Tonight I felt like a Doctor...

“Most doctors are prisoners of their education and shackled by their profession.” ― Richard Diaz


Monday August 8th, 2018. That is the date, when it happened. I walked into the Paediatric Emergency Department as an intern. No longer a medical student with limited responsibilities and an early dismissal time. That night, I found myself a prisoner of my education and surprisingly shackled by my new profession.

I realised that the mould I had decided within myself to break, was beginning to settle. My environment was doing its best to imprint its treasured norms not only into my mind but also my heart.

It was my encounter with a parent and her child that made me realise that I now wore loose shackles of medicine. Her tiny hand, warm smile and vivacious giggle despite her ill-appearance broke the trance that I unknowingly had fallen into.

Hopefully this post shares some tips on staying afloat in the fun world of the Paediatric Emergency Room while ensuring you're remaining true to yourself, your morals and values and your God-given purpose while taking initiative.

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Nick had been out of work for three weeks. He had known the downsize was coming, but he hadn't expected to be caught in it. What's wrong with me?  Nick thought. He rationalised that he needed to get his resume updated before he started looking for a new job, but he knew that was just an excuse. He just couldn't make himself get started. 

Each morning he'd vow anew to check out leads, make phone calls, and get in touch with agencies and headhunters, but first-there was always a "first"-he had to run by the church to help repair the roof, or he had to mow his yard, or he had to go by the gym to work out his sore muscles, or he had to sit down and figure out a new budget...

Nick knew he couldn't keep putting off his job hunt. "Help me, God," he prayed. He picked up his organiser and started making notes.

Everyone has something in his life that he seems to put off doing. It may be finishing a college degree, buying a house, or applying for a promotion. It may be something simple like painting the house, cleaning the garage, or balancing the check book. Ultimately, if some project never gets accomplished you have no one to blame except yourself. What a waste to look back and say, "If only I had..." Make yourself accountable to God to get yourself moving. -Renewing Faith 2017 Planner

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As the first point of patient care, working in the Emergency Department requires honesty, accountability, strong attention to detail and the ability to take initiative.

You will often be faced with persons and their egos which may lead to a delay in patient care and hence overall patient satisfaction and/or survival; do your best to maintain professional rapport, however you're not required to accept that type of behaviour as normal or adequate. 

These two weeks in the Paediatric Emergency Department has taught me: 

1. How to listen to patients (and their parents)
2. How to differentiate the battles that I can fight and those that would require referral to the "David" of the department and 
3. How to tame my shaky hands when unruly, frightened adolescents wiggle and continuously scream "doc, dat needle hurt!"long after the anaesthetic has been applied and taken effect and all sutures have been tied off, covered with topical antibiotic cream and secured with Bactigras paraffin gauge dressing and an IV 3000. 

THE DO's






1. Know your schedule.

By the end of this series of posts, I'm going to sound like a broken record, but I cannot say it enough. Know your schedule.

The rotation through our Accident and Emergency (A&E) Department is short and done in shifts. It is vital to know when you're expected to show up as some senior personal won't send you an email or any form of notification regarding which shift they have scheduled you for.

How it works here, is simple. For each specialty rotation there is one selected Consultant who is responsible for the interns/house officers. They are the persons everyone in the department goes to when they have an issue with the group or simply want to comment on how good the group is doing. That person is also responsible for the scheduling of the interns and organising our class and final examination.

As each section of the Paediatric department has their own expected work report times, the intern coordinator doesn't schedule you for a particular shift during a particular area of the rotation, that is done at the discretion of the persons in charge of that area.

For example, A&E has two shifts from Monday-Thursday, two shifts on Friday and one shift on Sunday and Saturday. Monday-Thursday you can be scheduled for the morning shift  or the evening; 8a.m.-4p.m. and  4 p.m.- 12 a.m respectively. On Friday the morning shift starts at 10 a.m. and ends at 6 p.m. with the night shift staying the same as Monday-Thursday. The weekend shift is from 8a.m.- 4 p.m.

