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March Madness – Dealing with the Stressing of Training

March is synonymous with college basketball, winning brackets (or losing in my case), and general merriment. For those of us in medicine, it may have a different meaning – stresses of matching, winter blues, and a general feeling of being burnt out. For me, March was one of the hardest months to get through in training, despite it being my birthday month.

Living in Massachusetts means long winters and I notice the general spirit of trainees tends to drop during this time. The novelty of winter has grown old, as the holidays have passed and we all seem to anxiously await the spring. The grueling winter days make it challenging to be outdoors, inhibiting us from enjoying our hobbies, and in short, tired of being cold. My friends who have trained or are working in cold climates (i.e Minnesota, Michigan, Wisconsin, Vermont to mention a few) have echoed the same sentiment. My personal interactions with interns and residents are often highlighted by fatigue, decreased empathy towards patients, and a desperate need for “the year to be over.” So, what are the tools we can use to help get through our own March Madness?

Here are a few tips and tricks that have helped me improve my wellbeing.

  • Stress to Strength: Growing up, I played soccer, basketball, tennis, tried picking up running (but limited by jumpers’ knee), and occasionally surfing. Clearly, none of these are great activities if it’s cold outside which caused me to feel claustrophobic in the winters. I instead work out in the hospital gym much more to try to stay active and have a positive outlet for when I am stressed. I often get asked, “what’s a good strategy for me to make it to the gym with our crazy schedule?” I’ve realized not everyone wants to go to the gym before work (which is my routine) but having small, achievable goals is the way to go. For example, try going one day before work, one day after work, and once during the weekend. You don’t need to go every single day to be healthy or stress-free. Having a few days per week in dedicated time slots will help create structure and not make going to work out feel like a chore.
  • Mindfulness: Mindfulness is becoming more popular in the west and for valid reasons. It is the ability to pay attention to the present moment with curiosity, openness, and acceptance. We can exacerbate stress if we ruminate about the past, worry about the future, or even engage in self-criticism; and I have been guilty of all 3. I discovered a great app called “Headspace” that helped me with guided mediation and mindfulness. The app has evolved to help fit nearly everyone’s needs and I have recommended it to several friends/colleagues.
  • Making my list, checking it twice: Trainees have so many tasks they need to complete: pre-rounding, rounding, Epic tasks, notes, discharge summaries, more Epic tasks, case reports, quality improvement projects, and if they have time – grocery shopping. I always keep a list of tasks I need to complete – partly because it helps me stay organized, but also my obsessive-compulsive personality LOVES to cross tasks off the list. If you get overwhelmed with the countless tasks you have to do, start keeping a list. This will help create structure, organization, and improve productivity.

 

  • Reach Out: We all need to have friends, family, and colleagues to turn to when we are feeling burnt out. Fortunately, many training programs have resources available from their GME office, which are often underutilized. My clinic preceptor (and friend) Dr. Brigid Carlson has invited me out for coffee, dinner with her family, and always welcomes me to speak to her if I am feeling overwhelmed. Knowing I have someone to turn to has helped me not “bottle things up.”

Although March Madness is traditionally stressful with college basketball, it should not be the same for the workplace. With spring on the horizon, many of us feel the stresses of training but there are resources to help us to continue to be successful.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

 

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On teaching Professionalism

Professionalism is a multi-faceted concept that carries different meanings to different people; it ranges from a physician’s bedside manner and acknowledging mistakes, to how one interacts with their peers and if they show up on time. Not only that, but this all-encompassing term is cited as a core competency by the American Association of Medical Colleges. It is also a part of the American Medical Association’s code of ethics and explicitly mentioned in the syllabi of most medical schools and training programs across the U.S. Despite the broad acceptance of professionalism as a key character component of a well-rounded clinician, there is a significant difficulty experienced in trying to teach this to trainees. This may seem a little long-winded, but this is a subject that really resonated with me, and with JAMA instituting a professionalism section a few years ago, there have been more and more pieces published on the topic; I’m happy to see that this is gaining more traction. Everybody will tell you that administrative burdens and needing to deal with insurance providers for prior auths and the like definitely contribute to burnout, but having unprofessional colleagues can be just as burdensome and unsafe for patients!

I recently came across an excellent piece in the New England Journal of Medicine titled “Responding to Unprofessional Behavior by Trainees – A “Just Culture” Framework” wherein Dr. Wasserman, Redinger, and Gibb attempted to tackle the difficult yet important concept of professionalism in medical training. The article made a strong case for treating lapses in professionalism as if they were medical errors of varying severity, and they included an infographic, as well as gave several examples to go with this framework. In my opinion, professionalism is one of those behaviors that is nearly impossible to teach in a classroom and is often developed through a mix of modeling behaviors from more senior physicians, as well as a little bit of one’s own personality/temperament mixed in.

