The Learner's Perspective

During my obs/gyne rotation in clerkship, I was given essentially no responsibilities and nothing to do. There were PGY1 - 5s before me in the OR and in L&D. I was as close to being useless as a person can be.

Whenever a patient came into the ER for assessment, I jumped at the opportunity. It was rare I could go since the PGY1 wanted the experience, but every now and then I was lucky and a call came while they were in teaching or scrubbed in and I would *have* to go.

I met a woman who came in from the periphery with abnormal bleeding. So abnormal, her hemoglobin (normally low for her) was half of what it was the week before. She was weak, pale, tachycardic and hooked up to a cardiac monitor. Kind of a big deal.

I did the usual med student thing - history and physical, wrote an admission note and orders - after I paged my consultant to ask if we could bolus her fluids then transfuse her since she was hypovolemic and headed to shock. This was a direct transfer so we were responsible for her care and the ER docs are supposed to be hands off - stupid politics. This made sense to my consultant so he agreed then left me to finish the paper work.

This was my patient! I finally had a Gyne patitent!

*ahem*

She was eventually moved upstairs and started on some of the miracle drugs we try when attempted to make the bleeding stop. It slowed down, but not enough as she was still requiring multiple transfusions to avoid complications of her anemia.

The consultant asked me to set up angioplasty for her fibroids with the interventional radiologist. Easy.

The day she was going for the procedure she was terrified - she’d never had surgery before - and her husband wasn’t allowed in the room. I was bored. There was another 4 vaginal hysterectomies on the board which meant that I would not be able to get close enough to the patient to determine gender let alone do anything. So I asked if I could accompany the patient into the IR suite, better to feel like I was doing something by holding her hand than gossiping with the OR nurses.

The patient was happy to have me there and the IR doc loved teaching me what he was doing. I got to show off my mad “switch out the empty IV bag” skills and generally kept the patient fairly calm. She was given a large amount of valium and some morphine because the procedure was painful but it didn’t seem to be enough. She was, to say the least, dopey. And adorable (not a professional thing to say, don’t care, you would have said the same thing if you saw her). She kept going on and on about how cute the doc was “do you think he can hear me?” “Yes, he’s standing right beside you.” “Oh, don’t tell my husband *giggle*.”

When the procedure was done and our patient moved back upstairs, she was in an enormous amount of pain. She was given a pain pump but it was difficult to control the amount of pain. Lesson one, when a part of your body is dying from ischemia, it hurts like hell. The bleeding was slowing down but not as quickly as she and her family expected which was really disappointing for them.

Things did eventually get better, both pain and bleeding, and the patient’s mother started asking again about getting pregnant and if we thought the procedure had saved her fertility. At this point, it was still impossible to know, but we did save her uterus and stopped the bleeding so we had been feeling pretty good. Lesson two, our patients often have different goals of care than we do, even if it felt like we were headed the same way at the beginning. Patients can hear what they want to (so can we). Neither us nor the patient likes having uncertain outcomes, but unfortunately, there they are, everywhere in medicine.

Chatting with my residents the next week in the lounge, I mentioned how funny our patient had been. They all jumped on me. Not for being unprofessional, but because they were jealous of getting to see the embolisation. They had never seen one and weren’t entirely sure how the procedure was done. I was able to see how the arteries of the uterus are laid out in real time and how they differ when a fibroid is involved. Lesson three, everything is a learning opportunity. Pay attention to everything going on or you may miss it. Your busy work project may be another learner’s gold mine so don’t take any of your opportunities for granted.

Yes - those kids in the photo are playing on a pile of manure - likely looking for the pony.

Post Rank Stress

Now that our rank order lists for CaRMS are in you would expect the stress level in the class to decrease. It has not.

On the day the ROL was due, people were still flipping around their top three choices of programs. Some were even still deciding their top choice of specialty. It was a stressful afternoon. I was threatening to glue classmates' fingers to their bums so they couldn't change their choices again.

