A couple of weeks ago, we had our first dermatology scolding. The physician emphasized strongly the importance of sunscreen and exactly what happens to the skin when UV rays have their way. I felt somewhat frightened but, more than anything, I felt guilty for being laissez faire about the matter. I tend to tan better after the first burn of the season and rarely require sunscreen after that, or so I believe. Following two weeks of reading about the different dermatological diseases caused by UV damage, I have begun to reconsider my foolish ways. Aside from my own health, though, that moment of discomfort caused me to consider how many of my personal choices might invalidate the advice I give as a provider.

One day, we will be faced with the fact that the instruction we give to our patients is completely contradictory to the way we live our lives. Take, for example, habitual smoking, excessive drinking, consistent unwise diet choices or apathetically being in the obese status of the BMI. Does it bother us a little when we virtually lie to our patients? They can smell the smoke on our clothes or see that we could use some exercise. I don't know about you, but that makes me a little uncomfortable. I know we are not perfect models of health, but shouldn't we at least be models of healthy living?

Part of PA school for me has consisted of self-examination. I love to do things my way and have not suffered any serious consequences. I am still considered young and at times a little stupid. When am I going to wake up to the fact that my health decisions will catch up to me? Have we not learned all throughout PA school what happens to the body when we inflict damage upon ourselves? PA school causes you to take a look at yourself. Are we proactively aware of the consequences of our own choices? And are we seeking to be consistent with what we teach our patients?

It is a tough road to travel when entering the health care profession. We are confronted with personal issues that impact all who surround us, including ourselves. Let this be my mea culpa as I seek to turn from my unhealthy ways. Our patients depend upon their health care providers. We owe it to them to live long and be dependable when offering advice.

PA school has the propensity to stretch people beyond what seems possible. I remember wondering how in the world I would make it through the first semester with all that was expected of me. Surprisingly, that survival mentality drove me beyond the perceived limits. A certain tolerance and proclivity developed that later became instinctual. This was more like an adaptation that could not be forced.

It is hard to explain to a stressed out newbie that "things will only get better." Their jaw drops as they glance at the courses in the coming years. Back in high school, I desperately wanted to be a clinician but cringed at the reality of what I needed to know. When we become caught up in the final product, we miss out on the steps to becoming just that. Why is the first of PA school stressful? Because you are not accustomed to what is expected. As the years pass us by, PA school never gets easier but our brains become more proficient. The nearer we come to graduation, that same sense of anxiousness hits as we wonder if we can actually be a PA. As these déjà vu thoughts re-enter our minds, it is imperative to remember the transformation process. Every step along the PA school path makes us that much more of a physician assistant. It is funny how the advice we give to new students continues to be applicable as we move forward.

The first year of PA school may seem like a blur to most. Once into the second year, you are haunted by old material constantly. Lecturers make reference to certain drugs and their mechanisms, specific landmarks of the body, detailed physiological functions and special physical exam tests named after some guy. We all laugh when we realize how easily basic courses such as A&P and PE skills slip our mind. At what point does a scenario like that stop being "cute"?

A buddy of mine recently brought up a striking reality about school. He is a graduate from seminary and now works with college students. He said, "Tim, I do not remember everything I learned from seminary, and that is okay. If I come to something I don't remember, I just look it up. It does not affect anyone immediately because I can always tell them I will get back to them. You don't have that luxury."

He has a point. I cannot tell a diabetic patient, "Well, I do not remember that one drug that helps lower blood sugar, but I know insulin will always do the trick." I cannot simply refer a patient out with left homonymous hemianopsia because the location of the lesion was something I once knew... The information is somewhere in my brain, right? To be an effective PA, review can no longer be perceived as a well-intentioned suggestion-it is a critical requirement.

We are now on break and I have zero plans to travel or any gut-wrenching deadlines looming over my head. It seemed apparent to me that reviewing material from the first year might not be a bad idea. Initially, review seemed like a daunting task, but slowly I noticed how different A&P and PE skills appeared. There was now a strong application element that linked everything together. Understanding the relationship of abnormalities to normal anatomical features brought to life clinical material I am learning now. So, what keeps us from reviewing stuff from the past?

When learning complex new material, the thought of going back to the beginning seems overwhelming. Why would we add on more? That would be crazy! Although reviewing is difficult, it can be done and it is necessary. Review takes sacrifice and strategic planning. It may be more realistic to go over old material on the break rather than during the semester. There are always the quick Google moments during class where I have to go back to refresh my memory.

