For a long time, I’ve been telling myself I’ll get into shape one day. I remember distinctly when I graduated from high school in 2007, I weighed 170 pounds and was in the best physical shape I’d ever been. I worked as a summer camp counselor and was in charge of a bunch of active young kids and we played tons of sports and ran around for three months. I went into college with an unfortunately soldering depression. I was struggling at the time to figure out my identity – my place in the world. I moved away from home for college and started learning my way. Four years later, I graduated from undergrad and was headed to medical school – but I was 37 pounds heavier. None of my old clothes fit. My family was worried about me. I’d let my emotions and bad habits get the best of me. I was going to medical school, I told myself. I’d get into shape then. Again, I got a job for the summer that was active and demanded a lot physically. I walked around Philadelphia and got acclimated to living on my own entirely for the first time. I managed to get down some weight. My group of friends was physically active and supported me, but I still didn’t make a full commitment. As medical school grew more stressful, the pounds came – and they haven’t stopped since. Residency was brutal and didn’t help my health whatsoever. I put off my personal wellness and health for yet another chunk of years. Today, more than a decade after I graduated high school, I am 220 pounds. I’m obese. I’m pissed off. I’m now dealing with health issues and I haven’t yet got to my thirtieth birthday. Enough is enough. Follow me on my journey to my healthier self here.
This post marks the first in my new campaign, which I have called #healthyinhc which stands for “Healthy in Healthcare.” It’s about individuals who work in the healthcare industry who struggle with challenges at work and elsewhere, who spend the better part of their day trying to help other people, often left with poor health inside and out for themselves. I encourage you to share what’s on your mind, what you’re dealing with, and what you’re going to do about it, so we can all create a network to support one another.
Since I was a child, I have always been chubby. In my younger years, it was all just part of being another awkward kid. As the years went on and I became a teenager, I got a little taller and slimmed a bit. At the end of high school, I worked as camp counselor and weighed the lowest I have ever weighed as an adult, 170 pounds. I was running around with campers and playing sports out in the sun, and it was easy to stay healthy. Then I went to college.
College is where I learned to stress eat. It was my first time being away from home and living on my own. Like everyone else in my situation, I was making my own decisions – in my case, they were pretty unhealthy ones. As I worked toward my degree and on my path toward medical school, my stress level increased. I had always loved food, but college is when food became my nemesis. I had a meal card with a certain amount of money on it each semester, and I was able to spend it how I chose – I chose extremely poorly. A typical meal for me in college was a combination of a slice of pizza, pasta, garlic bread, a burger and fries, or some other fast food type meal. To add insult to injury, I pretty much ended every meal with dessert which may have been cake, brownies, or my favorite – chocolate chip cookies.
With no one around to remind me to take care of myself, and in the uncontrollable spiral of stress that premedical students and college students in general know, I gained a lot of weight. You’ve probably heard of the “freshman fifteen.” Well, I sadly put on forty pounds in four years. I rarely ate salads or fruits. I tried to exercise, but went about five times per month during a good month. As I got toward the end of college, I felt out of control. My family and friends noticed and tried to have their own versions of a “come to Jesus” talk with me. I vowed to do better.
The next chapter for me was medical school in Philadelphia. I loved living in the city. I had my own studio apartment for the first time. I had a part time job. I was paying my own bills between my job and my student loans. I was still making my own decisions for meals. Now, I was forced to learn how to cook and prepare meals, but I still relied heavily on buying fast food. My relationship with food in medical school only grew more strained. As I faced academic challenge after challenge, and grew anxious about what would happen in my future, I ate my way through it all. For a short period of time in medical school, I actually lost some weight and got down to the 190s. That was big progress for me at the time. Unfortunately it wasn’t sustainable.
As I got toward the later years of medical school, I regressed and found solace once again in food. I realized then that I ate emotionally, not for nutrition. This has been a huge hurdle for me since I started college. I vividly remember finishing boxes and boxes of cheese-its while studying for my USMLE exams. In the moment, I was more focused on getting through school, so I could match into a residency program, and ultimately provide for my family. My health again took a back burner.
Match day came and went. Graduation came and went. Then I moved to Baltimore to start residency. If college was hard, medical school seemed simply impossible. If medical school seemed impossible, residency has felt like the hardest thing I will ever have to do in my life. Without getting into the specifics, it’s been a tough 30 months.
