Rotation in Palliative Care

This month, I decided to do a rotation in palliative care and already I'm wondering what on earth I've gotten myself into. The training is very valuable, but the process can be heart breaking. The Palliative Care Team that I am working with is extremely compassionate toward end of life care. I am learning all kinds of techniques for speaking with families and providing comfort measures. It is important to me that I learn these skills so I can give comfort and support to my own patients some day. If I had my preference, my patients would just live forever.

My first patient on the first day of the rotation was a patient who is my age. This patient is suffering from advanced lymphoma which is complicated by an intracranial bleed. They have been married for about as long as Matt and I have been married. I couldn't help but think about my husband when I was speaking to the patient’s family. It was difficult for me to look at the family without thinking of how tragic it would be to lose my own spouse. I had trouble keeping the tears back and it took every ounce of professionalism I could muster to hold it together. It's so difficult when patients remind you of your own loved ones, but I find that more often than not I begin making these associations.

The patient had been on comfort care measures only, but a new oncologist on the service had some hope for a palliative treatment that might improve the patient's neurological status. It would involve weekly intrathecal chemotherapy. The oncology team had good intentions. They were invested in saving the life of the patient. We are all trained from the beginning of medical school that the goal is to save lives. Death equals failure, but is ultimately unavoidable. Now the family is torn between keeping their loved one comfortable and doing everything medically possible to extend their life. There is no right decision.

According to family members, this patient is a fighter and has expressed his wishes to fight the disease until his death. Following this logic, should we do everything medically possible? Where is the endpoint? At what point do we cross the line of "do no harm" while using heroic measures to save the patients? Is the Palliative care team correct in their philosophy of comfort care measures or are the oncologist’s efforts more appropriate? I'm not sure any of us have the answer. It's a judgment call.

After reflecting on this case, I think the important thing for this patient was to keep the patient comfortable while doing everything possible to treat his cancer so the family can be at peace with the efforts to help their loved one. It is important that we don’t force our own beliefs on those that trust us in the end. The death process is very individual. The patient's wishes should be at the forefront of our thoughts when we are making treatment decisions. My own opinion is shaped and formed by my experience with the death of my father. He was also a “fighter” and wanted to treat his multiple myeloma until the very end. He taught me that some people value quantity of time over the medical profession’s judgement of quality of life and this must be considered if we want our patients to face their death with dignity and peace. I still have a lot to learn when it comes to ethics in medicine and I encourage people to respond with their own advice and opinions on this topic.

Taking the Boards

Recently, I had the opportunity to sit for Step 2 CK. Most of you probably know this already, but every medical student has to take (and pass) these "board" examinations. there is a lot of pressure. For four weeks, I have been studying for this exam. When I asked students who took the test last year about their study methods, it seemed the only universal recommendation from those who had gone before me was to use the USMLE World questions. After that, the answers varied. Some recommended Kaplan while others recommended "First Aid for Step 2" (by Le and Bhushan). I chose to work through USMLE World questions supplemented with "Crush Step 2" (by Brochert). Reading Crush gave me a nice break each day from the monotony of the vignettes associated with the question bank. I studied for at least eight hours per day (including weekends) to prepare.

Everyone will tell you that Step 2 is easier to prepare for than Step 1. I think my own experience coincided with this for the most part. The old adage is "Take two months to study for Step 1, take two weeks to study for Step 2, and take a #2 pencil to Step 3". This is an exaggeration of course, but I did feel more confident on Step 2 than I did on Step 1. I think the most helpful study tool was the USMLE World questions. I will pass that piece of advice down to students in the class behind me. The more questions you can do the better. I used the tutor mode so that I could take notes on questions I missed or important points within the answer explanations. Then I referred back to my notes each evening as a wrap up to the day. This won't be the best style for everyone, but it simply gives an example of what I did to work through multitude of questions.

I always take my favorite treats with me for these marathon tests. My test day lunch bag included a PBJ sandwich with raspberry preserves (yum!), an assortment of chocolates, and enough diet coke to last a week! It's critical to have a small little delicious energy source ready between questions blocks. My best medical school friend always takes a Dove chocolate bar to her boards. Just anticipate that you will be tired and worn out from question after question that day. Be ready to give your mood a lift with a little indulgence!