There was an example cited by the authors that centers around a medical student who has begun a collaboration with a mentor on some database analysis. The mentor states this is an IRB-exempt study and urges the student to begin analysis immediately, but the student’s research office instructs her not to download the data until getting an official exemption was issued by the IRB. The mentor pressures the student into downloading it anyways, and the student gets reprimanded for this. Wasserman et al suggest this is a lapse in professionalism at the lowest level – “no-fault suboptimality” resulting from the student’s faulty understanding that the supervisor (mentor) is right. They focus on teaching the student “strategies for diplomatically addressing her mentor” and acknowledge it is a difficult situation. What they don’t do, however, is acknowledge the context of this lapse of professionalism; they make no mention of addressing the mentor’s behavior or holding them accountable.

By all means, I agree that the student’s incorrect logic needs to be addressed. But, by not addressing the lapse in the professionalism of the mentor, I think the authors missed an opportunity to strengthen the analogy of professionalism and medical errors. In the “Just Culture” movement, physicians were just as accountable as nurses, who were as accountable as medical students for speaking up against unsafe practices. In this scenario, I would argue that the mentor is more liable, and should be held even more accountable than the medical student. As the authors have already made clear, trainees are still developing their understanding of professionalism, but this mentor is arguably an individual who has completed their training and should have a stronger grasp of professionalism than a mere medical student.

I concede that their article was aimed moreso at addressing lapses in professionalism of trainees, but this circles back to my personal view of how professionalism is developed. As others have stated, ensuring an individual trainee’s “competence in the area of professionalism requires the concerted efforts of many.” However, what about non-trainees? You could assume that a hospital board or professional society will self-govern to ensure professional behaviors, but with a term that is so loosely defined, and with financial incentives on the line, how much would someone be able to move the needle? I think most of us can remember at least one time (or many), when a senior physician tore into a helpless colleague, or became frustrated and lost their temper. How often do you think these individuals get a time-out or get part of their wages withheld as a punishment?

This brings me to my point: if the system is flawed, how does putting additional pressure on trainees fix that? The “do as I say, not as I do” approach has never been tested in a randomized trial, but conventional teaching theory (and common sense) will tell you that this is not effective. I myself am a trainee still (you’re reading the Fellows In Training blog, duh), so I certainly do not have all the answers.

From my time spent in developing medical school curricula, and sitting on academic disciplinary committees, I’ve come away with a few insights that I think might help. When the issue is a systems issue – such as “well everyone in my class skips grand rounds, I thought it was ok” the individual who got caught usually got caught due to chance, and reprimanding them would be unfair. Wasserman et al mentioned that the system needs to be changed, but didn’t talk about how. I’m gonna piggyback on that, because systems changes are difficult, and can be nuanced depending on the problem.

I think that lapses in professionalism should be addressed, but a better approach would be one that relies on positive feedback rather than only mentioning professionalism when it is missing. For example, in my medical school, and most training programs, at the middle and end points of a rotation, mentors would take the medical students for some formative “feedback”. Sometimes they were going off a form issued by the medical school, other times they would go off what they felt should be emphasized. If throughout a trainee’s career, different levels of professional behavior are emphasized by instructors, this could go a long way.

One example of this would be that mentors are instructed to focus on the aspect of timeliness and respectfulness with first-year students, making sure to comment on these in each student’s feedback; but when they give feedback to third years, they emphasize other aspects of professionalism, such as truthfulness, admitting to mistakes, knowledge gaps, etc.

Many theories have been put forth as to why professionalism can be such a difficult concept to teach and practice, but I think a critical shortcoming we have to acknowledge is the disconnect between the two worlds that trainees must straddle: the world in which we teach professionalism, and the world in which they practice.

 

References:

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Building an academic portfolio during medical training: Part 2 – finding your research team

In my previous blog, we discussed why it is important for medical students and trainees to consider research collaborations outside their own institutions, and what types of research studies can be performed using this type of collaboration between young researchers. In this blog, I will focus on how to find potential collaborators and/or join a multi-institutional team of young researchers.

