Month 4/12 of "21 Days to Expert Enough": Journals

     Every project I've undertaken this year has resulted in little breakthroughs in efficiency and knowledge, and April was no different. The process of reading 21 journals last month revolutionized the way I think about and read journals, and will forever influence the way I continue my medical education.

    First, an overview: I read 7 issues of the American Family Physician, 6 issues of Family Practice News, 2 issues of Consultant, 2 issues of The New England Journal of Medicine, 2 issues of PracticeLink, 1 issue of Journal of the American Medical Association, and 1 issue of Kansas Family Physician. Below are my thoughts on each one, and my overall takeaways from the month.


American Family Physician
     The AFP is the peer-reviewed bimonthly journal of the American Academy of Family Physicians. I found the their articles, which consist mainly of review articles on the diagnosis and management of fairly common conditions, to be the most helpful to my day-to-day practice. I even photoscanned into Evernote the tables I found most helpful, which was a neat little breakthrough in efficiency. Prior to this functionality of Evernote being available, I would either tear out a page to be filed somewhere I would never see again, or laboriously type out or dictate a summary in an Evernote document, which never looks as good as a table and can be harder to find later. This is something I plan to continue in the future, with not only the AFP but other useful tables I come across.

Family Practice News
    FPN, which is a free bimonthly independent newsletter that all residents here somehow have started getting, turned out to be a surprisingly readable publication with many interesting articles. All articles are fairly short, and most chronicle new developments in various areas of medicine, including Rheumatology, Dermatology, Endocrinology, Nephrology, Pulmonology, and Pediatrics. I found Neil Skolnik, MD's "Clinical Guideline" article each issue the most practical, though there were many other good ones. However, some of the articles are simply irrelevant to family physicians, and the overall quality of articles is lower than most of the other publications I read. In the future, this will be a great publication to quickly skim every couple of weeks when I pull it out of the mailbox.

Consultant
     Consultant is a monthly independent subscription-only peer-reviewed publication that focuses on case presentations. My former roommate had a subscription to this journal, and I took his back-issues off his hands when he moved out a couple months ago. We still get his new issues in the mail, too. Each article has over 20 articles that highlight interesting cases, as well as a few expanded review articles on the management of certain conditions. When I started reading these articles later in the month, I was struck at how this format stimulated my brain in a different way than did the AFP review articles, as I tried to solve each case and think of what I would do next in similar situations. One of the most important things I learned this month was how important it is to continue to stimulate yourself to think along these lines; the formulation of a broad differential diagnosis and a good working knowledge of the work-up and management of certain conditions is a central but often- neglected aspect of medicine. I'll keep reading this one.

The New England Journal of Medicine
     Widely considered to be the premier journal in American medicine as well as one of the top journals worldwide (along with the U.K.'s The Lancet), NEJM is an editorial- heavy and primary research- heavy bimonthly publication with an unabashed statist / liberal slant. I have a big stack of back-issues on my shelf, also obtained from my former roommate during his exodus. My favorite articles each month are the in-depth case reports and the image challenges with subsequent case descriptions. Though I disagree with some of their editorials, they are all well-written and are generally thought-provoking, so I also usually benefit from reading them. It's easy to quickly skim the abstracts of the original research articles and glean the take-homes of each publication without delving into any of the details, which is what I suspect most readers do-- especially those of us who aren't sub-specialists, actively involved in research, or preparing for a presentation. In the final analysis, the benefits listed above probably aren't worth the hefty annual subscription fee, so I'm just going to keep working through back-issues for now.

Journal of the American Medical Association
     Similar to NEJM, JAMA is a widely-respected peer-reviewed editorial- and research- heavy bimonthly statist / liberal publication. I enjoy their clinical challenges, and it's also nice to skim through the abstracts to see what new developments are coming down the pike. It turns out my free subscription just ran out, however, but I have a lot of back-issues to go through. Although it's nice to stay current with with the state of original research, I probably won't miss it when it's gone.

PracticeLink
     A free quarterly publication focused on helping residents and graduates find their dream job, PracticeLink is chock-full of helpful job search tips and perspective. Certainly worth a read at this time in my career, and something I'd recommend to any and all current residents.

Kansas Family Physician
     The quarterly publication of the Kansas Academy of Family Physicians, this publication focuses on local news, and the issue I read only had one clinical article-- on breastfeeding, which I skipped because it looked boring. Though nice to see photos of familiar faces, it's one I probably won't even waste time flipping through in the future.