Knowing your schedule allows you to mentally and physically prepare for your time in the department. It can also allow you to check (and see with whom you'll be paired with) if a printed schedule is available.

If you're switching from one area say on a Tuesday (which is how our switches happen every two weeks), use the Monday evening to find out where and when you're to show up. It helps with saving gas and allows you to make the most use of your time. Imagine, you've been scheduled to work on Tuesday night and you show up at 8a.m. thinking you're to work the morning shift. What a waste of sleep time and gas. Don't give anyone anything negative to say about you if you can avoid it. We all know there are lots of haters in the world.

2. Get Oriented

Maybe it's just me, but I like to know all the nitty gritty about any area I'm scheduled to be in for a certain period of time. It just makes the transition easier and affords me the opportunity to focus on  patient care without wasting time looking for things that I would need to perform my tasks during my shift. 

Since this part of the department is very different with its own set of needs and management, it is good to have a senior person give you the run down of how things work. 

As the intern in A&E, during the shift you're scheduled for, you're responsible for the following things: 

  • Seeing the patients before being asked to,
  • Present (Discuss) all patients to a senior person before initiating treatment,
  • Manually log all persons seen for the shift in the patient log book (physically write each person's name and particulars along with the nature of their injury, the service provided and the disposition),
  • Manually log all patients who had cultures done that are needing follow up in the culture book,
  • Check the culture book before the end of the shift and update (transcribe their report) it. In the event a patient's results need to be acted upon i.e. Blood culture grew a bug, inform your senior and contact the patient so they can be treated if warranted. 
  • Ensure the dry-erase board is updated at all times with the names of the patients who are currently being treated in the department or those who were admitted. This makes for a smooth handover and reduces mismanagement or a patient being overlooked from one shift to another. 
Also, in terms of being oriented, know where your supplies are kept. 

Our department has a cupboard that is usually locked at the end of the shift, that houses hard to come by supplies such as culture bottles, paediatric specimen tubes, aerochambers and other tools for educational purposes and even paediatric textbooks, computer mouse, diagnostic kits and working staplers. I sensed your eyes widening at the 'working staplers', trust me, it's hard sometimes to find a stapler. 

What I did at the beginning of the shift especially if I worked the night shift, was to stock up all of the trays and storage units on the floor with supplies such as sterile urine cups, IV catheters of various sizes, made splints for the night and stocked the cabinets, ensured we had specimen tubes for the basic laboratory investigations we ordered as well as ensured there was more than enough biohazard bags, gauze, heplocks etc. 

The last thing I wanted was to be unprepared in the event a trauma rolled in. I never got to experience a paediatric polytrauma, but following my shift one night, another Physician did and she was more than grateful to us for leaving the area stocked, clean and organised. 

3. Document! Document! DOCUMENT!

Practice proper documentation of everything

Some services are riddled with Senior House Officers with inflated egos who have a misguided sense of their duties. If you haven't encountered any as yet, prepare to meet one or two during your time in A&E. 

Get in the habit of documenting when you sent a page for a referral, when that page was answered, by whom and a synopsis of what was said. Document when they showed up and what was done and what was to be done in the future if they failed to document it. The last thing you want is for the next doctor following you to not know what was done or to be done for a particular patient. 

It's best to have some form of documentation (preferably in the patient's file) of the overall management in the event legal matters arise. 

If your hospital has certain policies regarding documentation, familiarise yourself with it. The one thing I wish our hospital was good at is providing Standard Operation Procedures for each department and the common scenarios encountered. Why? Because it would allow for standardised care and something to stand on if someone ever questioned why you did or did not do something. 

4. Do ask for feedback

As you move through the various areas, remember this is all another rung on the ladder of continuous learning. 

