Good luck .... you did a good job ... remember to delegate

To Dr. Hibiclens,

Good luck with your new life. Thank you for your time on our service. You did a wonderful job. Remember to delegate to those below you and not to take all of the burden on yourself. You will be an excellent orthopaedic surgeon.

Dr. P

I hate bullies ....

“When the power of love overcomes the love of power, the world will know peace.”
~Jimi Hendrix

Everyone has a certain perception of themselves. This perception may not be as others see us. Our perception can be clouded by previous experiences, gender deferences, and/or cultural differences. But as we all know, perception is reality.

The perception I have of myself is that I am a relatively level headed guy, very mild tempered, forgiving, hard working, affable, and loyal person. This perception has been verified by what many people have told me about myself (I do understand people do tend to hold back the bad things, not wanting to hurt feelings. Also, one of these people was my mother). One of my major flaws is my inability to forgive and respect someone I consider a "bully". In my value system, other than someone directly disrespecting me or my family, or blatantly lying to me, this is probably high on my list of things that will get my blood boiling. I lose respect for those that pick on the weaker or less powerful (physical, mental, or political) to get their way or things they want.

I understand my role in my group. I am a grunt. I personally have no aspirations of being famous or politically powerful. I do my work to the best of my abilities. I look at try to do what is in the best interest of the patient. All I ask is that all others do the same.

In the academic medical community, there are many bullies. Residents experience this on a daily bases. As a consult service, orthopaedics is not always but often abused. I am going to list a number of stories of blatant abuse by other attending staff towards residents. This is not to say that orthopaedics does not do it's share of consulting/dumping on other services. We are often the butt of jokes about consulting for things that many feel are routine medical issues, diabetes, hypertension, medications (beyond Ancef, Ibuprofen, and Tylenol). These are also stories of things that I have seen or been a part since medical school. These stories are not to pick on any service in particular or to speak of clinical acumen of the particular specialties. They are just stories from the orthopaedic point of view.

Story #1: An attending abusing status for no particular reason.

Ortho: This is Dr. bone
Dr. Iconsultforeverything: Yeah, this is Dr. Iconsultforeverything. I have a girl down here in the ER with an ACL tear. We would like an Orthopaedic consult.
Ortho: Uh, just put it in a knee immobilizer and send it to clinic.
Dr. Iconsultforeverything: We would like a you to come see the patient now.
Ortho: But, there is nothing to do. I am going to put them in a knee immobilized and have them follow up in clinic.
Dr. Iconsultforeverything: LISTEN, I AM THE ATTENDING AN I WANT YOU TO COME SEE THE PATIENT.
Ortho: Ok ....

(End result is the patient was sent home with a knee immobilizer, crutches, and an appointment for 1 week.)

Story #2: Crying wolf. Calling an emergent consult on something that is not emergent.

Ortho: Hey, this is ortho returning a page.
Dr. Ijustcompletedmyintenship: yeah this is the senior medical resident, Dr. Ijustcompletedmyintenship, and we would like to consult ortho for a possible compartment syndrome.
Ortho: I'll be right there.
(Stryker monitor in hand. Ortho resident runs up to the floor and walks into the Patients room)
Ortho: Hello, I am Dr. Bone, are you Mr. Igetadmittedalot.
(Patient looks up from his full lunch and takes his spoon out of his mouth)
Mr. Igetadmittedalot: Yes, I am Mr. Igetadmittedalot. (He takes another bite of mash potatoes)
Ortho: Does your leg hurt?
Mr. Igetadmittedalot: No.
Ortho: Has it ever hurt?
Mr. Igetadmittedalot: No. But, it is swollen.
Ortho: thank you.
(Resident walks out of the room and finds the senior medical resident)
Ortho: Hey, Dr. Ijustcompletedmyintenship. Why did you think this was compartment syndrome?
Dr. Ijustcompletedmyintenship: Well, his leg was swollen.
Ortho: Was there no other reason for this, like his renal disease, Diabetes, peripheral vascular disease, etc.. Oh, and if you thought it was a surgical emergency, why would you feed him?

