Ask a neurosurgery resident anything

[deleted728364]

Hi @neusu, do you think that senior residents are able to swing a sub-80 hr work week on average? Does the lifestyle get better as residency progresses?

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[jhmmd]

@neusu what has been the most challenging part of residency for you?

 

[neusu]

How do you alleviate the anxiety/stress of possibly harming someone in such a delicate surgical specialty? I've always wondered how a neurosurgeon can stay so calm for hours and hours straight during surgery, fully knowing that even the tiniest slip can cause permanent brain damage, paralysis etc.

At least for other types of surgery it seems like accidental damage can be fixed or mitigated pretty well before it causes harm, but with the brain/spine, it doesn't appear to be that way.

We tend to create an environment where this is less likely. Accidents do happen, it is part of being human.

 

[neusu]

Thanks so much for doing this @neusu ! I'm an incoming M1 this year, and am potentially interested in neurosurgery. I had a couple of questions (sorry if these were answered already!) -

(1) I've always been kind of paranoid with regards to blood-borne diseases / HIV etc. Both in general and compared to other types of surgery (e.g. ENT, general, vascular, ortho) how much of a risk do you think this is in neurosurgery in particular?
(2) If you have hobbies, that you plan to continue at a high level, which require very fine hand dexterity, is it best to avoid the field? Does neurosurgery wear on the hands after a while?
(3) I absolutely love research, but given how hospital physicians were treated during the COVID crisis I now have major reservations about going into academics and working at a hospital (I used to be set on academics). First, is private practice still viable in this field, and if so do you foresee it being this way 15-20 years from now? Second, if one does private practice, are there still ways of conducting good research / innovating in the field?
(4) If you're the type who needs at least 7 or 7.5 hours of sleep a day (or if you do pull an all-nighter, you need more sleep the next day), is it best to avoid the field?

Thanks again and greatly appreciate your feedback!

1) Neurosurgery has an average risk. It is surgery, so blood is involved. There are a multitude of sub-specialities that likely have a varying array of risk. I'd suspect spine and vascular are higher compared to functional or peripheral nerve

2) I do have many hobbies, several of which do require dexterity. I don't think there really is any "wear" so to speak

3) Private practice is very viable. Most neurosurgeons in the country are in private practice in some capacity. It likely will continue to be this way. There are many private practice doctors who do good research. They tend to be clinical studies. Likewise, volume tends to be higher in private practice, so this may be more feasible.

4) Historically, I would say yes, but with the work-hour restrictions it is less severe of an issue. Regardless of the surgical specialty you choose, sleep will come at a premium.

 

[Engrailed]

From your 3rd point above, can you elaborate on why private practice would have a higher volume? And is this true for other specialties (And non surgical) as well?

 

[neusu]

What are your thoughts on neurosurgeons turned other professions? Sanjay Gupta, Ben Carson, etc.

I generally am split on it. First, there are a limited number of training positions each year. Completing residency, only to not use this extremely focused skill set takes away from patients. That being said, using that experience in unique ways, does help. Dr. Gupta does still practice, at Emory/Grady. Dr. Carson retired, then pursued politics.

 

[neusu]

Hi @neusu, do you think that senior residents are able to swing a sub-80 hr work week on average? Does the lifestyle get better as residency progresses?

When I was a resident, the senior residents could typically work 80 or less. Chief year, not so much.

 

[neusu]

@neusu what has been the most challenging part of residency for you?

There are a lot of challenges, probably too numerous to list here. Physically, the constant fatigue and lack of sleep was challenging. Likewise, lack of personal time to do things like self-care, exercise, decompress. Navigating the politics of the hospital can be challenging, and within a program. Every program is different, so what is challenging at one institution, may not be at another. Further, each person is unique, and an individual. I have worked with some who struggled with the academic side of residency, others with managing patients, still others who had trouble operating. Some self reflection, and identifying these areas is important to addressing them.

 

[glee123]

@neusu : Thanks for your insights. If one doesn't have kids / doesn't invest too much time into a marriage / relationship and otherwise is free of relationship issues, is it possible to get a reasonable (8 hrs) of sleep a night throughout residency?