Speak to your seniors. Develop a professional relationship where constructive criticism can be given and where you are comfortable growing as a Physician. 

Ask them for advice for improving your histories in the department as A&E focuses more on the abbreviated history. Try to utilise your seniors for your success. These are the big kahuna's of the field, adopt their good practices and forget the rest. 


The Don't's


1. Don't Waste Time!

The main purpose of the A&E department, be it adult or paediatrics is to provide quality care, reduce turnaround time and to ensure overall patient satisfaction. 

Be efficient and try to get the patient in to be consulted, examined and treated in a timely manner and out if possible. 

2. Don't pick fights with Senior House Officers (who aren't aware of their roles or responsibilities)

This may be easier said than done but ensure you approach every Goliath cautiously especially if they are not in the same department as you. 

It is easier to report any issues, document the situation and its outcome and remain professional than to argue with someone whose main goal is to make life difficult for you. 

You will quickly recognise the culture of each specialty and each person based on their position in the hierarchy. 

3. DO NOT CONFORM

Do not be quick to settle. Three months in any place can start to feel normal. Be true to yourself and your morals and the overall purpose of you being there, which is to learn, advance in your career and to provide adequate and professional quality patient care. 

4.  DO NOT vent to everyone

Be wise with whom you confide in. There are lots of 'news toters' lurking around just waiting to start some confusion. 

If you can, start a journal and learn a new skill. Write down your experiences. Be cautious with how you vent on social media as well. 

You may not be aware, but most areas conduct evaluations of their staff, interns included; these evaluations at the end of your internship may work against you or for you. 

Be mindful that what you may mention to someone 'in confidence' may end up hindering your progress. 

5. DO NOT order unnecessary tests

Your patient is your answer book. In A&E, learn to be smart with your diagnosis and your differentials. 

Based on their vitals, the presenting complaint and the history of the presenting complaint you should be able to determine what tests you need to order to confirm your suspicions. 

It's up to you Sherlock to pay attention to the clues. 

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All in all, it's a great experience! 

In summary, be prepared and remember you're going to be faced with patients who you just don't know what's wrong or where to start. But remember, you're not alone. 

Be sure to: 

  1. Create lists: they will help you stay on track
  2. Keep busy: with purpose, but enjoy the downtime
  3. Always be bold enough to ask for feedback and to speak up if you're uncertain why you're doing something or being asked to do something. 
  4. Take the initiative but don't overstep your boundaries. 


Growth

"Thinking always ahead, thinking always of trying to do more, brings a state of mind
in which nothing is impossible."- Henry Ford



It's been two weeks since I've been employed as a Medical House Officer. I won't comment on whether they were tough or not, rather I've decided to share some tips for persons who will be rotating through any Paediatric Hospital Clinic, however some things may be more specific for my setting but nonetheless they may hold helpful to others elsewhere.

I recently read a devotional entitled 'Growth' which I would like to share before I delve into the tips, so bare with me a while.

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Derek and Jordan were neighbours who agreed to plant a small vegetable garden together. They would each help care for it and share the produce with their families. The friends looked forward to spending time together on the project, but neither realised how involved the task would become. 

It took time digging up the soil and breaking up the hard clods. Planting the seeds required precision. Some had to be deeper than others; some were planted side by side; others were planted eight inches apart; and still others were planted three inches apart. As the seeds sprouted, a portion of the plants required stakes to support them. Watering, weeding, fertilising and cultivating took a lot of time, but the guys kept their end goal in mind. 

Finally, they began to see the fruits of their labor-tomatoes, squash, beans, cucumbers and other vegetables. As they harvested their crops, Derek remarked, "Aren't you glad we don't do this for a living? It's fun, but it takes a lot of work."

The time and energy it takes to grow a vegetable garden can be compared to the effort it takes to "grow" your life. You must fill your life with healthy, nourishing influences. Be careful of what you read, what you listen to, whom you talk with, where you go, and whom you choose for friends. Living a fulfilling life requires planning ahead and maintaining your "soil" daily. The value of your life will be measured by the positive impact you have on yourself and others. 