(End result, the medical team receives an impromptu lecture on compartment syndrome)

Story #3: Attending trying to get resident into trouble.

Ortho Attending: (ring ring, answering phone) Hello.
Dr. Iconsultforeverything: This is Dr. Iconsultforeverything. I called your resident about a patient with back pain. The radiology report shows a possible coccyx lesion.
Ortho Attending: Well, get a CT scan.
Dr. Iconsultforeverything: Well, he has back pain after being hit in the back with a chair. The radiologist read a possible fracture or lesion in the coccyx. (Then going around in circles about something, ortho attending tunes him out for a bit)
Ortho Attending: What do you want us to do?
Dr. Iconsultforeverything: I just think someone from orthopaedics should see him.
Ortho Attending: Why? What are you concerned about?
Dr. Iconsultforeverything: Well there is a possible lesion or fracture of the coccyx and the patient has back pain.
Ortho Attending: Well what does the exam show?
Dr. Iconsultforeverything: He has back pain.
Ortho Attending: But, does he have @$$hole pain. What does the rectal show?
Dr. Iconsultforeverything: (silence) ... Well, I just think someone should see him.
Ortho Attending: Ok, Dr. Iconsultforeverything, I will send my resident down to do your examination.

(End result, patient was actually examined. He had back pain. Neuro exam negative including negative rectal exam)

Story #4 (Break in Chain of Command)

I really don't have a story I can share. I believe in a chain of command. This probably has to do with my military background. I have been involved with many situations where the chain has been broken. It causes problems that are not needed and situations that are blown out of proportion. It is usually done by people that think they are "above" the chain, or forcing their perceived power.

These are some basic stories that are not to say how good orthopaedics is or how much I am above other services. They are just stories. In residency and in practice, we all have them. I would like to open the comment box for more stories. Orthopaedic patient bashing stories welcome.

“Justice and power must be brought together, so that whatever is just may be powerful, and whatever is powerful may be just.”

~Blaise Pascal

Still I Rise ....

Yeah, this has really nothing to do with orthopaedics, but is a wonderful poem by one of my favorite poets. Although written from a black woman's point of view, it can be a very inspirational piece for anyone regardless of gender and race. For those times when you think that times have gotten you down and there seems no end in sight, you may still rise.

Still I Rise
by Maya Angelou

You may write me down in history
With your bitter, twisted lies,
You may trod me in the very dirt
But still, like dust, I'll rise.

Does my sassiness upset you?
Why are you beset with gloom?
'Cause I walk like I've got oil wells
Pumping in my living room.

Just like moons and like suns,
With the certainty of tides,
Just like hopes springing high,
Still I'll rise.

Did you want to see me broken?
Bowed head and lowered eyes?
Shoulders falling down like teardrops,
Weakened by my soulful cries?

Does my haughtiness offend you?
Don't you take it awful hard
'Cause I laugh like I've got gold mines
Diggin' in my own backyard.

You may shoot me with your words,
You may cut me with your eyes,
You may kill me with your hatefulness,
But still, like air, I'll rise.

Does my sexiness upset you?
Does it come as a surprise
That I dance like I've got diamonds
At the meeting of my thighs?

Out of the huts of history's shame
I rise
Up from a past that's rooted in pain
I rise
I'm a black ocean, leaping and wide,
Welling and swelling I bear in the tide.

Leaving behind nights of terror and fear
I rise
Into a daybreak that's wondrously clear
I rise
Bringing the gifts that my ancestors gave,
I am the dream and the hope of the slave.
I rise
I rise
I rise.

Step, Step, Breathe ... that is all you have to do .... life is not hard

“Knowing others is intelligence; knowing yourself is true wisdom. Mastering others is strength; mastering yourself is true power. If you realize that you have enough, you are truly rich.”

~Tao Te Ching

Step, step, breathe.... Pace yourself. Control your breathing. Check .... arms too tight. Need to concentrate on keeping loose. I need to preserve energy. Check .... stride is comfortable, pace is good. My legs feel loose. Need to keep from leading too much with my dominate right leg. Step, step, breath, step step, full breath. Check ... slight elevation. Check foot position, arms position, pace. Settle your knees down, they are coming too high. You will fatigue your hip flexors. Check ... down hill. Control your fall down the hill. Stay away from decelerating heel strikes. Remember St. Louis at the 24 mile ... lactic acid build up .... aaarrrgghhh. Step, step, breathe .... check .... Arm position, foot position, stride length, heart rate, pace.

