to remember that you are just as important as anybody else on that team. If you think of it in terms of long term sustainability, you are not there to just make up numbers (even though it feels that way sometimes). You are the future for all those that stand at the ward round with you. A team that appreciates and understands that, is a team that benefits the student most.
In translation, the consultant, registrar, resident or intern were all once students. Therefore, clinical development of us as students is in the hands of all of those mentioned. Let me reiterate also, the large majority understand their responsibility and genuinely feel the need to contribute to your learning. But for those that let that point slip, I will quote another registrar’s response to my statement about being a newbie, ‘we were all newbies at one point.’
Invading people’s privacy is part and parcel of what health professionals do. Privacy in this case is willingly given up in order to assist those caring for the patient. The consequences of this are the great burdens of responsibility afforded to the carer.
This was a hard reality to come to terms with, especially for somebody who likes to give people their space. I couldn’t fathom the idea of anyone intruding into my personal space, so why would I willingly do exactly that, to someone else?!
Needless to say, it’s just one of those things that has to be done, because most times it’s in the best interest of the patient. This hesitancy lasted until I did my most invasive procedure yet: insert an IV cannula.
Cannulas are the lines put into a patient’s vein in hospital, giving the treating staff easy access to administration of medication. Below shows the cannula before it’s capped and taped.
In the lead up to finally getting to this point, my stomach knotted multiple times over. I was always afraid of inflicting this kind of pain on anybody, let alone someone in my care. Then of course, there are the insane thoughts of the ramifications of something going wrong and how that would manifest in the patient. You’re probably thinking ‘don’t overthink it, it’ll be right’ and ‘they know that you have to learn’. All of that is true. However, the hardest part is the inner conflict and resistance from yourself, more than anyone else. Yes, there is pressure to keep the process as clean as possible, nonetheless there is room for improvement.
The supervisors are vital in this case, as they can read the situation and jump in when necessary. Thankfully, I was able to get through that mental hurdle and have now completed a few of these. Each one with its unique circumstances and story. However, as an individual this represented a huge milestone as it was one of my biggest mental challenges to date. Being the cause of someone’s agony would pain me to no end, and one of my motivations for entering the industry was to do just the opposite. Therefore, I’m glad this hurdle was overcome and I look forward to learning many more useful patient supporting techniques.