Tag Archives: sleep

A Hundred Words for “Tired”

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It has been said that the Inuit people have a hundred words for snow. When you live in a dangerous environment, it’s important to learn the variations of snow to survive. But, when you look into the origin of the “hundred words for snow”, it turns out it’s not exactly true – Inuits don’t have more words for snow than other languages…Their detailed understanding of snow is a lived, not spoken vocabulary. 

The same is true for those who spend nights awake working in a hospital. We, too, have a lived vocabulary that includes hundreds of subtle variations of fatigue, even though we don’t have words to describe them. (The closest I’ve come to being able to describe this fatigue is in “sleep equivalents”, specific events or things that makes you feel like you have had more sleep than you actually did. For example, a shower after being up all night can give you the equivalent of anywhere from 20 to 60 minutes of sleep depending on how tired you are. Brushing your teeth after a hard night of call is usually 5-10 minute sleep equivalent. A good strong cup of coffee can be as much as 45 minutes of sleep equivalent – although it’s important to titrate it so you don’t end up with anxious jitters instead of just being awake.)

Knowing how to manage this level of fatigue it is part of medical training. (Don’t get me wrong… I’m not advocating that trainees must get tired on a regular basis to “learn how to manage it”) Learning to successfully manage the fatigue of long days and nights on call hinges on two things and both have to do with deliberate choices.

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Learning not to trust your first instinct if you are sleep deprived is the first important lesson. Even if it’s a drug you know well, or the chest x-ray looks ok, stop and be deliberate. Consciously review the data, look at the options and, for really important decisions, ask someone to look at the situation with you.

The second lesson in managing fatigue is maybe even more important.  The bone deep fatigue of medical training is not solely the result of sleep deprivation. When you stay up all night you also lose the liminal spaces of waking and falling asleep, the threshold between night and day. In scientific terms, this means there is a major disruption of your circadian rhythms. But it’s more than just physiology. The drowsy moments between sleep and being awake take place in the liminal spaces of dawn and dusk. We lose more than orientation to daylight when we lose this liminal space. The Irish poet and priest John O’Donoghue, teaches that liminal spaces are moments and places where the spiritual touches the finite. By losing the profoundly important rhythm of rest – including these liminal spaces – we end up physiologically, psychologically, and spiritually unmoored.  

You have to be deliberate here, too. By trial-and-error work to find the things that ground you, the things that help you recover in a deeper way than just catching up on the sleep. Make lists of anything and everything that helps you recover from call for the times you are too tired to remember or choose. Look at those lists before you leave for your call day and choose something to do for yourself when you leave the hospital the next day. It might be going to the gym for a light workout, having a great cup of coffee in a cafe, a slow, grateful walk outside, playing with a pet, a hug from a loved one…or finding a way to “play” outside.

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May the sacrifice of time and sleep you make for others come back to you as joy … and may you find deep rest in knowing you make a difference in so many lives.

Study Tips for First Year Medical Students

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Yesterday was my first embryology lecture of the year to the new MS1s at Baylor College of Medicine, as well as the PA, DNP and Genetic Counseling students. For years, I’ve been including a few slides at the end of each lecture to help with the transition to medical school. Yesterday’s lecture ended with tips on how to study. I promised the students I’d share these slides in a written formate. I realized sharing them here might be the most appropriate way to do that!

Medical school (or any high volume graduate school) involves a dramatic change from what students have previously experienced. As you know, if you read this blog, I believe there are a lot of “tools” that can help students “thrive, not just survive”

The biggest change for many students is it really isn’t about the grades anymore. It’s about studying for the patients you will be caring for in the future. That means really learning the material, not just knowing it for a test.

Even though there is still a lot unknown about how the brain works to learn material, what is certain is that it is a physical process. You create new synapses when you experience or learn new things. As they are repeated, these synapses get stronger and stronger.

So, to organize the advice, I’ll share some basics, some specifics and then a little refinement.

Learning this volume of material at this level of complexity is about consistency. You can’t run a marathon by running 20 miles every weekend. This is no different. You need to study every day (except one). One of our great teachers at Baylor, Dr. Clay Goodman, tells our students that they have signed on for a 60 hour a week job. (which roughly means 1-2 hours of studying for every hour in the classroom). If you map out your week as a 60 hour job, it will work a lot better than ever trying to “catch up.”