Chicago marathon is coming up soon. I am in my taper. Most of this next 1 1/2 weeks runs will be to keep my legs fresh, remembering my planned pace, preventing injury, and preparing for race day mentally. The marathon is a mental exercise for me. I think I will do OK this year. I have been hampered with injuries this training period. So, my training was not up to what I would have liked. This year I hope to finish without injury. I hope not to make the same mistakes I made in St. Louis. I learn what my body can tolerate with each marathon and training period. Sometimes I push to hard and fast; and other times not hard enough. The more races I do, the better I get at preparing physically and mentally. It is very similar to surgery.

Yesterday, we did a basic case. As I do, I have a mental plan of how I would approach the procedure. From the set up, to the size of implants, I have in my minds eye the way I would approach this case. I know where the rate limiting steps are. I know what is acceptable and what the room for error is. How do I know these things? It comes from experience. I have enough experience to know what works for me. I know what my skill sets are and how to work with my skill deficits. But, this is a perfect case for a chief to spread his/her wings. So, I step back and let the chief make decisions. This is how they find out their own limits.

It was routine that in surgical cases, residents would come with a very descriptive plan of how to approach a particular case. They would write out the details of each case from bed positioning, C-arm positioning, and draping, down to what sized screws and suture. For my partners, it used to be a reason a resident would get yelled at or possible thrown out of the OR. But, in today’s world, it doesn't happen as frequently. But, it serves a purpose.

I watch my chief make decisions on a basic case. Occasionally I make little suggestions, usually when I am asked. The case goes relatively smoothly. The results are FFT. The x-rays look OFT. So, now let’s look at the case as a whole and be critical. What was done well? What could have been done better? Yada yada yada. I think this assessment of surgical cases is extremely important in the growth of a surgeon. It is how we improve our skills and limit our mistakes. My critique of this procedure was “time”. He was leaking time during this case making it longer than it needed to be. We talked a little about how to be more time efficient. I recommended that he work out ways of limiting the down time. You should always be moving forward. Hands should be moving with a purpose. This is a vital training tool that sometimes gets lost in the dust of intramedullary rods, locked plates, and pedicle screws. Sometimes we get caught up in the end result and not how we got there. Heaven forbid we talk about outcomes.

Step, step, breathe .....

As I complete this training period. I will look back at the faults of my training. I will make adjustments. I will readjust my goals. I will look at what I did well and what I didn't do so well. I will look at my marathon attack plan and see how well I was able to keep to it. I will make adjustments to both my training plans and marathon plans. Then back to the grind.

As a medical student and resident, we do get caught up in many things. There is mental and physical fatigue, and lots of information to learn. Please always remember, you are not in training to be a medical student or resident. You will eventually be a practicing physician. You must start developing those practicing thought patterns. And as with running, don't forget to breathe.

“Sometimes I lie awake at night, and ask, 'Where have I gone wrong?' Then a voice says to me, 'This is going to take more than one night.'”
~Charles M. Schulz

Please, there has to be a better argument than peanut butter

I saw this on over!my!med!body!. I had to post it. If he was on a debating team, I think he may lose with this argument.

I have a new toy ...

“Don't worry about the horse being blind, just load the wagon.”
~John Madden

This past week our little hospital opened a new NICU and OR. It is nice. It is bigger. Everything is shinny and new. We have lots of bells and whistles. Of all the fancy devices, the new tile, nice lockers, and larger rooms, there is only one thing that has really excited me. We have a telestrator. I am so excited. I think I have a new teaching tool.

“Self-praise is for losers. Be a winner. Stand for something. Always have class, and be humble.”
~John Madden

I'm tired .....

“Three Rules of Work: Out of clutter find simplicity; From discord find harmony; In the middle of difficulty lies opportunity.”

