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SMS Unplugged

Medical Education, Medical Schools, Palliative Care, Patient Care, SMS Unplugged

When Mr. Bailey passed away: A student’s story

When Mr. Bailey passed away: A student's story

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged categoryCertain details in this entry have been omitted or changed, and all names have been altered to protect the identity of those involved.

387521264_d1cd33d574_zBrief life update, since it’s been more than 3 months since I’ve last posted on SMS Unplugged:

  • I disappeared for most of April through the end of May to study for and take Step 1, which – for anyone who hasn’t heard of this test – is a pretty brutal, not to mention expensive (~$590!! One of many reasons why med students are poor), 8-hour exam that tests broad concepts of medicine (biochem, immunology, organ systems, etc.) and is widely heralded one of the most important tests for residency admission.
  • I started clerkships at the end of June, with my first clerkship being in internal medicine. The rest of this entry describes one of the most poignant experiences from my first month and a half on rotations.

It was just another call day, when all of a sudden, an overhead announcement rang through the ward: “Code Blue, respond to Room 281. Repeat – Code Blue, respond to Room 281.” Instantly, the atmosphere in our team room turned serious: We knew it was one of our patients, Mr. Bailey, there. As a group, we sprinted towards Room 281. Disorganized, panicked thoughts were running through my head – oh-my-god-what-happened-to-our-patient, thank-goodness-I’m-wearing-sneakers-and-scrubs-today-there’s-no-way-I-could-run-like-this-in-flats, oh-my-god-what-happened-to-our-patient, oh-my-god.

When we got to the room, there were at least 8 people there already, with more trickling in. Our patient was covered in wires, IV lines, a face mask for oxygen. My resident stepped up to the bed and began telling everyone else about our patient’s past medical history, what we were treating him for, how his clinical course had been. I stood in the back, with the single-minded goal of keeping out of everyone’s way. For the next several minutes, at least a dozen people worked to bring Mr. Bailey back to life – and when I left the room, they had succeeded.

I walked back to the team room in a bit of a haze, the relief beginning to course through me, mixed in with remaining vestiges of adrenaline. I had only met Mr. Bailey once before, as he was primarily being followed by another member of my team. From our daily morning rounds, however, I knew he was incredibly sick. We estimated that he only had a few months left. When I met him that one time, it was so clear to see that he was struggling, to breathe, to keep his state of mind. Still, I thought it would be months, not days before he passed away.

The morning after the code, I came into the hospital at the usual time, pre-rounded on my own patients, and headed back to the team room to prep my presentation and notes for rounds. As I walked back to the team room, I ran into another team member, who asked me, “Did you hear about Mr. Bailey?” “No,” I said. “He died last night.”

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Patient Care, SMS Unplugged

An anthropologist on the wards

An anthropologist on the wards

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

As my third year of clinical rotations comes to an end, I’ve been reflecting on the ways in which I use my training as an anthropologist on the wards. One patient comes to mind, a recent immigrant from South Asia who came into the hospital after an accident where he was bicycling and got hit by a car. He was scanned from head to toe for any injuries, and though his bones were intact and organs whole, a few spots lit up on his chest imaging. Because he was uninsured and had a high risk of not following up, he was admitted for a few nights for a workup to rule out cancer.

His first night in the hospital, he lay in his bed, back aching where the blood had congealed, hunger gnawing at his belly. The nurse had handed him a meal card with the Stanford Hospital dining options — but he wouldn’t call to make his order. By the time I got to know him, he had already been in the hospital more than 24 hours without eating anything.

He felt that in being his advocate, I was an angel sent to take care of him. In reality I had played the role of the anthropologist…

I had the fortune of understanding one of the languages he spoke, and he started to tell me his story. Before me, various doctors had come and gone to ask him the details of the accident (How fast was he riding his bike? Was he wearing a helmet?), and he had answered them in broken English, anxiously. It was only by speaking with him in Hindi that I understood his deep financial fears. He was worried that he would be held at fault for the accident, although it was the automobile driver who had hit his bike. He didn’t understand why doctors were asking so many questions instead of examining and treating him. And, he refused to eat because he was terrified that he would be charged an exorbitant price for the food, when he could not afford to pay for this hospitalization at all.

I clarified that either way he would not be made to pay. Stanford Hospital had options in place for those who could not immediately cover their medical bills. And besides, the food came with the cost of admission — if he did get charged for his stay, the food would be included in that price whether he ate or not. He agreed to have a chicken and rice bowl with some fruit, and fell into a fitful sleep.