Some poor folks cried, others threw things, it just wasn't a good day for us.

Since then, we are trying to come up with as many things as we can think of to keep us busy at night to prevent us from losing our minds. It's hard to not second guess the choices we've made. How can we know that we've made the right choice?

13 days between submitting our ROL and finding out our results is cruel and unusual punishment.

rank list

it's in

despite knowing exactly what I wanted to do, still felt like vomiting after hitting submit

Wanna Wanna Sweetie!!

I'm back to classes now in preparation for taking the MCCQE. There is an enormous amount of information we should have ready to complete the exam successfully. It's a bit terrifying to read through some of the objectives that I should have at my fingertips.

The fact that I've made it so close to the end of my medical school degree and feel this unprepared for the exam is unsettling. This is when the imposter portion of my brain kicks in and tries to keep me from focusing. One of the problems with reviewing for this exam is that you have many many options. There are books, including the Toronto Notes and the "purple book". There is a large number of US books too - USMLE Step 2 - and flash cards. I have so many books that can be useful already on my shelves too. Our class has also arranged review classes two nights a week. We have a large number of old exams that I can review.

There's a character that Terry Pratchett wrote, a little boy Wentworth who loves candies. He cries and cries for sweets during the books. Tiffany Aching is his older sister and she describes an episode at Wentworth's birthday where he is surrounded by sweets. He is so overwhelmed with the options that he is unable to begin to eat any of them. Wentworth sits, surrounded by the cakes and candies crying "wanna wanna sweeeetteeee". His mother is only able to squelch the crying by putting a bucket on his head and taking away all but 3 of the options. With the reduced number of options Wentworth is able to happily nibble away.

I need someone to put a bucket on my head.

Or even better, take away my study options.

some mornings, there can NEVER be enough coffee

so I was on my way to pick up review books for the mccqe

"instead I bought this book"

I love my classmates.

I realise the photos are hard to see, but the title is Street Boners. How great is that?

When there’s nothing left to do

A young patient showed up in our paediatric ICU from a periphery hospital. We were told that she had diarrhea and fever that was refractory to treatment, but the x-ray images which were supposed to accompany the patient were lost. Usually this was a hindrance to care but in this case, it meant that we were able to discover what was happening much sooner.

Looking at the abdo x-rays with fresh eyes, we realised that our patient likely had lymphoma which was causing the lymphatics in her abdomen to become so enlarged it was impeding her ability to pass stool, causing overflow diarrhea. Her decreased appetite noted in her transfer file was caused by an obstruction, not as a side effect of the suspected infection. A biopsy confirmed our suspicions and also let us know that this was not going to be curable. It was horrible.

Our patient was an adorable young girl, curly hair, puffy face, fever for months and clearly unwell. She played in her hospital crib while she could, but mostly she slept.

These conversations are never easy to have with patient’s families. They are especially hard to have when the family knew that their child was feeling unwell and the news they were about to receive was horrible.

My consultant took the patient’s family into the quiet room every ICU has. The parents did not want to leave their daughter alone but I was happy to miss this particular conversation. I stayed with the little girl, playing in her crib, then holding her in my lap and rocking her while we watched Dora. She eventually fell asleep there, I am known for being soothing and tend to make children fall asleep quickly. I’m proud of this super power.

When the family came back. obviously distraught, they stood around their daughter and I. These poor folks were so much in shock from the news that they had just received that they didn’t know what to do next. I ended up gently standing up and asking her father to sit down and take her, which he did, sobbing.

My consultant thanked me for caring for the patient, said that it seemed to comfort the parents while they were in their meeting. She really wanted me to go into paediatrics because I’m able to insert myself quietly where I’m needed and so few med students/docs seem to do this well. To me, it just makes sense to snuggle a sick child when she needs it, to hug a family who has just lost their husband, to cry with the woman diagnosed with breast cancer metastasis and to joke with the families under so much stress they don’t know what else to do. I try to do it in a way that isn’t “too familiar” but makes the patients and family feel cared for. I step out again as soon as I can.