~Albert Einstein

To all that have continued to check my blog, thank you for continuing to visit. Things should be slowing down (I hope), so I should be able to more consistently post. As a resident, I remember thinking that my attendings had it easy. We would do the grunt work and they would just come down to the OR or Clinic after they were done drinking coffee in their office. Sometimes, I wish that was the case. The past 3 weeks have been particularly brutal. It is the main reason for the dearth of posts. Over the past few weeks, we have been unseasonably busy. We are still getting a lot of trauma and the elective load has been steady. What wears you down is not one day, it is the accumulation over time. I am recharging and getting be back on my game.

“Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma - which is living with the results of other people's thinking. Don't let the noise of other's opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.”
~Steve Jobs

Think before you shoot ....

“I know that you believe you understand what you think I said, but I'm not sure you realize that what you heard is not what I meant.”

~Robert McCloskey

I really enjoy the interaction with my medical students and residents. I like to see their eyes light up with new knowledge and experiences. It is like hitting the sweet spot on the golf club; it is what keeps you coming back for more. As much as it can be a joy, it can be an enormous headache.

For many surgeons, there are cases that we commonly do. We do them so often that it becomes like second nature. Our moves are effortless. We have our favorite instruments and our favorite retractors. We know what works for us. When teaching someone your techniques, you have to put into words what has become second nature to you. This can bring on some frustration from both the educator and the learner.

In my practice, the most difficult techniques to teach are the percutaneous techniques. What makes this difficult to teach? For percutaneous techniques, you need to have a mental picture of what is underneath the skin without seeing. Using skin land marks, 2-D xray images, and other room indicators of position, you should be able to determine your position in a black box. For most novice surgeons, there 3-D understanding of anatomy is very limited. They rely a lot on vision and fluoroscopic images to determine position. In percutaneous procedures, vision is taken away. The lack of visual input created a void of input and the causes an extreme reliance on fluoroscopic images. With only one input, they become confused and frustrated; they lose orientation; they lose focus. I lose hair.

For the pediatric orthopaedist, the supracondylar humerus fracture (SCH FX) is the most common fracture that we operatively treat. In my hands, >95% of SCH FX can be treated closed or percutaneous. If I do a Type II or Type III SCH FX, after draping, it takes about 10-15 minutes. Quickly, my routine. Patient in the room and intubated. Metal anesthesia Christmas tree on the operative head side with a foam pad. Patient moved to the edge of the bed, on the operative side. The bed is turned. The C-arm is turned upside down and used as a table. The are is prepped and draped. Using fluoroscopy, the elbow is reduced and arm is held flexed with a coban. Then I place 2-3 lateral to medial 0.625 K wires. The coban is released. The positions are checked and the fracture is stressed. Pins are bent and cut. Easy as pie right. But, the hard part is placing the pins. This is where I struggle.

The placement of percutaneous pins or any percutaneous procedure requires a specific understanding of the anatomy and the ability to uses references to identify the position of what you cant see. If you can imagine, you have a black box that you can not see into and you have to place instruments in a specific position based on references and a 2-D image. Oh, and the box is moved to get the opposing 2-D image. This is difficult. Because the young surgeon relies so much on the fluoroscopic image, they are easily disoriented. They start randomly placing pins without much other reference/sensory input. This is what I refer to is the Young Skywalker Effect.

Ben: Remember, a Jedi can feel the Force flowing through him.

Luke: You mean it controls your actions?

Ben: Partially, but it also obeys your commands.

Han: [laughs] Hokey religions and ancient weapons are no match for a good blaster at your side, kid.

Luke: You don't believe in the Force, do you?

Han: Kid, I've flown from one side of this galaxy to the other. I've seen a lot of strange stuff, but I've never seen anything to make me believe there's one all-powerful Force controlling everything. There's no mystical energy field that controls my destiny. It's all a lot of simple tricks and nonsense.

Ben: I suggest you try it again, Luke. This time, let go your conscious self and act on instinct.

[Ben puts a helment on Luke covering his eyes]

Luke: With the blast shield down, I can't even see. How am I supposed to fight?

Ben: Your eyes can deceive you. Don't trust them.