That's not all. Next I will be traveling to Chicago for the Step 2 CS exam. To help prepare us for this test, my school has set up a mock exam with feedback. I have spent the last two months on Family Medicine rotations which I hope will help me with my exam skills. Additionally, I am using "First Aid for Step 2 CS" to read up on the best way to write my notes and develop my differentials on that day.

I was able to schedule my exam on a Friday so Matt will be joining me and we will be spending a little vacation weekend in Chicago! It will be the fun weekend we both need after I've been studying for boards for the past several weeks.

Call can be hard but you learn a lot!

During my Sub-I rotation, I had two evenings of overnight call that opened my eyes to the demands of being a Family Medicine resident physician.  The first call night took place while I was working on the pediatric floor, and the second during my week on the medicine floor.   Up until this point, I had no idea how different two separate nights of call could be.  On both days I reported in the morning for a regular work day.  Around 5:00 pm, the day shift residents checked out to the night float and they went home. On the pediatric floor, the night float resident and I had plenty of time to get to know each other before the night got busy. We became friends at once!  We had dinner in the cafeteria and as we got to know each other we began to find all of the things we coincidentally had in common.  About 10 pm, we headed to our respective sleep rooms, to wait for our pagers to summon us.  I was able to get a few hours of sleep before our first admission came in.  The resident asked me to go to the Emergency Department to meet the patient and to take a history and do a quick physical.  The patient was a pretty straight forward cystic fibrosis exacerbation case.  I got to practice writing my admission orders and calculating pediatric doses for medication.  After our patient was tucked in, we both headed back to our rooms and laid down for the rest of the night.

My medicine call was entirely different.  I reported for a normal work day and met the night float resident around 5:00 pm.  We didn't have a whole lot of time to get to know each other before the phone was ringing with several new admissions.  We went to work immediately, separating once we arrived to the ED to begin working up two different patients at once.  At the same time, my night float resident was getting pages with questions about patients that were in the hospital.  Most of our night carried on at a similar tempo.  We were able to break away for a late dinner around 10:00 and my resident took that opportunity to teach me a few concepts.  At 3:00 am, our night had slowed down enough for a quick nap before the 5:00 am day crew came.  Instead of letting me go to sleep, my resident decided to give me a quick primer on acid-base analysis.  At first, I groaned to myself but actually, it was the best acid-base lecture that I've had!  It was so busy that it would have been easy to use that as an excuse to not do any teaching. I thought it was kind of him to take a few minutes of his sleep time to teach me something.  I went to sleep at 4:00 am and emerged from the call room at 4:50 am.  As soon as I stepped into the conference area, the resident was asking me to recite Winter's formula!  I faltered from lack of sleep, but needless to say, I will never forget it again after that experience!  I stayed for rounding and morning report which tallied my shift to 28 hours in length. Right at the limit! These long days will definitely take some getting used to.  Intern year will be a challenge!

Tips from my Sub-Internship

After having my Sub-Internship experience, I would like to share some of my observations with you in the hopes that it will help you to avoid some of the pitfalls that I have seen.  From the beginning of medical school, people begin telling you about the magic of 4th year.  They tell you to hang in there with all the classroom time and late night studying during years 1 and 2. They say that it will be OK even though you are working 12+ hours a day during 3rd year. They tell you it will all be worth it when the 4th year comes along.  We build it up to the point that when it finally arrives, we feel entitled to take advantage of the relaxed schedule and improved hours.  But it's important to remember that while 4th year is (in fact) glorious, there is still some important work to do.  The Sub-Internship is a job interview.  Basically, you are sampling a residency program, and they are in turn sampling a potential resident (You!).  With that in mind, here are some tips to help you stay on track to impress. 

First, I made it a point to go in early and stay late every day.  If you are tired, suck it up. I guarantee that the intern that you are working with has already put in more hours than you have.  You want to show the program that you are a hard worker.  Volunteer to help even if its outside of your comfort zone.  I learned to dictate which is awkward if you've never done it before.  But it is a skill I will need, and it was a small thing that I could do to help out.

Second, jump in on procedures and other learning opportunities.  Be aggressive. This is not the time to be a fly-on-the-wall.  As a Sub-I, you can function like an intern without having ultimate responsibility.  You are first in line among the students for interesting cases and procedures.   The faculty are likely to let you do a procedure that you've only observed up until this point.  Seize that opportunity and show them that you are teachable.  They do not expect you to know how to do a circumcision by yourself, but they do want you to be willing to jump in and learn.