When I got home the night after my snuggle, and expected to be more upset than I was. I felt good with the choices I made that day and how we had been able to do what we could.

With the sick kiddos I met in the ICU, I decided to squish as much love and care into their teeny bodies as I could in the time I had with them. If I’m able to maintain this outlook, I really think that I may be comfortable with paediatric palliative care.

taking advantage of a weekend of freedom

classes start again on Monday when we're all back from interviews

MCCQE is in the first few weeks of May

much much studying needs to happen before then - but not this morning

The Unmatched

So what happens if your letter to Santa, err, CaRMS comes back unfulfilled? What if you are one of the dreaded unmatched candidates??

Last year, 3.7% of candidates went unmatched - at least one per school.

The class of 2011 will find out on March 7, 2011 where we are going or if we are re-entering the CaRMS process.

Why candidates go unmatched can be for a number of reasons. If all the programs I apply to are filled up by the time I get that far down my list, it could be me (see “Ranking”). It’s not that I’m necessarily a terrible candidate, just that at some of the crucial points in the algorithm other candidates were better.
I’ve known candidates who did not receive interviews because of something as silly as their reference letters were not in on time.
Other candidates are incredibly specific about where they are applying to residency. If you only apply to one specialty in one program, you better be a crazy rock star or incredibly lucky.
Some candidates have made it through medical school despite being a menace to society - these are rare - and are found out by the residency committees who don’t rank the students to come to their school. The committees are trying to find people they can work with.
Last year, Gen Surg had the highest number of unmatched candidates (13), followed by Anesthesia (11). Family medicine, always touted as a safe bet, had 4 spots unmatched. (these numbers are looking at the first choice of specialty candidates were applying to).
58% of the vacant spots in residency last year were in Family Medicine (176). General surgery had 3 vacancies, anesthesia had 2. In these cases it can be that the programs were picky about their applicants or applicants hadn’t ranked the schools. Or any combination … voodoo!!

If you have ranked any programs, CaRMS will automatically enter you into the 2nd iteration. In this iteration, there are fewer candidates who are Canadian Medical Graduates, more International Medical Graduates and fewer spots overall you are competing for. As a rule, CMGs do better than IMGs if only because we understand how the Canadian Health care system works.

This is the summary of vacancies to be filled in the second iteration in 2010 Every year is a little different.

The 2nd iteration goes faster than the first but is otherwise the same. After finding out on Match Day that you are unmatched, you go over your portfolio to make sure everything is in, apply to the schools and away you go. I’m not sure you interview again, it’s not explicitly said on the CaRMS website Then your new Match Day is April 13.

If the gods are not smiling on you, as sometimes happens, you end up in the scramble. Essentially, CaRMS only takes you through the second iteration and it’s up to you to take it from there. Our Student Affairs office helps students who reach this point. The students find out which programs still have vacancies and talk to them directly about taking a spot. Again, it’s not just the duds who are left unmatched at this point, it’s also the incredibly unlucky and those who have just made poor choices.

I prefer to emphasize the unlucky though - I feel it will bolster my karma.

Rather than enter the 2nd iteration though, some candidates decide to do a year of research to beef up their resume. There are pros and cons to this. Obvious pro is a beefier resume. Cons include the fact that the longer you are away from clinical experience, the harder it is to match (can’t find the stats, just remember that being emphasized at a conference CaRMS talk I was at). When you are away from med school but not in residency yet, it’s difficult to have insurance covered and so you are not permitted to work with patients. Yuck.

What must be almost as bad as not getting the program you wanted, is having to tell your classmates that you’ve gone unmatched. One of the past year’s plays was about going unmatched. It’s a very scary, very real thing. So many assume that they will get everything they want - it’s been happening for them their entire lives, hard to imagine it would just stop now.

