The Breast Care Center

I've done a poor job posting about my Project 55 position at the UCSF Breast Care Center (BCC), but am trying to change that this weekend. I'll start with a general post about the internship program, and then follow it up with posts about my specific work and life in San Francisco.

I began work at the BCC at the beginning of July. The collaboration with Project 55 is just part of a broader BCC intern program. There is another fellow from Princeton, a few from Harvard (they have a similar partnership), and then a number from other schools. In total, there are 10 interns. One just took the MCAT, and will be applying to med school next year, but the other 9 are all applying now.

The program really is set up as a nice 1 or 2 year commitment for students who might be interested in medicine, and it's viewed more as an educational opportunity than a strict job. At the beginning of the year, we had talks with different doctors in the clinic on breast oncology, surgery, reconstruction, pathology, and more. We are encouraged to go to the weekly meetings such as Tumor Board and other lectures that take place at UCSF (there have been a few on health policy, for example).

The student interns are involved in a number of different trials that go on at the Breast Care Center. Some of them are breast cancer drug trials, such as I-SPY 2 (which is what I am working on). Another big project is the ATHENA Breast Health Network, a UC-wide collaboration that aims to follow women screened for breast cancer and generate a repository of risk and outcome data. There are also quality of life studies, including yoga classes to prevent lymphadema and scalp cooling caps to be worn during chemotherapy to reduce hair loss. Within each of these trials, interns also take on different roles. Some are clinical coordinators, and do a lot of the work to consent patients for the trials, schedule appointments, follow up with patients, and make sure that the trial generally runs smoothly. Other interns are involved in laboratory work, policy research, and health economics research. Since there are so many different positions, and so much to be done at the BCC, there is the opportunity to tailor projects to your own strengths and interests (computer science majors, for example who work on the IT side of trials). Most of these projects have websites and other information online, so I would encourage anyone applying to get a sense of which projects most interest them. Of course, the day-to-day work on any given project may not entirely recapitulate the overall aims of the research. These studies are often long-term, and clinical trials do involve a lot of data collection/entering, paperwork, and so on.

The one constant for everyone in the internship is Decision Services, which is a sort of patient advocacy program. A lot of patients coming into the BCC have treatment options, such as the choice between a mastectomy or a lumpectomy with radiation. Especially for women who have been recently diagnosed, these appointments come at an emotional, stressful time, and can include an overwhelming amount of information. We work with many of these patients, calling them before appointments to help them to generate a written list of questions for their doctor. We then accompany the patients to their appointment, taking notes for them and making an audio recording. Patients really appreciate the service, and the comfort of having someone navigate the process with them. It's also informative and powerful for us as interns, because we really get to know the patients and become intimately aware of their priorities, goals, and fears about treatment. Someone once said that it is more like shadowing the patient than shadowing the doctor, and I certainly agree with that assessment.

I'll follow this post up with more details about my specific work and experience in San Francisco. If you can't tell from this post, though, I'm having a great time at the BCC. It's certainly a good deal of work, but I've had a lot of new experiences and have learned a tremendous amount.

"Won't Back Down"

(This post sort of straddles two locations since I'm a current fellow in Connecticut, but I will be a fellow next year in the Bay Area!)

As the next fellow for NewSchools Venture Fund for the upcoming year, I was lucky enough to fly to San Francisco to attend their annual Summit, attended by almost 1000 of the nation's top education reformers. To listen to and be among (and even having a chance to interview) the most innovative and rebellious thinkers and change agents in education reform today - it was truly the two most inspiring days of my life.

At the conference, I was able to attend an early screening of a movie called "Won't Back Down", which stars Viola Davis and Maggie Gyllenhaal (who are both absolutely brilliant in this film), as well as listen to a panel with the director. I cannot recommend this movie more, it is not only extremely powerful, it is also much too important not to see. While the film is centered around the controversies of the parent trigger laws of certain states (that allow parents to overrule administrators and bad teachers at failing schools), it touches on so many of the key issues with our school systems and so many of the reasons why education reform is critical.

"Won't Back Down" will be in theaters this September. Whether you watch it for the issues, the controversy, the touching storyline, or the incredible acting by Viola Davis, Maggie Gyllenhaal, and others - it doesn't matter, just watch it. And tell your friends and family! I promise that you and they will not only enjoy this movie, but will want to pass on the message.

