So this is it; During the course of this wee blog, I had several ideas about how to wrap it up- the range from just disappearing to a protracted series of farewell posts.

Like a long list of medstudent bloggers, I'm pulling the pin now that I'm finished. My aim with Degranulated was to blog weekly until graduation, and, well, that's where I am.

I started with the aim to keep my creative juices flowing at q time when medicine and pharmacy were all that was rocking around my brain- this endeavor was my creative outlet and relaxation.

As med school rolled on and I experienced more clinically, I tried to apply some of the teachings to life and thinking about the world outside of medicine.

I consciously reduced my writings about patients and clinical settings and in so doing lost the benefit of outlet. Simultaneously, my real-world network of support grew to include people, colleagues and friends, with whom I could share views, stories and frustrations about medicine.

And now I have come to the end of this step and the true beginning of my medical education. Last week, I finished my pharmacy work and, two days later, graduated my Medical Bachelor and Bachelor of Surgery. And so it begins.

I'm excited about returning to full-time employment, thrilled about the lifelong learning that is medicine and the prospect of a few entirely vacant weekends. Right now, I'm on holiday for another month.

This has been wonderful. At times, a lifeline and clarifier. I've been able to set goals and guide my future practice thanks, in part, to this small section of teh internets.

If you've ever been caught up in your thoughts and lacked a clear, coherent way of framing them, then blog.

If you've ever thought about changing careers, work out why that thought enters your head, and challenge it.

And strive for better. For a more informed society, both medically and generally. Strive for health professionals who care, who explain, who give neither credibility nor cash to snake oils.

Seek and enjoy creative, varied writing and congratulate those who produce quality (a selection of excellence is below).

In summary, thanks to my loyal readers, the cast of hundreds, my friends and loving family. I'm going to practice medicine now. Time to rock and roll.

________________

Medicine is taught to most people through television shows; having watched (and been inspired by) a fair-few television medics, I thought I'd make a wee list of my top five;

5. For long stretches of the West Wing, it's easy to forget that Abigail Bartlett (played by Stockard Channing) is a medic. She balances her medical career, family and her role as the First Lady with apparent ease. Dr Bartlett shows us that being a medic is part of your life, not your entire life.

4. George O'Malley put his finger in a cop's heart in a broken lift. TR Knight's character in Grey's Anatomy undergoes a mental transition from the "holy crap this is hard and terrifying and I'm tired" to the "hey, this is important and rewarding and I'm good when I focus" in the space of an episode. Realistic self-belief is something that often flourishes when we're put outside our comfort zone; George's elevator operation is less about being a gun whilst saving the officer's life than depicting personal growth under pressure.

3. B.J. Hunnicutt, the foil to M*A*S*H's Hawkeye, always struck a tone with me. His kindness and level-headedness in stressful, ghoulish settings was unbeatable if sometimes unconventional. Additionally, Hunnicutt (Mike Farrell) could rock a moustache like nobody's business. But it's is compassion, caring and inability to say Goodbye that rockets him up this list.

2. Omar Epps as ER's Dennis Grant. It was only in doing some research for this post that I discovered that prior to becoming the superb Dr Foreman on House MD, Epps played a role that affected my early awareness of the stresses of being a junior doctor. I remember watching the character's suicide by train as an early-teenager, and the long discussions it provoked with my parents. It's always been a reminder that medicine is not glory and heroism.

1. John Dorian vs Perry Cox have been battling it out as long as I've been at University; timing that, for me, is not withough significance. Zach Braff and John C McGinley (and Turk/Donald Faison) have managed to broach many of the contorversial and thought provoking aspects of medical ethics, death and whole-person practice that come with in-hospital experience. Evidently, I'm a massive Scrubs fan; each of the doctors on the show have strengths and weaknesses. I'll watch entire seasons on the trot, as much for the issues above as the fantasy sequences, plot, character development or scorching one-liners. The pilot episode "My first day" remains powerful and poingiant enough that I'll drop whatever I'm doing to watch it through. Where JD is overwhelmed by exhaustion, I feel inspiration and joy; It's two months until I face the music.

In my final year of pharm school, I promised myself I'd never work as a hospital pharmacist. It's not because I think it's unimportant, nor that Hospital pharmacists play an ineffective role in the health care team. It's because, for all thier skills at detecting errors and spotting interactions, there is just are three vibes that I find frustrating and counter to good patient care.

Firstly, Hospital pharmacists have been known to suffer a loss of perspective. Like the pharmacist who said that an antibiotic needed to be changed because it interacted (significantly) with the patient's statin. The patient is a late-septugenarian, and was unwell. They were to be on antibiotics for five days. The organism was only sensitive to this antibiotic. So, instead of holding the statin for the duration of anti-infective therapy and treating the infection, the pharmacist recommended a change to a less effective antibiotic. I've seen similar situations several times whilst on the wards, including in Intensive Care. Which leads me to my second beef;

Secondly, although this doesn't apply to all Hospital pharmacists, the sense of medicines-related arrogance and condescenion that I've been treated by a number of times is staggering. Notably, the same pharmacists have spoken to ICU consultants with similar disdain, so I don't feel as bad. But seriously, ICU consultants are freaking gurus. In this case, the doc concerned handed the pharmacist their ass on a plate, and deservedly. Good, well-read clinical Pharmacists know a cart-load of information about medications. what they're not so good on is the pathology, physiology and more complex situations. Hospital pharmacists play an essential part of the health team, but they're not the leading role and they're rarely on the same level of knowledge (medication or otherwise) as the specialists in their field. A little respect and understanding of the 'graded assertiveness' pathway would go a long way to improving the hospital pharmacist's face-to-face communication.

Thirdly, rigid thinking is generally unhelpful, particularly in the case of healthcare. Millions of reams have been printed on the importance of 'patient-oriented' care. If a doc writes 'tablets' and the medication only comes as capules, I've heard of hospital pharmacies not dispensing the prescription, or where the alternative is avaiable but not funded, charging a patient ten times what they'd pay for the intended formulation. Moreover, these pharmacists patronisingly note that prescriptions cannot be amended to fix these obvious errors. In community, these slips of the hand, especially for regular medications (think meloxicam caps instead of tabs), are regularly amended an the patient maintained on their exisiting formulation. But not in hospital.

But what was the final step to triggering this wee rant? Recently, a Hospital Pharmacist talked to the graduating crop of med students. She was patronising, absurdly impractical and took great pains to denigrate community pharmacy, along the lines of 'not caring' and 'have no idea'.

Pharmacy is a profession mired in tension - between healthcare and business, between evidence and outcome-based prescribing and bureaucratic penny-pinching. This pharmacist did nothing to assist this situation; Pharmacists need to see eachother for their flaws and strengths.