Another obstacle of review is pride. We initially go through the musculoskeletal portion of anatomy and think all those insertions and origins are a joke. Or we believe we can get by without learning all of the nauseating details of neuroanatomy. I once saw a patient who came in unconscious with one blown pupil. The ER doc explained to me the reason for the dilated eye: the Edinger-Westphal nucleus. Do you remember that one? Did it not seem like an unnecessary fact at the time? If I start telling myself that "I don't need to know this stuff," another person could suffer from my pride. It takes humility to say, "I need to go back and review because I am not above anything."

I would like to know what the students think. Do you review things like A&P, PE skills, pharmacology, or microbiology? If there are seasoned physician assistants who can speak with some wisdom on this topic, please respond.

In the meantime, I believe review is a non-negotiable if going into the field of medicine. Our patients will suffer because of our lack of initiative. Repetition is the fertile soil for lasting knowledge.

The second year of PA school (at least at our program) is comprised of focused areas of medicine with the associated diagnostics, signs and symptoms, and treatments. This is the last step before venturing into clinical rotations where it all becomes a reality. Most everything has been presented before in some way or another; however, the clinical aspects are linked together in a methodical way. Upon reading through my emergency medicine book, I come across topics that are not covered in class and will more than likely not show up on an exam. Yet something draws me into that extra bit of info or additional page of reading. Will someone with an Addisonian crisis or herpetic whitlow on their finger walk through the emergency department doors? Anything is possible in the ER, but these two may not be too common. But if that patient is mine, do I tell them, "Sorry, I forgot to read that section"?  Random scenarios like this have motivated me. 

It is apparent that not all of the material we cover in class will stick with me, but I expect to be pleasantly surprised when it pops into my head at just the right moment in a clinical situation. So the urgency of approaching clinical rotations motivates me to go the extra mile. Once I'm sitting face-to-face with a patient, my inspiration to study harder will rise to a whole new level. Now, all that spurs me on is the patient without a name. The closer I get, the more reasons I have to work harder.

Eleven months ago, I anxiously awaited my first day of school. Many thoughts went through my mind about books, equipment, course load, and the commute. Our program informally assigns a senior PA student to act as a “Big Buddy” to each newbie. The idea is for new students to feel as comfortable as possible in making the transition into PA school. Some “Bigs” continue on being mentors to their “Littles” and some simply help fill the gap. The mentor-mentoree/preceptor-preceptoree relationship is crucial in the Physician Assistant world.

Imagine being completely in the dark when entering PA school or even worse, when entering professional practice. It is very intimidating, more so for the patients than us. We would hit many dead-ends of inefficient methods, risky techniques, or unrealistic expectations. To avoid these types of pit-falls, there are guides who have gone before us, waiting for our arrival, ready to teach, clarify, and solidify our efforts. I would be lost if it were not for people in my life who knew what it was like to be a PA or to be a PA student. We are thankful for the ones who take time out of their schedules to lead us clueless individuals.

At what point do we cross over to the other side? When are we “qualified” to be a mentor/preceptor? I am sure there are protocols with certain criteria to be an official mentor/preceptor but the process obviously starts early. Once you begin to see people filling in where you used to be (i.e. pre-PA, 1st year of PA school, and so on), your role takes flight. We will never feel “qualified”, per say, but we always have something to offer.

The new student/professional originates their journey at a point quite familiar to us. We have an opportunity to help lead the way and set someone up for success. If we choose to be mentors/preceptors, an investment is made into the professional world. Also, by considering the needs of another, we too benefit.

When we make ourselves available to the “new guy”, our attention is shifted away from self. Why is selfishness so tempting in the medical realm of education and practice? It may have to do with the rigorous demands and emotional strife. Sure we need to take care of ourselves, but sometimes that can create a barrier to others. I believe it to be healthy when my focus is off of me and on others.

If you are in a place where you can offer up experience, wisdom, or clarity to someone in need, hop on that opportunity. The commitment is minimal but the difference you will make is immense. Start now by searching out people who could use a little light along the path.

When you taste the food at the banquet table, all other delectables pale. That is how I feel coming back from the AAPA conference. Not to say school is inferior, but I now view it in a different light. When you see the big picture, the finer details do not seem as intimidating.