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These two weeks were all about growth. Being able to work alongside other physicians more seasoned than myself and to communicate as a colleague has shown me that in life, we're all given the opportunity to grow. Some of us require more soil and sunlight than others, but that's alright, the goal is to continue to grow.

I started off with nine other colleagues in the Department of Paediatrics. This department has several areas each house officer is required to rotate through during the three month period on the rotation. These areas are: 

1. Community Clinics (of which there are 2)
2. Team 1 (which is a hospital based team consisting of 3 consultants with various specialties in addition to General Paediatrics)
3. Team 2 (same as above)
4. Accident and Emergency Paediatric Department
5. Maternity Nursery 
6. Hospital Clinics (all previously discharged patients and patients with particular needs are seen here)

Today's post will shed light on the intricacies of the Hospital Clinics and what you can expect on each particular day and ways to ensure clinics run smoothly and on time. 

INTERN TIPS

1. BE ON TIME



This pretty much goes without saying. First impressions are lasting impressions and if you're known to be punctual believe you me, everyone will notice. If you're new to the hospital clinic setting and what all it entails, arriving early affords you the opportunity to speak with the nurses in charge or the Senior House Officer or the Physician overseeing the runnings of the clinic so that you can be informed of the functions of each person on the team and how each clinic is ran if there are multiple clinics on the same day.

Arriving early also gives you the opportunity to ask the patients whether or not they are attending clinic solely to get results for tests that were done at their last visit since in our setting depending on the result, you would have to walk to or call the laboratory to retrieve the results. Once this is done you can attach them to their notes for the day which will expedite their visit.

When you're new to an area, it takes sometime to get acquainted with where things are located and where they belong. Being on time or earlier than scheduled particularly on the first day allows you the opportunity to get a tour of where things are stored, where the bathroom is (staff vs. patient), where the supplies are kept because you'll always be in need of an alcohol swab, tongue depressor or gauze as well as those infamous continuation sheets for the patients notes, growth charts (because every child is plotted) and referral forms. There are other documents that are dedicated for certain things that you will also need to know-headache diary for instance for patients who present with a history of headaches in whom you're trying to rule out migraines.

At our clinic all of the necessary documents for the various clinics excluding Infectious Diseases clinics are stored in a brown accordion folder which is placed on the desk in each examination room at the start of the day and stored by the nursing staff at the end of the day along with a cylindrical desktop container that houses all of the tongue depressors, alcohol swabs and gauze you'll ever need.


2. INTRODUCE YOURSELF



With changes being made to the schedule in terms of who goes where each month or every other week, it is important that everyone is aware that you are new to the team or service and it also allows you to familiarise yourself with the persons with whom you will be working over the next few days, weeks or month. 

By introducing yourself to everyone, you'll also have the opportunity based on the ranking to know to whom you are to report and who can actually review your consults and ensure your plan is in keeping with protocol and in the best interest of the patient. 


3. KNOW YOUR ROLE


In the Paediatric hospital setting your role as the medical house officer is to frankly, be on time, see patients, don't get on the nurses or any other team members' nerve and to ensure that you complete everything necessary for your patient. 

At this stage in your medical career, the goal is to gain knowledge, improve certain skills and to ensure that your history taking, physical examination and overall patient communication is improving and you're asking for help when needed. 

It is imperative that following the review with the consultant, you document everything that was discussed in their presence in the patient's note, you complete all necessary referral forms and fill out any prescriptions they may need and ensure they understand what was discussed BEFORE they leave. In our system, the medical clerk is responsible for making the follow-up appointments, but as the house officer it is our duty to ensure we inform the patient and/or the clerk of when we're wanting them to return for their next appointment. 