Sure, Community pharmacists might not have the impractically high knowledege of clinically irrellevant interactions of their hospital colleagues. But they see patients regularly, they know the finer points of how their patients live. Heck, the shop assistants might even visit the patient on a weekly basis. This is community caring; it's how life rolls outside the hospital.

I'm sure this reads as though I've a chip on my shoulder, so let me be clear - Hospital pharmacists save lives. Healthcare is built on knowledge, respect and effective communication between a myriad of health professionals and their patients. Community pharmacy, hospital pharmacy and doctors are on the same team. We need to work together, realistically , practically and with patient care as our focus for good individual outcomes.

Some events in health just stick in your mind. Obvious ones, like your first Rescus or a particularly abrasive patient, and other, rarer, stranger happenings. Today I was reminded of one such event by a regular patient.

I remember the first methadone patient who was younger than my little sister, half a decade younger than myself. He was a big bloke, in all directions. His knuckles wrote "SINK OR SWIM" and looked as if they'd been trying as much in dirty fuel. He had wisps of blond facial hair around his podgy babyface and better teeth than most opioid-dependant folk. Blond hair straggled from under his baseball cap and the glimmers of gang ink snaked towards his throat.

Despite his size and intimidating looks, He was timid, shuffling nervously like a naughty-schoolboy. I think that's what drove me to look at his age. He was old enough to be in Grade Eleven.

He didn't have a successful run on the program; only two monts later he disappeared, and I never saw him again. I hope he went back on the program; he has such a long time in which to change things for the better. For those few weeks, he was on a better track. That was five years ago.

My earliest memory of a doctor is Dr Shiner. I was in preschool with his daughter, and I remember visiting his office, walking up the dark-red brick stairs of his Coogee office, tightly holding my Mum's hand. My little brother was, I think, getting his two-year vaccinations. I was nearly four.

Of course, NSFW can be taken in another (albeit rare) context. We can all think of people who aren't very good at their jobs. In Medicine and Pharmacy, these practitioners are actually Not Safe For Work. There are numerous reasons that someone might be unfit for practice, but as students the reason we're most familiar with is someone who's incompetent, can't pass exams and just doesn't get it. This level of potentially unsafe practice is usually under the control of the University or Medical Boards, and by and large, they do it well.

The next step above NSFW is the DNR list. That's Do Not Refer. A person, who through their skills, knowledge or interpersonal manner, you personally deem unworthy of any referral.

At the other end of the spectrum are the kind of Doctors (and Pharmacists) we rave about. The General Practitioners who, if pushed, you'd see yourself, and the Specialists and Surgeons whose opinions you'd seek for yourself or family. These doctors, as far as a student's interaction goes, are keen to teach, excellent team-players and knowledgeable seemingly beyond comprehension. Dubbed as Referred In Clinical Excellence (RICE), these folk are the staple to any medical professional network.

As final exams approach, I've overheard chatter about personal DNR and NSFW lists, and plenty of talk about RICE. In the meantime, most of us hover on a middle ground, ans the next few years of experience and work help define our skills as DNR, or hopefully, as part of RICE.

This coming week, I'm in anaesthetics. It's a part of the Critical Care rotation which, thus far, hasn't exactly set my heart on fire. However, in the spirit of avoiding negativity or 'letting the man get me down', I'm going to share my top ten songs for Med School.

Not necessarily my favourite songs of all time, just ones that remind me of certain parts of Med School. The ones that refresh and conjure up some salient moments burned deep into the brain, the kind that both shape and describe what, for me, Med School is all about.

10. For You - Sarah Blasko. The first track on her album, "What the Sea wants, the Sea will have" went hand-in-hand with Curry nights. As Batman, Wonderwoman discussed Politics, Medicine and Literature as I tried to whip up creations that would both inflame and satisfy tongues and stomachs.

9. Fireflies - Owl City's catchy and absurdly over-played hit reminds me of Birth. Not mine, obviously, but the half-dozen catches and many more I watched whilst Obstetrics and Gynae earlier this year. The optimistic child-like tinkling electronica crosses between medical devices and babytoys.

8. Someone Else's Town - Josh Pyke. Sitting on a park bench in Sa Pa, Viet Nam during my first year Med elective, I watched the cool night encompass the valley. The 2007 Australian Election Night raged, on some far-off frequency. Aware of the occasion, but not the details, I instead observed evening life in Sa Pa. Ensconsed in Pyke's Memories and Dusk and relative serentiy of rural Viet Nam, I was truly watching someone else's town.

7. Three MCs and One DJ - Beastie Boys. It's only since I've been in Med School I've begun to truly appreciate the Granddaddies of Rap. After taking the time to actually listen to the lyrics, combined with their B-boy beats, my taste for the New York trio just flourished. Their 'To the Five Boroughs" album was on regular rotate through first year, when Med School was all about wading through large amounts of input to make sense and get the underlying vibe, not unlike the music itself.

6. Life In Technicolour II - Coldplay. The Prospekt's March EP featured heavily on my morning commute last year. Chris Martin's dominating and uplifting opening bars made driving through dew-covered cane fields half an hour after sunrise the best substitute for morning coffee one could wish for.

5. Please Forgive Me - David Gray. Remeber that scene from the Scrubs pilot, with JD standing in the Emergency Department at midnight, just out on his feet with everything rushing around him. It's supposed to engender a sense of exhaustion, of being overwhelmed. Watching that scene sets my heart on fire. It stirs something that makes me think, every time that I watch it, how much I'm looking forward to life in Medicine.

4. I am the Highway - Audioslave. For most of the last four years, I've worked some long, long shifts at the Pharmacy. This song, on a late night drive home, reminds me to pace myself both mentally and physically. Chances are, I'll have an early start the next morning and with the bare minimum of sleep, I'll be okay. And the riffs are epic.

3. Spirit - Moby. The entire B-Sides of Play appeared on my iPod at the end of Med1. The mix of deep, soulful melodies and swelling & inspiring surges make this an ideal travelling album. Spirit is one of those tracks that just makes my heart soar; it was playing when I checked my first year marks in a dingy Indian internet cafe, and the sensation of achievement and promise still hits me each time I hear it.

2. It's a long way to the top - AC/DC. This February, a visit to Fremantle Gaol re-introduced Bon Scott et al. to my eardrums. A Hospital Variety night on the eve of Pediatrics saw several department heads 'rocking out' to the bagpipes and a room full of moshing healthworkers. Seeing the consultants, at the top and enjoying it, refreshed that yeah, it's a long way to the top of a chosen specialty, but getting there (and staying there) is rewarding and fun. Are you ready to rock?!