On my rotations, I watched as students stood out for less than desirable reasons. Once a student mentioned that he really wasn't interested in doing OB in his future practice.  Tailoring your practice to your interests is one of the great parts of Family Medicine, but when you are on your Sub-I is not the time to draw your line in the sand. You have a lot to learn and the least you can do is be helpful.  Don't stand around simply because it doesn't interest you.  Another student told me that I shouldn't work so hard because I'm a 4th year student.  Do NOT fall into this trap!  I think about the residents working with me. I want to try to work as hard as they are working. 

Be careful about your interactions. Use good judgment and conduct yourself as a professional at all times (even socially).  A good rule of thumb is don't order alcohol when you are with residents. Be careful about your social networking. You can add new resident friends on Facebook, but be sure that there is nothing on your profile that will make you look bad (drunken pictures at the bar, crude wall posts, etc.).  

Finally, write thank you cards to the people that you worked with, especially if you are interested in their program.  It shows that you are grateful for the time that they invested in you and you are a thoughtful person. Do this and you will make a great impression while having fun!         

The Last Week of My Sub-I

I spent a few days during the final week of my Sub-I working at a women's crisis clinic which offers free ultrasound, counseling, and prenatal care.  While I was there, I met a woman who came in at eleven weeks gestation for her first ultrasound.  She had one young child at home and lived with her long-time boyfriend. She was very nervous during the ultrasound and joked about how many babies we saw on the screen. At first we saw only one gestational sac, but as the ultrasound tech continued to look we noticed a second baby. When the patient started crying, I was not sure what to think. I initially thought they were tears of joy until she sobbed "this is not good". She started talking about how she did not think that she could handle twins. It would be too much. I tried to console her and just held her hand while the tech completed the ultrasound. 

Afterward, I had a chance to sit with her and talk about her concerns for this pregnancy.  Her support system really only consisted of a sister who lived in another state. Her boyfriend was not supportive. He had been pressuring her daily about getting  an abortion. Now, she was afraid to tell him she was having twins for fear that he would become angry and kick her out of the house. His reasoning was that now wasn't a good time for him. It was hard for me to believe what I was hearing.  This woman was genuinely afraid of the reaction of her boyfriend.  She denied any history of physical abuse, but she believed that he would put her out on the street if he knew she was having twins.  She had nowhere to go.

She stayed at the clinic while a social worker contacted a local women's shelter. By the time she was ready to leave, she had made the decision not to tell him about the ultrasound until she had an alternative housing plan. The tech gave the woman her cell phone and told her she could stay with her if anything bad happened before she could make other arrangements. When she walked out the door, the ultrasound tech and I shared a hug and a tear for our patient. I don't know how things turned out for her, but I think about her often. I hope she is safe.

The third and fourth year are so different. You leave behind hypothetical patients and standardized tests and begin spending your time with real patients who have real tragedies. It is very difficult, sometimes, to separate the emotions that you feel at work from your personal life.  I have cried a few times after a particularly difficult day, but I think that's healthy. Hopefully, we all went into this field because we are compassionate.  The important thing is to do as much for you patients as you possibly can, and take comfort in that when you fall asleep at night. 

The Sub I continues

I spent the third week of my sub-I with the medicine team. I am really impressed with the training opportunities that are available in their residency program. And the residents are really smart. The first year residents (interns) are bright and efficient-they always seem to know the next step. I hope to be half that good when I start residency! The staff in this program are all very approachable and ready to teach. I haven’t seen anyone talking down to the residents, nor have I seen any friction between the residents themselves.

I have been paying close attention to these interactions because I want a residency program that will encourage learning and be a relatively happy place to work. The residents at this program seem truly happy and satisfied with their program. There are a lot of different personalities, styles, and belief systems, but I think since people are generally content with the way they are treated by the program, it is easy for them to work together regardless of their differences. Each attending that I have worked with has made a point to learn my name. I have been writing progress notes and even orders (they have to be signed by a real doctor) which has been excellent training for me. Everything here has been in a paper chart, but I’m getting the hang of it now. (Of course, just in time to leave!)