The next day we talked more. His back still emitted a dull throb, but otherwise he felt fine. “But what about those lesions they saw?” he asked me. “Am I going to die?” He put his rough hand on mine and started to cry. He explained that his wife and child were back home. He was a policeman in his home country. He had come here a few years ago to earn money, and worked long hours at a gas station — often through the night. He worried about his safety. Every screech, every car that slid up while he was on his shift, set his nerves alight.

I asked him if he had a chance to speak with his wife, and he said he was afraid because he didn’t know how to explain what was happening to him.

At rounds, we discussed this patient as our mystery case: mediastinal lymph nodes on chest CT in a previously healthy male who lived abroad. Could this be reactive tuberculosis? Lymphoma? We stood in a circle outside his room, throwing around diagnostic options, citing papers, making a list of tests to order and consultants with whom to confer. All of this without needing to see his face.

Another day passed. When I saw him again, he had moved to a positive pressure isolation room, behind two sets of doors, and nurses went in and out wearing thick blue masks. When I walked in to see him, also wearing the mask, he looked tense. “Why am I in here?” he asked.

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Medical Education, Medical Schools, Medicine and Society, Research, SMS Unplugged

Research in medical school: The need to align incentives with value (part 3)

Research in medical school: The need to align incentives with value (part 3)

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the SMS Unplugged category.

This is the final post in a three-part series on research in medical school. Parts one and two are available here.

confusion-311388_1280In my last two posts, I explored the research paradigm of American medical training. The takeaway was that research requirements may create inefficiencies that have a host of consequences, including an unnecessarily long training process, a potential physician shortage, and an underutilization of talent.

In this post, I’ll lay out a vision for a training process that can produce a more effective physician workforce. The role of a physician has changed over time, and the education system must evolve to keep up. I’ll consider three topics: what students should get out of medical training, how schools and residency programs can help them do it, and how the system at large can enable schools to make changes.

What should students get out of medical training?

First and foremost, medical training should produce doctors who have a strong understanding of human health and disease and have the clinical skills to translate that understanding into patient care. The goal should be to produce good clinicians – that’s what the vast majority of doctors will focus on in their careers.

With that said, I accept the premise that medical training is not exclusively about clinical skills. Physicians are bright, capable individuals, and are uniquely positioned to improve the health status of their patients by other means. Schools should empower their students to pursue those opportunities. For the reasons I discussed in my last post, medical schools have decided that the primary way to do that is through research.

Research is one way to push extraordinarily important advances in medicine, but it isn’t the only way. Doctors can also improve their patients’ health by taking on roles in community health, policy, entrepreneurship or management, among others. These involve many of the same skills and techniques as research, but medical trainees don’t get exposed to these opportunities. We should.

How can schools fulfill this mission?

So how can the education system make this happen? At some point, whether it is in college or medical school, students should be given the flexibility to explore multiple domains of medicine and health care. They should then be able to pick the one or two that fit their interests and pursue them in more depth. Many students will choose to do research, while others will select other specialties. If students explore these opportunities and decide that they would rather focus on being an excellent clinician, that should also be doable.

This would allow physicians to become more effective leaders and decision-makers in the health care system. The traditional training process treats medicine as a universe of clinical practice and research, but the physician workforce has unfulfilled potential across a spectrum of other fields.

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Medical Education, Medical Schools, Mental Health, SMS Unplugged

Free from school

Free from school

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category

Editor’s note: After today, SMS Unplugged will be on a limited publishing schedule until September.

girls running

Summer. It beckons with strawberry warm rays of sunlight, afternoons spent splashing in a pool, and the joys of watermelon-flavored popsicles. We, second-year medical students around the country, look out our windows and see children, newly freed from school, frolicking in the playground next door – and feel miserable. For this is the time when we are experiencing the worst of medical school.

We have completed the pre-clinical curriculum, some of us barely crawling across the finish line. We have spent weeks cramming for the USMLE, an exam described in no softer terms than “the most important exam you will take in your life.” And we are becoming familiar with a new kind of anxiety as we prepare to enter clinics for the first time. Or, rather, my classmates are – I chose to take time off between second and third year.

In the midst of Stanford-high expectations for our professional performance, we are seldom taught exactly how to take care of ourselves. I knew that I needed to change something halfway through second year when I found myself outlining a novel instead of studying during finals week. I nearly failed two exams. But I was happy.

I felt satisfied.

And so, I set about finding a way to incorporate more of writing into my medical school experience. Stanford has funding called Medical Scholars, which is set aside for every medical student to take a year off to work on a significant project or research experience. Their office willingly helped me apply for and receive this funding to work on my novel full-time for a year. I can’t imagine this level of support for an artistic endeavor from any other medical school. And so very soon, I too will be frolicking in the grass, newly freed from school.