1. Teardrop - Newton Faulkner's cover of Massive Attack. Most Medicals TV aficionados well know Massive Attack's Teardrop as the House MD theme song, but where the original is slick, shiny and a bit high-fa-looting, Faulkner's spin is raw and basic. A fine balance of cautious inspiration, the song lets us know we're both "stumbling in the dark" and "fearless on my breath". As the music swells, where Massive Attack's original is sad, Faulkner's Teardrop inspires and rejuvenates, without hiding the message. This song is, for me, what Med School is all about;

Textbooks, as we know, can be both goldmines or empty shells. They can be full of biblical prose, disjointed, ambiguous, verb-less sentences of verbosity, or witty, concise, razor sharp and, most importantly, informative.

We're familiar with the cinematic line "open your books and turn to chapter...", or "we'll start at page...". In the world of academic texts, this is often the way. We pick up the tome with a question in mind, flick first to the index and then directly to the focus of our attention. Be it to describe the conflicting pressure gradients of the nephron, or the capital of Kazakhstan, we seldom languish in the remainder of the text.

Recently, I've made an effort to read the first few chapters of a textbook, particularly the introduction. I suspect that this is primarily because I'm reading specialty texts, and I'm keen to learn the basic approach. That is, how the author (and by extension, their specialist colleagues), approach their field.

How strange that, after nearly eight years of tertiary education, I'm reading books with fresh eyes. Not the fact-seeking ruthlessness of exam-study precision, nor the trivial style of someone looking for a tidbit to impress their consultant. Instead, before diving headlong into the finer points of the Pathologic Basis of Disease for another round, I'm trying to see how Drs Kumar, Abbas and Fausto think about their field.

Pointedly, page 2 of the Oxford Handbook of Clinical Medicine tells us;

"Decision and intervention are the essence of action: reflection and conjecture are the essence of thought: the essence of medicine is combining these realms in the service of others."

The Coast Hospital has a new scenario based learning suite that Med Students, Docs and the rest of the clinical staff have been having some training sessions. The aim of the sessions is to more accurately replicate the real world; a challenge that anyone who's given Rescue breaths and chest compressions to a plastic shell will fully appreciate.

One of the real beauties of this kind of learning is the chance at a 'do-over' or as golfers say, a mulligan. Moreover, the ability to analyse and critique our reactions in a stressful 'real-time' environment is extremely helpful in future decision making.

For Med Students, the analysis unfailingly emphasises two key points; that a) we can recognise an unwell patient and b) that a systematic approach will yield positive results.

In many aspects of life, we are not afforded the chance to analyse an instantaneous decision; the situation progresses, and all hindsight is, of course, 6:6. We rarely, if ever, get a 'do-over'. To combat this, cricketers have net-sessions, rugby union players have tackling practices, and soccer squads practice penalty kicks. All those hours for one shot. To take the extreme, the intense, the unimaginable and have the brain convey normality.

I'm yet to be involved in an arrest situation; I'm hopeful it runs like in the scenarios. For those ones, there are no mulligans.

His fluoro shirt was visible a few seconds before the automatic doors whirred open, and he entered from the long dark night. As he stumbled across the shop floor, I almost reached preemptively for a sharps kit. As he reached the counter, he fumbled for his phone, dark eyes searching the screen. His gaze lifted to mine, focusing some seconds later.

"I... need... some... formula. ... For newborns." He slurred, before squinting hard at his phone and naming a brand.

Unfazed, I toddled over to the baby section and fetched the request, with a "No worries". Meantime, he'd begun to rant. About his girlfriend. About two hours of text-messages. About the baby crying.

"Plus, " he says, clearly now with a full waft of XXXX assaulting my nostrils and eyes, "I'm maggot."

"This is the one you're after?" I confirm, gently.

His pupils accommodate to the shelves behind me, and then to the behind of the leggy shopgirl, as he dumps the cash on the bench.

"Sooo, theeen... what time does your lady friend... get off?"

"You'll have to ask her yourself," I say with a wry smile. I'm met with a forty-five second string of abuse littered with F-bombs, C#$&'s and racial slurs.

I can be pragmatic about abuse; it happens in the health services. The sick feeling, biting like an ulcer in my gut, wasn't because I'd been sworn at, nor because my assistant had been abused. It was for the girlfriend, and the newborn.

Bob bounced back, his Troponin sky high, for the third time in as many months.

Under sixty and full of modifiable risk factors, a jolly round fellow, reclines relaxedly in his bed.

The cardiologist tells Bob he's in serious trouble, his angina's unstable but his risk factors for surgery are gargantuan, especially his fifty a day smoking.

Bob's round face bobs with laughter, he drives the speed limit and he doesn't chase the women, he says. There's no drama with half a dozen each night, eh doc? And what's a few smokes too, he says.

Objectively, his prognosis is terrible. The cardiologist tells him - in numbers - the chances of death, and when.

Bob bobs some more, "At least it's not cancer.", he smiles.

And the cardiologist pauses, looks square into Bob's eyes and gently says, "With most cancers you'd have longer."

And Bob, kindly, round, red-nosed, white bearded Bob, just doesn't get it. Because it's not cancer.

This week, one of the Intensive Care Registrars popped his head into the CCU to check up on a patient he'd been asked to see overnight. Luckily, they'd been well enough to avoid transfer to his unit. The patient's story was interesting enough to keep the ICU reg, well, interested, and he's the kind of compassionate fellow to actually follow up on consults.

In addition to his obvious empathy, one thing struck me about this Registrar. He had a textbook in the crook of his arm. Not the typical ICU fodder, nor a voluminous tome such as Harrison's latest offering. No, he had Guyton & Hall's Physiology, firmly within his grasp.

Somewhat surprised, I asked if he was sitting exams soon. "No," he replied, patting the red spine gently, "it's just that I like to stay on top of this stuff." He finished his observations and trotted off to the ICU.

I think every Pre-clinical Med student wishes for the day their textbooks are permanently burned into their brains, knowledge available for instant recall. Similarly, the clinical years instill in you a sense of simplicity through structure - all that basic, history based stuff. It's easy to draw the dots between chest pain and myocardial infarct. Dredging out first-year physiology, engineer-style, to explain symptoms and progression is another string to the bow.

The reg, unspeakingly, reminded me the books we use, at every level, remain relevant in every clinical context. That's why it's called life-long learning.

