*UPDATE* Psychological Effects of Heart Rate Monitor Use Study
Tuesday, March 31, 2009
I am 3.5 days away from the most important day of my coaching career, leading segments of the 9th Annual "RIDE FOR A REASON" 6-hour Spinathon on Saturday at the Burlington Sheraton. 125 bikes, big stage, all that. The opportunity of my dreams, to lead a massive audience through an individualized version of the reality I shape for them. The concepts, the visions, the rhythms -- the things that bring tears to my eyes at the mere THOUGHT of them (even now as I sit here, writing...) exploded in larger-than-life form. It's everything to me.
I am PETRIFIED. So petrified that I am avoiding full immersion in my prep work for my cues (the ride has been done for a while; it's the "what the hell am I actually going to talk about" part that remains elusive). I'm making excuses: medical school exam (heh), cleaning my house, doing the laundry, writing on Spintastic...
Deconstructing the Profile
The ride itself was easy. These 1.25 hours, arguably, have been in the works for an entire year. The profile and playlist are based almost exclusively on "Kaizen," my farewell ride at NYSC 86th/Lexington my last day in NYC before I moved to Vermont. Am I really playing the same stuff, saying the same stuff, since July 31, 2008? Perhaps I'm saying it slightly better, more confidently, able to draw on more sources to create relevance for my riders -- but it's the same stuff as when I was an entirely different coach, and entirely different person with an entirely different life. This shocks me, somehow.
"Kaizen" was named for the Japanese philosophy (and business management approach) of tapping into one specific subtle issue to improve -- making constant micro-adjustments, engaged in the process of change for the sake of improvement alone. When I learned of this concept, I loved it so much that I not only based and named a ride for it... but I also named my car after it when I first learned how to drive in August. Talk about a "life improvement" ;-)
Since July 31, I've run variations of this ride with different sub-foci and messages, different music, different vibes. It was even the basis for that New Year's ride that I did 3x a week for a month without anyone noticing. It's a format that, almost magically, allows me to be completely in my element -- a vehicle for projecting the most global or subtle message I want to convey with a given ride. Obviously, it's what I would use for Ride for a Reason.
Except it's this very versatility that now strikes me as so daunting! I have done 50,000 things with it -- and can do 50,000 other different things. All the messages I've covered in the past year in my classes, ALL of which directly and indirectly can contribute to the experience of someone who is riding a stationary bike for 6 hours.
Deconstructing the Message
First and foremost, I need to choose what my message will be. When I lack a unifying message, I am not in my element. I need to be in my element.
I am trying to inhabit the existence of someone about to start their 5th hour. I've ridden two 6-hour Spinathons before; I know what it feels to start that 5th hour. It's not as awful as it feels to start the 4th hour - but it's pretty damned awful. What do they need to tell themselves to be successful? What cognitive distortions do they need to combat? What pain are they pushing through? Do they remember why they're doing this crazy thing they're doing?
I think, and have written, SO much about my self-concept as a coach over time. One "big deal" part of that, for me, is the idea of helping people discover what it is that they want, and empowering them to go out and do it. (As it, promoting endurance training isn't as simple as getting people to do "this thing they don't want to do" -- it's actually inspiring in them a sense that they genuinely WANT to become a fat-burning machine, and that this is part of how to go about doing that). When I've done long endurance rides with my classes at UVM, as a component of training them for this very event, it's been all about that -- encouraging them to set short-term, specific, measurable goals WITH REASONS, and to motivate themselves by repeatedly reminding themselves OF THOSE REASONS.
I tried to test the efficacy of this coaching strategy (and life policy) of mine by doing another field experiment on myself, my go-to evaluation mechanism for most of my kooky ideas. I ran through a draft of my ride -- on the elliptical trainer, at 65-70% MHR, for two hours. GROAN. How awful! No, really, it was. Besides the tedious boredom, the elliptical inspires "hot feet" much earlier than a bike -- there's way more direct nerve compression; there are no upstrokes. I've been working for months on forward/backward shuffling and heel-driving on the elliptical (given the applicability to my uber-micromanaged pedal stroke) -- but by and large, that thing is TORTUROUS. I was specifically endeavoring to inspire the very challenges by which my riders would be most distracted (i.e, intense physical pain), to then practice paying attention to my thought processes -- to then translate into cues, of the self-talk that kept me going. Inhabiting another's existence is a lot easier when you've actually lived it. The real gift is inhabiting that existence without having lived it; if you're thoughtful and curious, you can tap into that through individual dialogue. That's what medicine is all about. But in group fitness, cheating is permissible. Actually enduring a challenge and paying attention to the strategies that work for YOU... those make the best cues indeed.