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Medical Education, Research, SMS Unplugged

Research in medical school: The need to align incentives with value (part 2)

Research in medical school: The need to align incentives with value (part 2)

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

This is the second post in a three-part series on research in medical school. Part one is available here, and a third post will run on June 24.

5713991403_99bbdea4e1_zIn my last post, I discussed points brought up by Ezekiel Emanuel, MD, PhD, and John Ioannidis, MD, about research in medicine. The takeaway was that students are strongly incentivized to do research during their training, but those incentives don’t necessarily reward high-quality work. Furthermore, they don’t directly contribute to clinical skills and becoming an effective practitioner. As a result, students may be spending time and effort on projects that fail to maximize value for both themselves and for the medical system at large.

This inefficiency has several consequences. At the individual level, it means students spend more time in training (arguably 30-40 percent more), accrue more debt, and lack the opportunity to pursue other interests. At a societal level, it may contribute to the growing physician shortage and potentially limits the productivity of highly talented and well educated people.

The stakes are high when it comes to designing a system of medical education. After my last post, I spoke to several other medical students about the subject, and many of them felt that research requirements don’t align with their eventual goals. This got me thinking about how we can improve things, but before proposing any solutions, it’s important to understand the mentality that led to the status quo. So in this post, I want to delve deeper into why there are such strong incentives for research in medical training.

In reading and thinking more about the subject, I’ve identified four reasons. The most commonly cited one is that research is a means to a pedagogical end. It’s a way to teach students how to think critically about a problem, analyze available solutions, test those approaches, and then synthesize the resulting information. It’s the scientific method at work, and doctors have to use that method every day.

While true, this alone doesn’t justify medical training’s emphasis on research. It’s possible to develop those same skills through many intellectual pursuits, whether it’s working on a policy platform, developing a health education and outreach program, or even working in a corporate job, among other possibilities.

The second reason is that medical schools are typically part of a research university. As the name implies, one of their primary purposes is to do research – institutional prestige relies heavily on academic output. As members of this community, medical students are expected to participate.

But once again, this line of thinking doesn’t entirely explain why medical training should prioritize research to such a great extent. Consider two other professional schools at a university – business and law. Most students in these programs go on to become practitioners (just like most medical students go on to become practicing physicians). Students have the opportunity to conduct research, but the emphasis is on pursuing extracurricular activities relevant to their career plans.

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Medical Education, Medical Schools, Research, SMS Unplugged

Flip it up: How the flipped classroom boosts faculty interest in teaching

Flip it up: How the flipped classroom boosts faculty interest in teaching

flipped classroom

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

Recently, the flipped classroom — a model of instruction in which didactic content is delivered outside the classroom (usually online), and in-person class time is used for active learning — has infiltrated the educational landscape from kindergarten to professional school.

As a current medical student, I generally agree with advocates for using the approach in medical education. For example, Stanford’s Charles Prober, MD, senior associate dean of medical education, argues in a New England Journal of Medicine commentary that the opportunity for enhanced time-efficiency, student self-pacing, and classroom time freed up for more interactive learning make the flipped classroom a potentially attractive approach for educating physicians. I say “potentially” because, like anything else, the flipped classroom is a good approach only if it is done well. For me as a learner — even a modern, Millennial learner — I’d much rather attend an engaging lecture or study a well-written textbook than watch a lousy online video or struggle through a poorly facilitated interactive classroom session.

So I have to admit I harbored some skepticism when, about about a year ago, Prober invited me to become involved the Re-Imagining Undergraduate Medical Education Initiative, an ambitious project to create a new, flipped classroom-based microbiology and immunology curriculum in collaboration with four other U.S. medical schools, which Scope covered last year.

Although I was excited to have a role in such a large-scale project, I worried that the hype of the flipped classroom trend would overshadow what I thought should be the priority: training our future doctors with the highest quality education — not just the flashiest.

Happily, my worries have proved unfounded. I have seen the faculty and staff from the five schools work tirelessly to produce an impressively high-quality final product. In fact, I have even come to believe that the flipped classroom model intrinsically helps incentivize medical faculty members to prioritize teaching.

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Medical Education, Medical Schools, SMS Unplugged

An extra year of medical school? Sign me up

An extra year of medical school? Sign me up

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category. 

sandglassesThe process of training to become a physician is a complex and mysterious process to most outsiders, but there are two things that everybody seems to know: 1) how expensive it is, and 2) how long it takes. (One of the first things people ask when I tell them I’m a first-year medical student is, “So, how many years do you have left?”)