On two consecutive days, in two consecutive areas, I've been reminded that I'm not at 'the next level'

Yesterday, I had a bicycle race, and the organisers put the top two grades together. I'm a pretty solid B-Grade rider, and rated my chances at finishing with the (relatively small) peleton. I lasted barely two of the five laps before getting dropped like a lead balloon, before riding alone to the finish. Don't get me wrong, I'm fit, riding pretty well and can flog almost anyone else I ride with for a good forty kilometres. But I'm not at A-Grade level, and I won't be for a while

Recently at the Hospital, it's been a similar thing, sort of. I can hold my own in discussions with medical students and interns. I have a pretty good 'clinical approach' to most things, I'm more systematic and I'm better at presenting. Today, though, I got schooled on rounds. It got me thinking about progression;

The phrase 'taking it to the next level' is well overused by hip-hop artists, film-makers and sportspeople alike. And usually, it's nonsense, garbled trash talk. Until, of course, you're the one who can see both sides of the level - what you can do comfortably, consistently and repeatedly, and what you cannot.

Since mid-year, this is what Med School's been like - both sides of the junction. Some days above, holding on to the peleton, making good plans and diagnoses. Other days, dropped, agog, out of my depth. The next few months I'm going to use to get comfortable. To consolidate knowledge and skills. To prepare for the Next Level.

Last night, I lost it. A meagre 48 hours earlier, my Mum asked if I ever felt like crying. I've just finished a month of oncology. Throughout the rotation, I felt like I had my emotions under control.

Last night, I watched a movie. Inside the first ten minutes, I was sobbing, fetal on. In a moment, all the pain, the hurt and overwhelming sadness I'd seen in the last month was draped over me a veil. Too heavy to cast off, to black to see through.

Last night, I remembered. Faces of terminal septuagenarians, stoic and brave. The disfigured faces of a few with head and neck tumours. Grieving families of comatose patients, one foot at the threshold.

Young mothers. Mothers searching for a way to explain death to their toddlers.

Sadness, incomprehension. Death.

And when I stopped crying, Batman and I watched the rest of the movie together. And the patients, those who are still alive, continued to live the rest of their lives.

Last night, the movie I watched was about Love.

My boss asked if I'm counting down. A few months ago, we had a chat and I said that I'm not yet at the stage of counting my remaining shifts in Pharmacy. I'm not.

As I walked into the Hospital around 7:30 this morning, the laboureres at the adjacent building site were singing, whooping and laughing as they worked. They'd started dismanting the four stories of scaffold concealing the hospital's new building several hours earlier. They shouted to eachother and guffawing at their humour. Smiling at life.

Below, a trio of tired nurses and an Admin officer trudged through the main entrance in silence. Their heads slightly bowed and gaze fixed on an indeterminate point some hunderd metres through the wall. Their day was just beginning.

In first year, my drive to uni went through downtown, usually at peak hour. In the snailled traffic, dark suits and skirts would weave their way through, en route to white, starched-collar monoliths. I didn't see laughter, and rarely smiles. Mondays were the worst, for them.

I love Mondays. Shiny, new, rested. On Mondays, I'm reminded about direction change. That I made a conscious choice to go back to Uni. That I love learning about medicine, life and people. That feeling of 'something new' that you get on the first day of school, or a new job, that 'fresh start' feeling, is always there on Mondays.

After arriving back into Queensland at 0740 with a meagre 5 hours of sleep in 50, I busied myself, intent on not succumbing to tiredness until nightfall. Especially as I was to be in Oncology clinic the following day at 8am, bright and shiny.

Sensibly, I unpacked. I did some washing. I put by bicycle together. I did some more washing. I called my family. And did some more washing. I ate. A lot. My eyes began to blur as I stared at the TV... Oh oh. This was going to end in sleep.

My phone rang - it was my cricket coach. He asked if I felt like coming down for a net session. I was mildly surprised, being the middle of the off-season. I'm not near the level of player who starts pre-season three months early. Either way, if fit the criteria for my main aim of the day - not falling asleep - so I headed down to the pitch.

As I wander across the field, slightly confused by this net session, I see a 'familiar' figure. Familiar, in the sense that it's recognisable from the television. The first-grade spinner says G'day and chucks me a ball. Next thing I know, I'm bowling at a New Zealand Test Cricketer, and a few First Class players, too.

I got home buzzing, despite being smashed all around the ground, including a cracking cover drive into through the hole in the nets into my (now dead) mobile phone. Oops. Getting a second (fifteenth?) wind, I went for a ride.

Recently, @sandnsurf at Life in the Fast Lane rolled out their version of Problogger's 7 link challenge, and I thought I'd have a crack. True to form, it was good fun trawling through the last few years of posts...

1. My first post;

Game on. I started this blog one Sunday at work. I wasn't playing regular sport because, in addition to Med School, was working 30+ hrs a week. It took me a while, but the question remained pertinent; "What do I want out of this?"

2. A post I enjoyed writing the most;

Medicine and Travel combined for a dream-like premier experience in My First Surgery. Reading the post made that night flood back, even the smells. There's really something special about the first one you do.

3. A post which had a great discussion;

Why I'm Against Pharmacist Prescribing. An oft discussed topic in pharmacy circles, this post was designed as a caution to over-zealous, ivory-tower, Pharmacists. The comments have also revealed some interesting public perceptions about prescribing and the value we place on diagnosis vs prescriptions.

4. A post on someone else’s blog that I wish I’d written;

@sixyearmed - Where the water is. I stumbled across sixyearmed when I was compiling Grand Rounds in July 2009. The rawness of this post just grabbed me, confounded me. An inspirational, honest writer and a pediatrician, Danielle is now the number one feed in my reader.

@precordialthump - Brainstem rules of 4 at Life in the Fast Lane. This post taught me more about clinical neuroanatomy than medical school has. Plus, it's logical, memorable and has wee follow-up self-tests. More than once, I've printed a copy and handed it to a confused colleague on their neurology/internal med rotation.

5. A post with a title that I'm proud of;

The Clinical Creep is a post about a truly awful Clinical Coach we suffered through in first year, before he was fired from the MedSchool. I like the name because, well, it's just him.

6. A post that I wish more people had read;

Failure. Medical Students don't talk about it enough. I don't mean the catastrophic, university-career-ending, multiple sunject failures. I mean the once-offs, the 'I didn't get this rotation/subject/idea' kind of fail that is much, much, much more common than the Medical Student Community will admit to. In the words of my little sister, "It's good to know that becoming a doctor is hard."

7. My most visited post ever;

Pseudoseizures: Not Funny. This post continues to recieve a large number of angry comments that I moderate, thanks to its prominence in Google Searches for 'pseudoseizures'. The message, without a breath of sarcasm, is in the title - pseudoseizures are not funny. The post aims to provide a rational and caring viewpoint about the condition.