Earlier in the week I joined a few of the girls for dinner. It was nice to sit down and relax with them outside of work. I thought it would be good for me to hear what my potential future colleagues are complaining about when they are on their off time. It could give me clues to the obstacles that I might face later on in my training. This group didn’t really have any complaints. In fact, we spent most of our time figuring out all of the things that we had in common. On Friday, one of the residents arranged for everyone to attend a baseball game. My husband, Matt, drove in so he could meet everyone. It was so much fun to spend time with the residents outside of the hospital.

I highly recommend that students rotating through their sub-internship go to these extra activities. There may be times when you are exhausted, but it is a wonderful opportunity for you to learn about the people you might be working with later on in residency. Plus, it gives them an opportunity to see you let your hair down (a little)!

Week 2 of my Sub Internship

I spent the second week of my Sub-Internship on the inpatient pediatrics service, which I enjoyed.  The service was not terribly busy, given the time of year, so the residents had time to teach me about various topics.  That’s something I really appreciated. 

I also spent some time this week working on my CV and writing my personal statement.  I had a rough draft of my personal statement down on paper, but I didn’t feel like it represented me and my goals very well.  Luckily, I got to sit down with one of the second year residents one afternoon and talk to her about why she went into family medicine.  She is from a small town like me. We had very similar views on what a rural family doctor should be able to offer a community.  We would both like to practice in a rural area and we both believe that people should have access to acute, chronic, and preventative healthcare no matter where they live.  I don’t want to tell my patients that they need a colonoscopy but they will have to take an unpleasant prep and drive four hours to get it.  How many patients do you know that would actually take you up on that offer?  The more we talked, the more I realized how important it was to get these ideas into my personal statement.  After our conversation I went home and rewrote my personal statement from start to finish.  Now I feel it speaks to my values and goals.  I sent it off for editing because it is always good to have a second or third look. Once that is finished one of the faculty at this residency program has offered to give me feedback about it. He also offered to write a letter of recommendation for me.

At the beginning of the 4^th year it seemed as though everyone had an opinion on how rotations should be scheduled and carried out.  Don’t do your sub-I too early or they won’t remember you when they vote on applicants, but don’t do it too late or you won’t have time to get a letter.  Some said you should definitely have a letter of recommendation from the program you would like to get into, and others said that was frowned upon because basically it boils down to the program writing a letter to itself.  I stressed over all of this, but now I am starting to understand that it doesn't matter that much. My advice is to plan your sub-I for whenever it fits into your schedule and then work hard while you are there.  I think that if you are eager to learn and a hard worker you will be memorable.  At least I’m hoping that’s the case! 

As far as letters of recommendation go, this faculty member offered to write one for the sub-I’s on the first day of the rotation, so I am taking him up on it.  If I discover the magic recipe for the 4^th year I will pass it along.

Just a side note for those of you following this blog from the start: my family medicine shelf score came back and all is well! 

The Fourth Year begins

I just completed the  first week of my fourth year of medical school.  I can honestly say that this past week has been one of my favorites since starting medical school!  This month, I am doing  a Sub-Internship at a Family Medicine residency program.   I think it is important for every fourth year student to spend some time away from your home institution. The theory is that this will help you to make a more informed decision later.  My biggest advice is to start the process early.  I began working on setting up this Sub-I last February. I did not get absolute confirmation until June.  I don’t think this reflects the average experience, but it’s better to be safe than sorry.

Meeting the residents that you will be spending the greater part of your life with for the next three years is helpful.  It gives you a pretty good look into how a residency program works. You get insight into resident satisfaction, the patients that they care for, and their procedural experience.     For this rotation, I applied online directly with the program.   Some programs require you to use VSAS which I’m not as familiar with. 

The Fourth year is fantastic! You get more responsibility in patient care.  It’s your time to start sticking your neck out--they actually want you to write down your plans and recommendations.  I have been having a great time. In four days (just off the top of my head) I’ve delivered six babies, scrubbed in on five cesarean sections, and performed three circumcisions.  I even repaired a second degree perineal laceration under  the close supervision of the attending.  This program seems to put its 4^th year Sub-I students near the front of the line when it comes to procedures.  I was worried that scheduling this in July could be a mistake since all of the new interns are just starting and just as eager for experience, but I haven’t had any trouble getting procedures. 