I hope that any folks in my class who do go unmatched feel supported by the rest of the class.

Ranking

Starting during the CaRMS interview period, we are able to rank our programs but CaRMS doesn't lock in our choices until February 22nd. We can stew in our choices and make changes until then.

This is where the voodoo really starts.

CaRMS insists that the student is always the one who comes out on top and that they are able to match most students with their number one choice. Last year, 64.6% got their top choice, 2.9% got their 7th or lower.


Here’s how I see it happening for my friends applying to urban family.
Friend 1 wants to rank Mac - Hamilton, Mac - Brampton, UofT - urban, UWO - London, UWO - Regional (that’s it, he’s ballsy and only applied to 3 schools).

He is a good applicant, not stellar though, and will likely show up on each of the school’s rank lists unless he told one of his jokes in the interview, then God have mercy on his soul...
For this friend, having a pool of potential partners is more important than the program. Fair enough given that most family programs are essentially the same, it’s just the location that is remarkably different.
He will rank 1 - UofT, 2 - MH, 3. UL, 4. MB, 5. UR

When CaRMS goes to match him, they will first put him in the pool of people who picked UofT urban. There are 106 spots available for Canadian Medical Grads, so his odds are good. But if more than 106 people ranked UofT Urban first, my friend needs for UofT to have ranked him higher than a bunch of the others applying. If he is ranked 120 and UofT gets to their 150 spot of applicants, he’s in. If UofT only gets to 110, my friend goes to his second choice instead.

Here’s how it happens with me applying to my many (many) rural programs. Because the rural programs are so small, it may be easier to understand. Also because they are so small, it’s absolutely terrifying for me.

I’m ranking 24 programs all together (at 6 different schools). My top 5 programs have 22 spots total. Very different from my friend’s top 5 which has almost 300.
A - 2 spots
B - 1 spot
C - 5 spots
D - 1 spot
E - 13 spots
So my top 5 programs span 2 schools who have ranked me. At the risk of sounding conceited, I’m a strong candidate. I’ve been to the conferences, done the FM research, sat on every FM committee I could plus all my usual extracurriculars. On the whole, not a sucky candidate. I’m hoping it’s good enough to make it into their top ten.

Program A has 4 people who, like me, are gunning for it and will definitely rank A as their #1. There may be more but my sources weren’t clear. If any 2 of the 4 rank higher than me, CaRMS will look at my number 2 spot. If I’m lucky, no one else will want B as number one and it will still be in the running. Then I’m competing against all others who have B as #2. If that school ranks me above all others with it as #2, I get B. If not, I’m moved on to C. And so on.

It’s easy to see that if this continues, given how small the rural programs are, I could potentially end up at my 24th choice.

The trick with the ranking though, is to ignore what the schools are going to do and rank the programs according to what you want. Easier with the big programs than the small in my opinion... The other trick is to only rank the programs you can honestly see yourself in. Even though I have a program ranked 24, it would still be a good program for me. It’s clearly not my favourite, but if sent there by my binding CaRMS contract, I’m OK with it.

There are some programs I’m just not ranking because I don’t want to be sent to them. Worst case scenario I’m sent to the 2nd iteration and start over again.

The Interview Tour

The interviews account for a certain percentage of our overall score that the schools use to rank us. How much they make up depends on the program and usually we have no idea. Personally, I think voodoo is involved.

The goal of our interviews (and everything to this point actually) is for the schools to want to rank ME number one. ME ME ME ME. That makes it much more likely that I will get the program I rank number one. I’ll explain this in a post about ranking.

Prep for the interviews includes collating all our best stories from our clinical experiences. We want to make sure we have examples of good and bad team interactions, leadership, earth shattering awareness that THIS is the specialty for us, strengths, weaknesses, difficult ethical experiences, conflict with a “superior” and anything that shows that we’re not the babbling idiots we usually feel like we are. We practice answering questions but have to be careful not to practice too much because it tends to make it sound too rehearsed.