These posts, I think, represent this blog as a whole. Evolving, honest, rational and questioning. Feel free to have a chop through the archives on the side...

Welcome to another edition of Grand Rounds! This week, Grand Rounds 6:43 pays tribute to our friends, with a little help from Messrs Lennon and McCartney (with Ringo on vocals...)


# ACP Hospitalist's Dr Manning tops the bill with a tale of hell on call, complete with a technically absent colleague. A scary and frustrating look at a night with THE pager.



# Medical Resident extends the hand of friendship (not just medical care) to a patient with Brugada Syndrome, in this insightful and well-written post.


# Delia O'Hara over at Birth Story applauds the Pioneering women in Medicine at Johns Hopkins, in this informative look at few of the Medical Schools benefactors.

# OBCookie (great name), puts a loving, and practically educational, touch on her sumptous looking Chicken Roulades. Yum!

# Dr Val and Better Health submitted a recent guest post from Dr Alan Dappen about Canaries and the Primary Care Crisis. Just 'cos it's chirping doesn't mean you're there to hear it...


# Mental Notes looks at an interesting manuscript about Anxiety and Religious Zealots, highlighting that it's essential to solve the concrete issues first. Great post!

# How to Cope with Pain Blog suggests Why You Should Try A Pain Support Group, and not be all alone, because...


# Recently named as the Nicest Person on the Internet, Dr Ramona Bates adds to her vocabulary after renewing her friendship with folderol.

# Happy Hospitalist floats the genius notion of Open Source H&P, to reduce duplicity in medicalcare; friends and colleagues (?lovers), we should all work together.

# Will Meek's discussion of the time-honoured Interpersonal Circles model could help to both win friends or hold foes at bay.


# Highlight Health celebrates 50 years of birth control, in this well referenced post, complete with fantastic infographic.

# Inside Surgery remembers Kit Carson, frontiersman and self-trained surgeon. He even helped with an amputation aged sixteen - talk about a fast-track residency!


# Bongi's writing often gives me pins and needles, and is true to form in his ever-eloquent post, Silence.

# In my submission for this edition, darkness adds a bit more risk to a situation, as I was reminded in Getting Back.


# The Good Samaritan Laws are about being good (and legally protected) friends, as Dr Ed Pullen writes, citing two memorable experiences.

# The UK health system is looking to cut bureaucracy, InsureBlog reports, and notes that it's by no means a bad thing.

# Health Blawg celebrates and explores the new definition Meaningful Use as applied to EHRs.


# Health AGEnda honours visionary geriatrician Dr Bob Butler, pulitzer-prizer winner and first director of the National Institute on Aging.

# GlassHospital draws a touching obituary for Harvey Pekar, comic writer, clerk and Cleveland hero.


# Is Medical School a Hostile Environment? Not Withstanding Blog poses the question of educational institutions and anti-harrassment laws.

# Dr Rich, at Covert Rationing Blog, observes with great interest the debate between those who want to change the guidelines, and those who believe that changing the guidelines would be the greatest of travesties, in this excellent post about rosuvastatin.

# Louise at Colorado Health Insider, puts forward an Economist's view of midwifery.

Thanks again to Billy Shears and especially Dr Nick Genes and Dr Val for running the Grand Rounds travelling carnival; Next week, Grand Rounds is hosted at Inside Surgery, see y'all there!

It was dark. Stupidly dark. And I had no lights. E and I had summited the 1600m climb some twenty minutes earlier as the sun dropped behind the ridgeline. And now, half way down the road, it was dark in the open and pitch black in the trees. I was, frankly, terrified.

The road, on the way up, had been shaky at best. Less than ideal for climbing, and a challenging descent, even in daylight. Wanton golf-ball rocks were strewn across a cracked and undulating bitumen tongue, each threatening a catastrophic puncture or fall from the route as it snaked its way up the Col, two gravel fords and eighteen hairpins climbing 1200m in 12km. The descent should have been quick but challenging.

Despite starting at relatively reasonable time, a wrong turn or two had put us at the bottom of the climb about half an hour longer than expected. The col, too, took another twenty minutes longer that we'd planned. And now, in the last remaining light, there were no better options.

The other option, of course, was to walk. It was getting cold, and all food and water had been consumed to recover at the summit. Walking would take four or five times as long, without walking shoes, and would increase the odds of getting hit by a car going up or down the narrow road.

So we rolled on down, hands hard on the breaks, careful not to snatch a handful of lever and send ourselves sprawling. Eyes reaching, squinting to seek out the cracks and rocks that only an hour ago had been as plain as the day. As the trees enveloped the road, only a wisp of road was visible, punctuated by a grey hairpin, open to the sliver of light and treacherously sharp, followed by a long, steep straight of black and nothing, road somewhere beneath skinny tyres.

It occured to me that the same thinking would, one day, be necessary in a medical situation. The situation is less than ideal. Everyone's in the dark and uncertain of the fastest, safest solution. There's blame to be had. Something must be done. So the options are weighed and the least risky, with best result is chosen. Textbook stuff, really.

But it doesn't make the journey any easier, nor safer. Just a heightened awareness of the risk, that, over time, changes with the situation. There's no sense dwelling on how you got there, just choose the remedy and make it happen.

At the bottom, I took a deep breath, lesson learned. E took a photo;

He looked to be in his late sixties, and was probably ten years younger. His face lined with life, worry, nicotine and grit, he sat quietly watching television.

Aside from the hacking productive cough, which emptied his airways and filled his handkerchief, he didn't say much.

Every fifteen minutes, he would limp to the threshold, suck back a smoke and return to his seat. On occasion, crutches in hand, he'd festinate away for a few gulps of red wine, returning with a glazed, sad look and stained teeth.

As Wawrinka lost to Federer, he said "Those boys used to train around here." And we talked about where he was from; locals don't often stay in Youth Hostels, I thought.

He was a local. He'd fallen and injured himself, and lost his apartment. Now he had nowhere to go, no money, nothing. He was lodging at the Hostel, at the expense of his health insurance, sharing a four-bed dorm with an endless parade of rowdy travellers and the odd drunk teenager.

He sat watching the tennis. Coughing. Homeless.

The large black circles around his bloodshot eyes are not just from crying. His hands grip the industrial fabric and plastic chair, nails white, knuckles pale. Dark eyes filled with sadness and loss. He nervously whets his bottom lip, purses and exhales slowly.

His Cote d'Ivoire football shirt, once tight, hangs limply around his withering shoulders, flapping and shuddering as he tells his story.

He's seventeen. First-generation Swiss. Everyone always asks where he's from, when he moved here. His parents, a teacher and an accountant, moved for a better life, so he could get a degree.