At the 37th annual AAPA conference, I learned about the intricacies of student and practicing PA policy and position statements. Issues such as specialty certification and building relationships with other health care professionals were discussed in depth at the Assembly of Representatives (AOR). I was able to sit in on a House of Delegates (HOD) session where they discussed whether or not the nominations committee should endorse prospective candidates. I saw PAs from all 50 states and even from other countries coming together to celebrate our progressive impact in health care. This is the big picture I am talking about!

There are two years remaining on my student bill, and I know I have to make the most of it. I would be a fool to think that the challenges I face with a master’s project, the intense blocks, the inconvenient rotations and studying for my PANCE are bigger than what lies beyond the horizon. When in the thick of things these next two years, I have to reflect on the bigger picture. This is even true when I am a practicing PA, when my patients are driving me nuts! Physician assistants are leaving their mark on society, and we must not forget the opportunities we have to be a part of that. The greatest downfall we can make is to be lost in the constituent parts amidst the larger sum. Daily we fight the battle together, not alone.

Once I fill in the last bubble on the pharmacology final, I will officially be a second-year PA student! It is hard to believe how far I have come this first year. I remember wondering on the first day of school if I could be a competent PA. When you have little on which to base your thoughts, this does not seem unreasonable.

The first semester, you may feel like you have no idea what you are doing. You can tell people all the fun facts and names from anatomy and physiology. You can even do a full physical exam to tell someone that everything is normal. The second semester is like a bridge into the life of a PA. You begin to feel as if you know what you are doing. You can tell your friends and family what happens to the body when inflammation is present. You can assess someone’s symptoms and be able to give a few differential diagnoses. You can even know what to give someone who complains of chest pain. The second semester makes you feel like a PA.

With it being only one year, I cannot imagine what it will be like at the end of the second year. The transformation can be a little overwhelming at times; however, when you consider what changes have taken place throughout the course of your PA education, it is pretty amazing! I have truly enjoyed blogging about life as a student. I hope it has been encouraging to all realms of people with a connection to the physician assistant profession. I am excited to tell you all of my adventures this summer as I spend as I take emergency medicine and intro to EKG, and maybe a little shadowing here and there. One thing I learned this year was to avoid doubting until you have reached the other side. When you consider what changes need to take place to become something else, it can be a little intimidating. Hold on, because each step brings you closer to the final result.

Last week, two lectures brought to light an area of medicine I often overlook. The professors discussed the issues surrounding death and how we will be involved as PAs. Most of my classmates, including myself, had not experienced death in a medical setting. The closest we have come thus far has been the cadaver lab. We were each left with somber thoughts of the future conversations we will have and the personal issues we must deal with.

The first lecture centered around the stages one goes through when approaching death. Our behavioral medicine professor has a background in grief counseling and was able to speak on ideas and situations that seemed inconceivable. We all sat with fixed eyes and alert minds as he told stories of patients who asked the difficult questions. Each one of us wondered if we could give an answer, but the professor assured us that we may not have the answers. He told us, “The greatest fault health care professionals can make is believing that death is the enemy. You must not fight against death when treating a patient. Death is inevitable for us all. You must realize that disease is the true enemy, and you will fight for the patient’s health while they live.” The question was brought up, “How do we stay mentally sound when facing death each day?” He answered with, “You must first deal with the issue of your own death.” We all left with the bleak reality that we will all die. How does that change the way we interact with our patients?

The following day, a different professor spoke about advance directives. Now, they had not planned ahead of time to coincide with each other, but we received a double dose of this tough topic. The main message was that the dying patient may have wishes that make no sense to us. We may want to save lives at all costs, but our patients may be OK with dying. How do we deal with that? What does it look like to respect a patient’s wishes? How do you support the family members who do not understand why Grandma does not want to stay alive?

In medicine, you hear of all the success stories of wellness, and that is what draws many people into the field. However, when working with people at a biological level, you have two sides of the coin: life and death. You cannot have one without the other. As health care professionals, we cannot look the other way, become numb to loss, or chase after a specialty where everyone lives. We must first address our personal issues with death. Next, we must practice empathy while being in close contact with those who are dying or experiencing loss. We are their “go to” people to discuss this difficult topic. It is never easy, but knowing how to deal with it can make the world of difference in the lives of others.