Which brings us to the age-old questions:
What are you climbing for? Why are you climbing for it?
Yeah, yeah, I get it. I am riding because my performance is a reflection of my self-concept. I see myself as strong, as capable of enduring through this challenge. I control my heart rate because I enjoy the experience of having complete control over a physiological process, of quantifying parameters of my performance that I have specifically invested time to improve for improvement's sake alone. I push through pain because I know that I really CAN do this thing I want to do, as a symbolic reflection of my belief in myself.
But can't I accomplish that in, say, two hours? Why am I still on this friggin' bike at Hour #5? What does it mean to me, specifically, to commit to this?
When I rode in my previous two Spinathons, I didn't ask myself those questions. I finished them. But when I look back on them, I remember three things: a) how much pain my feet experienced (I suffered WICKED cases of "hot feet" both times -- I actually started CRYING during my first spinathon, in so much pain. I remember saying out loud: "I can't do this. I can't do this. This hurts so bad."); b) how surprised I was to NOT be exhausted, after spending six hours at 50-65% MHR; c) how boring most of the ride segments were, how uninspired I felt.
You'll note that I did not say that I remembered how proud I was of myself. Even now, I can't say that either were major accomplishments -- even though, in theory, each was its own indoor Century. It didn't feel like that big a deal. It just hurt, and I was miserable.
How do you want to feel when you finish? What is it going to take to make this something you remember for the rest of your life, as a reflection of your strength, your passion, your supreme mastery of your experience?
The Hour that Sucks
As I told my riders in class tonight who are participating in Saturday's event, all they have to do is make it through Hour #5. Hour #6 is cake -- it's so close, you've come too far to turn back. The investment justifies the reason. The energy is high, the adrenaline's pumping. It's fine. It's Hour #5 that sucks.
Hour #4 sucks, too. But the nice thing is that all the hours before mine will be led by exceptionally gifted MI's (Angie Scott, Raquel Schmidt, Anthony Musemici). I'm not concerned that people will be lacking in energy and happiness. But come Hour #5, no joke, there's nothing on earth that makes that hot-foot pain bearable.
I decided that I would lead Hour #5 on Saturday because, for me, it represents the part of the ride when I am likely to be miserable -- and can I channel that pain constructively, to motivate and inspire to not just ENDURE... but to tap into the joy, the passion, the meaning of it all? That's the challenge with which I am tasking myself.
You Are What You Think About All Day Long
I titled this sub-segment and, just like that, arrived at my message.
Hour #5 is going to be about controlling your mind, coaching yourself through your most difficult hour. OBVIOUSLY this is my theme. It's what I talk about all day long. How the hell was this not obvious to me until right now?
I accidentally just found a blog post I wrote just days before I initially debuted "Kaizen," when this concept first started to become dear to me. It doesn't suck: "It's All About How You Talk to Yourself."
I can absolutely work with this:
Block 1: Remembering why you started this. Remembering what you love. Tapping into your passion, the thing that gives you purpose and meaning.
Block 2: Identifying ANYTHING that is interfering with that purpose. Your doubt? Your fear? Your pain? Acknowledge how you feel. It's okay. But use that as a stimulus to reset, recharge, reconnect with what brought you here to begin with. WHAT WAS YOUR REASON? What did it mean to you... to YOU, not to anyone else? "Surge" to conquer those inhibitions, to replace them with affirmations of strength and power.
Block 3: Celebrating the freedom from those now-shed restraints. Charging forward, launching into the final hour.
That, that's a structure on which I can hang my h...eart rate monitor. I sure have a lot of work to do... but I'm slightly less petrified. I just need to adopt the role of the character I play when I'm nervous and awkward, the character who has no need for any of those doubts. The character who knows exactly what she's going to say, how she's going to say it... and why.