I learned to cook better meals, but I simply still could not avoid stress eating. Furthermore, with the lack of time I have, I made lots of excuses and relied on free food inevitably available in our resident lounge and the many break rooms I have learned to seek shelter in over the years.
But now, I am drawing a line in the sand. Today I decided that I would forever make a commitment to change my relationship with food. Today I decided to make a decision to value my health. Today I decided that I know better, that my medical training gives me an even more unique upper hand toward a path to better health, and that I want to be an example for others to follow.
I went to my local gym, and re-activated the membership I had let lapse last year. I had my first workout in months. I ate healthy today. I ate for nutrition. It’s not easy to make these decisions, but I know what it means to set a goal and achieve it.
Fifteen years ago, I sat in my high school guidance counselors office, and voiced my desire to go to medical school. I wanted to help people toward better health, to use my love of science and combine it with my slowly growing love of people. I sit here now, in 2018, in the last 6 months of my residency training. I have my independent medical licenses pending. I have my sights on graduation. I will soon finally finish the journey toward becoming a doctor.
It’s time. It’s time for me to stand up for myself. It’s time for me to get well, inside and out. Right now, here, today, I put my reputation and struggles out there for you all to know, so I can hold myself accountable, and share my trials and tribulations.
The truth is that this July may mark the end of a chapter, but what comes next – that’s the meat and potatoes, as my best friend Bharat would say. Join me as I take on my biggest challenge in life…
Fortunately, the topics of burnout, wellness, and resiliency have been popping up more and more frequently over the past 1-2 years across the media, social media, and even professional conferences. I welcome the increased transparency and willingness people have to open up about their experiences, concerns, and struggles, but most importantly, what we all are currently and will soon do about it.
Burnout is not a new problem. In the research journals the topic has been discussed and analyzed for decades. I searched Pubmed for “burnout healthcare” and the earliest indexed articles there were from the late 1970’s. In fact, the earliest article was from the Journal of Nursing, entitled “Burnout: the professional hazard you face in nursing,” by Seymour Shubin.
I’ve read through at least 30 articles on the topic ranging from the 70s to earlier in 2017, and what’s encouraging is that we are finally starting to see a shift from describing the issues involved to how we can address them. As of the past 5-10 years, studies have emerged that actually analyze how effective or ineffective specific interventions have been on the issues of burnout, wellness, and resiliency. Even more hopeful, the large medical journals which historically are last to catch onto new waves and new ideas, are also publishing more on these issues.
I am glad for this change. Over the coming weeks and months I’m planning to discuss a couple of studies per week on related issues. Consider it my first #FOAMed contribution.
But in all honesty, personally I feel that the keys to addressing this issue are so broad, multifactorial, and involve both systems issues and individual professional level issues, that it will require much more than just discussing the issues and publishing about them to create real changes.
One of the things I want to focus on here is discussing and creating dialogue about the individual level options that can make a difference for us all.
Here are some thoughts from the above mentioned article which I thought were important to highlight.
I can’t stress this enough.
IT IS NOT SELFISH TO TAKE CARE OF YOURSELF.
Let that sink in.
The more you take care of yourself, the more you have to give at work. The more caring a professional you can be. The more reliable and dependable a colleague you can be.
Contrary to what you may feel is expressed by supervisors, managers, administrators, colleagues, coworkers, etc, your longevity in the career you chose is important. Your longevity in your chosen work (physician, nurse, nurse practitioner, physician assistant, social worker, respiratory therapist, etc), is directly related to your “wellness factor.”
If you work with a negative wellness factor, meaning your experiences are multiplied by an overall negative sense of self image, self worth, and self care, means you are ultimately cutting career satisfaction and your own wellbeing down.
If you work with a positive wellness factor, meaning your experiences are multiplied by an overall positive sense of the above, your experience in general is going to be augmented. It helps set you on a trajectory for success, career satisfaction, and personal wellbeing.
As the Thanksgiving holiday has come and gone, I challenge you to think about how your current wellness factor is. What is your current state of affairs? What are the things that you struggle with? What’s causing you stress right now? Identifying issues is the first step toward improvement. Let’s get well.
“Are you listening to me?”
“Hey pay attention to me”
“Did you call x about y?”
“Why hasn’t this been done?”
“Did you finish that note?”