The SQ3R system is the best system I know to learn what you need to know during the basic sciences. So, how do you translate the SQ3R system into practice?

The night before lectures, spend 30-40 minutes skimming the lectures. No “studying”. Be curious. What questions are going to be answered during the lecture? How is it organized?  (BTW “Mike” is a fictitious patient with muscular dystrophy that Dr. Goodman uses in an introductory lecture to show how everything you learn in medical school matters – from the DNA to the psychosocial context of the family)

This 30-40 minutes is basically the “S” and “Q” of the SQR3 system.

  • SURVEY to get the big picture
  • QUESTION = what questions are going to be answered during the lecture? What else do you want to know to really understand this? (write them down!). Do not try to look up anything now.

During the lecture stay ACTIVE. Don’t sit in the back row and look at FaceBook – even if the professor is reading the slides.* You’ll need to take notes for this to be really active. Put the questions you want answered on an outline you prepare the night before lecture and fill it in during the lecture. Use mind maps or other powerful visual aids to learn. Click here to get to my post on taking notes during basic sciences.

*(If you are a lecturer who does this, stop it! – otherwise you are guilty of “death by PowerPoint.” Find someone who is a good lecturer and ask them to coach you.)

After the lecture, you move on to the 3Rs. Now you get down to the real studying. Read through the printed notes (or slides). Did everything get answered? MAKE NOTES that synthesize what you learned.

Review. Review. Review. Here’s the deal. Medical school is a lot like learning a new language.  The first part of basic sciences (anatomy, physiology, embryology, etc) is learning the vocabulary. The second part of basic sciences (diseases, pharmacology, etc) is learning the grammar. When you get to the clinics, you are practicing the language until you are fluent. “Flash cards” such as Anki are great at learning “vocabulary”. They are terrible at synthesizing and learning connections and concepts.  That’s why you need a single page summary of every lecture. The summary is the “forest”, your notes (plus or minus flash cards) are the “trees”. If you really want to succeed, you need both. BTW, I made the class repeat (out loud) after me (twice) – “You cannot learn medicine from Anki alone.” (It’s on tape. I really did this.)

Here’s an example of a single page summary of the embryology lecture I gave the class yesterday. I spent time to make this really look nice – more time than you will want to spend. It doesn’t need to be typed, it doesn’t need to be particularly legible to anyone but you, but take the time to do these summaries!

Did I already mention that you need to review?

This is probably the single most important slide I show when explaining how to best study in medical school. It’s the basis of many apps in medical learning, including the NEJM Knowledge+ courses. There are two really important points in this graph.  First, it takes at least 5 repetitions to really learn something. Second, they have to be spread out in a logarithmic fashion over time.

Here’s how to do it. The first three repetitions should be same day, next day and 2-3 days later. The more times you review it, the better, but it should at least be 1 week later and 3 weeks later.  More is better.  Plan another review a month later and three months later, too. For the Type A folks in medical school (i.e. all of you), make a spread sheet!

 

Another thing about our brains and learning.  Pushing through for hours without rest is as stupid as thinking you can build up your biceps by doing an hour of uninterrupted reps. Speaking of reps… use “study reps”. Get an app if you think it will help. 50 minutes of studying.

Stop studying for 10 minutes (no matter how engrossed you are) when the alarm goes. Repeat.

People sitting next to you in your study areas are going to look like they have it more together than you do.  It might be true… but it probably isn’t.  If someone has a study technique that looks like it will work for you, by all means try it!  Just don’t change too often. I was a liberal arts major in college. If you come from a non-science background, the first 6 months are going to be a little tougher on you because you have more “vocabulary” to learn but don’t worry, after that you’ll be caught up,

Read this slide. Believe this slide. The most important point on this slide is the last line. You cannot make those physical synapses you need to really learn without 8 hours of sleep.

Keep notes about what works for you and what doesn’t. Everyone is a little different, but you will find a system that works best for you through conscious effort.