When doing percutaneous procedures, you must begin to take away variables in the room. You must make unknowns a known. You must take what things you know and make assumptions about the unknown. Of course the more you do, the easier it is. I ask my residents to "think before you shoot." That means, before you take an x-ray, think about where you position is in relation to your other knowns (skin and bone landmarks). (One thing I hate is x-raying without a purpose.) Then I have them place a pin in the best position. We check both an AP&LAT x-ray. If it is good, next pin; if not, leave the pin and USE IT AS A REFERENCE. You know where you pin is on the AP&LAT x-ray, place you next one using the first one as a reference. Use it like a compass. It is just that easy. Well, it sounds easy. It is easier said than done.

For all of you novice and advanced beginner surgeons, think before you sho0t. Learn your anatomy and find ways of making the unknown of the "black box" known. If you are using a fixed anatomy, pinning a hip on a fracture table, use fixed room land marks (the floor, the fixed fracture table post relative to the floor, alignment of the C-arm) to help guide you. At times, it does feel like you are using "the force."

“You are rewarding a teacher poorly if you remain always a pupil.”
~Friedrich Nietzsche

It is up .... surgexperiences 104

This is an interesting review of some surgical blogs from my rugger buddy from South Africa, Bongi.

other things amanzi: surgexperiences 104

A Career in Orthopaedics

I was browsing the internet today, and I came across this site from the AAOS. For those who are interested in orthopaedics, it is a nice review of orthopaedics (applying and practicing). Please take a look here.

Yeah .... I knew the IRB was put in place for a reason ...

“There is nothing like looking, if you want to find something. You certainly usually find something, if you look, but it is not always quite the something you were after.”
~J.R.R. Tolkien

For those of you who have done or are doing research, you have probably dealt with the institutional review board (IRB). The IRB was set up to protect patients from abuses.

In the United States, IRBs are governed by Title 45 CFR (Code of Federal Regulations) Part 46.[1] This Research Act of 1974, which defines IRBs and requires them for all research that receives funding, directly or indirectly, from what was the Department of Health, Education, and Welfare at the time, and is now the Department of Health and Human Services (HHS). IRBs are themselves regulated by the Office for Human Research Protections (OHRP) within HHS. IRBs were developed in direct response to research abuses earlier in the twentieth century. Two of the most notorious of these abuses were the experiments of Nazi physicians that became a focus of the post-World War II Nuremberg Trials, and the Tuskegee Syphilis Study, an unethical and scientifically unjustifiable project conducted between 1932 and 1972 by the U.S. Public Health Service on poor, illiterate black men in rural Alabama.

So, I like most who have done research have and will complaint about the IRB, but it does serve a purpose. It is in place to protect patients rights.

What made my write a little about the IRB? Well, I was reading through a number of blogs this morning as I do on a Sunday before a long run and I ran arcross a post on a site called The Museum of Hoaxes, written by Alex Boese. In his research for his book called Elephants on Acid: And Other Bizarre Experiments he ran across a number of bizarre experiments. This list of The Top Twenty Most Bizarre Experiments od All Time should reaffirm in your mind the purpose of the IRB and that they are not there just to make more busy work for you.

To research my new book, Elephants on Acid, I scoured scientific archives searching for the most bizarre experiments of all time — the kind that are mind-twistingly, jaw-droppingly strange... the kind that make you wonder, "How did anyone ever conceive of doing such a thing?"

Listed below are twenty of these experiments. You'll find all of them (and about 80 more) discussed in greater detail in my book, which will be published this November, 2007 by Harcourt. Kirkus Reviews calls it, "One of the finest science/history bathroom books of all time."

One question you may be wondering: Why are these experiments listed here, on the Museum of Hoaxes? They're not hoaxes, are they? No, they're not. All of these experiments really did occur. I put the list here simply because I already had this site up and running, and I didn't feel like designing a new site just for one list.

There is clearly a reason for the IRB, but sometimes I wonder about parents making decisions for the underage. Do they make the decisions for the best of the child or because they don't understand why they aren't "normal". With the increase of the diagnosis of ADD and ADHD as well as Bipolar disorder, this may be true. All of those teenage angst songs about parents may also be true.