Once you decide to explore this non-traditional way of doing research, the first challenge you will be facing is how to find potential research team members. At this point, you need to take a step back and ask yourself 2 essential questions:

  • “What area(s) of research am I interested in?” – This will largely be dependent on the particular specialty you are interested in pursuing as a career, and whether you have a general interest in this specialty or a more focused area that you would like to explore.
  • “What skillsets can I bring to the table in such collaboration?” – No matter how novice you are in medical research, you can always be a valuable team member provided that you are willing to learn, work hard and acquire new skills. But it is essential for you to know exactly what you can or cannot do, to be able to find your right position within a team. A successful research team requires a myriad of skills, some are basic, such as searching the literature or collecting data, some are more advanced, such as conception of research ideas or scientific writing, and others are specialized, such as relevant statistical knowledge and competency in using a statistical software or experience with using one of the databases that we previously discussed e.g. National Inpatient Sample (NIS).

Answering these 2 questions will help you present yourself in an honest and practical way to your potential collaborators, and will ensure that you achieve the 2 fundamental goals of any collaboration: to benefit and to be beneficial. It also gives you an idea about what potential skills you can work on acquiring to increase your value as a team member.

Now that you know what you want and what you can offer, it is time to find your collaborators. The easiest and most straight-forward way is to collaborate with people that you had previous experience with, like your medical school colleagues, or co-residents from your previous training program who have similar research interests. However, this may not be an available option to you, so what to do in this case? – If you are still taking your very first steps in the research field, you would be better off joining a team that is already established rather than building a new team. There are several ways to identify multi-institutional research teams that are already up and running:

  • Word of mouthyou may have heard about one or more resident or fellow who does this type of research, and in that case, you could reach out directly to them.
  • Medical literatureyou could search within your field of interest for recently published meta-analyses, systematic reviews, or articles that use one of the publicly available databases that we mentioned, and examine the authors’ list. What you would want to look for are articles that are authored by people affiliated with different institutions. Next step, would be to look up some of these authors on PubMed and see if that same group of authors (or some of them) publish these types of articles frequently together. Once you identify a particular group of collaborating authors, then you could look them up to check if they are mostly residents and fellows.
  • Social mediathis is another great tool for research collaboration. Twitter, in particular, is becoming an invaluable platform for sharing medical knowledge and recent research articles. Many of the currently active research groups promote their work on Twitter, and using the same process we just discussed, one can easily identify active members of these groups and reach out to them directly. Further, many researchers nowadays reach out on Twitter when they need young motivated medical trainees to help out with ongoing projects. So I would strongly encourage you to get on Twitter if you haven’t already done so and to start following people with similar research interests.

At this point, you know your research field of interest, you are aware of what you have to offer as a research team member, and you have identified potential research team(s) that you would like to be part of. You should be ready to reach out. What is the best way of presenting yourself? How can you maximize your chances of success in joining a team? This will be the topic of my next blog. So stay tuned…

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Learning on the Go – Some Podcast Recommendations

As researchers, clinicians, and/or trainees, there never seems to be enough time in the day to get all the stuff done that we want to get done. There seems to always be more papers that we want or should read. One of my favorite ways to try to stay up to date with the latest research publications is listening to podcasts. I enjoy listening to podcasts while commuting and doing chores, and sometimes while working in the lab when no one else is around. Depends on my mood whether I can listen to a podcast while exercising or would prefer to listen to more energetic music.

Below is a list of some of my favorite cardiology podcasts. This is not a comprehensive list and I am not affiliated with any of these podcasts. I also am not endorsing any of the content discussed in the below podcasts. This list is also biased towards those podcasts that are easily accessible via smartphone podcast/listening applications and do not require downloading individual episodes from specific websites. These podcasts are not listed in any particular order.