We buy a suit, or two, and worry about which shirt to put underneath.

Then the actual interviews begin. CaRMS interviews take place in the last week of January to February. In Canada, winter can be less than reliable. Students in my class have had their flights and trains cancelled. Roads have been slippery. I haven’t heard of any interviews that had to be cancelled for weather, just plenty of stress in getting in on time.

The kind of interview you get depends on what specialty you are applying to. Since I want family, my questions usually went something like this:
1. why family?
2. what skills do you bring to family medicine?
3. what challenges do you see family docs may have?
4. challenges the residents may have?
5. tell me about a good/bad team experience and what you learned from it
6. tell me about a particularly difficult clinical encounter and how you feel it has shaped the doctor you will be
7. why this program?
8. tell me about this thing you wrote down on your cv...
9. tell me about your strengths and weaknesses
10. tell me about yourself (very few actually asked this)

Family is a very chill interview - they try to make it more like a conversation so they can get to know us and figure out if we are the kind of person they can work with for the next few years. I was always interviewed by a doc and a resident in a clinical exam room, except one where I was in a board room of a hotel. The interviews lasted 10-30 minutes, with an average of 20.

Friends in other specialties had different kinds of questions though. My friend applying to gen surg was asked “if you were a salad, what kind would you be” - what?? Another in obs gyne was asked multiple ethics type questions and had MMIs rather than just hanging out with the one group. Safe to say that the type of interview you will get really depends on to what discipline you are applying.

With family and some of the other disciplines, there is a morning orientation when they go over the program in detail and why the residents *love* to be there. Family is split into programs on multiple sites so we always get several lecturers to talk to us about the different programs available through the school. This can take hours and is why family med orientations take so much longer than the other specialties. On the upside, we often get at least one meal out of the deal, usually two.

The orientation is followed by the actual interviews. Having such a long introduction to the day has the odd benefit of lulling us into a close to coma state so we are not as stressed about the interview itself. Or maybe it’s just me.

The interview tour has brought out the best and the worst in some people.

Some are acting like competitive children, ignoring conversations started by students from other schools. Others are actively trying to psych one another out. Still others are so insecure in their own worth, they are lashing out at those around them.

The majority are just trying to get through interviews in one piece.

The best though are sticking up for one another. Sharing hotel rooms when the weather is terrible and requires colleagues to stay in the city an extra day. They are meeting the people from other schools and getting to know them as well. Some even help up clumsy candidates when they fall all over the ground...no one I know I’m sure...

They are being the genuinely nice people they are. These are the classmates I am incredibly proud to know.

I was definitely not immune to the stress. The night before one of my interviews I had a dream that the school had decided to get rid of the usual Q&A and make it a spaghetti eating contest instead.

I decided it would be easier to not rank that school than deal with the insanity.

Interview Invitations

Invites for our residency invitations begin coming out a day or two after our CaRMS applications are submitted. Some programs that don’t fill up regularly in the first iteration will send invites before even going over the apps. These are lovely to receive - to know that you will indeed get at least one or two interviews!

Then you wait for the programs you actually want to go to.

These are scary days. One program in particular was a bit evil to me. They sent out invites to one half of the alphabet before the second. Five days before. I thought for sure that despite all my efforts to learn as much as I could about Family Medicine and all the time I’d spent on research and picking electives, not to mention the application preparations, were all in vain. People who were, in my awful opinion, less worthy than I was for an interview. I was terrified to think that those people were getting interviews and I wasn’t. Did my references fail me? Was I an undesirable candidate after all?

Interview invites came in over a month or two. Some of the people in my class didn’t get invites until the week before the CaRMS interview period had begun. That’s scary.