Here is a New York Times article on "Won't Back Down": http://www.nytimes.com/2012/02/21/movies/viola-davis-and-maggie-gyllenhaal-in-parent-trigger-film.html?_r=1

Glimpse of the UCSF Breast Care Center

Happy New Year everyone!!!

It’s been roughly 6 months since I started my project 55 fellowship at the UCSF Breast Care Center and I couldn’t have asked for a better way to spend my gap year between college and medical school. Matt and Alyse have done a great job of describing components of our job that we all share at the BCC, such as Decision Services, so I’ll talk a little more about some specific projects that I’m working on.

My position is sort of unique in that I work at two different UCSF campuses. For half of the week I am at Mount Zion with Matt and Alyse, and for the other half of the week I am at Parnassus, which is UCSF’s main campus. While being split between two different campuses can be at times hectic and crazy, I’m thankful for the different projects that I’ve been able to work on at the two locations. At Mount Zion, I work on two clinical studies, one of which involves consenting patients for collection of blood and bone marrow samples while they are sedated in the operating room. This is really cool because it allows me to have patient contact and view surgeries. I’m also working on some other projects looking into the role of the immune system in breast cancer and how the presence of different immune cells in the tumor may affect prognosis.

At Parnassus, I am working in a bioengineering lab, which is a completely new experience for me. I did get a MSE certificate so the engineering world isn’t completely foreign to me but there is definitely a steep learning curve. My project involves looking at the mechanical effects of intraoperative radiation therapy (IORT) on the tumor microenvironment. IORT is a relatively new procedure of delivering radiation to the patient while they are in the operating room. After the tumor is taken out of the breast, an applicator is inserted into the tissue cavity where radiation is then locally delivered. The applicator then comes out after which the surgeon can close up the incision. By using the tissue that the surgeon takes out from the breast right before and after delivering radiation, we can look into the effects of radiation on tissue composition and organization as well as changes in cell to cell signaling.

Besides the work I am doing, I am loving San Francisco and trying to take advantage of all it has to offer! The city is an awesome place to live with so much diversity and culture. Public transportation can take you anywhere in the city and there’s always a bunch of events that are open to the public on the weekends. I’m looking forward to further exploring SF and all it has to offer in the next 6 months and will update everyone again!

Great times in SF at the Breast Care Center—where has the time gone?

It’s been an interesting few months at the Breast Care Center! My fellow “interns” and I have all been busy with our respective projects, and learning tons about both breast cancer care and the world of medicine at the same time.

My work centers on the information technology aspects of I-SPY 2, an innovative national clinical trial (spearheaded here at UCSF) that aims to speed the rate at which we develop new therapeutic agents for breast cancer. (It’s been recently featured, albeit somewhat inaccurately, on NBC Nightly News.) Being introduced to the world of clinical research has been an experience in itself—something very different altogether from my basic research endeavors as an undergrad. Clinical research is saddled with plenty of regulatory red tape and approvals upon approvals—necessary measures, no doubt, when your fellow humans are also your test subjects. But this regulatory burden is uplifted by a true sense of urgency, the unmatched experience of being on the front lines in the battle against our most pressing medical problems. I’ve found myself attracted to clinical research in a way that I never truly was to basic science, and this has made my time at the Breast Care Center all the more rewarding thus far.

So, what do I actually do here at the BCC? One of I-SPY 2’s many innovations is its novel informatics system, TRANSCEND. TRANSCEND not only was custom-designed for the trial, but is also envisioned as a proof-of-concept for how clinical trial systems can integrate with medical record systems to greatly facilitate medical research in the future. That’s a mouthful, but essentially I help to design and specify new features for TRANSCEND as it undergoes a major update/revision, with the collaboration of the National Cancer Institute and other organizations. In contrast to my previous experiences—viewing software from a programmer’s perspective, as a computer science major—this job has placed me in a high-level, “project development”-type role, where I get to see how projects such as these are negotiated, orchestrated, and eventually implemented. Especially in the context of national healthcare reform, the HITECH Act, and the current rollout of electronic medical records right here at UCSF, this is a fascinating time to be involved in health information technology.

The Decision Services component of our jobs (described in detail by Alyse in a previous post) arguably ties the whole experience together for all of us. Meeting with a patient each week to discuss her concerns and summarize her appointment provides a refreshing context to what we all do on a daily basis. It’s also wonderful to see how such simple interventions and changes in the care process can make such a meaningful difference to the nervous, confused, frustrated, and often afraid patient. Attending appointments with a wide variety of patients, who are in turn seeing a variety of different medical and surgical oncologists, has also allowed us to witness the spectrum of treatment approaches for all types and stages of breast cancer. It’s more medical exposure than I’ve ever had before, and I’ve valued every minute of it.