  • Circulation on the Run: Summarizes the articles published in a specific issue of Circulation and has a more in-depth discussion of a featured article.
  • Discover CircRes: Summarizes the articles published in a specific issue of Circulation Research and also has a more in-depth discussion of a featured article often with the article’s corresponding author as well as the trainee involved in the article.
  • The Bob Harrington Show: Interviews and discussions of various topics in cardiology and the practice of medicine.
  • This Week in Cardiology: Dr. John Mandrola summarizes and provides his insight on some of the top news in cardiology for the week.
  • JACC Podcast: Dr. Valentin Fuster, editor-in-chief of the Journal of American College of College (JACC) provides an overview and summary of the articles published in a specific issue of JACC.
  • Eagle’s Eye View Your Weekly CV Update from ACC.org: A weekly cardiovascular update from Dr. Kim Eagle, editor-in-chief of ACC.org.
  • ACCEL Lite Features ACCEL Interview on Exciting CV Research: Interviews and summaries of some of cardiology’s most interesting research topics, hosted by Dr. Spencer King III.
  • Heart: Summaries of original research, editorials, and reviews from the BMJ’s Heart
  • Heart Sounds with Shelley Wood: Discusses some of the top stories in cardiology covered by the TCTMD reporters.
  • CardioNerds: This is a podcast that I just started listening to. It discusses high yield cardiovascular topics in a case discussion format.
  • AP Cardiology, ACC CardiaCast, Cardiac Consult A Cleveland Clinic Podcast for Healthcare Professionals: Three different podcasts that provide summaries of various cardiology topics.
  • JAMA Editors’ Summary, JAMA Clinical Reviews, JAMA Medical News Interviews and Summaries: Three different podcasts which provide summaries of various medical topics.
  • Annals of Internal Medicine Podcast: Highlights and interviews from a specific issue of Annals of Internal Medicine. The American College of Physicians has another podcast, Annals On Call Podcast, which features Dr. Bob Centor discussing influential articles that are published in Annals of Internal Medicine. I have not yet started listening to Annals on Call, but hope to do so in the near future.
  • ED ECMO: Discusses resuscitative extra-corporeal membrane oxygenation (ECMO) and extra-corporeal life support (ELS). At the University of Minnesota, cardiologists manage veno-arterial ECMO (VA-ECMO). More to come about this during an upcoming blog!

I am always open to hearing suggestions for new podcasts related to science/medicine or other topics!

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

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My Three Tips for “Getting Involved”

While we are still incorporating the knowledge from AHA Scientific Sessions 2018’s late breaking trials like REDUCE-IT and TRED-HF into our daily practices, the AHA has already started planning for Scientific Sessions 2019 being held in my current home of Philadelphia, Pennsylvania. My co-AHA Early Career Blogger, Jeff Hsu, M.D., Ph.D., and I are excited to serve as Co-Vice Chairs for the AHA’s Fellow in Training (FIT) Programming Committee, and we are hard at work incorporating feedback from AHA18 into our vision for AHA19. For a recap of the AHA18 FIT/Early Career Lounge experience, check out my November blog here and FIT Insight blogger Anum Saeed, M.D.’s January blog here.

Becoming involved in my professional societies as a trainee has been hugely rewarding for me, but admittedly, making those first breakthroughs was not easy and took a few years to accomplish. In this blog, I will share 3 of my tips that can help you seize these opportunities.

1) Seek out a well-connected sponsor: Our professional societies are very eager to involve more FITs and Early Career members in a majority of their initiatives. Often, they advertise and require an application for trainee-specific opportunities like blogging, editorial, and leadership council positions. But, there are a host of positions that are not filled via an application-based process and are frequently offered to trainees through a personal connection within the society. If you have applied to formal engagement opportunities and your application has not been selected, instead of being discouraged, seek out a well-connected sponsor within the society with whom to share your motivation. Faculty usually know of other available opportunities for trainee involvement within their own councils or committees and can connect you with other members volunteering in clinical and research areas of your interest.

 

2) Offer concrete ideas when you make contact: When you connect with a society member whether in person, via telephone, or via email, instead of just saying that you would like to “be involved,” offer a few concrete ideas for the society and its mission. By doing this, you can demonstrate your enthusiasm and establish your dedication to the potential role. Your new sponsor will be more likely to engage with you and find an opportunity for you that is aligned with your interests and skills.

 

3) Form relationships with trainee colleagues who are already involved: When societies have formal councils or committees comprised of trainees, they often rely on them to disseminate news and opportunities nationally and internationally. While tip #1 can definitely help to launch your involvement, following the same practice with your FIT and Early Career colleagues can sometimes be more impactful. Trainees’ professional networks are usually smaller than those of the faculty in society leadership positions, so when we are asked to submit names of colleagues for opportunities, our selection pools are more limited. In the AHA18 FIT/Early Career Lounge, I met multiple medical students, residents, and fellows who expressed interest in the AHA FIT program and shared their feedback with me after Sessions. In turn, when I was offered the chance to nominate FITs and Early Career members for other roles, these new colleagues were at the top of my list.

 

If you are a FIT or Early Career member, watch out for emails about AHA Scientific Sessions 2019 programming in the coming months. If you have a great idea about what you would like to see at AHA19, reach out to Jeff (@JeffHsuMD) and me (@noshreza) on Twitter!

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Deconstructing Habits & Engineering Good Ones

For roughly the past 15 years, I essentially have eaten the same breakfast every morning – a bowl of oatmeal with a sliced banana. And every morning, as I wait for the oatmeal to heat up in the microwave, I do push-ups and sit-ups. It has come to the point where my body reflexively moves towards the small area in my living room right after I push the “Start” button on the microwave. This activity takes all of two minutes and is often rather automated. But during busy stretches on inpatient services, these are sometimes the only two minutes of dedicated physical exercise over the course of a long day.