     To sum up, I enjoyed getting in the habit of reading a few articles before I go to bed every night, and really benefitted from the opportunity to critically evaluate the pros and cons of each journal that hits my mailbox. I now clearly divide articles into ones I benefit from (clinical reviews, case presentations, and certain editorials) and ones I should skip (most original research, specialty articles, and most political / statist editorials). In addition to journal articles, I constantly read Medscape and New York Times articles I get via email, and have done so for years now. I've also made a habit out of listening to Audio Digest lectures via cd or the Audio Digest app whenever I'm in the car, which has been of huge benefit to me. The topics I benefitted the most from were ones which I read or listened to with the intent of teaching, so I hope to eventually make this my default mindset with everything I read.

     As I look toward to future, I'm excited about increasing my efficiency at going through articles, ultimately via Litz, which is a speed-reading app I recently purchased which I hope will soon be compatible with the online versions of many of these journals. I also hope to use it to speed-read some books next month, as I try to plow through 21 books in 30 days-- but more on that next time. Right now, I'm switching gears and starting to think about building a website, which I've never done before. Does anyone out there have any helpful tips or resources on how to do this? I would appreciate anything you could send my way. Hopefully by the end of the month, I'll have a hot, fresh link for you all to feast your eyes upon!

     Until then, keep climbing.

     Dan

Three Months' Review and One Month's Expectation

It's that time again-- time to reflect on the month that has gone by and see how well I met my goals, and to look ahead to the next month. But first, I want to briefly review January and February again, because there are some things I'm still learning about my areas of focus during those months. As a refresher, my goals were to approximate a direct primary care practice in my clinic in January and to do a bunch of procedures and learn 21 French words a day while in Togo.

January: Clinic

The most beneficial thing about trying to make my clinic a direct primary care practice is that I am much more intentional about how my clinic operates now-- even though I have found that I do not have as much control over my schedule as I would like to have. The main issue I am coming up against is that I continue to be scheduled for 8 or 9 patients per 3.5-hour half-day when I have repeatedly made it clear to my schedulers that I only want 6 or 7 patients on my schedule. This conflict is just a foretaste of what I would be in for if I was to join a traditional-style family medicine group, and is the sure-fire path to burnout. Every clinic I have had in the past 3 weeks since I have been back from Togo, I have had at least 8 patients on my schedule, and every evening, I leave the clinic stressed, frustrated, and knowing I could have done a better job. So, even though January is long since passed, I will continue to work with my clinic staff to find a way to see less patients each half day so I can give each patient the time and attention they need and deserve.

February: Procedures and French

The main barriers to achieving my procedural goals in Togo were the needs of the hospital and patients, which I was happy to oblige. It just so happened that I visited at a time when there were a lot of surgeons and not very many doctors or PAs in clinic, so I felt like the right thing to do every day after rounds was to head over to clinic and see some of the many patients who were waiting rather than run off to the OR. Nevertheless, I got a dozen or so spinal blocks (they rarely intubate) the last few days, when there were less surgeons around and a few more medicine people to cover the clinic, and also snagged four Caesarians and a few other surgeries. On the language front, I sometimes had the head-space, willpower, and energy to apply myself to French study, but often felt led by the Spirit to take a long nap. I'm not sure how many days I hit my mark of 21 words a day, but it probably wasn't very many. A major reason for this is that I had translators in clinic who often spoke in Ewe to the patients anyway, so it was so much faster to communicate with them in English and let them communicate with the patients in whatever language they were most comfortable with. In the future, I hope to live in a home-stay with a French-speaking family, in order to be immersed in the French language rather than being exposed to it as a third-party.

March: Teach

My specific goal for this past month was to teach medical students and interns about 21 different topics. Well, I haven't been tallying every little conversation I've had with the students, but I'm confident I've not yet reached my magic number. But I've learned and grown in my teaching skills in several important ways. First, I've finally come to the point this block of medicine where my own work is smooth enough that it can sometimes take a back seat and allow me to focus on teaching. On medicine, we have four medical students at a time, and my strategy has been to send the medical students to start seeing new admissions when we get them (which is standard), but to always have the other students who aren't seeing patients working on a little presentation they will give to the group. Taking advantage of this down-time has been a big stride for me. I've typically been giving them 30-60 minutes to prepare their talks, which provides the urgency and eustress that will allow them to focus and learn efficiently. Today, I gave them the afternoon and evening to work on topics I assigned them, and promised we would go over them tomorrow. This will hopefully allow me to go over their topics briefly on my own tonight or tomorrow, although it's getting late so that might not be possible. But ideally, I will brush up on the topics enough to feel comfortable giving a mini-lecture on them myself to supplement the students' presentation, which will reinforce the material in my own mind and become part of my growing repertoire of spiels on sundry medicine topics.