Is it enough to stop at the "B" or hard earned "A"?  In PA school, it's not.  I live 45 minutes away from campus and am a married man without children. I treat PA school like a 7a-4p job so that I can give my full undivided attention to my bride. I try to keep studies at school which works most of the time I have noticed pockets of time opening up at home where I could study; however, because of my habit of not studying at home, this proves difficult. I tend to fill those times with play, which is not wrong in itself.  This month I pondered that in one year, I will be in clinicals. This humbled me deeply. I thought of how I stop at being satisfied with knowing the information well enough to excel in the classroom but do not push further for my patients one day. Here me say that it is OK to play and take time off from studying.  This will greatly increase your return. However, there is a reality that still seems like an afterthought during that first year.

We are lucky to have 34 months of formal education before really learning how to be a PA in the real world. That first semester of school will be filled with reminders from professors that you are not here to make good grades but to learn how to take care of people. Those "reminders" seem to fade as you progress further because everyone wants to do well.  The day will come when our "report card" has a heartbeat and does not care what grade we made on the Pharmacology test. The true results that matter have to do with something that I have yet to encounter. I am a fool to stop short at settling with "test" knowledge. In the moments where I would rather check out, I need to review that extra PowerPoint. My living report card depends on it.

During PA school, time is more precious than ever. Students evaluate commitments, appointments and class time as to whether it will contribute to their success. Although attendance is not mandatory in most programs, it is highly recommended. However, some absences are inevitable. For instance, you become sick, have a doctor’s appointment or simply have to deal with something unexpected. However, every student has gone through the personal dialogue—to skip or not to skip. You will find many opinions on this matter. I will discuss the main perspectives.

We have all heard about learning styles before and in PA school these are magnified. Every student has a unique method, but sometimes there may be a conflict. You may be an auditory learner who thrives off the lecture or a visual learner who relies upon the book. Where this presents a problem is in the classroom. If you are a visual learner, class time may be a waste. Hence, you may be more likely to skip while studying in the library. Is it wrong to spend more time in the library than the classroom?

Attendance can also carry a moral obligation that seems immoveable. There are students who vow to never skip a class because that would be an unforgiveable sin. Regardless of their state of mental or physical health, they will be in that seat. Could this be a trait of obsessive-compulsive personality disorder? Probably not. Props to the perfect attenders.

The final perspective is one we have all been tempted with or chronically give in to. Class can sometimes seem like such a drag that attendance is painful and pointless. The common mental dialogue looks something like this, “I am so tired after a week of tests. The weather is too nice to be inside. I can not stand how monotone that professor is.” These are common thoughts of the “burnt-out” individual. Sometimes, this can be a fixed thought-pattern leading to a long list of absences. PA school is mentally draining and taking a personal day may be what you need. However, consider it a last resort. There are many ways to push through the fatigue.

Regardless of what opinion you may have, attendance becomes something more in graduate school. There are times to skip, but mostly we should be in class. Why? It is a quality of professionalism. The professor relies on the class for participation and the rest of the class benefits from questions and comments from other classmates. So, in a sense, attendance is a matter of respect. It shows you value the time of both the professor and your classmates. It looks unprofessional when a significant chunk of the class is missing. It is unrealistic to coordinate with your classmates on who will skip what day. The rule of thumb is to question your motives and weigh your needs. This will help prevent a massive exodus from the classroom. There are many times during PA school when you do things that you do not feel like doing. It is in these times we grow in professionalism. Now get to class!

This week I have been reflecting on the dynamics of a functioning group of students going through PA school together. Each person is taught the same material and receives the same testing tools. However, not every response is similar. Some people have difficulty while others seem like they could teach the class. Going a step further in considering the dynamics, everyone has a life outside the classroom. Some lives are filled with joys and celebration while others experience pain and loss. We each carry more than medical knowledge and experience into the classroom. Whether it sounds cliché or not, PA students are a family that travels the 2-plus years together.

What does it mean to be a “family” in PA school? In my opinion, it means remembering there are more important things than learning and excelling. If you are a student, you have heard the adage “We are in this together.” It does not seem that way when students go into “survival” mode. They become so fearful of failure that they turn inward, looking out for only themselves. I was there at times last semester but have found how futile that can be. In the eight months of my PA education, my classmates have had birthdays, celebrated anniversaries or got married, experienced loss, suffered physical or emotional pain and continued to maintain their academic load. Life does not stop when you are in PA school. Do not believe the people who say “You have no life in PA school.” Those are the folks who struggle the most because they want to make PA school their life. There is necessary balance to continuing that life and it begins in the classroom.