Once the invites are in, you need to decide how to schedule them all efficiently. You can literally be flying from Halifax to Vancouver to Montreal to Calgary. Expensive, especially if you have more than one specialty you are applying to. Some of the people I know have close to twenty interviews. Trying to coordinate all these interviews in all these cities can be confusing and really make you wish you’d paid more attention in computational mathematics.

There are emails and phone calls to make to program secretaries as you beg them to fit you into another day to maximize the number of interviews you can get to. Online purchases of flights, train tickets, bus tickets, reservations of hotel rooms and B&Bs. Deciding whether or not to room with classmates - in the program or not? Will they stress you out or make you feel more confident? How much money will you save really?

Our credit cards all had an incredibly workout in the weeks leading up to the CaRMS interview period.

I mentioned before that I decided that going across the country was not as important for me as saving the money for a trip in the future. It was a difficult decision but enough people were doing the same thing that I felt convinced that it was going to be safe for me to just apply within Ontario. Especially since that’s where I plan to stay.

But I was lucky enough to get invites to each program I applied to. Not all my classmates were as lucky and needed to do the travelling.

They are becoming very competent travellers. One friend has perfected the art of packing to be able to pack all she needs for a two night stay and an interview into one backpack. Impressive no?

The CaRMS Process; Years 1-4 prep

For the uninitiated, CaRMS is a mysterious thing. For those of us going through it, it is also mysterious, but with the extra added benefit of being terrifying.

Here’s how it works...

In first year of med school, some of us decide what we want to be when we grow up. Others don’t. Some of us have known for ever. Some are gunners for their particular specialty and start doing research in the first year and setting up appropriate observerships. We all join clubs and go to conferences and speeches and try to learn as much as we can about what we can do in the future.

In second year, many students who hadn’t previously chosen what they wanted to do begin to have an inkling. Some of these students see what the gunners have been doing and freak out, thinking they need to get to work as well. Some of the gunners decide they must have been nuts and start to change their research focus to something else. Other students remain comfortable in not really knowing what they are going to do since that is the situation of so many others.

In third year, lots changes. We experience the clinical side of medicine and rotate through different core specialties. We also need to choose our ‘electives’ for fourth year which will display our desire for one specialty over another. It’s a stressful choice to make for most of us. We need to make sure that our faces are seen at all the programs we plan to apply to during CaRMS. But most exciting is when we figure out that everything we’ve been planning is for something we don’t even want to do anymore.

So many of my classmates figured out in the last few weeks before beginning electives that they were looking at the wrong specialty. This is exhilarating and terrifying. Electives need to be rearranged at the last minute across the country but doing so means that you are showing so much passion for a field of medicine they now love. It’s something that we are told will happen in first year but we never believe them until it happens.

In our final year, it’s time to enter the CaRMS process. We find consultants who will write us reference letters, then dwell on whether or not these consultants were the right choice. Will they say something that the programs will take the wrong way? Which consultant will put us in the best light? Did I really spend enough time with this person for them to know enough about me to write a good letter? Will they resent me asking?

We need to choose which specialty (s) we are applying to. Should we back up with a less competitive specialty just in case? Should we apply to all the schools in Canada? Am I planning on couples matching? Can I stand to live in these places for years?

We write letters and essays about why we’ve chosen our specialty, what we’ve learned about ourselves and why we want to be in the program we’ve applied to. Then we fret about whether or not we have said the right things, that our examples are beefy enough or that we have accidentally left the wrong specialty or program in the letter when we copy and pasted the lines from one letter to another.

We also need to chose which comments from our third year evaluations will best communicate the type of resident we will be. Which of the ‘code words’ used by the consultants are most flattering.

All those clubs, conferences and research need to be pared down into something that will fit into the CaRMS prescribed CV template. Choosing which should be included and which discarded is something else entirely. Anything included is fair game during the interview. We want to look well rounded but not flakey, responsible but still like we’d be fun to work with.

The week that we need to finally submit our application is terrifying as we go over everything again and again to make sure it’s all there. Birth certificate, photo. letters, essays, transcripts.