 

[jhmmd]

There are a lot of challenges, probably too numerous to list here. Physically, the constant fatigue and lack of sleep was challenging. Likewise, lack of personal time to do things like self-care, exercise, decompress. Navigating the politics of the hospital can be challenging, and within a program. Every program is different, so what is challenging at one institution, may not be at another. Further, each person is unique, and an individual. I have worked with some who struggled with the academic side of residency, others with managing patients, still others who had trouble operating. Some self reflection, and identifying these areas is important to addressing them.

Thank you @neusu! I hope that you weren't writing this post while sleep-deprived, although I'm sure that you were

 

[someqsaboutstuff]

Are consulting opportunities available only to neurosurgeons at top universities with a startup culture (stanford, harvard etc), or does any neurosurgeon have a realistic opportunity at consulting? I'm referring to biotech consulting, not McKinsey etc

 

[neusu]

@neusu : Thanks for your insights. If one doesn't have kids / doesn't invest too much time into a marriage / relationship and otherwise is free of relationship issues, is it possible to get a reasonable (8 hrs) of sleep a night throughout residency?

This depends on the program, but generally, no.

 

[neusu]

Are consulting opportunities available only to neurosurgeons at top universities with a startup culture (stanford, harvard etc), or does any neurosurgeon have a realistic opportunity at consulting? I'm referring to biotech consulting, not McKinsey etc

Biotech is a broad term, can you be more specific?

Most any neurosurgeon has the opportunity to be a consultant. Personality, motivation, and ability tend to drive this.

 

[MilesDavisTheDoctor]

Do you ever feel regret about not choosing another field in medicine?

 

[neusu]

Do you ever feel regret about not choosing another field in medicine?

Not at all

 

[MilesDavisTheDoctor]

Can you describe what an average day on call is like? ( how often you have to go in, what type of patients you're seeing etc...)

 

[someqsaboutstuff]

Biotech is a broad term, can you be more specific?

Most any neurosurgeon has the opportunity to be a consultant. Personality, motivation, and ability tend to drive this.

I suppose one example is working with a startup that's developing a high density electrode for intracranial recording, or perhaps viral vectors for drug delivery. (to be a bit more broad, technology for functional neurosurgery)

Semi-related: do you think neurosurgeons have an "easier" access to patient data (especially DBS-related data/intracranial recordings) by nature of being a surgeon compared to, say, a neurologist?

 

[neusu]

Can you describe what an average day on call is like? ( how often you have to go in, what type of patients you're seeing etc...)

It varies if it's trauma call, stroke call, or general call as well as which hospital.

 

[bubblymed23]

Hi @neusu, asking for a friend. He’s been set on neurosurg since undergrad. He got his step 1 score back yesterday and ended up with a 239. He’s unsure if he would still be able to match into neurosurgery with that score. Do you have any advice/ thoughts on this?
Thanks so much for your time.

 

[neusu]

I suppose one example is working with a startup that's developing a high density electrode for intracranial recording, or perhaps viral vectors for drug delivery. (to be a bit more broad, technology for functional neurosurgery)

Semi-related: do you think neurosurgeons have an "easier" access to patient data (especially DBS-related data/intracranial recordings) by nature of being a surgeon compared to, say, a neurologist?

Anyone can design an array of electrodes with a high density, or viral vectors for drug delivery. Only a neurosurgeon can implant those electrodes, or infuse the virus in to the brain.

Neurosurgeons take one of two roles when it comes to human research. 1) They are involved in the design and development of the technology, and are the surgical arm of the project. 2) They are the technician who does the surgery. It really depends on ability and interest as to which role the individual plays.

 

[neusu]

Hi @neusu, asking for a friend. He’s been set on neurosurg since undergrad. He got his step 1 score back yesterday and ended up with a 239. He’s unsure if he would still be able to match into neurosurgery with that score. Do you have any advice/ thoughts on this?
Thanks so much for your time.

People match with much higher and lower scores every year. I would advise him to maximize the other areas of his application, and have a well thought out statement for anything that is less desirable.

 

[jhmmd]

Good bedside manner is one of the best ways to prevent lawsuits
Good communication skills
Good people skills

 

[Premed2295]

Is there anything a student can be doing right now to increase their chances of matching into Neuro>

 

[longhaul3]

Is there anything a student can be doing right now to increase their chances of matching into Neuro>

Depends on what you've already done and where you are in med school. More research is always the answer. If you are already involved in a research group or lab, now is a great time to crank out some lit reviews, case reports, etc. If you haven't taken USMLE, study for that. Do everything you can to excel in school and rise to the top of your class. If you mean match this year, it's a little late—just polish up your personal statement, talk to your department mentors and come up with a realistic list of programs to apply to, and figure out who's going to write your letters.