Here are some practical suggestions to function as a “PA family” that will enhance your time in the program. These are solely my opinions:

1. When people have something to celebrate (birthday, anniversary, a victory, etc.), pause to rejoice with them. Everyone wants to be celebrated.

2. When someone experiences loss (death of a family member or even a pet, a divorce or break-up, etc.), mourn with them. This looks different in every situation. However, simply showing up, resisting the urge to say something profound, and anticipating their needs will make the world of difference.

3. Remember that there are others in the classroom. It is a matter of being considerate. Refrain from talking during a lecture, pick up after yourselves, and do not forcibly impose your opinion.

4. We are not medical students so there is no need for competition. Both the bottom of the class and the top of the class become PAs in the end. Help one another out, recognize those who struggle to grasp a concept and offer up study resources you have made.

5. Support your classmates who are holding a meeting, fundraiser or celebration. I this is schedule dependent but if there is margin, be there. I think this communicates respect by offering your presence.

It will look different in every opportunity to function as a family. Not everyone will be close enough to recognize pain or joys that happen on the outside. If you are among the perceptive, do something about it. Avoid the urge to think only of yourself. PA school is an opportunity to work together as a team, which is the premise of your future.

We survived midterms this week. At least, that is how it felt after our intense, almost panicked, preparation. A few of the students had lunch with our program director the day before the monstrous exam. We were all exhausted after spending multiple hours over the past couple of weeks studying for this test. He asked us how this one particular course was going and you could see every head cock and uncomfortable grins in response to the question. We answered by telling how great the professor was but how impossible her quiz questions were. You see, we have many quizzes that make up 10% of our grade and two tests worth the other 90%. Many people in the class had failed the first couple of quizzes, so, you could imagine that each of us had a slight fear of failing. The director began to smile and offered up some very encouraging words.

He opened up a discussion about how our program is filled with faculty that are not out to get us. They all believe in us and clearly the admissions council had enough faith in our capabilities to invite us into the program. He went on to say that we need to have more faith in ourselves and put our fears into good use. The professors know what they are doing by piling on material to our proverbial plates. The intimidation factor causes us to prepare harder or in some cases over prepare. The take-home message was to believe in ourselves and keep working hard. Sometimes we just need to be reminded of those things.

Test day came and the class felt a little anxious—with some confidence mixed in. We opened the exam and were incredibly surprised by how much our studying had paid off. It was not easy by any means but the overall feeling from the class was positive. Maybe we did not prepare as much for the quizzes or have the same motivation. I continue to remind myself that PA school will get more and more difficult. There are days where we all wonder if we can make it. The challenge is to remember that there are people who believe we can, and we should do the same. Maybe it is a good thing that we are not completely aware of our own potential. I guess the old saying “what won’t kill you, will only make you stronger” is true.

This past weekend I had the opportunity to participate in the Texas Academy of Physician Assistants (TAPA) conference. It was made up of various informative lectures, workshops and town hall meetings. The conference was a place where PAs from all over Texas could come together to talk about issues that uniquely involved them. I have never seen so many PAs under one roof. It was definitely a sight to see. After the conference, I walked away with a new perspective of specific matters that affected Texas PAs.

Politics never interested me before I began PA school. At the conference, I met a third-year student who is very involved in the TAPA legislative committee. He told me of how practicing PAs and PA students can be active at the governmental level. To know that a group of people can come together as one voice to make a difference really interested me. Towards the end of March, TAPA will facilitate lobbying session at our state capital. We will have the opportunity to discuss the issues affecting PAs in the state of Texas with the actual legislatures. By giving face time with our Texas representatives, we help them to pair people with issues. Those matters will then be brought to the next level by the legislatures and hopefully it will pass as a law. I know lobbying is not that simple but it does take a bunch of passionate people who are willing to voice their opinions. The TAPA conference gave me a vision that was beyond the pharmacology and pathology books. It enabled me to see that there is much more to the PA profession than practicing medicine.