It’s like running. Some of this is just “time on feet”. Remember the 60 hours a week job concept and you’ll do fine.

I end with this slide to remind my students that there has to be balance for this to work. Most of what I tell my students about finding and keeping that balance is in this blog, so feel free to use the word cloud to the right or search for what you might need. Please contact me if you have a specific question I can answer or if you have an idea for a new blog post.

Welcome to the best career in the world! We are all happy you are here!

 

 

 

 

 

Duty Hours, Interns and Training Doctors

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For most people, talking about a 16-hour workday is outrageous.  For doctors in training, it may not be enough.

Training doctors is not easy.  It’s not just a matter of learning what is in the books or latest articles. Under the supervision of attending physicians, young doctors learn the art of doctoring by staying with and caring for their patients.  Because of the work they do while they are learning, resident salaries are supported through Medicare… mostly.  That’s another issue, but not unrelated to the issue of duty hours.

Twenty years ago, it wasn’t unusual for an intern to arrive at 5 or 5:30 in the morning, work all day, stay up all night on call, and then work the following day until evening rounds were finished.  That meant 36-hour shifts and many weeks with more than 100 hours in the hospital.  It was clear that this wasn’t sustainable, nor was it safe.

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After much debate, in 2003, the initial duty hour regulations were put into effect.  In a nutshell, residents couldn’t work over 80 hours a week (on average) and they weren’t allowed to stay longer than 24 hours.  If they worked all night, they had to go home the next day.  In 2011, the regulations were revised.  The major change was that interns (residents in their first year of training) could only work 16 hours in a row instead of 24.  On the surface, this made sense.  Fewer hours should mean more sleep.  More sleep should mean rested interns and fewer mistakes.

I wasn’t surprised to read the article published by Time magazine entitled “Fewer Hours for Doctors-in-Training Leading To More Mistakes.”  This report, summarizing the on line JAMA Internal Medicine article from this week, noted that “interns working under the new rules are reporting more mistakes, not enough sleep and symptoms of depression.”  In the same issue, authors from Johns Hopkins reported the results of a prospective, randomized crossover trial comparing the new regulations (16 hr work day) to a 24 hours work day with the next day off. They showed no significant difference in the number of hours the interns slept per week between the 16 hour and 24 hour shifts.  However, there was a marked decrease in educational opportunities, a significant increase in the number of handoffs, and less resident satisfaction with the 16 hour work day.  Most importantly, both the interns and the nurses caring for patients felt that the quality of patient care was decreased by the 16 hour duty hour regulation.

Why would there be more mistakes? Patient care is usually transferred in the morning (to the entire team) and in the evening (to the resident covering the patients at night).  That’s roughly every 12 hours.  When a portion of the team is rotating on a 16-hour schedule, it results in more handoffs (usually to fewer team members). Increasing the number of times information is transferred between doctors means increasing the risk of communication errors.

If they are working fewer hours why are they not more rested?  The new regulations almost require a “night float” system to insure that the patients are taken care of.  Working nothing but nights for one week a month followed by 16 hour days is not conducive to being rested.

Why are interns depressed? Remember, decreasing intern work hours didn’t change how much work there was to do in a day – and most hospitals didn’t respond by hiring more people to help.  Interns worry that they are “dumping” on their colleagues because they are being required to leave earlier than the other residents.  Less obviously, they are learning to be professionals but are being treated like they can’t “take” the hours of the residents one year above them. The message is subtle but real.  There’s also a perception that the quality of patient care is decreased by the new system – which is reason enough for a young doctor to feel bad.

Education is clearly impacted.  These studies document what we have all observed on the wards.  Interns working 16 instead of 24 hours admit and follow fewer patients.  In the surgical specialties, they participate in fewer cases.  They also attend fewer teaching conferences.

The solution to this complex problem isn’t going to be easy.  It’s an ongoing struggle to balance service vs. education, fatigue vs. experience and, maybe most importantly, how we pay for the incredibly important mission of training doctors.

I’m working hard to be part of the solution – along with everyone else in medical education.  We owe it to the future physicians we will train and the patients they will take care of.

How to Spend Your Day Off

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“I know I should study for the Absite this weekend, but I haven’t had a real day off in over a month”.