4. KNOW YOUR SCHEDULE



Knowing your schedule allows you to keep track not only of where you're meant to be at a particular time of the day, but also when you have some free time to get other things done. 

If you're like me, a new house officer with some things to follow up in the Human Resources Department then knowing how much free time you may have ahead of time can help you take care of other matters. 

In regards to the hospital clinics, there's usually a clinic on every day of the week excluding holidays or during MBBS examination time which is around May/June each year. Here's an idea of our hospital clinic schedule: 

On Monday mornings as you can see, there are three clinics running simultaneously, so on those days it really is a gamble as to which patient you will see. Team 2 patients basically are kids who were admitted on a call when Team 2 was 'on take' or designated to receive the patients on that call. Once they are discharged by the service, they are then scheduled to return to clinic (all at the discretion of the Team) for a follow-up to ensure they haven't had any problems since, or if they did have any medical issues, what they were and whether or not they would need to be readmitted or watched closely before being completely discharged from the clinic. 

The consultants on Team 2 are General Paediatricians with Paediatric subspecialties such as Paediatric Neurology, Endocrinology and Asthma. 

Like previously mentioned, Monday mornings are a toss up. The patients needing to be seen in Paediatric Chest Clinic (patients with PTB for example) or the Diabetic Clinic is dependent mainly on the week as these two clinics alternate on a weekly basis. So if this Monday was the week for Chest clinic then the next week would be the week for Diabetes clinic. Following the morning clinics which can sometimes run a little late (all depending on the patients needing to be seen and the complexities of their case) is asthma clinic.  

In asthma clinic the main goal is to ensure that each patient is controlled on their medications and whether or not they are in need of being stepped up or stepped down based on the severity of their symptoms and their overall diagnosis and assessment. The main questions you must be familiar with asking are mainly based on the symptoms: 
  • When were they first diagnosed with asthma?
  • How did they initially present when first diagnosed?
  • How many hospital admissions or visits to Asthma Bay did they have since being diagnosed to the present time? What treatment did they receive?
  • What medications are they on?
  • Do they take the medications as prescribed? If no, why not? Were they on any medication for asthma before? What was the dose? Please demonstrate how they take their medication and when. Do they use an aerochamber? Do they have an asthma action plan? Do they use a peak flow meter?
  • Since their last clinic appointment did they have any asthma attacks? Any nighttime awakenings because they had problems breathing? Any decrease in their activity or exercise levels due to asthma? How often do they have symptoms of asthma such as wheezing or chest tightness? 
  • How many times in the year, or since their last clinic visit have they had to use their reliever? 
  • How many days of school have they missed due to asthma?
  • What are their triggers (change in weather, cold, flu, illness, smoke, dust, pollen etc)? 
Tuesday mornings there are no Paediatric clinic scheduled. However, all Paediatric interns and Residents have a teaching session at 8:30 a.m. At 12:30 on Tuesday afternoons, there is an Intern presentation session scheduled, from which you are excused by 1:30 in the event the session is running longer than normal so that you can make it to clinic in time to see patients for Sickle Cell Clinic. 

Be prepared to leave clinic around 4:30 or 5:00 on a Tuesday. Since there is only one Sickle Cell Clinic per week and one Paediatric Haematologist in The Bahamas, this clinic is one of the well attended clinics (which translates to sometimes 10+ patients). Punctuality to this clinic is essential mainly because there are so many patients to be seen and sometimes plenty pathology to be exposed to which means the teaching opportunities are endless. 

When seeing patients in the Sickle Cell clinic it is vital to ask the following questions: 
  • Since their last clinic visit have they ever had the following: fever? chest pain? dyspnea? cough? 
  • Age of diagnosis? 
  • Last date of crisis? 
  • Number of hospitalisations and the reason (acute chest vs. vaso-occlusive crisis)? treatment while in hospital
  • Number of transfusions if any
  • Steady state
  • Immunization history
  • Current medications their on and whether or not it was changed at any point
  • Any symptoms of anaemia (fatigue, lethargy, pallor etc)?
  • Abdominal distension or pain recently or in the past? Any surgeries in the past?
  • Dehydration status (water intake)
  • History of jaundice
  • Any exercise intolerance or cold intolerance or history of swollen joints? hands or feet?