April: Read 21... Journals. And Teach.

My goal for this month was originally to speed-read 21 books, but I have decided to switch that goal out with June's, which is to read 21 journals. Part of the reason for this is that I have a giant stack of journals on my bedside table that have been staring me in the face for months. I'm tired of the guilt that rises when I take note of them in their silent yet pedantic condemnation. Another reason is that I'm still on a service block this month (Pediatrics), and want to continue to focus on teaching medical students and interns. Journals are much more pertinent to teaching than most of the books I plan to read, and will help me focus on learning more about topics I can teach to my junior colleagues. I also just picked up another batch of Pediatric AudioDigest cd's, which are medical lectures I like to listen to in the car. 

Perhaps this month, I'll be able to keep track of the topics I teach about, and may even surpass that magic 21. It should certainly be easy to keep track of the journals-- I'll just have a "Have Read" stack to supplement my "To Read" stack, and will count them up at the end of the month. I'm excited to refocus this month on my goals, and plan to make a more concerted effort to quantify how close I am to reaching them. Hopefully in a month, I'll have success stories to share with you all. I will at least be sharing some lessons learned.

Until then, keep growing.

Daniel

Togo Week 4: Bringing it home

Last week, I stocked up on Vitamin D at the pool, did a lot of spinal blocks, saw a lot of patients in clinic, and said my goodbyes. One day, I saw thirty patients in six hours, which averages out to one patient every twelve minutes! I also performed two Caesarian deliveries and a tubal ligation, and helped on a hysterectomy and a couple inguinal herniorraphies. Finally being able to get in the OR my last couple of days felt like a reward for all the hard work I'd done the previous month.

I wanted to come away from my time in Togo with new tangible skills, and I did. I'm comfortable doing spinal blocks on my own now, and a lot more comfortable with Caesarians now than I was before I went. To reinforce what I've mentioned in prior posts, I also feel much better about taking care of sick or potentially sick newborns, as well as malaria, typhoid, TB, parasites, HIV, schistosomiasis, and snake envenomations.

I also had a lot of time to reflect over the past week on larger learning points from the trip. An important one is that it's basically impossible to meaningfully connect to people with whom you do not share a language. This motivates me to continue to learn French, but also to try more to learn the local language of whatever place or places I spend more time working in the future. My gains in French over 3.5 weeks were fairly good, but would have been much more if I had had the head-space available that was taken up by medicine. In the future, I would like some dedicated time for just language learning, 24/7 for at least a couple months. Right after residency or fellowship would be the best time to do this, though I'll have to see what my life looks like at that time.

A related musing was how we should approach everything in life as a challenge, a puzzle, a problem, a question to be answered, solved, and overcome. This perspective is so empowering. When I was hot, I did not succumb to the temptation to dwell on how I wasn't meant to be in Togo or how I could never work at a mission hospital in Africa; I borrowed some thinner pants from Brett and took short breaks in air-conditioned areas, and felt just fine after that. Similarly, when I didn't understand what people were saying in French, I decided to make more of an effort to study and try to speak what little of the language I knew, and could at least understand bits and pieces of what people were saying by the end of the trip. When I wasn't sure how to get something done in the hospital, I would try to ask more questions rather than resign to futility. The list goes on. I'm frequently struck by how so many people resign themselves to being bad at something rather than approaching their weaknesses as solvable problems. Sure, not all of us are wired to be math whizzes or golf champions or social butterflies, but unless you have a personality disorder, a physical disability, or a below-average IQ, you can become decent at just about anything. We should all strive to be Renaissance men or women, not only to increase our antifragility but also so that our lives may be enriched. That's been my goal for a long time, and it's made my life immeasurably richer. But I still have a long way to go!

In addition to medical experiences, I was also able to connect to most of the English-speaking staff members of the hospital. I really enjoyed getting to know the CRNA's in the OR, who were all my age and spoke decent English. One guy even gave me an invitation to his wedding! During my down time, I watched Frozen with some other short-termers and the first half of the expanded The Hobbit 1: An Unexpected Journey with my house parents Mark and Donna Thompson. Church also offered a chance to engage with Togolese culture in a different venue, and the dancing and music did not disappoint! I also got my first djembe lesson by the long-term surgeon, Eric Miller, and am excited to play more and maybe get some drum circles going in the future.