Submit.

Wait for the interview invitations to come.

Tenth Anniversary

It has now been ten years since one of my uncles passed away. He will never know what kind of difference he has made in my life.

Seeing how he and his family were treated in the hospital when he was diagnosed with a terminal brain tumour was pivotal in my decision to pursue my medical training. I had already decided that I really wanted to be a physician, but seeing how much my family needed to know what was happening in their decision making process, an advocate who spoke the language of the hospital. The docs who were speaking with the family were patient, kind and thorough. I'm not sure there could have been better people to walk my cousins and aunt through the difficult decisions they needed to make. We were lucky/blessed that these were the docs we had for this process.

My family stood vigil over my uncle and his family. We took over the entire waiting room and, not to put too fine a point on it, harassed the staff with our questions. There were arguments among the family about withdrawal of care, whether or not this is what my uncle would have wanted. It was both an awful time for us and a fabulous time. We were close and pulled apart at the same time.

The night before care was withdrawn, the family threw a SuperBowl party for my uncle. Pizza, beer, football being thrown around.

On the day of his funeral later that week, I was very upset. Not just for the loss of my uncle, but because I wasn't ready for losing this generation of my family. I think I've mentioned before that I have a large family. My younger brothers, all much larger than me, surrounded me in a circle and took turns rubbing my back and comforting me. They made me feel safe.

My aunt did not take her husband's death well, as anyone would expect. Unfortunately though, she didn't have the resources I seemed to have nor a physician who saw the warning signs of someone who was not coping well with loss. Her daughters did all they could to help.

I always like to think that I learn from tragedy. So what I have learned from my uncle's illness and death is the following:

1. Families are complicated - never assume that the person standing in front of you speaks for the entire family.

2. Families deal with death in different ways. Mine is very used to family members dying - a side effect of having so many members. We know that touching one another and the dying person helps us get through. We know that bringing "busy work" keeps us grounded when our world is spinning out of control. We know that there is often a magical time just before death when the patient becomes lucent, and needs to speak with their children/partner so whoever is with the patient needs to go and get them for this window is fleeting.

3. Families will have a lot of questions. They need to know the steps in what is happening next and how to prepare for the death itself. They will also ask these questions again and again. It's tempting to say "I already told ... this", but imagine this is your family. You need to be patient and explain it again or even better, have a large family meeting to explain it to the entire family at once, answering questions and decreasing the misunderstanding that can lead to family conflict.

4. Sometimes those closest to the ill member need to be told, lovingly, to get their butts home to bed.

5. Since these members of the family are spending so much time in hospital, offering to clean their homes, make some casseroles for the freezer, do their laundry can be the best way to help a family going through a death.

6. Laughing is OK. So is crying. Showing that you care about the ill patient and their family is most important. While you never want to presume that you are feeling more than the family, letting the family know that their grief and emotions are justified can be helpful. It should never be easy to withdraw care from a patient. Never, no matter how ill the patient is.

7. Never presume to know what a family wants or needs. Ask. A SuperBowl party meant quite a lot to my uncle's family, brothers and sisters. It made them feel a bit of control over this completely uncontrollable thing that was happening.

8. I've learned that I'm not alone. I have brothers who love me as much as I love them.

9. The family of a patient who has had to have care withdrawn is particularly at risk and needs to be cared for by their family and their physicians. Judgement of the choices they make to deal with the pain they are feeling is not appropriate and will not help. There will be times that tough love may be needed, but gain the respect of the family and try to understand their choices before pushing your own agenda.

Though all of this learning came from his illness and death, I think what my uncle would appreciate most today, is that they were good enough to throw a SuperBowl in his honour.

of course I remember cousin Imposter

She's a doctor. She fixed Ryan's broken arm. She played clay with us.

What a wonderful description of me!! I wish I'd learn this before I went on my interviews...