Here’s the scenario. It’s Friday evening. You’ll be back at work on Sunday. You’re sleep deprived because you are a resident.  You haven’t spent any quality time with your significant other, friends or family because you haven’t had any real time off. Next week has plenty of call and it would really help if you planned out good food for the week and cooked something.  And, by the way, you have the inservice exam coming up, so you really should study.

There is no one answer how to balance these things. Everyone will be a little different in what is most important to them, and different weeks will be different, too. But, there are some basic concepts to think about that might help you plan how to spend your time off.

  • Sleep is actually a high priority even though it feels like you are giving up social time.  Whether it’s visiting friends, studying or just goofing off, you won’t get the benefit of your time off if you are completely exhausted. If you are sleep deprived, try going to sleep really early (8 or so) the night before your day off and see if it doesn’t make a big difference.
  • Good food is important. Be efficient, but be conscious about what and when you eat. Use a little of your down time to think about your week, plan what you are going to eat, and go shopping. Find a good recipe for something easy to make and make a big batch for the week. Or at least buy good quality frozen food that serves the same purpose.
  • Get some exercise, but be realistic. A serious workout can use up a big hunk of a day off. For some, that’s great – the hours will be more than worth it. For others, don’t beat yourself up. It’s far better to figure out how to do 30 minutes 3 or 4 times a week than to be a “weekend warrior” for 4 hours on your day off.
  • Don’t plan for huge blocks of study time on your day off. You’ll wear out your neural pathways and you just won’t remember what you are trying to learn. Like exercise, a little every day is much, much more effective than a big block on the weekend. Plan now for the big test months from now… pace yourself!  (If you’ve just started studying for the Absite later this month – go for it. But, as soon as the exam is over, map out a way to study for next year so you don’t do the same thing again.)
  • Absolutely use a significant part of your day off to socialize with your family or friends. It’s very isolating to live in the hospital and these hours are critically important.
  • Once you think about what’s important to you, and make a decision about your day – enjoy it! The worst way to spend a day off is to spend the time worrying that you should be doing something else. There’s a reason that almost every religion in the world has the concept of “Sabbath”. Human beings need real down time once a week to refuel.  It’s not “wasted” time, it’s essential time.

Writing an “Exercise Prescription”

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According to exercise physiologist Michael Hewitt, PhD, health can be viewed as a four-legged stool.  The four legs are physical activity, optimal nutrition, stress management and sleep.  If any one of them is missing, the stool will wobble.  If two are missing, it will fall.  For practicing physicians and trainees, sleep is often the hardest of the four to manage.  Stress is next – it is part of our job, but can be reduced with with meditation and exercise.  Paying attention to what you eat (especially on call) and cooking your own food will help improve your nutrition.  The fourth “leg” may be the most important (and most neglected) aspect of physician health – physical activity.

It doesn’t matter how healthy (or not) you are  – if you add more physical activity to your week you will improve your health.  We all learn this in medical school – exercise helps prevent and treat a wide variety of chronic diseases like diabetes, hypertension, myocardial ischemia, arthritis… the list goes on and on.  Exercise is medicine! The message is clear, we should be increasing our own physical activity and “prescribing” activity for our patients.

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Dr. Hewitt suggests that it’s not that hard to write an actual prescription for exercise.  First, decide what “dose” is needed – disease prevention, basic health level, enhanced fitness level, or performance level and then – literally – write a prescription that includes each of the 5 components of exercise.

Here is what the prescriptions would look like (below).  You can actually write them on prescription pads for your patients. (Don’t forget to write one for yourself… this is a really good exception to the rule that we shouldn’t write prescriptions for ourselves or our families.)