My trip to the airport in Lome on Friday was eventful, as our first driver drove away with the keys to our van after we switched drivers halfway. Brett took off down the road waving his hands in the air, but she didn't see him. I'm sure it was quite entertaining to all the locals. Fortunately, the driver picked up when our driver gave her a call on her cell phone. Thank God for cell phones. We had a good time chatting with Koffi, the second driver, as well as a neat guy named Serge we met at a pizza place where we ate before heading to the airport.

The twenty-four hour series of three flights home was about what you'd expect; a never-ending stream of customs agents and airline clerks, movies and podcasts, carb-heavy food and cramped seating, naps and attempted blog posts that got lost multiple times. I finally gave up on the blog post, but think the added few days of perspective has helped things.

I already posted my photos from last week on Facebook, but will put up a few of the same here for posterity. Another post is coming where I will reflect on how well I met February's goals and what March is looking like. Until then, stay on the rise.

Togo Week 3: Pushing farther

This week, Brett, Felisha, and I met with a number of challenges, but today offers a chance to reflect on how we are overcoming them. Firstly, Brett got malaria (we think) on Thursday, and had about 48 hours of flu-like symptoms. But after taking a 6-drug cocktail last night and getting some good rest and prayer, he is back in the saddle today and taking Medicine call. Apparently not even malaria can keep that guy down for long! Compared to him, I haven't had any major challenges, but had to work through another couple days of low motivation and fatigue after taking two call shifts back-to-back earlier this week. But I'm back in the saddle today, too, thinking and learning and working, and taking OB call.

The challenging, sometimes sad, but always interesting cases continued this week. I got my wish and saw my first snakebite. A young man came in on Monday after being bitten on his foot by a snake 3 days prior. His leg was swollen and painful and he was having some bleeding from his mouth as well as from numerous little cuts a traditional medicine man had made on his body. He identified the saw- scaled viper in our handy-dandy Snakebite Guide as the one that got him (and got away), and we gave the appropriate antivenin along with antibiotics, the tetanus vaccine, tetanus antiglobulin, and Benadryl for a mild reaction to the antivenin. And he got better, which is always nice!

Look closely and you can see two fang marks just anterior to the abrasion near his heel.

On my call shift on Thursday morning, an elderly lady was brought in shortly after being struck by a moto. With her decreased level of consciousness, blood coming from her mouth, blood (which turned out to be a bloody CSF leak) pouring out her ear, and her Cushing's response (hypertension and bradycardia), it was clear she had sustained a basilar skull fracture and had a major head bleed. She remains unresponsive with fixed pupils this morning, and as there is no neurosurgery here, we are planning on withdrawing care in the next day.

We also saw a couple children with cerebral malaria complicated by meningitis Those kids have not done well; if they ever wake up, they will be permanently disabled. 

The ICU-- one of the cerebral malaria patients is in the corner bed

I diagnosed several patients with metastatic breast cancer in clinic this week, along with a couple others with intranasal masses. It can be frustrating and heartbreaking having so little to offer. I did start the breast cancer patients on tamoxifen in hopes they would get some palliation. One 22-year-old patient came in with obvious TB, but because his sputum smears were negative for TB the government had refused to treat him. I prescribed him quadruple therapy from our dispensary, but it turns out the pharmacy is currently out of pyrimethamine. Ultimately, after talking to one of the long-term missionaries, we decided to wait on starting him on treatment. Not starting him on treatment and not knowing whether he will ever get treated has been the most frustrating case of the whole rotation.

No C-sections for me this week, though I did place three spinal blocks and first assisted on an inguinal herniorraphy on a 2-year old. I should be able to get some more spinals and OR time this coming week, and I'm also hoping to primary a Caesarian on a transverse-breech set of twins scheduled for Thursday, if she doesn't go into labor before then. Like many patients, she is staying in the Cuisine, which is a building on the grounds where patients who need to be followed closely can stay for free. 

The Cuisine on the left and OB ward on the right

OR 2

My "NICU rotation" continues-- after some reading and discussion with the Pfennigers, I feel good about how to evaluate and make decisions on babies at risk for sepsis. I can see this knowledge being put to use both back in Wichita and also in my future practice. I'm very appreciative.

Maternity

My pleasant diversion this week was this morning's solo hike up the mountain road behind the hospital-- about a 45 minute walk each way, although the road was still ascending at a modest grade when I turned around. It was fairly peaceful at times, affording some moments for reflection, but also offered many opportunities to practice the situational awareness of Jason Bourne by staying out of the way of a steady stream of motos, trucks, and cars.