Before this. Before all the medicines.

He rubs his tightly curled hair nervously, waiting for his newest numbers. He mumbles in rolling French, pausing and recalling how this happened. He itches the lesion on his arm.

He never really liked beach volleyball. His friends wanted him to play. Really, he says, I'm a football guy. Switzerland doesn't even have beaches. This is no 1980's Venice or Bondi, he says, grimacing.

You can't play volleball in shoes. Football, he says, you wear shoes. Who shoots up at a beach?

The doc reads his numbers and he nods slowly, takes his pile of prescriptions and leaves. Today his CD4 count is greater than 400. For him, it feels like just another result, a figure, a pile of soothsaying digits.

He feels faceless. A number.

He was mighty quick on the downhill and on the flats, but lost a lot of time over the climbs. At each climb, his face turned to pain and his eyes glazed as he seemed to look inwards, his face drawn and mouth gulping as he suffered silently.

He inspired everone he rode near; his huge changes in speed made him nearly impossible to ride with. The race, nearly a hundred miles, climbed mountains in first snow, then rain and hail.

Mountains that broke Tour de France riders. Perilous, hairpinned descents at eighty kilometres an hour. For hour upon hour he rode.

A Brit was just about to quit. It was too hard, he said. The rain was no fun. Then the man rolled past, and the Brit's eyes and mouth hung wide. He remounted and tried to chase him down, soul lighter.

The man reached the final climb of the day, several hours ahead of the last rider. He pedalled and struggled, in a world of his own as he climbed.

He hauled over the mountain, one pedal stroke at a time, as the rest of the field rode past him.

By hell, he finished, the cyclist with one leg.

For the first two years of Medicine, I slept in lectures. I refused to wag lectures entirely, as that would be denying myself should all things align, the chance to learn. But usually, I slept.

This week, I attended, unexpectedly, one of the best lectures I've ever been to. About 93 seconds before I was heading to lunch, my senior research registrar sticks his head in the door and says;

"So, um, Capt.Atopic, we have a lecture from an international professor. In one minute."

Um, okay. I sat down with six others from the department, and the Prof, a senior WHO Director up from Geneva for the day, gave us the goods on Public Health and Prevention of Mental Illness.

An intersting topic, delivered openly, interestingly, honestly and inspiringly. There was not a snowball's chance in hell that I was going to sleep through this one.

The Prof interacted. He talked about the flaws of Public Health; that often funds were wasted on inefficient, meaningless fluff and nonsense. His vision was to move past the smoky ideas and into action.

The main point of the presentation was emphasising primary prevention; that is, preemptive behavior that seeks to avert disease before it develops. Applied to the entire population.

Things like folate in bread and ameliorating iron deficiency, to reduce neural tube defects and congenital pathlogically-low IQ, respectively.

Public Health, like Evidence Based Medicine, is one portion of medical school that is introduced didactically, fuelled by misguided passion. Both are taught from a theoretical perspective, without solid, coal-face examples.

The Professor spoke from the heart. He sought to inspire, with knowledge, with practicality; one of those Doctors who genuinely and realistically wants to make the whole world a better place.

Yesterday, one of the senior registrars gave a presentation about adolescents who smoke. It was well compiled, informative and had clear conclulsions and signposts for the future. But there was one thing about the presentation that felt wrong. I just couldn't put my finger on it, but slowly, the cognitive dissonance began to take shape.

No matter the message of the article, be it on the large number of dead due to lung cancer, or the horrible effects of Chronic Obstructive Pulmonary Disease, the media dressed the article with a glamourous photo. Talk about mixing the message.

"You see, but you do not observe. The distinction is clear." - Sherlock Holmes in Arthur Conan Doyle's "A Scandal In Bohemia"

My ear for languages is not strong, which means that, in the French-speaking area I find myself, I have two choices;

Firstly, I can attempt to train my ears, to dissect the rolling and flowing vowels and softly-said consonants. Scanning, searching, aching for familar nouns or verbs and aurally squint intently listening for tenses, pronouns and conjunctions. This I do when in lectures, meetings or group discussions.

For once in my life, I say almost nothing.

The brain bends and I'm soon exhausted with mental effort as I try to convert spoken sounds to the written words with which I'm more accustomed, attaching unpronounced letters to establish a notion of linguistic sense. Soon, the words overpower me and the conversation merges and blurs as I lose the thread, then the needle itself, as the sewing machine turns to a quiet hum and I am lost in thought about the last phrase I interpreted.

Secondly, I can observe. In meetings, it is the responses of others, the sideways glances or brightening of eyes just before a punchline. Gestures, microscopic, indicating grandé or petité, hauté or en basse. Movements of the mouth, as if to speak, before the biting of the lip, or the twitch of the hand. The pauses to ensure a point is made, quick looks at the superior for affirmation.

For this, my ears numb. Eyes wide, watching the mouth of the speaker, the eyes all around, the flickers of faces. Lips, teeth, brow, shoulders all interacting in a symphony of message. The Philharmonic Orchestra as interpreted on mute, crescendo and decrescendo as estimated by bow speed or drumming intensity.

In the street, kids yell to eachother, in adolescent franco-anglo-moroccan hybrid, complete with german and english expletives. But they're smiling at eachother as the football game continues. Only the sworn-at is sluggish, and only for a minute or three.

I still say nothing, mute, observing. Still too scared to venture the smallest of sentences, Australian accent hampering my attempts of self expression. In three weeks, I will be in clinic, en Français. Presently, I can read the language, understand scraps and meet and greet with a few phrases of politeness.

I see and I understand. I can express myself and my thoughts to but a few. A far cry from the mother tongue of ready-made puns, expression and linguistic subtelties. I want to learn this language; a challenge to be sure. To express, to pun, to navigate novels. To navigate streets. To be understood at the supermarket when I ask where the sultanas are.

Lunch today, with a four able anglophones, left me comfortable, relaxed. At the end of the outing my registrar says;

"From tomorrow, you speak French."

Here goes.

Some years ago, I embarked on a Road Trip with a two carloads Uni friends around New Zealand. Two of our number resided in the Waikato (Hobbit country), and we thought it prudent to drop them off for the summer holidays.

During this time, we passed the kilometers by playing the "Tractor Contest". The game has few rules, as I twittered earlier in the year. They are;

A few nights ago, I had dinner with a dozen people I'd never met before. All were either at university, or completing post-graduate or post-doc work. We hailed from 10 different countries.

In addition to politics, sport and other religions, the conversation wandered to what each person was studying. The young-un's (and myself) could simply state which course we did, but the challenge came for those in research. Particularly, they had to explain their topic, why they chose it and how it was relevant and practical in the real world within a minute.