Thursday, March 19, 2009
There's a framed poster in my medical school's library that I really dig: "Knowledge is making the people around you feel smarter." When I saw it for the first time eight months ago, I saw it as a most profound concept that applied to both my medical and coaching "life spheres" -- and from then on, walk a few steps out of my path every so often just to see it. The poster makes me smile; the concept makes me get out of bed in the morning. Conceptualizing my role in the world to try my darnedest, every day, to teach somebody SOMETHING that empowers him or her to make a meaningful contribution to his or her own life -- the art, of course, being to develop the tools necessary to convey that SOMETHING in the specific right way for the right person.
A while back, I accepted a colleague's request to sub her 6:30AM class this morning -- forgetting that I'd be working til 11PM at the rural medical clinic (an hour away) where I recently started training. In New York, I used to teach 6:30AMs every day: they were my favorite. I taught one in VT over my first four months here before I found my "groove," and it was miserable. I counted down the weeks til I could drop the class. Today would be my return to the AM scene, and I was not excited. I anticipated that I'd have zero "regulars" (I teach a permanent class tonight, too; they'd be at that one!), and running on four hours of sleep (after having woken up at 4AM yesterday to make time for studying AND the gym, going to school all day, then spending nine hours on my feet at the clinic and two hours of interstate-driving was sub-ideal to say the least.
I hadn't officially even decided what ride I'd do. I don't wing rides (when I do, they suck -- and, as a general life policy, I try not to suck) but at any given point in time, I'm typically prepared to present 2 or 3 different profiles (an old habit from my 21-classes-a-week days in NYC -- I'd often get sick of myself and want freedom to "abort mission" whenever I so chose). I hadn't decided because I just plain didn't want to present ANY ride. I just really friggin' didn't want to do it. I wanted to go back to bed and sleep as long as I can maintain 65% MHR (i.e., forever).
As I got into my car and thought about how awful life was in that moment, I had an epiphany. Even without caffeination-induced clarity, it became clear to me what ride I would do.
The ballsiest one in my arsenal.
Yes, at this sub gig, a 6:30AM sleepy crowd of college undergraduate strangers with whom I have 0% street cred, I would do the most TEDIOUS endurance ride in my arsenal. Clearly, it was not enough to keep 'em aerobic for 45 minutes when I know they're used to, ahem, something different. No. I would go for broke. I would take these complete strangers, keep them exclusively between 70-75% MHR (not that they'd have HRMs...), and keep them seated the entire time. And I'd friggin' make them love every minute of it.
Oh, and for kicks, I also decided to coach it entirely off the bike (but for periodic demonstrations of posture).
Suddenly, I got a burst of energy -- and it wasn't just from the loud, booming techno blowing out my ear drums in the car.
Arrive to class. Meet n' greet, mingle, all that for 15-20 mins. Nobody's awake. There's no way this is going to work. Intellectual challenge. Intellectual challenge, I repeat to myself. Shut the lights (I coach in darkness with some white Christmas lights for safety, always. The mirrors are nowhere near the bikes to monitor form-- annoying -- so there's really no reason NOT to facilitate complete self-absorption). Introduce myself, give my safety "I'm only here as your guide" speech and permission to ignore me whenever they feel uncomfortable.
When I do a ballsy ride, I always open with a purely absurd comment. Not "kinda strange." Blatantly ABSURD. It's all in the way you grab their attention. I employ the same device in my writing.
"I woke up yesterday at 4AM just to practice feeling awful..."
But now they're listening. I see it in their eyes.
"... Indeed, there's something about waking up at the crack of dawn to get our workout in before the day, because we're "supposed to," and feeling like we should 'make it count' by pushing hard and giving it everything we've got..."
Starting to lose 'em... window of opportunity closing. Gotta make it count.
"...which is great. Until 3 hours later, when we fall asleep in class or at work and are completely USELESS for the rest of the day."
Oh, they're listening again.
"See, as it turns out, it's a myth that the harder we push, the more results we get. In fact, physiologically, we have different energy storage systems -- different ways we use fuel. And as it were, the system that allows us to burn fat actually ONLY works when we're working moderately intense -- able to use oxygen to carry out those processes. I don't know if you guys have heard this before -- but, a good way to think about it is that majority of fat-burning takes place, loosely, when our heart rates are low enough to be able to talk.