I would never trust a Togolese parachute.

Not much change in certain other areas: I continue to miss Mindy as well as other familiar comforts of home, The Book Of Daily Readings and Celebration of Discipline continue to inspire, and I'm still slowly learning French. My final session with Professor Tupo yesterday was excellent as usual. My nurse translator Maman Cherie continues to share the gospel like a boss and rock out an average of 2 conversions a day. It's amazing to watch.

Mindy and snow

Tupo

Maman Cherie

I'm thankful for the margin I've had during my time here to set fresh new goals for the year and consider the pros and cons of my various post-residency options. I'm sure I will return home inspired. Until next week!

Togo Week 2- Working Hard

Today marks the halfway point of my rotation here in Togo. Appropriately, Dr. Gayle (a long-term family doc here) and his wife Cheryl took several of us on an outing to the largest town in this region of Togo, Kpalime. We toured the local school for the blind ("The Village of Light"), checked out their nifty aquaponics set-up, shopped at their artisan boutique and the larger local artisanal market, dined at a nice local restaurant, and shopped in the town's outdoor market. All of the experiences-- as well as the drives there and back-- were eye-opening and enjoyable. I continue to derive pleasure from spending time with all the folks here, and am coming to appreciate more how truly wonderful most of the Togolese people are.

Yes, that is a goat on top of the van and two pigs on the back of a motorcycle. Not all that surprising when you think about it (how else are poor people going to transport their livestock?), but entertaining nonetheless given the novelty.

The workweek was also varied and productive. Since my last post, I have performed two more Caesarian deliveries (both of which went well from a surgical perspective, although one was on a known fetal demise), gotten pretty comfortable in both inpatient and outpatient OB and Medicine, and seen a lot of neat cases. There are too many stories to tell and cases to review. In rough order of frequency, on inpatient medicine we see malaria, typhoid, new HIV, anemia, schistosomiasis, acute kidney injury, osteomyelitis, and pneumonia most commonly. Common outpatient issues include dyspepsia, parasites, other infections, back and hip pain, infertility, diabetes, hypertension, orthopedic issues, HIV, and new TB. Yesterday, I was finishing up clinic when I heard a commotion in the waiting room, and a support staff person burst in the room, grabbed a fistful of gloves, and rushed out. Shortly later, I followed him out and discovered two motorcycle accident victims being rushed in on stretchers. I also discovered I was the only doc around. I instructed a nurse to get me some help from one of the local PA's, and began to run through the ABCDE's for each patient. Turns out both had head injuries (hopefully superficial only) and one had an open tib-fib fracture. Fortunately, both were protecting their airway and didn't show any obvious signs of imminent shock. After I got them exposed, I had them moved over to the hospital triage area, where we got IV's started and I was able to promptly obtain a surgery consult. That was fairly exciting.

Kristi, me, Chantal, Amanda, bowel gas, and Chuck

Alcoholic GI bleed in hemorrhagic shock

Peds ward at night

Bronchiolitis-- would have been intubated in the US, but still survived with non- invasive positive pressure ventilation

Myelomeningocele

Sundowning in same baby who really needs a VP shunt

In regards to surgery, I have not pursued getting in the OR (aside from C sections) because of my workload on Medicine and OB and the presence of five surgeons here for the past two weeks. I do still hope to get a few intubations, as well as a few spinals and some General Surgery cases if I can find time. 

Tomorrow, I'm back on OB call, then on Medicine call Monday. We have some people leaving so it will be busy, but hopefully in a good way. I also hope Brett, Felisha, and I can find some time in the afternoon to repeat our Sunday Swim! 

Though it's been a busy week, I've been encouraged by reading Celebration of Discipline by Richard J. Foster and following via group text the experiences of my house church brothers and sisters as they have sought to make meditation (the topic of this week's chapter) a meaningful part of their lives. Being a part of a group of people committed to strengthening and encouraging each other is a key to making spiritual progress, and I've come to appreciate that more this week.

I also had an African feast on Wednesday, which was the first time I had knowingly eaten cassava. It was super bland. The rest of the food was ok. Though I knew cassava wasn't paleo, after reading the Wikipedia article on it, I realized it ranks somewhere near Little Debbie Cakes in its un-paleoness, consisting of almost 100% carbohydrates and requiring extensive processing to remove toxic levels of cyanide. And it's not even native to Africa, having been transplanted here from Brazil by the Portuguese in the 16th Century. Next time, I think I'll pass.