Additionally, the conversation (and explanation) was in English, the mother-tongue of only two people at dinner. The topics ranged from applying spin theory to neural association networks, to the solar treatment of waste water.

As a pharmacy student, I remember my frustration with a PhD student not being able to explain clearly the principles of Pharmacokinetics. This wasn't because they had savant-like intelligence (which I'm sure happens for some), but because English was not their first language. And seriously, some ideas require a very fine handle on a language, both to explain and to understand.

Unfortunately, I was the sole-monolinguist present at dinner. Whilst this didn't hinder the students' explanation, I was humbled. Clearly, one of my goals whilst en Suisse is to develop a functional level of French.

Long-haul travel is surely one of mankind's oddest examples of selfharm. Nonetheless, after several 8+ hour flights, almost as many hours in stopovers, I'm in Springtime Switzerland.

While "summering in Europe" is usually the stuff of decadence and holiday, I'm here for my Elective. I'm placed at a hospital in South-west Switzerland for eight weeks of Adolescent health.

Before that kicks off, however, the plan is to spend some time with Batman, who's been Medical-globetrotting for the last rotation, aswell as watching some Bicycle Racing in the Dolomites.

So, a few quick observations from the last week;

1. Sure, it's cool to have a soft-toy attached to your stethoscope, but if you only put it on for the exam, then maybe you're missing the point.

2. Exams. If you're in the final year of medicine, then a) you've done more than 100 exams in your life, b) they now closely mimic professional practice, and c) they're only looking to weed out the bad eggs. This means you shouldn't freak out at the word 'exam'.

3. If you can't speak the same language as the person serving you at a cafe, be prepared for the service to take just a touch longer. You'll be madder if the wrong food comes out, right?

4. Cycling Paradise as Europe is, I still can't understand why no-one wears a helmet.

5. Something I already knew, but was yet to see in action from a first person point of view, is the speed at which face-grazes heal vs. ankle-grazes.

6. When airlines lose your bag, they really don't care. Whilst it might turn up eventually, you're still stuck in the same clothes for two six days. Bad luck Batman.

Switzerland is a truly beautiful place in the Spring; wildflowers, waterfalls, azure lakes, snow-capped peaks and the ringing of cowbells. Next week, to the Giro!

About the time the last [Anaemic] post went up, I looked like this. I'd been in a crash at the local cycling club's criterium circuit and been knocked for six.

Keen cricketers and cyclists alike will appreciate that if a red, round ball goes for six, it's good. If, however, it's a red, hairy head getting smashed out of the park, well, that's usually a bad thing.

I took it - literally - on the chin. After unexpectedly slowing from 40kmh to zero in a matter of two meters, I sat dazed and confused on a cold black and white part of the road as cyclists variably whizzed past or stopped and asked are you all okay? I was in outer space. One bloke fractured his collar bone, I'm told.

The next person to ask 'are you okay?' didn't really expect an answer. He wore a green jumpsuit, and had a nice white van with sirens and flashing lights.

I don't remember much of the next part at all, aside from being schlepped up to the Coast Hospital in a C-spine collar and with a 16g cannula providing my sore head and neck (and, as I found out shoulder and leg) with morpheus sensations.

The DEM team poked and prodded me appropriately, fired good amounts of x-rays at my shoulder, ankle and brain and concluded that I was "within normal limits".

With the headaches presently being replaced by memory, thankfully, my noggin hasn't responded too badly to the abrupt 'Hard reset' it received. Touch wood.

This morning I'm sitting my Paediatrics exam, and from Tuesday I'll be reporting from my Elective placement in Sunny Europe. Stay tuned.

It's a week until my paediatrics exam. I've enjoyed the rotation tremendously; it's had the challenge of internal medicine, the wonder of babies and, above all, hope.

Hope is something that tends to be forgotten in hospitals; prognosis boils down to a chance number, a percentage, a fact. Of course that applies to kids too, but the odds seem so much better. A small difference now makes a huge difference down the track. Of course that statement goes both ways, but hey, I'm an optimist.

Paediatrics has been hard. In fact, it's been the most intellectually challenging and rewarding part of medicine I've done. Part of it, I know, is about gaining more experience, thinking systematically and broadly. The other part, I can't explain. The part that gets me out of bed in the morning and to the hospital full of beans (and biscuits). The part that finds me the energy to study late into the night. The part that gets me out cycling for hours at a go, not to avoid study, but to have a clear, sharp, focused mind when the books again fall open in front of me.

I know that, in the wide world of paeds, I have so much to learn. I want to learn it. I'm willing to take my time, soak up the experiences on offer, talk to kids, mums and dads, consultants and junior docs.

Paeds isn't about wolfing down a ginormous meal and digesting it, nor is it about finding a magic key to a hidden lock; it's a long, hard, intellectually and emotionally challenging road. I don't expect to wake up and be the best, nor will I get top of the class in this rotation, but I want to be good at this for a long, long time. I am ready and I am willing.

The last seven weeks has crystallised what I already know;

I want to be a paediatrician.

We can all think of doctors who are less than ideal. They might be rude or arrogant or uncommunicative. Recently, I was unfortunate enough to witness a doctor who is barely safe.

This doctor doesn't understand many disease processes they treat on a daily basis. This doctor doesn't understand the key points of presentations or what they mean or why, if untreated, the patient is in the deep end. This doctor cannot 'hand over' care of a patient to another doctor clearly, accurately or concisely.

The doctor concerned, lets call them Dr F, applies an algorithm to each diagnostic scenario. This approach isn't entirely flawed, in fact, it's often a good way to go, especially if you've got no idea what's happening and you have minimal experience. Importantly, every part of the algorithm needs to be remembered for it to be valuable. And you'd think that with several years of clinical practice under the belt, Dr F would begin to understand what is happening, and why it happens. I'm pretty sure they don't.

Several years ago, I wrote about the Clinical Creep. A jerk of a doctor, to be sure, but a very different beast to Dr F. Essentially, I think that my problem with Dr F is that despite their efforts to be active with their assessments, plans and management, they just seem to miss the point. It's a bit scary.

I appreciate that I'm at the bottom of the clinical tree, and Dr F is several steps above me on the ladder, but I'm just befuddled at how they made it this far. Thankfully, Dr F's superiors are aware of the problem. I wonder what will happen next.

Two teenagers are on the ward, same age. They dress similarly, have similar interests and are the same sex. They don't know each other from a bar of soap.

Both showed up with serious symptoms with potentially life-threatening differentials.