“Why are you so quiet?”
Her screams echoed through the unit
Her screams are the only sounds I hear
This is, thankfully, changing.
I contributed to this by standing up in front of 60 people and telling them that I had struggled with burnout in residency. It was, though not a big deal, a big deal. I was squeezed between a lecture on the life-saving use of ultrasound in critical care patients and a discussion of the latest and greatest in the management of respiratory distress. It’s still considered “edgy” and maybe even “taboo” in 2017 to teach doctors to discuss their emotional experiences and struggles. It’s still considered unusual for a doctor or nurse to tell their colleagues about their struggles. That culture still exists – but the wall is coming down.
Day by day, one person at a time, one hug at a time, one moment of beautiful vulnerability at a time, we are working to change this. I realized when I was recovering from burnout that we spend much of our time in medicine finding ways to take care of others, but we constantly neglect our own health. Worst of all, the culture of medicine is that this is how it SHOULD be. When I started medical school in 2011, it was obvious the expectation was I would show up, do whatever it takes to get the job done, and simply never discuss what’s hard about the job or what keeps me up at night.
In a typical day at work, I take care of anywhere from 15-20 individuals and help them with a large range of medical problems. Most are minor issues, like an ache or a pain that is not serious. Some are dealing with severe infection, heart attacks, strokes, or other emergencies that will require admission to an ICU or even emergent surgery. If all goes well, I will help most of these people and they will have good outcomes. It often doesn’t go well.
One of the weaknesses in medical training is that I get ample preparation on how to handle good outcomes and facilitate them – but I get no training on how to handle bad outcomes. The patients, and their loved ones, who suffer the poor outcomes, are the ones I feel for the most. But not far behind them, I worry about those that devoted the hours, days, weeks, months, and even years to care for them. Second victim syndrome is real, and I have felt the pain it can cause.
If a physician or medical professional is involved in caring for a patient, and the patient has a poor outcome, it does not matter whether it was simply the course of the disease or illness, or if there was some error or problem with the care delivered. Truthfully, the medical professionals involved always feel some responsibility for what happens. Even when it may not have been their fault. No one wants to have a bad outcome on their watch. No one wants a patient to die. The problem is that they do, and often it has, unfortunately, little to do with the decisions we as medical professionals make. This is hard to understand unless you yourself are a medical professional. It contributes to the emotional and spiritual burden medical professionals carry with them.
You see a nurse who is quickly drawing up a medication to help treat a sick patient, but I see a nurse who has seen so much death and hardship he doesn’t even know where to start to process it.
We all carry baggage. Medical professionals carry graveyards.
Writing is an important way that I communicate with the world. I spent my childhood reading a lot of books, and I developed a desire to put my own thoughts into words and share them at a young age. It started in grade school and junior high with keeping personal journals. Photography was my primary creative outlet in high school and college but as I moved forward with my education, writing became such an integral part of my learning that I turned back to it. Today, as a training physician, writing is a large part of how I take the experiences I have and process them and share them with the world.
I am starting a new project and I welcome any and all to join me. The rules are simple.
1. If you’re a human being, you can participate. As a physician myself, much of my writing and inspiration come from my work in the hospital. As such this project may be more appreciated by others in the medical profession such as nurses, techs, prehospital providers, etc. There is no qualification here. We are all together in this. We are all here for each other regardless of title.
2. Once a week, each Tuesday morning, I’ll be posting a writing prompt on my site.
3. Participants can take the prompt and write a response however they prefer – their website, email to me at firstname.lastname@example.org to post on my site, a link on Twitter, or even in your own personal journal. I’ll share any submissions that are sent to me with the world, with the permission of the authors.
4. The idea is to communicate through writing & create a community of people who are trying to support each other.
With that, here is the first #WeWrite prompt:
“When is the last time you were extremely frustrated or overwhelmed at work? What were the circumstances? What would you do differently if you could go back in time? How would you change the situation to improve it?”