Cassava (agbeli) balls, third bowls from the front

I also had my second French session with Professor Tupo yesterday, and have made some good progress in vocabulary and verb conjugations this week. I'm hoping to practice more each day as I become able to articulate a few things and understand more. Brett has studied with me a couple times, which has been good. I have one more lesson to finish learning the rest of the language!

Though it's been a good two weeks and I'm looking forward to another couple good ones, I'll get to see my girls when I get home! And other people too, I guess. I miss you!

That's Mindy and Molive. I'll never be a cat person, but do have a special place in my heart for Molive. Mindy's ok, too.

Togo Week 1- Growth

To those of you who don't know, I've been working at a mission hospital in Togo, Africa for the past week. I'm here with my friend and colleague Brett Hoffecker and his lovely wife Felisha. 

The first four days I was here, I was hot and exhausted all the time, didn't know how the hospital system worked, and somewhat anxious about how the month would go because I had so little energy. The last two days, I have felt like my normal self and been a lot more comfortable rounding on patients in the hospital. I'm not sure what changed, but for whatever it was I am thankful. Brett and I are alternating medicine and OB coverage every two days, which corresponds to each of us taking calls every other night (q2 call) either on medicine or OB. The other night, Brett was up literally all night delivering four babies, all of which were complicated by some combination of prematurity, pre-eclampsia, chorioamnionitis, and fetal distress. Fortunately, I haven't had a night like that yet.

My medical goals are to get lots of procedural experience and learn how to take care of some tropical diseases. This week, I did one C-section and two lumbar punctures and saw a few cases of malaria. The topic I actually learned the most about this week was taking care of newborns. My second day here, I performed a difficult neonatal resuscitation on a baby that ended up dying later that day. Although I did the resuscitation with another doctor, I felt like I could've done an equally good job on my own with the training I have received at Via Christi, which was reassuring. But I still learned a few things. The few other resuscitations I've been in on have been uneventful. But I'm also rounding on babies that would be in the neonatal intensive care unit in the United States, a setting in which I have never worked. So I am getting comfortable with treating babies who possibly have sepsis, premature babies who are not yet feeding well, and babies who aren't breathing well. It's been good. Since there are a lot of surgeons here my first two or three weeks, my only real time in the operating room was for the C-section I did and a couple neonatal resuscitations. I hope to get some more time in the OR my final couple weeks of the rotation.

Another goal of mine is to learn lots of French, which is the primary language of the staff here. Yesterday, I had my first of three hour-long French lessons with a local dude who comes here every Friday to provide lessons to the missionaries. His name escapes me, but he has a close-criopped white beard and is a pleasant guy. I'm starting to learn, which is exciting as it represents the start of a new journey.

My interactions with the short- termers, intermediate-termers, and long-term missionaries have all been positive. I'm enjoying their company and learning a lot from them. Some of them are truly inspiring. Today, a few of us short-termers went for a three-hour hike to a nearby cascade and back, which was pleasant. I'm also getting to know the national staff pretty well, and played with a bunch of kids on my run yesterday and ended up with a good story I'll perhaps share another time. I'm particularly looking forward to learning from an OB who just arrived yesterday and continuing to learn from the two Family Medicine and OB fellowship-trained missionaries here with World Medical Mission's 2- year post residency program.

Things are pretty good for me spiritually too. God is teaching me how big He is, how to live more other-directedly, and what walking by faith looks like for me, being a critical and very analytical dude. I'm going through literally the best devotional I've ever come across, a gem of a book I was given by Mindy entitled A Book of Daily Readings. It's basically a bunch of the best quotes you've never heard, some of which are religious but most of which are simply very thought-provoking and heart-pricking. Mindy found it second-hand somewhere and it blows my mind every day. I'm also starting to go through Richard J. Foster's Celebration of Discipline, which has been good so far.

Last but certainly not least, my first week of engagement with Mindy and our first Valentine's Day have been wonderful. Though we have been separated by oceans, mountains, and many miles of flatness, we have had time to process together in a way that would not have been possible if we had been in the same location, partly thanks to the power of the internet and partly thanks to journalling. I'm growing more excited and thankful for her each day as October 4th (our tentative date... not yet set in stone) approaches. 

Thanks for all your thoughts and prayers. A lot has gone into making this trip happen, and it's encouraging to look back over the past week and see some real gains in all the areas I've mentioned. If you'd like, pray that the growth continues.