 

[neusu]

@neusu : Thanks again for doing this. Another question I had was how you / neurosurgeons generally dealt with the possibility of lawsuits? Does it tend to affect the way you treat patients / are there certain ways to avoid getting into them (aside from being a good surgeon)?

Lawsuits are a part of medicine, no matter what field. The standard of care may be influenced by prior lawsuits, but for the most part, I don't think most surgeons practice defensive medicine. As others have mentioned, having a good bedside manner and rapport with patients and families is equally, if not more, important than being a good surgeon. Patients are human, and have varied responses to treatments. Even the best surgery can have a poor outcome, or perception of a poor outcome. Management of personalities, in that sense, is as significant as medical management.

 

[teriyakibeef]

Hello @neusu, I am entering my MS2 year. I am hearing about how faculty connections/letters of recommendations from "well known" neurosurgeons are very important for residency applications. Would you agree with this? What can a medical student do to build professional relationships outside of his or her home department, maybe prior to 4th year/SubIs.

Attending conferences, presenting at conferences, shadowing, getting involved in research, others?

 

[neusu]

Is there anything a student can be doing right now to increase their chances of matching into Neuro>

What year are you? If first or second year, study for classes, learn the material, do well at your school. Most US allopathic students take Step I after the 2nd year. Try to score as well as possible. In third year, learn how to be the go to person on each rotation. Understand the work flow, the personalities. Certainly surgery is one of the more important rotations, if interested in a surgery sub-specialty, but a lot of non-operative management is medical. Finally, for any year, look for opportunities to get involved with the home program, or a nearby program. Help with research projects so you get on papers. As a medical student, often your role is simply chart biopsy and data collection. It can be tedious and boring, and many/most students show much interest at first, and then never finish their project. If it's not published, it didn't happen. Showing up to interviews with 1 or 100 different research "experiences" with nothing to show for it shows you either can not deliver, or have poor insight on where to invest your time.

 

[The Buff OP]

Hi @neusu big fan. How did you pick out your username?

 

[neusu]

Hello @neusu, I am entering my MS2 year. I am hearing about how faculty connections/letters of recommendations from "well known" neurosurgeons are very important for residency applications. Would you agree with this? What can a medical student do to build professional relationships outside of his or her home department, maybe prior to 4th year/SubIs.

Attending conferences, presenting at conferences, shadowing, getting involved in research, others?

I would not worry about that. The vast majority of medical students applying for neurosurgery have little to no relationship with neurosurgeons even at their home program, let alone at another. The A's of surgery (availability, affability, and ability -in that order) will get you most of the way for most things. Certainly, with research, ability becomes a bigger factor, but the point remains.

Interesting anecdote: I was working with a younger neurosurgeon who had a brand name pedigree and was reputed to be an up and coming hot-shot. At a department conference, when we had a visiting professor, the younger guy introduced himself to the guest, who was mid-career/in his prime, and attempted to reminisce on a shared experience when the younger guy, then a medical student, rotated at the guest's program. Needless to say, our illustrious guest had neither recollection of this, nor any interest in the conversation. Moral of the story is there are many med students over the years, few if any leave a lasting impression.

Whomever is informing you is misinformed. Make a good impression at your home program, do your best to make connections there and utilize those connections to gain aways where you might like to match. At the end of the day, most letters are written by senior residents (I've written many for attendings in my day) or simply a form letter (ala "mad libs") where the author substitutes the applicants name, school/information, and adjectives to grade their abilities.

 

[Pseudostrategy]

Hey @neusu. Appreciate your insight. M3 here who is 98% set on Nsgy. 260+ step1, 20+ first author pubs, will have good letters from some well-known surgeons.

Little concerned about my chances at higher tier programs however...How are tattoos viewed in the field? Couple on my arms, nothing vulgar, in the process of being removed but will take awhile.

 

[agiraffe999]

Hey @neusu. Appreciate your insight. M3 here who is 98% set on Nsgy. 260+ step1, 20+ first author pubs, will have good letters from some well-known surgeons.

Little concerned about my chances at higher tier programs however...How are tattoos viewed in the field? Couple on my arms, nothing vulgar, in the process of being removed but will take awhile.