So, this morning we're going to 'shake things up,' OK? Your job is going to be to BURN AS MUCH FAT AS POSSIBLE by paying attention to your breathing, which I'll teach you how to do, to control your heart rate to feel like you're able to have a conversation the entire time. You're not going to push as hard as you can -- you're going to work at a level that you can SUSTAIN the entire time. This way, when you're done, you are PROUD of yourself for waking up and investing in yourself -- ready to take on your day and conquer it... not ready to go back to bed. Ready?"
They didn't cheer or hoot or holler or any of the "validation signs" that I so value from MY classes. But they "got" it.
How do I know? Because my class of strangers, who didn't know me from a hole in the wall, who owed me nothing, stayed in the saddle for 40 minutes when I ABSOLUTELY know that this is not what they usually do.
I didn't tell them not to stand. In fact, I kept giving them the option to stand. And they DIDN'T stand. It's not that they weren't working, either. I saw them adjust their resistance as I coached them through three blocks of progressive loadings with accelerations (yes, profile will follow...). I saw them breathing. I heard them breathing.
I kept reminding them about their controlled intensity, their breathing, their form, and how they were training their heart to get better at doing more work without working harder. I cued them to think about what it meant to them to control their heart rates, the physiology of their being, how proud and strong they felt to have that kind of power. I asked them to think about what they were able to accomplish, with their newly empowered energy. I asked them to soothe themselves with their forceful, controlled breathing.
When I invited them to stand, I did so with the caveat that they acquired this option solely by the ability to control their heart rates to continue to burn "oodles of fat."
And they all stayed seated.
And it was awesome.
PROFILE: "SHAKE IT UP" (45 mins)
Loop 1: Maintain 70% MHR - 3 minute seated climb (progressive loadings) + 3x accelerations to maintain 70%
Loop 2: Seated climb 2 minutes 70%, 2 minutes 75% (progressive loadings) + 3x accelerations to maintain 75%
Loop 3: Seated climb 2 minutes 70%, 5 minutes 75% (progressive loadings) + 3x accelerations to maintain 75%
Yes, that was it.
Afterwards, one girl came up to me and said: "I've been Spinning for 2 years... I've never done a ride like that, making those adjustments to keep the same heart rate. It's crazy: I feel SO energized."
I didn't need more coffee anymore. That was enough for me.
Tuesday, March 10, 2009
Sunday, I decided Winter should be "over" -- and thus, it was. For me. After 5 months of hibernating in the closet, I took Triumph (my bike) out for our first ride of 2009. Turns out, we'd been a bit overly ambitious; though it hadn't snowed in Burlington in *gasp* two weeks and actually hit 50 on this particular afternoon, I'd forgotten that even as awesome as my new town is, bike paths don't *get* plowed -- which I was reminded when I fell flat on my face, riding over a patch of solid ice. Good times. I needed a matching battle wound on my right knee to match the uber-impressive one on my right arm. Clearly. Besides, I got to watch the four physiological steps of the inflammatory response play out in sequence right before my very eyes. Dork.
Anyway, wipe-outs aside, it was an AMAZING ride. Why? Because it was so clear to me that, through my winter training, I'd actually gotten better at the specific things for which I had trained. The parts of Burlington where I mostly rode for my few bike-able (for me) months in my new home are false flats -- a concept I knew about and coached about indoors, but truly had never lived until I got here. I learned about them after repeatedly having the experience of cruisin' smoothly on a "flat" down the block from my condo, glancing down at my HRM and seeing 85% MHR -- and taking forever to get it to come back down, as I wasn't fully warmed up before I hit it. Not okay. Stop that. So, yes, I decided that I would stop that. In my own raining on my Spinner this winter, I incorporated a lot of simulation of the terrain I knew I'd want to get better at climbing. It's not ALL I did; but I spent a lot of time playing heart rate games, getting good at making subtle changes in resistance to accomodate 80 rpm hills at 80%, then 75%, then 70% MHR at varying levels of speed. I wasn't training for any special race; I was training for life, just envisioning getting better at navigating the routine challenges of merely getting around.
I knew it was no accident that this translated outdoors -- and yet, when it happened, I was shocked. Stretches of road that, previously, I was pushing at 85% MHR (or higher!), I was now able to cruise quite comfortably at 65-70%. The coolest part of this non-accident was that it was just that: NOT an accident. Even in the moment, I was so mindful of the fact that my improvement was the direct result of deliberate goal-setting, thoughtful planning, and commitment to execution. And in the moment as I accelerated, breathing out forcefully and rhythmically out the mouth, I could honestly tell myself: This is what you were training for. See it. Feel it. DO it. Just as bringing lessons outdoors to training on a Spinner, it was a pretty darned cool experience to take it in the other direction.