When you're assessing them, be sure to look in the their mouth and refer if needed to a dentist if you happen to see a number of dental caries or poor dentition. Also, be sure to review the tanner staging and comment on the Tanner stage. The consultant in our clinics loves to ask about the tanner staging as well as the surgical history and the conditions sicklers are prone for which would result in them needing to undergo surgery. 

Wednesday morning clinics are dedicated to Infectious Disease clinics. Be sure to speak to the Senior Registrar or the head nurse in charge of this clinic as this clinic runs differently compared to the others. They will be the ones to advise you on which patient they would prefer you see and how to go about conducting your consultation. This clinic runs fairly smoothly because the nurses are so efficient.  Once this clinic is done, be sure to get a bite to eat in between. Technically afternoon clinics are scheduled to begin at 12:00 p.m. however, the team may decide to work through a break so clinics can end a few minutes earlier. 

Neurology clinics can be long as well but they are filled with learning opportunities so be sure to make the most of your time there. Wednesday afternoons are usually for follow-up patients so reviewing their drug levels and reading EEG's to determine if medications are to be adjusted. Sometimes though, you may have one or two new patients who were referred to Neurology clinic that are seen on a Wednesday afternoon as opposed to a Thursday. One main tip for Neurology clinic in addition to a detailed CNS and MSK examination, be sure to complete a mini mental status examination where needed. For example if the patient has some developmental delays and during the exam appears to be cognitively impaired. It will help in your assessment when you're presenting to the consultant.

Thursday- all day- you'll be stationed in the Neurology clinic. Team 1 clinic patients are usually seen by the senior house officers and more seasoned members of the Paediatrics department. The physicians in charge of Neurology clinic will be the ones with whom you are to report and who will be responsible for dismissing you from clinic. 

Friday's are usually interesting clinic days where you don't really know what to expect. Neonatology clinic sees patients who were admitted to the Neonatal Intensive Care Unit at the hospital and discharged. Some patients may be in clinic for results of a karyotyping study that was done or just to know whether or not they will be discharged from clinic altogether.  Fridays can be an early day depending on what needs to be done for a patient and how many patients the Consultant has to see. 

Although our schedule says Cardiology clinic and consults, since there is no Paediatric Cardiologist in the public setting of the hospital this clinic unfortunately doesn't exist. 

5. BE PREPARED


Nothing beats preparation. 

That said, prepare yourself each day for the worse. Pack your bag with snacks, water, lotion, hand sanitisers, extra gauze, alcohol swabs and don't forget your diagnostic kit (since clinics aren't furnished with them). By preparing yourself for anything you'll ensure that you aren't loosing anytime from your consultation with a patient because you're either looking for something or dying for a bite to eat. 

I forgot a few times to pack my bag the night before with snacks that I eat and had to wait until clinic was over to get something. Let me tell  you, the last thing I wanted to eat were peanuts. 

By knowing what clinic you're to attend the following day, you're able to read up on common topics so that you can take advantage of having a consultant present to discuss topics with and why certain things were suggested for a patient's management. 

6. BE WILLING TO LEARN AND TO TEACH


It's all up to you to make the most out of this year of internship. Although you've successfully completed all requirements of medical school and attained a degree in Medicine, it is important to remember that learning is lifelong. 

The clinic settings affords you the time and opportunity to learn. You are in a setting with persons at different levels in a particular specialty who are still learning themselves. Most times they're excited to discuss something with you and to guide your thinking. 

