The Development Process for a novel “Peer-Assessment Lecturer Survey” (PALS)

The Development Process for a novel “Peer-Assessment Lecturer Survey” (PALS)

(available on request by word format)

The peer-evaluation of an instructor can be approached from different perspectives.  In reviewing methods of evaluation, I found the social-cognitivist theory elucidated by Bandura (1986) to be helpful. It links the behaviourist approach, which emphasises the influence of the environment on our actions, and the cognitive approach, which emphasises the importance of cognition in mediating our learning and functioning. (Kaufman 2010)

For lecture evaluation, the behaviourist approach focuses on the presentation process, learning environment and instructor content.  This is best demonstrated by microteaching of skills of Allen (1969) and Passi (1976) seeing the instructor from a mechanical perspective.  For example, the microskill of “stimulus variation” in which an assessor may critique “using gestures to help convey extra meaning” or “at various times, the teacher was noted in the left, right, forward, and back of the teaching space” (Figure 1) (Allen 1969).  These principles are old-fashioned and mechanistic but useful.

The cognitivist approach shifts the emphasis to learner-centred content and outcomes where the substantive parts of evaluation occur internally within the minds of the instructors and students.  Lecture evaluation may utilize instructor processes such as Gagné’s nine instructional events (1985), the one-minute paper by Schwartz (Wilson 1986) or the course material and classroom observation checklists designed by Brent and Felder (2004).  For example, Gagné’s eighth instructional event of “assessing performance” (1985) helps the assessor gauge the success of achieving a stated instructional outcome.

Keeping the social-cognitivist theory of learning in mind, I designed a Peer-Assessment Lecturer Survey (PALS) which unites the requisite components of an instructor’s cognitive process, content organization and presentation behaviours into a simple checklist.  The PALS follows an instructor’s instructional event matrix (Figure 2) (Gagné 1985, Okey 1991) and utilizes a simple yes/no checklist to quickly tick off points and provide comments as it unfolds in real-time.  This procedural framework provides opportunities for both a rigid process checklist and as well as subjective, interpretive and content-based comments similar to Brent and Felder (2004.)  Instead of including numerous sub-checklists or Likert scales, a short tally of “positive” and “delta” points is used with cues that mentally prime the assessor to actively provide presentation and guidance comments on lecture skills (Allen 1969, Passi 1976).  Finally, the inclusion of questions from the one-minute paper (Wilson 1986) helps the assessor hone in on the most important points for peer-feedback.

Figure 1. Sample concrete Behaviourist skills on Movements and Gestures (Allen 1969)

Figure 2. Gagné’s Instructional Event and Learning Outcome Taxonomy Matrix

Bibliography

Allen, D.W. et.al. (1969) Micro-teaching – A Description. Stanford University Press

Bandura A (1986) Social Foundations of Thought and Action. A Social Cognitive Theory. Prentice-Hall, Englewood Cliffs, NJ.

Bloom, B.S. (1984) Taxonomy of educational objectives.  Published by Allyn and Bacon, Boston, MA.

Brent, R. Felder, R. (2004) A protocol for peer review of teaching Proceedings of the 2004 American Society for Engineering Education Annual Conference & Exposition

Gagné, R.M. (1985) The conditions of learning and theory of instruction. Holt, Rinehart and Winston.

Kaufman, D.M. (2011). Ch 2 Teaching and learning in medical education: how theory can inform practice. In Swanick, T. 1^st ed. Understanding Medical Education: Evidence, Theory and Practice (Kindle Locations 1809-1810). Wiley. Kindle Edition.

Okey, J.R. (1991)  Procedures  of  Lesson  Design  Ch.  8   In lnstructional Design: Principles  and Application  2^nd edn. Edited by Leslie  J Briggs et al. Education  Technology  Publications pp192-208.

Passi, B.K. (1976) Becoming Better Teachers. Baroda : Centre for Advanced Study in Education, M. S. University of Baroda

Wilson, R.C. (1986) Improving Faculty Teaching: Effective Use of Student Evaluations and Consultants. Journal of Higher Education, 57 (2), pp. 196-211.

(prepared for a Medical Education assignment)

Sample.