When I told my high school guidance counselor at the age of 14 that I wanted to become a doctor, I had this sense of what that meant. It had a lot to do with my dad, who has been a primary care physician trained in Internal Medicine practicing in NYC for the past 32 years. It also had something to do with my position in a local Emergency Department as a volunteer clerk after school and on weekends. I had witnessed my dad speak to patients and their families, fielding phone calls during family outings and dinners, or while we watched old sitcoms on “Nick at Nite” when I was young. Sometimes I would go to the office and do homework in one of the empty offices while my dad worked. I met his partner and the administrative staff that worked in his busy private practice in the center of Queens. I met some of his patients, too. They loved my dad. They never stopped gushing about how much they loved him. They sent cards thanking my father for his support and help. They sent gift baskets, chocolates, and even alcohol, which my father gave up early in my childhood. So, when I sat down with my guidance counselor and spoke the words for the first time, “I want to be a doctor,” I thought of my dad, and what I had seen until that point. I had no idea what I was actually signing up for. The photo attached to this piece is of my dad and me when I was exactly 374 days old. It was my first time putting on a stethoscope.
I have seen and done some incredible things over the past 12 years. I have grown from a naive, inexperienced and socially awkward young child who suffered from tremendous self-confidence issues into a hard-working and eager young physician. Today, I can walk into a patient room in any of the 12 Emergency Departments I have worked in over the past two years, introduce myself, and get to work helping patients, without even blinking. I can obtain their medical history, figure out what’s ailing them, and come up with a plan to help them – most of the time. When I am not sure, or if I am going down the wrong path, which happens, my attending physicians and supervisors reel me in and get me back on track.
Practicing medicine is not a yes or no question. It is not a multiple choice question where you choose the best answer (like all of my unhelpful board exams to date have been.) Sometimes, the answer is black and white. Sometimes, when doctors are lucky, the issues they face are clear. It is then easy to move forward, and do what is best for your patients. However, I must emphasize that this is not usually the case. There is incredible variation in how doctors manage disease and treat their patients. They have such wide styles in how they communicate – or don’t communicate – with their patients and their families. Physicians of different fields and specialties all have different focuses and strengths, as well as weaknesses. Talk to a generalist like me, and you will likely get answers that address a bunch of information about a variety of organ systems and diseases. Talk to a specialist like one of my social media heroes, Dr. Eric Levi, a seasoned fellowship-trained head, neck, ear, nose, and throat surgeon, and you get a ton of expertise in a more focused area. Most people think that a doctor is a doctor. And that we are all the same. But that’s just plain wrong. Each physician, even within the same field, is a different human being. And every human being sees the world differently, sees disease and its treatment differently, communicates differently, has different values, and thus, will treat a patient differently. If there was one thing I wish I could share with those who are not familiar with a physician’s work, it’s the incredible uncertainty and lack of clear answers for what we do. More often than not, when I take care of you in my Emergency Department, I will rule out life threats and emergencies, and if I think you can survive to live until you can get follow-up with your primary care doctor or a specialist who knows more about your issue, I will discharge you home. But just know that for hours, days, weeks, months, and sometimes, years, I will wonder whether I did the right thing for you, and if you are okay.
I know I do the best I can, but I don’t have all the answers, and any physician who tells you they know everything, or they know better than you and that’s why you should listen to them, you ought to walk the other way and find another one. There is nothing more dangerous than a physician with hubris. Eventually, all physicians are humbled. Sometimes it happens quickly in their career, like with me. Sometimes, they may carry on with their pride and “I am God’s gift to mankind” attitude for a longer period. But one way or another, we are all humbled. The part of medicine that we don’t discuss enough is the art of it. The gray areas. The nooks and crannies. These areas make our work challenging, but not impossible.
If not for these difficult and complex scenarios and situations, being a physician would be, well, boring. Computers and artificial intelligence systems can analyze an incredible amount of data and use protocols and reach decisions which can closely mimic or even surpass those of human beings. But the reason that AI systems or computers can never fully replace or replicate what I do at work is that a tremendous part of my job involves holding a patient’s hand, letting a family member cry on my shoulder when there’s a bad outcome, or getting someone a turkey sandwich and a blanket. There’s a human factor to what I do. The pro is that if I do it right, I can give someone support and guide them through complex situations to the best of my ability, and hopefully guide them toward better health and a better tomorrow. The cons are that I am imperfect and as a result, my decisions, recommendations, and professional work is, sadly, also imperfect.