The first knew their symptoms were serious, the other suspected. The first was scared; properly scared. The second was quiet, contemplative. Both kids smiled, just once or twice, in spite of their condition.

The first was investigated and diagnosed with a relatively minor ailment. The second was also investigated and diagnosed with a similar ailment. Both need inpatient treatment.

The next day, the first is surrounded by peers vying for attention; oohing and aahing over the surrounding medical paraphernalia, the patient is cocky, confident, riding the attention. The second sits quietly listening to an iPod, reading.

As they both get better the first's mother says, "Can they go home yet!?". The second's mother asks, "Is my child safe to come home?"

Both go home, safely. The first with fireworks and ceremony. The second calmly picks up the overnight bag, smiles awkwardly at mum as they leave ward.

We all approach mortality with a different style. Our insecurities, however universal, manifest individually.

Mistakes rarely manifest as split second incorrect decisions. Sure, in Pharmacy, dishing out the wrong medication often involves a short, momentary, lapse of concentration where the deed occurs. But many other errors, as such, occur through misreading a situation over a period of time.

We often hear of a patient whose diagnosis was 'missed'. Often these diagnoses are not glaringly obvious. The picture changes over time; it's when there is a level of clinical dissonance the doc needs to rethink their diagnosis. There are many possible outcomes for any given constellation of presenting complaints.

These thoughts wafted into my conscious early this morning, about halfway through a cycling race. In previous cycling races I've been in, when the breakaway jumps off the front of the race, either you see it coming or can react fast enough to go with it. From this piece of information and the fact that my mind was wandering to medical errors, pharmacy and planning a blog post, all whilst racing, you would assume, right then and there, I missed the break.

But today's race was in the hills. Plenty of time to think whilst two young fellows managed to make the weaker riders do all the work, and one by one, we all ran out of puff. Then could they ride away to the victory, we other riders turning the pedals and going nowhere as they launch off to victory.

So, about the time I'm sitting on the front, mind wandering into fairyland and using my energy to maintain a decent pace, something clicks. This is where the mistake happens. For me, it was a cascade of errors; taking a turn at the wrong point, staying on the front too long, burning up energy earlier than necessary, not really concentrating of when to save or burn energy.

And, in fact, the vast majority of medical and pharmacy errors appear to occur the same way. As I discovered during my PharmSchool research project, the literature describes it as a Swiss Cheese model. Only when slices of Swiss Cheese line up, can a certain trajectory of error pass through.

In pharmacy, this is characterised by multiple procedures, checks and double checks for each 'script. In medicine immediate analysis occurs by peer-reviewed diagnostic and management plans; and retrospectively by Morbidity and Mortality(M&M) conferences.

In these meetings, clinicians analyze situations that are considered to be less than ideal, either for the outcome of the process. My previous impression was that M&M was a bit of a witch-hunt; a finger-pointing exercise. They're not.

In the ideal M&M meeting, the scenario is reproduced objectively, and the other clinicians challenged to think;

"What would I do here? What am I concerned about? What information do I need to gather?"

At a particular time point.

Decision making becomes much easier if you already have all of the information, and a 20:20 retrospectoscope. In real life, decisions are made much earlier, borne of necessity with the information available at the time. Often cases in the M&M meetings have a "swing point", where suddenly everything comes together, just like an episode of House MD. In M&M cases, that point is "too late". In near misses, that point is "just in time". In most cases, the ones that are well handled, that point happens well before the critical time. Long before the break has gone and the teenagers have ridden everyone to the ground.

Mistakes happen. The best we can do is to learn from them, analyze them, and try our level best not to repeat ours or others. But they happen. That's medicine and that's life.

Her hands adjust her rings nervously. Anxiously, she twists them 'tween forefinger, thumb each adorned with fake pink tip and sparkling butterfly. The nicotine stains are deep.

She looks through the window at the small boy as he watches television.

She's barely fifty, crows feet scrabbling at fading eyeliner and foundation, small lips dry, voice leathery. She says;

"He's not my son, I'm trying my hardest."

He's not her son. Her daughter has gone somewhere else. Her daughter now comes and goes in both mind and body. Most days, her daughter forgets she has a son. This boy.

The woman is trying hard. She is a flight attendant, she's only new. Her shifts are fifteen hours, six days a week. She's a busy lady, and besides, money is a problem for just her, let alone a kid. She sighs and looks away. Her partner doesn't like the boy either. She's barely home.

He's better now, fixed up in hospital. He's not a well child; he needs care and love.

He watches television. Unwanted.

The Gunner knows the most. They want it the most. They're going to be first to the top.

There are two kinds of Gunners; the self-centered kind, who snipes his colleagues and brown-noses the consultant, who doesn't share notes or knowledge and never, ever gives tips to his colleagues. This Gunner won't stay late without reaping a rewards.

The other kind of Gunner is to be admired. This Gunner loves his work, his joie de vivre emanates throughout his interactions, conversations and study. He shares his knowledge, teaches his colleagues and encourages their zest for his passion. He lends a hand when the burden is great, thanklessly doing more than his share - he knows he does it easier than some others - his passion drives him.

He appreciates that his passion is not everyone's and is open-minded about the foibles and strengths of others. When it comes to his area of expertise, the Gunner knows. And, he knows when to ask for help.

The Gunner isn't yet at the top; that allows his charisma and determination to shine through. He's learning, so comprehensively, so passionately, so logically, so intensely. This Gunner knows his stuff.

This is the Gunner you want to treat your child.

In all the fuss of my first podcast and this week's Grand Rounds submission, I missed my second bloggiversary. As of Monday I've been at this for two years, and as graduation approaches I'm thinking more about how I want the blog to continue when the hospital system eats more of my time. At this stage I'd say it's more than likely to continue; I just can't resist a challenge!

Speaking of challenges, at the end of last year I knocked over the Razorback Challenge. Since then, I've been eyeing up my next physical endeavour. This May, I'm heading to Switzerland on a ten week Elective. And I'm taking my bicycle. The plan is to ride the Valle d'Aulps, a 164km ride with over 3600m climbing. A great opportunity, it looks to be a giant slogfest of altitude climbing, for which I'll need to spend many more hours in the saddle in the next few months.

I'll keep you updated as it unfolds. Importantly, it's a part of a larger challenge, one that extends beyond Medical School; I want to finish an Ironman Triathlon before I turn thirty.

So, in the next four three and a half years, I'll train towards swimming 3.8km, cycling 180km and running a marathon (42.2km) inside 17 hours. By the end of this year, I also plan to run a marathon. It's all about baby steps, starting this weekend with the Mooloolaba Triathlon; my first olympic distance tri.

Meantime, paediatric lectures are calling!

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