There’s been some room for fun in our jobs, of course: We recently all participated in a local event called Taste for the Cure (organized by one of our fellow interns), featuring tons of great food, where we got to showcase each of our respective projects at the BCC to interested attendees. As a group, we easily beat out the competition in our hospital Halloween costume contest. And, per BCC intern tradition, we just recently performed our humorous holiday skit—where we poke fun at the doctors and administrators that we work with every day—to resounding applause!

Admittedly, at times, things have been crazy, hectic, unclear, and uncoordinated—but so is the world of medicine at large, and true satisfaction comes from breaking through those obstacles to make and see meaningful change happen every day in our clinic, on our trials, and in the initiatives that our center supports. I’m certainly looking forward to what I’ll be doing in the next six months—and I’ll be sure to provide more updates during that time!

Highlights from SF and the Breast Care Center

Hello everyone!

I apologize that this blog post is extremely overdue. I have been living a full life in San Francisco and to date haven’t taken as much time as I should to reflect and write about my experience. As I (hopefully) settle into a more steady pace of grown-up living, I will make this blog-writing a routine part of my coming months as a fellow.

I moved to San Francisco’s Inner Sunset neighborhood on July 3 and began work at UCSF’s Breast Care Center (BCC) on July 5. In the past three months, I’ve learned about the work of the BCC at a rapid pace, immersed myself in a couple of different projects, and met some incredible clinicians and staff. The BCC is full of visionary and integrative initiatives and is a wonderful learning environment. Below are a few words about the experiences that have been highlights for me here so far.

Decision Services

I devote about 20% of my time working for a program at UCSF called Decision Services. In this role, I work most closely with patients and this service has become my favorite part of the internship. Through Decision Services, we help patients to come up with a list of questions that will help them to choose between complex treatment options with multiple risks and benefits. We then give the list to the patient’s doctor and accompany her to the appointment. After the appointment, the patient receives our typed summary and a CD recording of the appointment, with the hope that these resources will allow her to make thoughtful treatment decisions based on what matters most to her. Through working for this program, I have learned about the diverse factors that are important to women who are choosing, for example, between a lumpectomy and a mastectomy or between different types of reconstructive surgery. Accompanying patients to their appointments also offers a perspective on a wide range of different styles of doctor-patient interactions. I’ve witnessed unusual appointments (such as one where a patient was accompanied by 12 of her family members) and very difficult appointments (for patients struggling with various other diseases or breast cancer that has progressed to metastatic disease).

Athena Project

The Athena Breast Health Network is a project pioneered by the BCC’s director, Laura Esserman. It intends to be a “Framingham 2.0” of breast cancer, alluding to the seminal Framingham Heart Study that established many of the correlations between lifestyle and heart disease. Furthermore, the project is trying to spearhead a culture shift to break down some of the barriers that separate clinical care and research in breast cancer. Ultimately, the Athena network will include 150,000 participants across 5 UC medical centers. Now, I’m working a great deal on some of the nitty-gritty details surrounding a questionnaire that accompanies participation in the network, but I cherished the opportunity to learn about the big picture vision at a conference a couple weeks ago in San Diego.

Tumor Board

Tumor Board is the weekly meeting that convenes all the BCC doctors and staff to discuss difficult cases to diagnose or treat. I find it fascinating to learn through observing the clinicians’ different personalities and clinical approaches at play in interpreting ambiguous cases (often, it seems that the two are linked).

Outside of work, I hang out a lot with my fantastic class of eleven “pre-medical interns.” We are currently making preparations to compete in the annual Halloween costume contest at UCSF – apparently, we have an esteemed reputation to defend. On the less festive end of things, I spend a lot of time these days studying for the MCAT :-/.

In my free time, I try to keep up my violin playing. I’ve joined an orchestra called Symphony Parnassus, which is rehearsing for a November concert. Once a week, during my lunch breaks at the Medical Center, I am starting to play my violin through a music program at the Hospital. Last week I played a song for a man who was on his way being wheeled into the OR. I also love playing chamber music and joined a friend from Princeton ’09 yesterday for a chamber music sight-reading party. Finally, I have been trying to keep up my Spanish-speaking skills through this “Conversation Exchange” program, where I talk with a conversation partner from Costa Rica each week. She is also in the health care field, so our Spanish and English conversations have been really fun.