In May, I will represent my school at the AAPA conference in San Diego. There I will hopefully be introduced to a broader array of issues affecting PAs at a national level. I believe it is very important for students to be involved in their state organizations and, if financially feasible, the AAPA. There are many opportunities to network, be informed on the latest medical innovations, and see more to the PA profession than making money and helping people. It is an exciting time to be a PA student because the field continues to change. We have the opportunity (some believe it is an obligation) to be a part of that change. It does begin with a selfless perspective and a balance of priorities. Managing extracurricular activities while dealing with a massive academic load is another topic in itself. Students, if you can, get involved. You are investing in the future of others as well. The biggest temptation of PA school is thinking there is nothing else that matters. However, the hardest part is looking beyond the tests, papers, and projects. It will make the world of difference in your education if you are involved in your state organization and the AAPA. Together we will become PAs and together we can make a difference.

Last week was a first for me. I am sure my own pride blinded me from this possibility but our initial Behavioral Science test took me by surprise. My five-year psychiatry work history and BA in psychology were not sufficient for this exam. I did study, but not like I should have. I figured that my “behavioral” intuition would carry me through with flying colors. Ha! As I look back, it is apparent how my past experiences hindered my current perspective.

I have heard before that EMTs and paramedics have a hard time while in school because their previous education and experience has led them in a direction that is not consistent with their current academic setting. I can see how this could be a problem. You may have learned a certain procedure or a given drug regimen in an instinctual situation and the professor tells you something different. This may be in the form of a lecture or on a test. Academic settings are not always consistent with the real world. There is no way to cover every possible situation or every protocol. PA school will do its best to include what is necessary and most of the time it stays within in the box. When experience has shaped our response, the automatic action or answer may be misleading.

How do you survive academia when experience has brought you this far? First, we must consider all encounters to be different. This type of challenge will be more important when out practicing. Every person that walks in the door with chest pain is having a heart attack. What do you do? Respect everything that comes your way by pausing long enough to collect the facts before jumping to conclusions. Remember past experiences as a reference not as a template. Lastly, be teachable, because we never stop being students.

I know I failed to consider these tips when approaching that test. Past experience can be an incredible asset but may interfere with our present learning opportunities. PA school is not a time to unlearn all that we learned before, but a marriage of past and present. Throughout the rest of our careers, we must learn to be critical evaluators of the present while utilizing our past to press forward.

Things do not always turn out like they seem. That has been the theme so far this semester. I am not referring to my experience in school. I am talking about our preparation for the real world. This is not a shock to the physician assistant vets out there and probably not to the students. When we read over a patient case and everything in us points in one direction, what do we do when the answer reveals something totally opposite?

I was reading over a case last week about a 31-year-old male who was in great health. He was on a jog and began experiencing chest pain and shortness of breath. The pain continued to get worse as he tried to rest from his jog. He came to the ED where all the gamut of tests were run, only to find that everything was normal. The final conclusion was that there was nothing wrong. We discussed this case in a small group and everyone had their opinion about the etiology. However, no one knew the answer. The professor later told us that there was nothing wrong with this guy and everyone was in shock. All the signs pointed to either an early MI or unstable angina, but how is it that there was no underlying problems?

Last semester, I read a book called How Doctors Think and the premise was that health care professionals can make thinking errors in subtle ways. We either go hunting for zebras and fail to see the horses or we play it safe and miss the big one. This stuff takes years of practice and exposure. We will never see it all and that is what makes this profession so exciting. Every day presents a new opportunity to learn. There is something inside of me that does not want to settle for “everything is normal with this one.”

I believe there is an answer for every manifestation of pain or lesion. However, I know that most of the causes out there are much bigger than me. I may not have the answer but someone else might. What was hard for me with this case was settling on the fact that nothing was wrong. Now this was a fictional scenario or maybe not; I did not write it. However, I have to ask myself, “Am I ok with the outcome if it is nowhere near what I thought?” I guess this is a part of learning. Sometimes we cannot be ok with the answer and dig much deeper, but I know there will be times when we dig and all we find is the truth. It is what it is.

I never thought these would be the things I would be learning in PA school. It never occurred to me that behind every set of signs and symptoms, there may not be a clear cut diagnosis. Does this make medicine an art? Do we require a sense of flexibility to think outside the box and sometimes be confined to the box? I want to be careful in settling with the dead ends because sometimes there is that trap door that leads to the other side. The challenge of medicine is knowing when to stop and when to continue when things seem out of place. I know this skill is not learned in school but in a lifetime of practice.