So, I decided to plan a ride based on that concept for my class the next day.
The premise of "Training for Something" was simple: identify what, exactly, you're training for -- and make choices throughout the 45 minutes that reflect those goals, being mindfully absorbed in your work and reminding yourself how your work will lead you to what you will accomplish. This was nothing new to my riders; I'm forever talking about the merits of being "always climbing for something" and self-coaching to remind themselves of their technical, mental, and spiritual (i.e., sense of themselves and their place in the world) goals.
I opened with my story above, and then posed some examples. A lot of my riders are
participating in the annual Burlington "Ride for a Reason" 6-hour indoor cycling marathon (benefits the Special Olympics) at which I am instructing in a few weeks (petrified but BEYOND excited!). I asked them to envision that day, and how they want to feel -- and to give thought to what they needed to do TODAY to reach that point. (I've been sending them weekly mailings of things they should consider wanting to feel -- it's not always intuitive to someone who has not done this before; i.e., HR control aside, your feet are going to hurt like hell unless you invest time NOW perfecting your pedal stroke -- eliminating ANY remnants of mashing, being mindful of "top of the foot" pedaling.) And wouldn't it be great to improve their mental focus, knowing that to get through an endurance challenge like requires maintenance of super-low HRs -- thus susceptible to distraction-seeking. Knowing that many of my other riders use my classes as cross-training for the Burlington Marathon in May, so I suggested the merits of perfecting breathing control. And for those riders who are "in training for life," wouldn't it be just great to invest in their self-concept as fat-burning machines?
The ride itself was simple: Find target heart rate and commit to it for each of four blocks. Use controlled breathing techniques to modulate the interplay of speed and resistance.
Block 1: 3 minute seated climb - 3 accelerations (30 seconds, 45 seconds, 60 seconds).
Block 2: 6 minute seated climb -- 3 accelerations (60 seconds each)
Block 3: 9 minute seated climb -- 1 acceleration (2 minutes)
Block 4: 6 minute seated climb -- 1 acceleration (2 minutes)
Yes, I kept my class seated for 45 minutes. For the first time in my career. It was AWESOME. They were awesome. We took one super-speedy posture break, and I certainly gave options to stand on a few of those accelerations (with the caveat that this was only available with sufficient breathing to control their heart rates entirely -- and that these efforts reflected the goals with which they started). And you know what? All but two people stayed seated the whole damned time. I was so proud of them... it was so clear to me that they "got" it. That they appreciated the science, saw how it applied to them, abstracted another layer of meaning, and disciplined themselves to commit to their goals.
At the end of the ride before the last acceleration (a particularly dramatic one with temptation to go anaerobic), I offered that there were three key things between people and their goals, as I saw it:
1) Actually having them.
2) Knowing the specific things required to make them happen, and plan to do those things (i.e., effective intensity parameters, desired terrain, focus on form and technique, self-coaching techniques)
3) Remembering WHY those goals exist, to fuel one's discipline to stick with it
As David Campbell said, "Discipline is remembering what you want." To be training for SOMETHING -- anything -- means to be mindful of those three things at all times.
And you know what? They ALL stayed seated.
Monday, March 2, 2009
I introduced a ride a few weeks ago with this premise. That we can't conquer our worlds if we're exhausted -- so, therefore, we should probably pace ourselves. People giggled/chuckled/etc. (I even thought I heard a bona fide "guffaw" coming from the back). But I was serious. And they knew it.
I'm writing this post, inspired by four big-deal personal experiences within the past week:
1) I received a most LOVELY email from an instructor who reads "Spintastic," describing her challenges of showing her riders the light of aerobic training -- as well as her steadfast resolution to stay true to what she believes in. I was so encouraged (actually a bit misty-eyed), knowing with full confidence that this coach is absolutely making a difference in the world around her.