Once you've been taught, it's important to pass that knowledge on to the medical students who may be present in clinic as well. Remember you were literally months ago a student, continue to be kind and willing to teach. After a while you'll realise you won't need to ask all the time the dosage of certain medications and why you're checking the levels of Tegretol in a month as oppose to a couple of weeks (remember autoinduction?) and you'll be now able to store new information. 


7. BE WILLING TO HELP


Regardless of your position on the medical totem pole, you're always find that you're in a position to help. A colleague may be in with a difficult patient and in need of a radiological report but they're unable to move at the moment, if you're free to, why not offer to run and retrieve it? 

What I've found over the last two weeks in clinics is that a little goes a long way, especially if persons were on call the night before and weren't able to get a night's rest. 


8. COMPLEMENT SOMEONE EVERY DAY


Complements go a long way! 

From a simple "you look nice today" to "the way you handled that situation was impressive, you did a great job with that" can create an environment that is comfortable to work in and to grown in. Once people realise that you're teachable, genuinely nice and have great work ethics, your daily experiences -despite the unforeseen circumstances that may arise (i..e that close call with explosive diarrhoea or having kids pee on your lap) will be so rewarding. They may even have a ripple effect that changes the culture. 


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My very good friend Dr. M was so kind to send a video of his tips based on his two weeks in the Hospital in Scarborough Tobago. I've posted it below. 


If you're a new House Officer or an experienced one please share in the comments section your tips and tricks on how you survived your initial weeks of internship. 
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Foundations

"Time is a gift and to use it wisely is admirable"-Renewing Faith Publishing








Did you know that the Empire State Building was built during 1930-31 in a record one year and 45 days? It is known to rise over 1,453 feet from the ground with 103 floors of steel, limestone, granite and brick weighing in excess of 365,000 tons. A total of 1,860 steps extend from the street level up to the 102nd floor. 

Given this construct, the building doesn't sway. It gives, but only to a total extent of 1.48 inches in 110-mph winds. The architect took great pride that the building's movement off center was limited to less than 0.75 of an inch on either side. So what holds up this mighty building and keeps it standing so tall and proud? A 55-foot deep foundation of steel and concrete embedded in solid ground. 

A crew of 600 men working day and night dug the foundation for this engineering marvel in just 45 days, but without these extreme footings, the building would not possess its strength.- Devotional January 2017, Renewing Faith Publishing

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As graduation season rolls on, like the Empire State Building, the members of the graduating class of 2018 worldwide, took the necessary steps to ensure their foundation of knowledge was deeply rooted. I can attest that many sacrifices were made as the New Year began which trumpeted the countdown to graduation. Study groups were formed with persons whom we knew only in passing that blossomed into the most wonderful of friendships. The fickleness of those who we perceived to be close friends was exposed and as life would have it, the ball kept rolling. 

Each day, we saw just how much our lives were like this architectural giant. From the inception of medical school, our character was shaped, as we advanced, we noticed how easy it was to stand tall with assurance in spite of our challenges because we knew our feet were grounded on a solid foundation. 

It may have taken us longer to grasp, however, we learnt to Q-TIP (quit taking it personal) because at the end of the day when a patient's life is on the line, whether or not we are friends with our colleagues is not important, rather having respect and a mutual understanding and a common goal of placing the needs of the patient first is all that matters. 

We sat exams, we performed and we even exceeded our own expectations and now stand proud, not because we made it, rather because we recognise that it was not by our own strength but that of God, that we overcame. 

So to all of my fellow graduates entering the working world or advancing to higher academic heights, remember that despite crossing this hurdle, a new chapter has begun and new challenges await you. 

As Dwight L. Moody once said "character is what a man is in the dark". The people you encounter each day notice how you act and react in various situations. Persons you don't even know form impressions of your character and integrity just through observation; the test is not behind, it now lies ahead. 

Keep stepping out in faith and don't ever forget that God has already placed Jesus Christ as the one and only foundation (1 Corinthians 3:11 NLT) stay grounded in Him. 

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