I hope everyone is having a great fellowship and enjoying autumn!

finally

After ten weeks of work here in the Bay Area, it's about time for an update about what I'm actually doing. I work for the Boys and Girls Clubs of the Peninsula (BGCP), whose vision is to have every member of our community graduate high school with a plan for post-secondary education or training. This scope of this vision is contextualized by a few basic facts about the neighborhoods we serve (which are East Palo Alto, eastern Menlo Park, and Redwood City): less than half the kids graduate from high school; less than 30% are proficient in math and writing; less than 10% of kids' parents attended college (and less than 4% graduated); and the median per capita income is less than $15,000. These numbers paint a basic picture of the difficulty an organization like BGCP has in making a meaningful impact on a community while practicing an open door policy that accepts any child that wishes to attend.

My work at BGCP is firstly in outcome analysis for grant writing and reporting, as well as fundraising. I'm responsible for overseeing the databases for our donors and our club members; for our club surveys for new and existing members; for our "On-Track" indicator program, for which we partner with our members' schools to collect grades and disciplinary records to help design more individual programming for our at-risk kids; and for fundraising research. These, however, are only a handful of my day to day tasks -- my position places me at the intersection of several departments, and it's the constant juggling of different projects that keeps this work interesting. Just now I'm off for a 5pm meeting at a school site about the results of their summer programs data. More posts to come about what I've learned so far and how things have changed in the workplace in just a couple of short months.

KSS 2011

So although I've been at the KIPP Foundation for almost two months now(!!!!), most of my time has been spent preparing for and executing our annual KIPP School Summit, this year held in Nashville.

I never realized that putting on a conference was so intense. It was 3/4 professional development conference 1/4 pep rally for 2200 teachers and school leaders. We also had 170 potential/current investors and partners who attended (this is kind of my jam, as I'm on the Development team), each of whom needed a registration packet, complete with personalized itinerary. Which is fine, but because they're such big deals, their plans change a lot :/ Kept us on our toes, for sure.

Best parts about KSS in Nashville:

- Seeing the impact we're having on real students. We had a bunch of co-curricular groups come in, and I got to meet a lot of the KIPPsters. I also got a chance to meet some graduated KIPPsters who had made it through college. Seeing the growth that happens between the two stages was incredible. I was definitely proud to be part of the movement.

- Nashville is awesome. Maybe it's because I'm pretty country myself, but I LOVED the city. Live music everywhere, tons of people who dress like me (who I never really managed to find in Princeton), perfect nighttime weather (remember, I live in SF now), and a great opportunity to get to know my coworkers better

- I got to run with Former Mayor Adrian Fenty. yup. we're tight now. He was down to go as far as I wanted and only kind of kicked my butt. In my defense, it was 5 am on the day after the hottest day in Nashville since 1956 and my 6th day of training @ 5 that week, but I'll give him the win on that one anyway :) There were all sorts of rock stars like him who attended (Meg Whitman, Reed Hastings, Pam Flaherty, John Fisher, Doris Fisher, Mark Nunnelly, etc) and while I tried to be as professional and levelheaded as possible, inside I was leaping up and down like a three year old.

What I didn't like about Nashville:

***crickets chirping***

...but in all seriousness, it was a LOT of work. I only had time to go out and see the city a couple of times throughout the 7 days I was there and the days were ridiculously LONG. Guess I know what it would feel like to be in banking, now ;) And they don't get to change lives every day. Oh yeah. I went there. Sappy, but true.

In short, I'm loving it here. I drank the KIPP Koolaid. I'll save my thoughts on what I love/ don't love about SF for next time.

NewSchools and Waiting for Superman

This past summer, I moved to San Francisco to begin my fellowship at NewSchools Venture Fund, a venture philanthropy firm that invests in social entrepreneurs working to improve public education. In addition to supporting early stage organizations as they grow into sustainable solutions, NewSchools’ mission includes acting as a hub for education innovators – from school leaders to policymakers – to share best practices in order to more effectively drive systems change. As a non-profit that applies capitalist principles to solve problems yet seeks only social returns, NewSchools constantly confronts the challenge of attempting to gauge a new idea's functional value within the context of stark cultural, political and financial realities.