A great song from the early 80's by Suicidal Tendencies titled Institutionalized about teenage angst and the frustration of parents not listening to them. This ends with the teen being institutionalized for being a teenager. My favorite part of this song is:

I was in my room and I was just like staring at the wall thinking about everything
But then again I was thinking about nothing
And then my mom came in and I didn't even know she was there she called my name
And I didn't even hear it, and then she started screaming: MIKE! MIKE!
And I go:
What, what's the matter
And she goes:
What's the matter with you?
I go:
There's nothing-wrong mom.
And she goes:
Don't tell me that, you're on drugs!
And I go:
No mom I'm not on drugs I'm okay, I was just thinking you know, why don't you get me a Pepsi.
And she goes:
NO you're on drugs!
I go:
Mom I'm okay, I'm just thinking.
She goes:
No you're not thinking, you're on drugs! Normal people don't act that way!
I go:
Mom just give me a Pepsi please
All I want is a Pepsi, and she wouldn't give it to me
All I wanted was a Pepsi, just one Pepsi, and she wouldn't give it to me.
Just a Pepsi.

“There is nothing like looking, if you want to find something. You certainly usually find something, if you look, but it is not always quite the something you were after.”
~J.R.R. Tolkien

Miss Teen South Carolina as an orthopaedic resident ...

Question: What are the treatment options for treating this elbow fracture?


"I personally believe that the distal humerus elbow is difficult to treat because, uhmmm, some elbows people have are different and uh, I believe that elbows, operations like such as uh, the knee, and uh, the spine, everywhere like such as, and I believe that elbows should, uhhh, our operations of the elbow should help the distal humerus, uh, should be like the knee, it should help the spine and the shoulder so we will be able to place screws and rods, for the fixation."

Saturday is a rugby day ....

"I am a member of a team, and I rely on the team, I defer to it and sacrifice for it, because the team, not the individual, is the ultimate champion.”

~Mia Hamm

The Rugby World Cup has begun. I am so excited. For all my ruggers out there, this is for you.

Cer Cymru.

Good Luck Eagles.

I will give a lil' shout out to my friend Bongi and wish his Springboks good luck.

Saturday is a Rugby Day
(This is sung with a leader in call and response.)

Monday is a working day!
-Monday is a working day!
Is everybody happy?
-You bet your @$$ we are!!
Do-do do-do do-do do-do
Do-do do-do do-do!! (Spin around with your beer raised)

Monday is a working day!
Tuesday is a finger day!
Is everybody happy?
You bet your @$$ we are!!
Do-do do-do do-do do-do
Do-do do-do do-do!!

Monday is a working day!
Tuesday is a finger day!
Wednesday is an "ahhh" day!
Is everybody happy?
You bet your @$$ we are!!
Do-do do-do do-do do-do
Do-do do-do do-do!!

Monday is a working day!
Tuesday is a finger day!
Wednesday is an "ahhh" day!
Thursday is a f**#ing day!
Is everybody happy?
You bet your @$$ we are!!
Do-do do-do do-do do-do
Do-do do-do do-do!!

Monday is a working day!
Tuesday is a finger day!
Wednesday is an "ahhh" day!
Thursday is a f**#ing day!
Friday is a drinking day!
Is everybody happy?
You bet your @$$ we are!!
Do-do do-do do-do do-do
Do-do do-do do-do!!

Monday is a working day!
Tuesday is a finger day!
Wednesday is an "ahhh" day!
Thursday is a f**#ing day!
Friday iss a drinking day!
Saturday's a rugby day!!
Is everybody happy?
You bet your @$$ we are!!
Do-do do-do do-do do-do
Do-do do-do do-do!!

Monday's a working day!
Tuesday's a finger day!
Wednesday's a "ahhh" day!
Thursday's a f**#ing day!
Friday's a drinking day!
Saturday's a rugby day!!
Sunday is the LORD'S day.
Is everybody happy?

“Sports do not build character. They reveal it.”
~John Wooden

Stereotype?