Peer-Assessed Lecturer Survey (PALS)

Instructor:                                                                    Topic:

                                                                                                                                                                                    Notes & Comments

I. Gain Attention: Was your interest aroused?	[  ]  Yes       [  ]  No		When providing comments, make them: supportive, descriptive, specific, & behavioural.
II. Objectives were stated at the beginning and 1.     Clearly utilize active verbs from Bloom’s taxonomy 2.     Demonstrated what was expected of the Learner by the end of the session	[  ]  Yes       [  ]  No   [  ]  Yes       [  ]  No
III. Review of prerequisite knowledge 3.     Started at an appropriate challenge level 4.     Checked-in with audience to adjust & match needs 5.     Covered in less than 5 minutes	[  ]  Yes       [  ]  No   [  ]  Yes       [  ]  No   [  ]  Yes       [  ]  No
IV. ORAL Presentation skills Tally up positive and delta points ( ) on subjects like: ·         Voice: clarity, volume, energy, speed, um’s/er’s ·         Non-verbal cues: directive focusing (pointing/laser pointer), gestures/movement, & deliberate pauses	(+)	Δ
V. A-V & Guidance skills Tally up positive and delta points ( ) on subjects like: ·         Overhead/PowerPoint/Prezi, graphics, & videos ·         Used cases, story, analogy, examples, prompts & hints appropriately	(+)	Δ
VI. Facilitated Practice 6.     Opportunity provided for active involvement, student participation and/or practice	[  ]  Yes       [  ]  No
VII. Feedback 7.     Provided active feedback to audience 8.     Comments were supportive, descriptive, behavioural	[  ]  Yes       [  ]  No   [  ]  Yes       [  ]  No
VIII. Assessment of Objectives 9.     The instructor “closed the loop” on learning objectives with a post-instruction assessment 10.   Higher-order thinking questions were asked	[  ]  Yes       [  ]  No   [  ]  Yes       [  ]  No
IX. Further review after instruction 11.   Summary/outline provided 12.   Additional opportunities to master material (i.e. tools/homework) were provided for further practice	[  ]  Yes       [  ]  No   [  ]  Yes       [  ]  No

The most important take-home point was:

The muddiest point in the lecture was: 

FUN Teaching Principles (based on learning theories)

Teaching is the process in which learning is facilitated through planning, presentation, observation, active reflection and feedback that results in external stimuli being perceived, translated, converted and comprehended in a manner which results in cognitive and/or behavioural changes.

Kaufman and Mann’s ‘Teaching and Learning in Medical Education’ chapter in “Understanding Medical Education” inspires this personal definition of teaching.  My interpretation reflects a cognitive constructivist philosophy in which the teacher and learner engage in a “continuous, dynamic, reciprocal interaction among three sets of determinants: personal, environmental (situational) and behavioural.” (Kaufman & Mann 2010)  The personal factors are the behind-the-scenes models/schemas the learner mentally constructs, the environmental factors are the learning setting/material and the behavioural factors primarily are the outcomes, building on prior knowledge.

My philosophy of teaching guided me to derive a set of simple teaching principles that form a simple mnemonic: FUN!

·         First things First (Planning and Presentation)

·         Understand the Learner (Observation)

·         Nurture and Guide (Active Reflection and Feedback)

These principles are not a step-by-step guide to develop a lesson plan, but they provide a framework for considering elements of cognitivist and social constructivist perspectives.  I will elucidate these points and provide an example from a lesson plan I developed with second-year residents on office efficiency.

First Things First:

Before a teacher picks up a set of learning objectives/syllabus or launches Powerpoint to make lecture notes, it is important to reflect and set priorities.  A series of questions based on Schön’s Reflective Practice (1983) may help create a learner-centered lesson plan.

Question	Schön’s Reflective Practice
What was MY EXPERIENCE when I first started this subject?	Knowing-in-action
What did I find most CHALLENGING initially?	Surprise
What did I learn that was most IMPORTANT to me at that time?	Reflection-in-action
How has my understanding of this subject CHANGED since then?	Experimentation
How do I use the subject-matter on a DAY-TO-DAY basis?	Reflection-on-action

These questions walk a teacher through a mental progression starting as a novice learner, synthesizing the content into a mental model and then applying it.  Schön’s steps can help a teacher to recall a time when he or she was an early learner so as to avoid the expert’s pitfall of unconscious competence: taking mental short cuts and making assumptions that novices find difficult.