Because these issues represent major barriers to entry to the medical profession, some medical schools have begun piloting MD degree programs that are designed to be completed in three years rather than the traditional four. The benefits are easy to see: By shortening the training by one year, students save on a year of expensive medical school tuition and are also able to contribute to the health-care workforce one year sooner.

In a climate where much of the discussion is about how we can shorten and streamline medical education, many people are surprised to hear that I, like many of my Stanford classmates, will actually likely choose to take an extra year during medical school – for research, service, or an additional degree. Given that I also spent two years working between college and starting at Stanford, my inefficient path will have added three or four extra years on to my education when all is said and done.

Am I foolish for condemning myself to years and years of training before actually starting my “real life” as a doctor? For me, the thought process behind extending my training an extra year is actually very simple: I just really like being in medical school. How many other opportunities will I have to take classes in medicine, law, and statistical programming – all in the same term? When else in my life will I be able to soak up wide-ranging experiences from general pediatrics to neurosurgery, without committing to either?

To be sure, I don’t view these experiences as being part of the “most direct path” to becoming a competent, successful physician. But from a selfish perspective, they might help me better find a career path that suits me well. And from a societal perspective, I like to think that these larger life experiences will help to shape and define my unique set of values, philosophies, and skills as a caregiver to people in need – a framework that goes beyond the highly standardized requirements for medical training.

This is not to say that years of additional time are the best thing for everyone. I admire and envy those people who already know what they want to do and how they want to do it, and three-year MD programs offer those people a chance to make much-needed contributions to society as quickly as possible. However, to the degree that longer programs allow us the flexibility and independence to develop ourselves, I believe that they are an invaluable option for many aspiring doctors.

Nathaniel Fleming is a first-year medical student and a native Oregonian. His interests include health policy and clinical research. 

Photo by Leland Francisco 

Medicine and Society, SMS Unplugged

My grandfather’s body: Loss and mourning in India

My grandfather’s body: Loss and mourning in India

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

6847161038_c6e69c4185_zI’ll pick up where I left off – after the rain.

My grandfather, a pioneering cancer surgeon in the city of Kolkata in India, a dynamic and daring individual, had been ill since a fall in February. I flew home to be with him, and our family took close and attentive care of him both at home and through multiple trips to the hospital.

The morning my grandfather ultimately passed, I had been by his side from an hour before, called in because his pulse was dropping to half of its normal range. His eyes were still closed in sleep, his forehead cool, and a feeble pulse fluttered at his wrist. We called an ambulance, realizing that he was sinking, but feeling ambivalent about transporting his body to the hospital and having him hooked up to intravenous lines and various leads and wires – something he had told us he did not want. In the meantime our family crowded onto the bed, surrounding him with loving thoughts, and I turned on one of his favorite CDs, a collection of devotional Hindu songs dedicated to his guruji, Sadhu Baba. By the time the emergency doctor came up to our seventh floor apartment, about thirty minutes later, his pulse was gone and his heart had stopped. I checked the time: 7:10 a.m.

I share my experiences as a reminder of the poignancy that these rituals may hold. Though these may be private moments…doctors can and should be attentive to them

Mourning is a culturally-mediated experience, and in the world of our family grief was a physical, tangible thing. When the uncertainty of my grandfather’s situation (Was he really gone? What else could make a pulse disappear?) turned to disbelief, and the disbelief to heavy acceptance, our first reaction was to hold the hands that lay tenderly on either side of him, to run a palm along his cool, sunken cheek, to hug his flesh.

I was with him as his body was painstakingly dressed in his favorite cream suit and a lilac tie, with fresh socks on his feet and gold-rimmed glasses in place. He remained resting in his bed, as family members and friends poured in to offer their respects, to pay darshan: to see and be seen by him. The air conditioning was turned on to keep the body cool in the draining April heat.

I was there two days later, when his body, this time in his black suit with a red tie, traveled through the town in a long, silver hearse and was brought back home. We pulled into the apartment complex, where loved ones lined up. They opened the doors at the back of the glass case where his body lay, and placed flowers over his chest, or touched his feet in a gesture of respect toward one’s elders. Some mourners wailed and threw themselves onto his body, or pulled at his clothes, letting their tears dampen his clothes. One bewildered, heartbroken friend and former patient kissed my grandfather’s feet.

And I was there – along with at least 50 other people – at the cremation grounds, where his body was showered with petals, blanketing in fragrant wreaths. Then, the flowers brushed away, we prepared him for cremation, covering his skin with ghee. His three children held a flame and circled around him in prayer, then his body was hoisted into the electric cremation pyre. I was there when we waited thirty, forty, long minutes for the flesh to disintegrate and liberate his soul.