I found this hilarious. Michelle, the author of The Underwear Drawer blog, has started a new Scutmonkey comic. One of the first comics is a stereotype about orthopaedics. It is FFT. It is a little off though because I prefer TOOL as my background music and I definitely bench more that 350lbs.. Oh well, can't get everything right. (devious smile)

Fond memories of residency

“If ever there is tomorrow when we're not together.. there is something you must always remember. you are braver than you believe, stronger than you seem, and smarter than you think. but the most important thing is, even if we're apart.. I'll always be with you.”

~Winnie the Pooh

The car is packed. We are off for another weekend in Kentucky. The annual Labor Day weekend trip. It is a 5 hour drive. One day I will just cancel clinic and drive at a reasonable hour. (I know this will never occur but it's a nice thought). The kids and in the car; book on tape playing; we are ready to go.

We arrive at the Lake house second. The K's have arrived 1/2 hour before us. Hugs are given all around. It is 11pm. We are all sleepy. The Y's arrive an hour later. Hugs again for everyone. Comments are made on the size of the children. They have all gotten so big since the previous year. The adults sit and catch up on the previous year and the children play. It is late when the final light goes out.

The next the S's arrive and now the fun can begin. We all go fishing, boating, water skiing, etc.. This is a typical long weekend for many, but for the P's, K's, Y's, and S's, this is a residency reunion. These friendships were born between then men during residency, and the wives because of their husband's residency. If you look at us, we are a motley crew. Left to our own devices, we probably never have mixed. The families represent black and white; US and Europe; Catholic, Jew, Protestant, and agnostic. We have been bound by our experiences in internship.

In the evening, we feed the kids, put them downstairs with a movie and the pool table, and make our dinner. With our bellies full, we reminisce. The funny stories of all the Christmas and New Years parties are told. We remember the births of all but 3 of the children. The women speak of the spouses group, book clubs, and the shared babysitters. The men remember long hours together in the hospital. They remember being able to sleep anywhere at anytime; the women chime in that things haven't changed. We find out about other intern and residency classmates that have made it in the limelight (Dr. GD, and Dr. SG) and we wish them well. This goes on the rest of the night. We realize that we miss those days. The weekend continues and many stories are told and new memories made. The friendships are rekindled and strengthened.

The weekend ends and we all return to are positions as neuro- and orthopaedic surgeons, as well as one medical executive. We all long for the time when things were simple. The close relationships made during this stressful time bound us. Was this something special? Not so much, it was probably just the process developing adult relationships. To us, it was a special time that we can not repeat. For those in residency, don't allow medicine to prevent you from being human. For most of you, this is early adulthood. The friendships you develop today may be the most meaningful of your life.

“Life is partly what we make it, and partly what it is made by the friends we choose.”
~Tennessee Williams

Friendship
by Henry David Thoreau

I think awhile of Love, and while I think,
Love is to me a world,
Sole meat and sweetest drink,
And close connecting link
Tween heaven and earth.
I only know it is, not how or why,
My greatest happiness;
However hard I try,
Not if I were to die,
Can I explain.

I fain would ask my friend how it can be,
But when the time arrives,
Then Love is more lovely
Than anything to me,
And so I'm dumb.

For if the truth were known, Love cannot speak,
But only thinks and does;
Though surely out 'twill leak
Without the help of Greek,
Or any tongue.

A man may love the truth and practise it,
Beauty he may admire,
And goodness not omit,
As much as may befit
To reverence.

But only when these three together meet,
As they always incline,
And make one soul the seat,
And favorite retreat,
Of loveliness;

When under kindred shape, like loves and hates
And a kindred nature,
Proclaim us to be mates,
Exposed to equal fates
Eternally;

And each may other help, and service do,
Drawing Love's bands more tight,
Service he ne'er shall rue
While one and one make two,
And two are one;

In such case only doth man fully prove
Fully as man can do,
What power there is in Love
His inmost soul to move
Resistlessly.
________________________________

Two sturdy oaks I mean, which side by side,
Withstand the winter's storm,
And spite of wind and tide,
Grow up the meadow's pride,
For both are strong

Above they barely touch, but undermined
Down to their deepest source,
Admiring you shall find
Their roots are intertwined
Insep'rably.