I believe he mentioned earlier that tattoos don’t meant much in NSG although you should cover them up during interviews. I have to ask (since you mentioned it) how’d you pull off 20+ 1st author pubs? That’s amazing!

Good luck matching next year as well

 

[someqsaboutstuff]

I believe he mentioned earlier that tattoos don’t meant much in NSG although you should cover them up during interviews. I have to ask (since you mentioned it) how’d you pull off 20+ 1st author pubs? That’s amazing!

Good luck matching next year as well

I’m gonna guess a lot of case studies and posters...

 

[Pseudostrategy]

I’m gonna guess a lot of case studies and posters...

Peer-reviewed pubs. Yes, a few case reports/case series, a couple reviews but the rest original studies. Research year + proliferate mentor + making myself available + hard work.

 

[someqsaboutstuff]

Peer-reviewed pubs. Yes, a few case reports/case series, a couple reviews but the rest original studies. Research year + proliferate mentor + making myself available + hard work.

Yeah, with 20 pubs and the majority original studies, I’d say you deserve a tattoo or two

 

[neusu]

Among required rotations, are there any that aren’t particularly important for NSG residency? That is, any rotations where you can get away with a “pass” rather than honors?

Rather than ask "what's the least I can do?" perhaps refocusing the question to, "how can I learn and retain the most from this?"

Every rotation is important. I could joke, more than half my spine patients are undiagnosed Axis II, or level with you, I've had arrange for a STAT c-section to deliver a baby prior to surgery. In residency, you will deal with kids, premies, and perform surgery on those with pathologies. Rather than simply fighting with the ER, ICU, nephrology, ophthalmology, understanding what they do, why, and what their concerns are with your management helps have a meaningful discussion as opposed to a contentious relationship. Knowing, for instance, that you may put a stage III renal failure patient on dialysis for the rest of their life by getting a stroke study, or how to pre-treat for contrast dye allergy certainly aids in discussion of the issue at hand. Likewise, much of practice is medical management. Having a general understanding of what an EKG is, or how to evaluate an N-STEMI etc, or appropriately diurese your CHF patient on coumadin/xarelto etc when you blast them with FFP/PCC. Think about who you are competing against to get in to residency. Did they slack on a rotation and get a pass, or did they do what was needed to honor everything? Demonstrating a track record of consistent success is important to program directors to ensure they are comfortable you will do the same for them. Finally, think about your future patients, or if that's difficult, think about your family members, or even yourself. Would you want the surgeon who did the bare minimum to get by, or the one who strived to do their best? At the end of the day, the person with the lowest passing board score etc is still a neurosurgeon, but why set the bar there? You are much more likely to fail with that mindset, than setting the bar as high as reasonably possible, and perhaps, coming up somewhat short.

 

[neusu]

Hi @neusu big fan. How did you pick out your username?

Thanks! Hmm, I don't quite recall, exactly, but it's the first couple of letters in neuro and surgeon.

 

[neusu]

Hey @neusu. Appreciate your insight. M3 here who is 98% set on Nsgy. 260+ step1, 20+ first author pubs, will have good letters from some well-known surgeons.

Little concerned about my chances at higher tier programs however...How are tattoos viewed in the field? Couple on my arms, nothing vulgar, in the process of being removed but will take awhile.

Neurosurgery tends to be a conservative field. Given yours are on your arms, they likely would be covered during interviews since you are wearing a collared shirt and suit. That is, if there are travel interviews this year. Even so, it might raise some eyebrows at the scrub sink if you have bilateral sleeves.

 

[anon12380]

I can't believe this thread still is ongoing; I asked a question on page 12/13 back in 2013. Crazy. I thought surgery was the ticket for me back in undergrad. Now likely to apply EM this year.

Good work @neusu. I rotated for 2 weeks with a neurosurgery private practice/academic group and oh my God, those guys are another breed. Super friendly to medical students and even let us help out where we could.

I gotta ask -- do you think most neurosurgeons "live to work" or "work to live"? I would assume most fall in the former rather than the latter.

 

[someqsaboutstuff]

I rotated for 2 weeks with a neurosurgery private practice/academic group and oh my God, those guys are another breed. Super friendly to medical students and even let us help out where we could.