That being said, physicians and other medical professionals are constantly researching and learning. The world of medicine is ever changing and ever growing. There is much to learn and better understand about what we do. The best physicians, in my humble opinion, are passionate about delivering quality care for their patients, and they understand that in order to do that, they have to be the best students for the rest of their lives. Our learning never ends. Do not be frightened when a physician says they don’t know the answer. Don’t be scared if they say, “I don’t know, but I will look it up, and find out for you.” It means they care to take the time to grow themselves, so they can provide you with the best recommendations, advice, and guidance humanly possible.
Physicians and the medical professionals they work with are part of numerous systems. These systems and the people that work within them are healthcare. There are a tremendous number of moving parts and the entire ordeal is more complex than I can begin to understand. The best I can do at this point is be passionate about the areas I am a part of on a regular basis – namely, the Emergency Departments where I work and the community I live and work in. Often, medical professionals are burdened by the systems they are a part of. Resources are distributed poorly. Laws are passed which are not based on the latest research or knowledge. Politicians play games with people’s lives. Hospital administrators emphasize and prioritize a better bottom line than better patient outcomes. And no, no matter what anyone tells you, a better bottom line and a better patient outcome can never be the same priority. Because better patient outcomes by definition require the worst bottom lines, and administrators, insurance companies, and the big wigs in healthcare will never let that be the case.
Next time you see a doctor who is stressed out, or doesn’t know the exact answer right that second, or seems exhausted or troubled, it’s not because they are incompetent and can’t do their job right. It’s not because they’re inexperienced, “too young,” or a “bad doctor.” It’s because they’re not just thinking about prescribing you antibiotics for that cold you have. It’s because in the room next door, someone is dying of cancer and them and their family need help getting into a hospice program. It’s because before they walked into your room, they just lost a young patient who went into cardiac arrest because they had a genetic abnormality of their heart that was not previously diagnosed and it was too late for them. It’s because yesterday, they sent an elderly patient back to their nursing home, and when they got to their shift today, they got a call from the patient’s mother that she passed away on the floor, in her sleep, of uncertain causes. It’s because the week before, their supervisor called them into their office and told them they weren’t working fast enough and they needed to pick up the pace. It’s because when they decided to go into medicine, they thought it was about saving lives, when in reality, it’s about reading research and textbooks and translating it into terms their patients can understand, and then doing their best to guide them to the choices that are right for them.
I’ve been meaning to get back into blogging for quite some time. I hope to share more of my thoughts and experiences here in the coming months and years. I would love if you could follow my journey and share your thoughts, too.
Having been a resident in Emergency Medicine for more than 2 years now, and having completed 4 years of medical school, preceded by 4 years of college, I feel I’ve had a bit of experience within the culture of medicine. I’ve seen it from many perspectives. I was a volunteer in high school and college. I participated in clinical research in college. I became a volunteer EMT and ultimately AEMT-CC in upstate NY in college and rode for my college agency for two years. I was a medical student in Philadelphia as well as the Lehigh Valley in Pennsylvania. For the past two years I’ve been a resident in the Department of Emergency Medicine at the University of Maryland Medical Center.
There are a lot of things I’ve seen and been a part of over the past 12 years that have impacted me, and changed me. I’ve gone through a lot of growth, and been through some challenging times. I do come from a background of privilege, and I am not aware of this. The challenges I have gone through are not the kind you may think of when you think of the word challenges. I have never needed to worry about survival, whether I would have a safe place to live, or food on my table each day. I have also been fortunate to come from a loving and supportive family that has been behind me every step of the way.
I will be discussing more about my experiences as a creative outlet.
Many of those who interact with me on social media picked up on my brief hiatus from Twitter. I am now back and thought I would get back into the swing of blogging by discussing what happened and why I decided to take a break.
As a resident, my brain is constantly swimming with details about work, whether it be me wondering how a patient I admitted or discharged is doing today, or a dose of a medication, or whether I will pass my USMLE step 3 exam I’m taking tomorrow, or about my personal life, such as how I will spend time with my wife and pup on my next day off or how I will pay for my medical licenses, required training courses, and DEA number before I graduate residency. In between all of that, I ponder my own mortality and health, and try to maintain relationships with family, friends, and colleagues.
Social media has been a huge source of support for me ever since I started to participate and engage. I have met some truly remarkable people, most virtually and a few in person too, through my activity on Twitter. After the 2016 presidential election, and during it, social media was ablaze with political discourse. Some of it was productive and healthy debate but a lot of it was cruel, intolerant, and upsetting to witness.