2) By some crazy fluke, I taught the best ride of my Spinning career last Friday -- in the face of two majorly crazy challenges: a) the speakers were broken; b) it was a 90 minute ride... which I'd never coached before, and NONE of my riders had ever ridden before. Getting 25 people to remain focused, engaged, AND aerobic... for 90 minutes? With compromised volume? OH my goodness. I was petrified of this being the worst ride I'd ever presented. Instead, I truly felt like it was some of my most creative and precise coaching language -- I could SEE people "getting it." I even taught them about mid-ride re-fueling, and even got them on board (I expected people to think that they "knew better," not bring food, hit the glycogen-exhaustion "wall" and crash). Not so. Everything just WORKED, right to the tee. And afterwards, three people made me cry. (Noticing a pattern?)
3) I presented a pretty lame ride yesterday, same heart rate parameters, similar themes of focus and mindfulness. But didn't take the time to re-explain fat metabolism from scratch, reminding people of the basics behind why they were being asked to demonstrate self-discipline to maintain a low heart rate. It was scientifically sound and occasionally engaging -- but mostly, it was a pretty boring Endurance ride. But afterwards...? 5 people came up to me asking about HRMs. 24 hours later, 3 of them actually ordered some. No joke.
4) I learned about the actual biochemistry of endurance training today (what hormones are going where to direct a muscle's "choice" of energy substrate: fat vs. glycogen; what substrate uptake molecules kick in; who activates and/or inhibits whom). I was super-existed to soak up all the subtleties that go above and beyond my current knowledge base -- as, clearly, MEDICAL SCHOOL would offer. Turns out, not so much. I was SUPER-underwhelmed at how, consistent with my own experiences and those of my riders and clients, the average doctor knows NOTHING about exercise other than "you should do it." The appreciation of intensity having an impact on... anything? Non-existent.
So what's a person to do when he or she knows better... and knows it? I believe that one, in possession of knowledge that will improve the lives of people who experience one as a resource, has an obligation to share it in a meaningful way.
If that means that your classes aren't packed to the nines like the psychospin cheerleader-type calling for the "10 out of 10" (of resistance, of course -- to layer on the tragedy thicker) hills and balls-to-the-walls 10-minute "sprints," SO BE IT.
It's a matter of figuring out a way to share your knowledge in such a way that people come to LEARN a) what a good, solid aerobic base actually is; and b) why they should train to develop one.
One of my life policies to try to find a new way of doing this at least once a month, to keep it fresh and interesting. I don't do this perfectly by any means. But I did have a line backed out into the hallway, having to turn away people from my Friday night 90 minute "boring Endurance ride." But in thinking back to how it was that I initially commenced my master plan to woo the masses, converting them to fat-burning junkies, I actually did it by tricking them. I'd been teaching for about 6 weeks at that point. I made my first loop ride. Called it "Loop It. Loop It Good." (Point of trivia: I hate all of my rides once they are older than 4 months old, as I feel that my coaching -- and even musical -- style changes so rapidly. Even rides from 6 months ago strike me as such amateur stuff -- and 6 months ago, I felt the same way about rides from 6 months prior to then, and 6 months before that and... so on and so on. But I've been doing "Loop It. Loop It Good" for years, and continue to dig it.) I didn't have the confidence to do an all-out Endurance ride... yet. So, I told them that the trick to this ride was that the last 6 minutes were the hardest part -- so that their job would be to pace themselves, to conserve their energy, so that they'd have enough left to really "go at it" when we hit that 6 minute mark. During the warmup, I explained a very BASIC overview of fat vs. sugar as fuel, where your HR or perceived exertion should be to increase your likelihood of burning fat. Periodically, I would remind them of that ever-anticipated "6 minute mark."
So how the profile worked was thus:
3 loops: seated climb + run
6x "accelerations" -- first 5 seated for 30 seconds; last one standing for 1 minute
SO SIMPLE. And they walk out remembering that high-energy finale. A "stunt" to lure them for buy-in.
Then, I built on that. "Hey remember that thing we tried? Wasn't so bad? Can we add another layer to that?" -- start to work in progressive resistance loadings, aerobic speed intervals (maintaining or at least controlling heart rate). Oodles of variations you can do with that. And, turns out, you don't even need that "stunt" at the end anymore if you coach it the right way.
Want them to "want it bad?" Educate them. Make them understand WHY they should want it bad. Choosing your words with precision, translating science into concepts that mean something to people, is a profound responsibility as a coach. It's one of the life skills that I try my darnedest to continue to invest in, as it perhaps has its most direct application to my life as a physician-in-training. It's a big deal, a tremendous privilege.
It's just a matter of making it count.