Can you go into more detail? This thread may not be the best place for it but I’m curious to know (i can DM if you prefer)

 

[anon12380]

Can you go into more detail? This thread may not be the best place for it but I’m curious to know (i can DM if you prefer)

They just work a ton of hours and take call. I mean attendings have better hours than in training, but I'd say relative to other specialties probably still work more than most.

 

[Rachapkis]

I apologize if this has been asked before but I was curious regarding what percentage of your working time is spent in surgery, as opposed to in meetings, doing paperwork, doing rounds, etc.? Other than performing surgery what aspects of the job do you enjoy the most/like the least?

Thanks so much for answering our questions!

 

[neusu]

I can't believe this thread still is ongoing; I asked a question on page 12/13 back in 2013. Crazy. I thought surgery was the ticket for me back in undergrad. Now likely to apply EM this year.

Good work @neusu. I rotated for 2 weeks with a neurosurgery private practice/academic group and oh my God, those guys are another breed. Super friendly to medical students and even let us help out where we could.

I gotta ask -- do you think most neurosurgeons "live to work" or "work to live"? I would assume most fall in the former rather than the latter.

When I was in academics, my life was more of the former. In PP, it's the latter.

Part of the difference is the amount of free time vs non-clinical work obligations. In academics, rounding etc was more structured. There were conferences, research, and students/residents to teach. In private practice, I round whenever is convenient for me. I have much more control over my schedule. If i don't feel like teaching, or doing research, then I don't.

I had hobbies and interests and family outside neurosurgery in academics, though it tended to take a back seat. In PP, I tend to move work around my outside life.

 

[neusu]

I apologize if this has been asked before but I was curious regarding what percentage of your working time is spent in surgery, as opposed to in meetings, doing paperwork, doing rounds, etc.? Other than performing surgery what aspects of the job do you enjoy the most/like the least?

Thanks so much for answering our questions!

In practice, I'd say 40% of my time is spent in the OR (e.g. 1 full day a week). That can be tough to calculate, exactly, as the non-surgery hours can vary, and likewise, the OR schedule can go late. Add in call, which adds rounds and such, but also cases. On paper though, looking at my operative blocks etc, it should work out to 40%.

I like follow-up visits with patients who had severe issues before surgery, and are now back to real life. My least favorite part of the job is the administrative hassle dealing with insurance companies. Also, difficult patients make everyone's life miserable.

 

[lagunabeach26]

hi @neusu just wanted to say thanks for all the information! have spent the past couple days reading through this thread and it has been incredibly insightful. hope you and yours are doing well

 

[deleted1095841]

Sorry if this has already been asked, but I have heard from some people that neurosurgeons tend to retire early. From your experience, is this true?

 

[neusu]

Sorry if this has already been asked, but I have heard from some people that neurosurgeons tend to retire early. From your experience, is this true?

I wouldn't say there is a rule that they retire early. I know many who never retired, especially in academic settings. They certainly slow down, or even stop operating, but come to clinics or conferences and pass along their wealth of knowledge.

 

[longhaul3]

Thanks neusu!
Is there a rough age range when they start slowing down and perhaps transition more into education/administration?
I'm 28 and an M1 right now. By the time I finish med school (4y) and residency (7y) and functional neurosurgery fellowship (1year) I'll be starting my career at 40. And people are telling me that I should consider getting a PhD if I want to do functional neurosurgery. It would be a shame to go through so many years of training if I can't practice for very long.

You don't have to do a PhD to do functional neurosurgery. You just have to be a nerd.

 

[neusu]

Thanks neusu!
Is there a rough age range when they start slowing down and perhaps transition more into education/administration?
I'm 28 and an M1 right now. By the time I finish med school (4y) and residency (7y) and functional neurosurgery fellowship (1year) I'll be starting my career at 40. And people are telling me that I should consider getting a PhD if I want to do functional neurosurgery. It would be a shame to go through so many years of training if I can't practice for very long.