Disease Prevention

Cardiovascular Exercise: Accumulate 30-60 minutes of physical activity most days

Strength Training: Include weight-bearing activity most days

Flexibility: Maintain range of motion by bending and stretching in daily activities

Body Composition: Men <25% body fat, Women <38% body fat

Balance and Agility:

Basic Health Level

Cardiovascular Exercise: Play or large muscle repetitive activity 20+ minutes 3 times a week

Strength Training: Leg press or squat,chest press, lat pull down or row 1-2 sets 2x/week with enough weight to challenge your muscles

Flexibility: 2-4 limitation-specific stretches after activity, hold 20-30 seconds

Body Composition: Men <25% body fat, Women <38% body fat

Balance and Agility: “Act like a child” – balance line, “step on a crack”, brush teeth standing on one foot

Enhanced Fitness Level

Cardiovascular Exercise: Play or aerobic activity 40-60+minutes 4-6 times per week

Strength Training:  Balanced whole-body machine or free weight program, 2-3 sets, 3x/week to “functional failure”

Flexibility: 6-10+ whole-body stretches after activity, 1-2 reps

Body Composition: Men: 12-20% body fat, Women 20-30% body fat

Balance and Agility: Recreational sports:  tennis, bicycle, tai chi, dancing, stability ball training

Performance Level

Cardiovascular Exercise: Add interval training and/or competition

Strength Training: Add muscle endurance or power training, add pilates work, add ascending or descending pyramids

Felixibility: Add yoga, pilates, facilitated stretching with a partner

Body Composition: Men 8-15% body fat, Women 17-25% body fat

Balance and Agility: High level sports: ski, skate, surf, yoga, martial arts

Other resources:

How to Write an Exercise Prescription – Uniformed Services University of Health Sciences

Measuring body fat (caliper and tape measure calculators)

Book Recomendation: Iron Doc by Mamta Gautam, MD

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I became aware of this book last week through one of the anesthesia residents at work (whose chairman made this book required reading for all residents in his department).  Dr. Gautam is a psychiatrist who has specialized in caring for physicians and is an expert in physician wellness.  She uses training for an Ironman triathalon as an analogy.  Physicians have to “train” for different roles (personal and professional) if we want to prevent burnout.  She proposes a training program that helps keep balance in the complicated life of a doctor. The book primarily addresses physicians already in practice, but the information is very applicable to trainees, as well.

Here’s her website if you are interested:  http://www.drgautam.com/gautam/books.htm

Post Call Recovery

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I’m on call this weekend.  As we started rounds this morning, the conversation turned to one of our superstar residents who (uncharacteristically) was late to rounds.  He was up all night and overslept after falling asleep in the wee hours of the morning.  What struck me was what he told us… “I knew something was wrong when I woke up feeling good.”  Being on call, and being up all night is part of medical training (and practice).  And it’s not just an occasional event – we often have to do it every three or four days.  It’s essentially iatrogenic jet-lag and it takes some time to learn how to manage this kind of fatigue.

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Being tired after call takes two major forms:  with sleep and without sleep.  Depending on the type of call, the recovery is different.  If you have been inundated with work, but were able to sleep, you will be physically (somewhat) and emotionally (a lot) tired.  The treatment for this is play.  You need to spend some time doing something that is not related to work, preferably in the company of friends.  You need time to process what you have just seen and done, but, more importantly, you need to feel like you are still connected to the world outside of work.  Physical activity is essential.  Even if you get home late, do something to stretch and use your body.  Even a 15 minute walk outside followed by 5 minutes of stretching will do the trick.  If you live with a significant other, make sure you have dinner together and really talk.  Put on some nice music.  Call a friend.  Go out to eat.  Whatever you do, don’t “numb out” by drinking a beer in front of the TV set.

Being tired without sleep is a physiologically abnormal state for human beings.  No matter how much the culture says you should be “tough enough” to go without sleep, it’s crazy.  We are designed to sleep 7-9 hours every night and, when we don’t, we don’t function as well.  There is an amazing amount of literature on the effect of sleep deprivation on performance, competence and health.  Suffice it to say that we all realize we don’t want the pilot of our plane to have been up for 24 hours prior to our flight.  It’s no different for a doctors.

There is  literature on this problem, but these are studies that doctors don’t often review.  A sleepless call night is basically a shift in your body clock i.e. jet-lag. The big difference is that the light cues are the same after call (unlike when you fly to Europe).  So what have business executives and airline pilots learned about dealing with this kind of time shift?