This fall, NewSchools partnered with Participant Media and Paramount Pictures on a variety of initiatives related to the release of the documentary Waiting for “Superman”. In addition to organizing and hosting screenings of the movie around the Bay Area and joining the film’s pledge progress meter, NewSchools is currently producing a short video to be included with the film's spring DVD release. As part of this project, I have traveled to New York City and Los Angeles as our team has conducted interviews with a diverse group of education experts – including Teach for America founder Wendy Kopp and Newark Mayor Cory Booker – as well as students, teachers and parents at innovative organizations such as School of One and KIPP LA Prep.

The personal side of clinical trials: life at the BCC

Pager buzzing frenetically in my hand, I jog through the hallways of UCSF’s Breast Care Center to consent a patient for one of the clinical trials that I am helping to coordinate. Breathless (and, admittedly, a tad nervous), I arrive at the door of the patient’s exam room, compose myself and knock. I hear a muffled “come in,” and I turn the handle.

This scene has repeated itself several times over my past four month’s at the Breast Care Center. What has not repeated itself is the scene I find on the other side of the door. Some patients are surrounded by a mob of friends; some are with sisters, partners, children; a few are alone. Some are in their 70s, and some are only two or three years older than I am. In the hour or so before I am paged, most have received the news that they have breast cancer, and so I often find tears or stunned gazes. But I also meet stoics, and the occasional patient whose response to meeting me is a broad grin and a joke about how young I look. As I discuss the trial with these patients, their responses are equally variable, and one of the most challenging aspects of my job this year has been learning how to guide and tailor these conversations for each patient and every situation.

For many of us, myself included, the words “clinical trial” have mixed connotations. We all benefit from successful clinical trials—they are the gold-standard by which we determine if new therapies are safe and effective. But these words also conjure stories of ethical misconduct, fibbed data, and incomplete analysis, not to mention the risks of untested treatments. Before I arrived at UCSF, I knew what clinical trials were. I understood the concepts of control arms, of double-blinding. I’d read about trials that had brought miraculous new drugs to market, and others that dragged on for years, eating millions of dollars, only to yield null results. But I had never really thought about how these trials are actually orchestrated. Who makes sure that extra study lab tests are run for study patients? Who dispenses experimental medications to patients? Who analyzes their specimens to determine how patients respond to new therapies? How does a patient’s complaint of nausea make its way, several years later, onto the list of expected side effects for a new drug? Who tracks patients five or ten years after they have completed treatment to assess survival? While a few doctors and scientists will write their names on the publications resulting from a trial, the entire operation of a trial actually involves a huge cast, a massive engine with interconnected parts. My job as clinical coordinator is to make sure that the spinning parts remain greased—I schedule appointments, I enter data, I answer patients’ questions about the trial, I make sure that patients, tissue specimens, chemo orders, physicians, etc. arrive at the right place at the right time and for the right purpose.

The trials I am helping to coordinate assess new chemotherapy drugs to treat breast cancer, as well as a host of biological markers, tests and imaging techniques. Our hope is that not only will we find new drugs to treat breast cancer with, but we will also figure out how to tailor treatments to individual patients, using the specific biology of the patient’s tumor as our guide (see a recent Wall Street Journal article about one of the trials I am working on here: http://online.wsj.com/article/SB10001424052748703882404575520190576846812.html).

The broad scientific aims of these trials are certainly inspiring, but one of the unexpected benefits of my job is the relationships I’ve been able to build with patients. I see each of our study patients about once a week during her several months of chemotherapy. I hear about children and grandkids, I swap travel stories and eat home-made chow-mein. And I listen to each woman describe her experience on the physical and emotional rollercoaster that is breast cancer treatment. It is these personal connections that are ultimately the most rewarding aspect of my job.

Hello from San Francisco

Next week is the three-month mark of my P55 fellowship. Time seems to fly much faster in the working world than it did at Princeton. I've been working for the KIPP Foundation in San Francisco. KIPP (or the "Knowledge is Power Program") is a national network of college-preparatory public schools dedicated to preparing students in underserved communities for success in college. As a Development Associate, I work with the fundraising team to solicit corporations, foundations, and individual investors for donations.

It's difficult to summarize my responsibilities for P55 as my work has been varied. Officially, I maintain our donor database and process and acknowledge all gifts we receive. However, this only takes up about 15% of my time. Every day is a little different. Other duties have included proofing grant reports, helping coordinate and execute a 2,800-person summit in Las Vegas, preparing presentations for my managers, and even meeting some significant philanthropic figures (i.e. the Fisher family, who founded and owns GAP Inc.). Fun facts: Fisher Hall in Whitman College is also named after the same family. The Fishers also temporarily donated the headless statues that used to be in front of Princeton's art museum.