It is important to try to identify early on what you would like to incorporate in your future practice.  Family medicine is wonderful in its flexibility.  I plan to practice in a rural town and I would like to do OB and procedures, which makes it very important for me to find a program that can provide adequate experiences  for these things.   Every program has a different emphasis, so if you can narrow down your likes and dislikes it helps. 

When Matt and I first started looking at residency programs, I really didn’t have a good idea of what I wanted to do in the future.  We began by narrowing it down by places we would actually want to live….that got us down to 80 programs!  Since I started this Sub-Internship,  I have been able to talk to a lot of residents and feel I’m getting a much clearer picture of what I want my practice to look like.  I now have my choices narrowed down even further.  I will be attending the AAFP National Conference for Family Medicine Residents and Students from July 28 to 30th. This will give me an opportunity to talk to residents from lots of different programs and hopefully get a better idea of the ones would be a good fit for me.  Matt is coming  along so he can get a feel for each of the programs.  It is important to me that he likes the location just as much as I do. And we have to have job opportunities there for him too. 

I will continue to blog about this process as I go along.

The Great Disappointment

Up front, I should say that it is very difficult for a medical student to discuss their short comings.  Most of us are Type A by nature, and not eager to show weakness.  With that being said, I will share my most recent disappointment with the hope you will not judge too harshly.  For the past eight weeks,  I have been enjoying my Family Medicine rotation.  It was the one rotation that I've looked forward to nearly all year.  I had a wonderful time working with my community preceptors and KU attendings in clinic.  The first seven weeks of the rotation reinforced my opinion on how wonderful seeing patients in the clinic can be.  I enjoyed the patients I met and loved the ambulatory setting.  You can solve problems for 25 patients and it is all in a day’s work. 

I worked hard and tried to learn as much as possible in preparation for my upcoming sub-internship in Family Medicine.  I took notes, read up on new topics, and did everything I could to show initiative.  Unfortunately, I hit a speed bump during week eight.  During the final week we had several tests that would be used to help determine my grade. We had a clinical skills assessment which I thought went fairly well.  I did a presentation from my underserved clinic experience which also went fine. But when I took the NBME shelf exam, I quickly realized I had not adequately prepared. My study plan was not adequate.  I assumed that since I had done well on the Pediatric and Internal Medicine exams, I would do fine on Family Medicine.  I used a case study book, but the content didn’t have enough depth.  I was not prepared for the test.

After the test I went home nearly in tears, telling my husband Matt that I bombed the shelf and my future career was in jeopardy.  He doesn’t put much stock in this complaint any more since I have a habit of feeling this way after every shelf and they inevitably work out fine.  But I told him that “No really. This time I really, really mean it!” Adding insult to injury, on the last day of the clerkship, we took a departmental exam on which I did absolutely, positively horribly.

On the last day of the clerkship I had to meet with three of my KU attendings, all of which I respect and one I consider my mentor.  I was embarrassed to sit down with them after they had sung my praises for seven weeks.  I didn't feel like I was able to finish strong and now they knew.  I learned at the meeting that even the clinical skills exam didn't go nearly as well as I had thought.  My department exam score was above the average, but still embarrassing to me.  My shelf score won't be released for another few weeks. Despite my performance on the exams, my attendings gave me kind words of encouragement.  I felt a little better afterward, but I am still kicking myself over potentially blowing a superior grade on the most important rotation of my third year.  We will see what the shelf score does for my grade.  I’m trying to stay hopeful.  For now I have learned my lesson.  I will never again assume I know enough.  The enticing thing about medicine is that there is always something more to be learned. 

I began medical school with the idea of going into anesthesiology. My sister, Jennifer, is an Anesthesiologist in Colorado Springs. She successfully juggles 3 year old twins, a husband, and her career. She has tremendous job satisfaction and has always been eager talk about the wonders of her trade. Jennifer was the first person in my family to go to medical school. She paved the way for me, and after seeing how happy she is with her career I had every intention of following in her footsteps.

The first rotation of the 3rd year was my Geriatrics clerkship. I spent most of my time stressing about proper roundsmanship and learning medications by their brand names, but mixed in with all of that I realized I really enjoy working with this patient population. As the year went on there were several rotations that stood out for me. I was fascinated with OB/GYN, couldn’t stop smiling during Pediatrics, and felt like everything was finally starting to make sense during Internal Medicine. While each rotation was great, all of them were lacking one thing or another. For example, Internal Medicine was rewarding but I missed taking care of kids and pregnant women. The hospital was OK, but I really enjoyed my time in the clinic. I decided during that rotation that Family Medicine is the best fit for all my interests.