  • Stay hydrated.  It may sound silly, but paying attention to drinking enough water will make a big difference.  How much is enough?  Enough to keep your urine clear.  It is amazing how, during a busy day, you can forget to drink water.  Start looking for the drinking fountains and stop for a drink when you see them.  Carry a water bottle in your on-call bag and pull it out when you are doing sign outs, or taking a break.  Having a bag of cut up lemons helps, too.  A tall glass of ice water with fresh lemon in it is a fabulous treat in the middle of a busy night.  Mild dehydration will increase your level of fatigue.  Watch out for soft drinks and tea – the caffeine may give you a little kick (and there is nothing wrong with that from time to time) but, if you drink a lot of caffeine,  it will really mess up your sleep cycle when you do get to sleep.  Also, tea and coffee act as a diuretic, so your net hydration may be negative.  Water is by far the best choice.
  • Don’t skip meals.  Most importantly, don’t skip breakfast.  Most students and residents have to get up really early to get to work. And, most people just don’t feel like eating a big breakfast at 5:30 in the morning.  Eat something before you leave the house (a cereal bar or piece of fruit, for example) and then take something more substantial for later in the morning.  Even if it’s only an energy bar in the pocket of your white coat – take something and then eat it!
  • Don’t go too long without food during a long shift.  You need to eat something every 3-4 hours if you are working hard.  You should carry at least one snack in your coat pocket such as a small bag of nuts, an energy bar, some raisins, or some dried fruit.

Probably the worst mistake people make in recovering from call is what they do once they leave the hospital.  You can really help your recovery, enjoy your time off more, and return to work ready if you realize one fact:   You have shifted your biologic clock by staying awake all night.  If you go home the next morning (or afternoon) and sleep for 8-10 hours, you will have shifted it even more.   So how do you best recover?

  • No matter how tired you are, your first stop should be the gym, a park, or someplace you can work out.  This does not have to be (and shouldn’t be) a hard workout.  This should be a “work out the stress” workout.  Don’t push yourself hard, but work up a little sweat.  Even if it’s just 20 minutes of walking in a park, you will feel better.
  • Treat yourself well.  Take a nice long shower when you get home.  Make yourself a nice meal, but not junk food.  Eating a lot of protein and fat will put you in a fatigue tail-spin.
  • Take a nap, but make yourself get up so you can sleep that night.  3-4 hours is usually about right.  Make arrangements to have dinner with friends, if you live alone.  If you have a significant other, make plans to do something together in the evening.  If you want to have a glass of wine, or one beer, do so – but don’t have more than that.  It will mess up your sleep and it’s not worth it.
  • Don’t drink caffeine after the morning.   Even though you will be sluggish in the afternoon, don’t sabotage your night time sleep with caffeine.
  • Go to sleep early.  In addition to being sleep deprived, you will also feel socially deprived.  It’s natural to want to go out with friends when you feel this way.  However, they are not as sleep deprived as you are, and they don’t have to do this again in a few days.  If you’ve had a hard call, with very little sleep, you should plan to get 10-12 hours of sleep the next night.  You have to get at least 8 hours.  In other words, if you have to be up at 6, you should be in bed no later than 10 pm, but, as crazy as it sounds, if you can get to sleep at 8, it will be better.

Life Math: An Essay by Marion Bishop, MD

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This is a profound and wonderful essay about the “cost” of doing a residency. By comparing medical training to the life of Anne Bradsteet, a 17th century American poet, Dr. Marion Bishop discusses the sacrifices we make to practice medicine and how to consider them in the context of the gifts we receive as healers.  If you are discouraged about the years of training, the sleepless nights and the financial cost of medical training, please read this beautiful essay.

” …..    life is not a zero-sum game. A gain in one column does not necessitate a loss in another, and winning does not correlate with being debt-free or having the fewest losses in the final tally at the end of life. Rather, all losses are gains. All gains have corresponding losses. This is not harsh or bleak or cruel. This is being human. This is life. Sometimes you are talented enough to write it down.  And sometimes you are lucky enough to read what a wiser writer had to say about it 329 years ago.”

The link for this essay is no longer available to the public, but can be accessed through PubMed (JAMA 2007 Jul 18;298(3):266-8)