I was finding that I was using my Twitter more to vent my anger and frustration at current affairs than for engaging with others to better myself, both from a medical standpoint and as a contributing member of society at large. It all came to a head when I realized that I was posting only political rants and I was not growing from my investment in social media. So, I realized it was time for a break. I shut down my Twitter for a while.
At first, I did feel the urge to check. I had gotten so used to checking my phone in between conversations, activities, and whenever I had some down time. Truthfully I was glued to my phone a little too much, but no one’s perfect, right? Then as I settled in, I found new and different ways to get news and information. I used to rely on the Twitter moments a lot when I was heavily active on Twitter. I started to look up articles on specific news sites. I used other news applications available such as Apple News and others. I discussed articles with my wife. I asked her for recommendations and sent her articles I read myself.
I had hoped to make more profound changes in how I interacted with people digitally and how I sought information and news. I made some changes, for sure. In the end, what I really gained from my break was a chance to reflect on what I wanted to gain from my social media presence. What did I want to say? What did I want to think about and converse about with others? What did I personally gain from my tweeting and blogging?
This and more I pondered for a couple of months, all the while intermittently logging into and deactivating my Twitter to keep it alive in the shadows. I’ll probably delve into all of this more in the coming months and years, as there’s much to share, but it’s good to be back.
Why do you use social media? What are your reasons for blogging, vlogging, tweeting, instagramming, or snapchatting?
The clouds are fluffy and the purest white. I have a window seat on the left, just a few rows in front of one of the pair of powerful jet engines, propelling us onwards and upwards. Beside me, my wife reads. An eighties hits playlist helps to fill the low drone of the turbines. I have just finished Paul Kalinithi’s When Breath Becomes Air.
As a physician myself, I have never read any one piece of literature that could get to the heart of my very existence better than Dr. Kalinithi’s masterpiece. Since the day I sat and met with my high school guidance counselor for the first time at the age of 14, and declared my decision to become a physician, I have never had this level of clarity. I never met Dr. Kalinithi, but his words echo throughout my soul, and I have internalized them as the wisdom of an older brother.
In the medical field, we joke amongst ourselves that the most important characteristics that go into a great physician cannot be taught – not in grade school, college, medical school, residency, or even fellowships. We must learn the lessons, develop the communication skills, and find the strength and love to provide compassionate medical care on our own, individual journeys. In his memoir, Dr. Kalinithi shares his own journey, from an inquisitive young man who showed the signs of future brilliance, to an exceptional neurosurgeon and neuroscientist, and finally, to a loving, fulfilled, and complete father to his daughter, Cady.
I myself have wondered about my purpose in this world a great deal. I spent many late nights, especially as a troubled teenager, trying to wrap my head around existence, and what it all meant to me. I have studied philosophy, literature, the scriptures, and the sciences in my quest to find meaning. Even as I near the end of my residency training in Emergency Medicine, thankful to have married my high school crush and celebrated our first anniversary this past September, with our future stretched out before us, I had felt this sense that I wasn’t anywhere closer to the understanding of my purpose and place in the world as I was in high school.
However, in Dr. Kalinithi’s words, and in his and his family’s experiences, I have found that which has eluded me in my almost three decades of life. Never before have I encountered such a complete and honest treatment of what it means to be a physician, a patient, or the relationship between the two. Furthermore, as a young husband myself, I have yet to read words which have touched on the challenges that physicians and their partners face in relation to the training and work that we do. Reading When Breath Becomes Air has felt, in more ways than one, like coming home.
I will explain it in this way. Last year, I read the wonderful Being Mortal by Dr. Atul Gawande. A gifted surgeon and writer, he addresses end of life care in this work, discussing the story of end of life care as it is, or is not, delivered in America today. He uses the stories of specific individuals, including the challenges his own father faced battling a terminal condition. However, Dr. Kalinithi’s When Breath Becomes Air has that total commitment to the mission that only he could achieve, by nature of his own challenges and how he rose to face them with his family.
The world needs more men like Paul Kalinithi. The world needs thoughtful, hard working, and loving individuals who care about the people around them and dedicate themselves and their lives to the understanding of the human condition and the pursuit of meaning through meaningful work. Dr. Kalinithi inspires me to plan for the future while living with total attention to the present, to strive toward perfection knowing it may not be attainable, and to forever seek ways to better myself and the people around me.