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Medical Education, SMS Unplugged

“Us” and “them”: Losing the patient perspective

“Us” and “them”: Losing the patient perspective

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

holding hands - smallThis past Saturday, I received a call from a close friend from college that went something like this:

Friend: “Hey… so I’m in the ER right now, and I didn’t know who else to call.”
Friend: “They think I have appendicitis.”
Me: “Ohhhhh – oh my gosh, thank goodness. I thought it was something really bad.” (nervous, relieved laugh)
Friend: “Wait, why are you laughing? I’m freaking out right now. What if my appendix explodes inside me? I’m so scared.”

A flush instantly spread across my face. I felt terrible.

In my head, appendicitis was relatively low on the list of all the possible horrible things that could have happened to my friend. I knew it was a common condition, that an appendectomy was a straightforward procedure, with minimal risk, and that of all the body parts to lose, the appendix wasn’t the worst by far.

When my friend mentioned that he might have appendicitis, my mental reaction was to think of all the factors that go into that diagnosis, and I was bursting to ask if he had guarding or rebound tenderness, and if the doctor’s said anything about McBurney point. (Side note – I’m currently studying for Step 1 – not that that excuses my impulse to run through a mental illness script). When that flush washed over my face, it was because I was shocked at myself: Why did I not – first and foremost – put myself in his shoes and try to feel the same pain and panic he was feeling?

I immediately apologized – again and again and again. Over the next few minutes, he asked me questions about appendicitis, how likely it was that his appendix would rupture, and more. At the end of the phone call, we had made plans to meet the next day, after his surgery, and my friend was calm. I, however, felt unsettled, and so guilty.

At our “Transition to Clerkships” retreat this past Friday, we sat in small groups and reflected on our individual hopes and fears for clinics. One of my fears was that I might become jaded or desensitized to patients’ conditions and not react with the empathy my classmates and I have cultivated and practiced so carefully. This incident with my friend brought that fear to the forefront of my mind.

I think that in many ways, it is a blessing for a physician to be somewhat desensitized to human suffering (after all, I can’t be fainting all over the place, can I?). But I also think there’s value in reflecting on how we can work to retain and prioritize that element of emotion that makes us human and that makes a doctor someone who is kind and trustworthy. As I move into clerkships this June, I sincerely hope I’m able to find that balance.

Hamsika Chandrasekar is a second-year student at Stanford’s medical school. She has an interest in medical education and pediatrics.

Photo by george ruiz

Medical Education, Patient Care, SMS Unplugged

The first time I cried in a patient’s room

The first time I cried in a patient’s room

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

Moises bedside sketchThis blog entry marks my last contribution to SMS Unplugged. I am two months from graduating from Stanford Medical School and starting my adventures as an intern. My fiancé and I happily matched at Baylor for our residencies and look forward to contributing to patient care in Houston. Having finished my clinical duties and finding myself spending less time in the hospital, I didn’t anticipate the powerful experience I would have at a patient’s bedside this past week.

In my clerkships I have encountered various situations in patient care that are difficult to deal with: the weight of sharing a negative prognosis, the death of a patient, disappointments in personal performance. Through these encounters I took pride in remaining professional and controlling my emotions, finding a balance between showing empathy and connecting with my patients but not allowing my personal feelings to take over. More specifically, I have never cried in front of a patient. This changed last week, and it happened in the most unexpected of moments.

As a teaching assistant for the second-year class my responsibilities include recruiting patients for students to interview and examine. For the most part, it’s a tedious thing to do and can be a task to dread. But every now and then I meet a patient that reminds me how amazing patient – and human – contact can be. During my last recruitment session, I met a patient that made me cry. I cried not for her, but because she cried for me.

In the process of introducing myself I could tell that she was a warm and caring person. This made it easier to open up to her when she asked about me, where I was heading next, and what life plans my fiancé and I have. It’s not usually a conversation I would have with a patient that I’ve only known for two minutes, but something about her genuine interest was welcoming. Wrapping up our conversation, I began to thank her and make my exit when she reached for my hand and asked if I could give her just two more minutes. Instead of continuing with generic conversation, she closed her eyes and began to pray while holding my hand tight.

Praying with a patient wasn’t new; several patients in the past have asked for me to share moments of prayer with them, and they were beautiful moments. But this time it was about me. She prayed that I have a good residency experience and that I emerge from my training well prepared. Then she opened her eyes and revealed the tears that she would bless me with. She asked that I never forget the dynamic that I will share with my patients. She asked that I always remember to look my patients in the eye, check my position of power and recognize the intelligence of my patients, and more than anything “kick the heck out of life.”

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