I just finished listening to the audiobook, “The Power of Habit” by Charles Duhigg, and while I never had put much thought into it, I realized my morning ritual is indeed a habit, and just one of many I have throughout my day. In the audiobook, Duhigg expounds on the central role that habits have in our daily lives — essentially comprising a sizeable percentage of our days and forming a large part of our identity. Habits, once formed, become automatic responses to the various triggers we encounter in our day, and often, we carry them out mindlessly. He describes the three components of the habit loop:

  1. Cue: The trigger that prompts the action. This can be a location, a time of day, a person, an emotional state, or another action.
  2. Routine: The actions or thoughts that occur in response to a given cue.
  3. Reward: The physical or emotional satisfaction that results from the habit loop.

The continued repetition of the habit loop leads to a craving for the Reward, which links the Cue to the Routine and promotes the automaticity of this loop.

For good habits, such as my breakfast pushup routine, this can be beneficial and can help structure physical and/or mental well-being or productivity during the day. For bad habits, however, this can clearly be troublesome.

As early career trainees, we often find ourselves complaining that we don’t have enough time in the day to do the things we want to do – exercise, read, write, cook, etc. However, while there are definitely difficult stretches, there are indeed opportunities to do all of these things. And perhaps one effective way is to incorporate them into a habit loop.

For instance, a Cue that everyone experiences daily is waking up in the morning. Consider using this opportunity to link this Cue to the Routine of going for a jog. Reward yourself with your favorite breakfast afterwards (oatmeal & banana, anyone?) or listen to the newest episode of your favorite podcast during the jog.

A particularly challenging habit to develop is giving yourself time to write about your science, as was discussed by senior AHA Early Career Blogger, Bailey DeBarmore, in a recent blog post. Find a way to schedule this Routine into your week by attaching it to a Cue (e.g., Saturday morning) and a Reward (e.g., favorite cup of coffee, checking off that box on your to-do list).

These routines are notoriously difficult to instill at first, and it takes several weeks to develop them into a true habit. But with time, as they become more automated, these good habits become easier to perform. The “Power of Habit” is rife with case examples of the role of habit in our daily lives, and the very brief overview above is just a small sliver of what was covered in the book. However, it inspired me to deconstruct the habits that form my days and encouraged me to re-engineer them into habits that can help me feel better and more productive in my busy schedule as a physician-scientist trainee.

What good habits can you cultivate in this new year?

 

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The Struggles of Scientific Writing

After months of collecting and analyzing data, the time has finally arrived to start writing your manuscript. You are excited and ready to share with the research community your groundbreaking findings. Now the only thing standing in between you and your published articles is that blank Microsoft Word document.

Can you remember the daunting task of writing your first, first author manuscript in graduate school? Including months of intense writing and re-writing, attempting to get the perfect final draft just for the reviewers to eventually rip it (and your ego) to shreds.

Well, there is no quick fix for scientific writing. However, what if I told you that there is a close second? Recently, I had the esteemed pleasure of attending the American Physiological Society Writing for Scientific Journals live workshop. This professional development course is designed for trainees, with the sole purpose of providing the necessary tools for crafting a better manuscript.

After being accepted into the program, one of the requirements, along with having a draft manuscript, is to complete the online homework assignments before the start of the in-person workshop. Over Christmas break, I eventually found the discipline to sit down and read the pre-course readings. This is when I realized that I knew just as much about scientific writing as I knew about slugs. I understood there was an order to the sections, along with what was generally supposed to go into each section. However, this was still just scratching the surface. Writing for science is a very hard task and one that should be done properly. So many times, poor writing has watered down great science. It is not only our responsibility as scientists to do good research, but we also must ensure that we are communicating our findings to the public properly.

Another great aspect of the program is the networking opportunities in place. The course was led by six amazing mentors with a special expertise in the scientific journal publishing business. As trainees, we were split among these six mentors who helped to lead small-group discussions on how to address flaws in our manuscripts. As such, not only are we learning how to draft a better manuscript, but also how to be a good reviewer and respond to reviewer questions. After leaving this workshop I had the tools in hand to write, better respond to reviewer suggestions, how to select a journal for submission, how to be a good reviewer, and learned about resources that can further build my writing and reviewing skills. On top of everything the course is held at a Disney World resort in sunny Orlando, Florida. Overall, it was an unmatched experience that I would recommend to trainees struggling to write that first draft.