Anyway, if you're interested in the American education reform movement, I recommend seeing the upcoming documentary Waiting for Superman. Directed by Davis Guggenheim (also the director of An Inconvenient Truth), Waiting for Superman explores the problems and potential fixes of American public education. As our KIPP schools are featured in the film, I was able to attend a sneak-peak showing in August and thought the documentary was very informative and moving. It releases nationwide September 24th.

Unfortunately, I don't have insights to share regarding apartment-hunting, as I am SF native and am living at home this year. While having roommates would have been a great social experience, I love my family and am also excited to be saving more than I could with San Francisco's high rent prices. To spice up my social life, I have made a commitment to doing a minimum of 2 activities per week with people. This past weekend I attended a chocolate festival at Ghirardelli Square (white chocolate cheesecake = amazingness) and began attending an oil painting class.

Busy Days at the BCC

Wow, I can't believe that it's already been nearly two months since I began working at the UCSF Breast Care Center (BCC)! Orienting myself within a new city, finding and furnishing an apartment, and, of course, gaining an understanding of my job responsibilities have each kept me very busy since my arrival in San Francisco. The cold, gray, windy weather in July also added to the sense of uncertainty early on. Bizarre as it may seem, the weather in July is supposed to be the worst of the entire year here in SF. I cannot tell you how many people quoted Mark Twain's famous statement "The coldest winter of my life was the summer that I spent in San Francisco." I was warned, but now I really understand. And it would be one thing if the entire region was subjected to the same meteorological fate, but, instead, the fog just tends to sit over the city.

But now that September has arrived, the sun is shining, and I have fallen in love with the city all over again. I share an apartment with two other interns at the BCC, and we live directly across from the Presidio, down the street from the Romanesque structure that is the Palace of Fine Arts, a short distance from tons of fun bars and delicious restaurants, and within view of the Golden Gate bridge. And there's always something going on in the city-- I've been to lots of farmers' markets, saw Wicked at the Orpheum theater, went to a Cal Academy of Sciences nightlife event, visited Angel Island, hiked in Marin, ran along the rugged coastal trail, fought the crowds at Fisherman's Wharf and Ghirardelli Square, went shopping in the Mission, and relaxed on the beach. Each day, I also take in spectacular views of the city simply while riding the bus up and down SF's famous hills.

While all of this makes it difficult to return to the office after the weekend, I always look forward to Tumor Board and New Patient meetings on Monday mornings. As a pre-medical intern/ clinical trial coordinator at the BCC, I have been granted tremendous opportunities to work directly with BCC doctors and to become involved in patient care. I am the clinical trial coordinator for three studies at the BCC: two are data collection studies intended to assess the efficacy and tolerability of technologies intended to prevent hair loss among breast cancer patients undergoing chemotherapy, and the third study is a tissue banking study intended to aid researchers in better understanding the molecular mechanisms underlying metastatic breast cancer. As a clinical trial coordinator, my primary responsibilities are to obtain patient consent to participate in the studies, to collect data (either in the form of surveys for the hair loss studies or tissue samples for the metastatic study), and to monitor each study for reported adverse events.

Beyond my role as a clinical trial coordinator, I also spend time each week working for the Decision Services department. In this capacity, I contact patients about their upcoming appointments and offer to help them in developing question-lists; in addition, I also offer to accompany them to their appointments in order to take notes and make audio recordings. These services may seem relatively straightforward, but they have been proven to significantly enhance patients' understandings of their medical treatment options. By providing patients with more information, we hope to improve the decision-making process. Indeed, at UCSF, it is well-understood that doctors should make therapeutic recommendations but that it is ultimately patients who must make final decisions, for it is the patient who can best calibrate the various personal and institutional factors that influence the decision-making process.

While I understood these principles at an intellectual level before arriving at UCSF, it has been incredibly enlightening to witness them in practice. Now that I have a better grasp of my particular responsibilities, I look forward to making more meaningful contributions at work in the future. I also intend to fully embrace the beautiful fall weather in the city! Not to be missed next weekend is the Ghirardelli chocolate festival, and then my roommates and I are planning a weekend road trip down scenic highway 101!