By that time, I also realized a few things about myself that I hadn’t really taken into account. For instance, I like working in the clinic and I loathe the OR. I love talking to my patients, I enjoy patient continuity, and my attention span is short. Just short enough, that I would benefit from a smorgasbord of diagnoses walking through the door rather than focusing on one organ system. After throwing Anesthesiology out of the running, I called my brother-in-law. He is a family doctor in practice out in rural western Kansas. Like my sister, he is a success story of juggling kids, a spouse, and a career. Unlike my sister, however, his daily schedule seems much more flexible. He is able to tailor his work week around his kids’ activities. This flexibility is important to me, since Matt and I want to have kids in the not too distant future. (Mom if you are reading this--no, I am not pregnant!) I value family time which makes Family Medicine appealing to me.

This year I realized that the secret to job satisfaction (and my search for a specialty) is honestly zeroing in on my personal preferences. You can’t run someone else’s race. My sister would be miserable in Family Medicine and I would be miserable in Anesthesiology. I’ve come to realize that the 3rd year of medical school is an enlightening year. We discover our likes and dislikes, our strengths and weaknesses, and at the end we make one of the most important life decisions when we choose our career. I feel much more at peace now that I have chosen my own path to Family Medicine. Now the adventure begins!

Hi. My name is Brooke

Hi. My name is Brooke. I am a third year medical student. Dr. Delzell asked me to write about my life and what is like to be a medical student--going through the process of applying for residency. So, to start out, a little about me...

I grew up in a middle class family in a small town in Kansas. My Dad worked on the family farm when I was very little, and owned a company that serviced heavy equipment servicing company. He was a quiet man in public, but he doted over his daughters at every opportunity. Growing up as the youngest of 3 three girls definitely had its perks. There was always someone to shop with, someone to argue with, and someone to borrow clothes from. My oldest sister, Jenifer was former Miss Garden City. She taught me the finer points of tight rolling my jeans and eyebrow tweezing. My middle sister, Heather was an all-star athlete and taught me the importance of hard work and a sense of humor. Our house was always busy with work, school and sports. While in high school, I worked at the local golf course and played on the Varsity golf team.

During my junior year of high school, my Dad injured his back while working in the yard. We thought it was just a muscle strain but the pain became progressively worse. He collapsed at work two months later, having lost all the feeling in his legs. It was obviously not just a muscle strain. We soon learned he had multiple myeloma at the age of 47. He spent the next several months at the KU medical center receiving a stem cell transplant and other treatments. He went into remission for a short time, but the cancer came back. I accompanied him to his appointments at KU whenever possible and paid close attention to the physicians and their recommendations. I realized at that point that I wanted to be a doctor. I saw, firsthand, the impact that a physician can have on an entire family. I thought to myself, “what an honor that would be.” The doctors gave my Dad ten quality years and gave my family peace. They stood by us from the moment of the initial diagnosis, through the various treatments, and in the end with palliative care. When Dad passed away in 2007, we received a letter from one of his oncologists at KU. The words were kind and gave us comfort in our time of mourning.

In September of 2007, Matt and I were married. We got married in Colorado Springs, among friends and family. The day after the wedding, we were heading up into the mountains for our honeymoon. There would be no internet access and cell phone service would be nonexistent. Before we left, I received the long awaited email announcing my medical school interview time and date. After relaxing in the mountains for a week I returned to the KU School of Medicine for my interview day. I thought it went OK. Maybe I will blog about medical school interviews another day.

Five months later I got a letter from the School of Medicine. It was the letter that announced my acceptance. Matt had just left the house to go on a long run when the mail came that day. I couldn’t wait to tell him my wonderful news. I jumped in my car and drove around Newton, Kansas until I found him jogging along the side of the road. I parked my car in the middle of the street in my excitement and ran to him crying and holding the precious letter above my head. Later on, Matt would tell me he thought to himself “this could go either way…”. It wasn’t long before we found ourselves in a U-Haul truck, moving our dog and rabbit and all of our stuff to Kansas City to begin my medical school adventure. That letter is now framed and hangs proudly in my home office.