Ha, realistically ~PGY-4 year. But in practice it varies by individual. Do what you enjoy in life, but not everyone always has the best advice, nor most insight in to the world of what you are pursuing. My rule of thumb, when deciding what educational venues to pursue centers around the rule of "cans." As an MD neurosurgeon, what can you do that a neurologist or PhD can not? Simply put, you can do surgery on patients to place the devices. What can a neurologist or PhD do that you can not? Realistically, nothing. Certainly, a more rigorous and formal training in the scientific method would be of some benefit, and there is something to be said for credentialing by paperwork (e.g. you have a PhD, therefore you are qualified to run a lab), but in reality the ability matters more. Furthermore, the NIH and other funding ventures do have postdoctoral opportunities to train MDs interested in research (e.g. a post-doctoral research fellowship, which may be allowed to be enfolded in residency during your research or elective years), with a more formal and rigorous approach. That being said, if you didn't do your MD, or neurosurgery residency, and did a PhD alone, a post-doctoral fellowship is, in essence, a defacto requirement to pursuing academics. Just my $0.02

 

[deleted1095841]

Ha, realistically ~PGY-4 year. But in practice it varies by individual. Do what you enjoy in life, but not everyone always has the best advice, nor most insight in to the world of what you are pursuing. My rule of thumb, when deciding what educational venues to pursue centers around the rule of "cans." As an MD neurosurgeon, what can you do that a neurologist or PhD can not? Simply put, you can do surgery on patients to place the devices. What can a neurologist or PhD do that you can not? Realistically, nothing. Certainly, a more rigorous and formal training in the scientific method would be of some benefit, and there is something to be said for credentialing by paperwork (e.g. you have a PhD, therefore you are qualified to run a lab), but in reality the ability matters more. Furthermore, the NIH and other funding ventures do have postdoctoral opportunities to train MDs interested in research (e.g. a post-doctoral research fellowship, which may be allowed to be enfolded in residency during your research or elective years), with a more formal and rigorous approach. That being said, if you didn't do your MD, or neurosurgery residency, and did a PhD alone, a post-doctoral fellowship is, in essence, a defacto requirement to pursuing academics. Just my $0.02

Thanks! That really helps.
The other thing people (friends, doctors, university professors, letter writers) tell me is that neurosurgery and other surgical specialties take a toll on health, with many late nights and not many chances to eat a home-cooked meal. Is this true?

 

[neusu]

Thanks! That really helps.
The other thing people (friends, doctors, university professors, letter writers) tell me is that neurosurgery and other surgical specialties take a toll on health, with many late nights and not many chances to eat a home-cooked meal. Is this true?

Glad it helps.

This is absolutely true. Further, it can significantly redirect your goals during training.

Specifics across programs vary widely, but let's use an example:

As a 28-year-old M1, best case, you'll be a 32-year-old PGY-1 in neurosurgery. Your next 7 years, your salary is ~$45k-80k/year. Your work hours are "limited" to 80/week. While PGY-2 year in neurosurgery tends to be the most intense, the PGY-3-6 years also have their pitfalls. As a PGY-3, you typically continue to take a lot of call, or have a lot of nightfloat. If you are at a 1-a-year program, when the PGY-2 is post-call, you are the PGY-2, so in effect, your worst year is now two years. The reprieve of electives and research years may lighten your clinical and operative load, but the call/nightfloat schedule continues to pull you away at intervals. Even if you are 1-call a week, that takes away 20% of your research or elective time being post-call. Chief year, again, is much more fulfilling, but also much more demanding administratively and in the OR.

Arbitrarily, let's follow the 80-hour work rule and say the average working week is 5 x 13 hour days, for 65 hours. This leaves 15 hours under budget each week, but given you are on every other weekend, they get taken back in some capacity. So 13 hours, let's say 6 AM to 7 PM, or 5 AM to 6 PM. There goes home cooked breakfast, lunch, and often dinner. You get 4-days "off" a month, so those days are possible, or getting up early to eat breakfast at home, or put in the time when you get home at night and cut in to sleep time.

Needless to say, most of us come in to one end of the meat grinder doe-eyed and bushy-tailed, but hit burnout some time around mid-year PGY-2. Seeing your friends and family move through life, and your medical school classmates finish training, fellowship, etc, or even the med students who rotated on your service when you were a PGY-3 are now your ER attending friends when you are the chief resident can induce a bit of envy. So, the hours, low pay, and social and emotional stressors can feel like a pressure cooker. The can and do take a significant toll on health.

Training in medicine is stressful and does take a toll, no matter the field. While we all mock the wellness and resiliency power-points, the underlying premise is strong. Find ways to decompress from work stress and healthy outlets for things that occur like frustration and anxiety. No one is perfect, nor is any system. This is what we have to deal with, so being our best within the rules given to us is all we can do.