For example, when I created a lesson plan to teach second year residents how to function efficiently in the outpatient clinic, I first stepped back and recalled how I felt at that time in my learning.  I was overwhelmed and often fell behind because of the increased load of patients that I had to see in 20-minute segments.  I often felt I survived the day only by finishing hasty notes that felt sparse and inadequate.  I learned tools and workflows from co-residents and a teaching fellow.  Eventually with time and reflection, I was able to change my practices to shift from a 40-minute visit per patient to a more efficient 20-minute visit per patient mentality.

Based on this reflection, I decided that my lesson planning would follow a “typical day in clinic”: I would have each resident read and react to scenarios that progress through a normal resident’s workday.  The teaching would focus on practical issues like chart review/prep-work, lecture note-taking/review, and clinic/charting workflows, while reflecting on the frustrations of time management, chart closing, and difficult patients.

Understand the Learner:

While the first step emphasizes the teacher’s personal perspective to assist with priority setting and lesson planning, Understanding the Learner shifts the focus to learners’ perspectives to understand what learning styles may need to be considered in the lesson.  The Kolb Learning Cycle (1984) and the Honey and Mumford adaptation close the gaps through an experiential learning approach, building in elements that reinforce the lessons to be learned long-term.  During the process of lesson planning, the teacher considers where students enter the learning cycle and engages them using a variety of approaches.

Accessed 9/2013 from: http://bonlinelearning.com.au/blog/learning-styles-in-elearning/

For example, in my lesson on office efficiency, I devised various case scenarios from a typical day to access Kolb’s “concrete experience” and “reflective observation” stages.  The group’s discussions accessed “abstract conceptualization” and their homework and subsequent ‘real work’ would access “active experimentation” to complete Kolb’s learning cycle.  These steps mirrored the reflective practice model as well: as each student read their scenario out loud, they reflected on what they would do (virtual reflection-in-action), discussed strategies with other R2s (experimentation) and then as homework, they created/utilized/tweaked personal workflows to gauge if there were any improvements (reflection-on-action).

Nurture and Guide:

Using the ‘clinic as the curriculum’ is a prime driver for my residency and this orientation helps facilitate individual learners to become self-directed adult learners and information masters, drawing strongly from an Adult Learning Theory/Andragogy model.  Knowles’ principles (1984) encourage a fun and safe environment, resident engagement in diagnosing learning needs and developing their own learning resources, and aiding them in carrying out their learning plan.  A curriculum that promotes an open, accepting, transparent and sharing culture of learning promotes a strong Community of Practice. (Wenger 1998)  Scaffolding occurs by building on prior knowledge and utilizing higher learners in a Zone of Proximal Development (Vygotsky 1986).

Accessed 9/2013: http://lmrtriads.wikispaces.com/Zone+of+Proximal+Development

Initially, the suggestion to learn more about office efficiency came from the residents as they were transitioning to more solid roles within the clinic.  This is an example of andragogy, wherein the R2s actively engaged with their curriculum development.  I deliberately crafted the office efficiency lesson so they would scaffold each other’s learning using principles of social constructivism.

The scenarios I created provide a framework: embedded within the cases are best practices that they share aloud.  The scenarios end with a point of contention: questions like “what do you do to keep yourself organized and how do you stay on track [with clinic flow]?” and “what sort of preparation work do you do tonight? The morning before [you see your patients]?”  If they are stumped, they can turn to me as a resource: as a fellow, I am a step between residency and attending, placing me in the role of a “more knowledgeable other.”  My recent experiences make me receptive to their needs and subsequently, they are receptive to my pearls.

In conclusion, the teaching principles “First things First,” “Understand the Learner” and “Nurture & Guide” or FUN, form the basis for my teaching philosophy.  Their application reflects the teaching theories of andragogy, reflective practice, cognitivism, and social constructivism. FUN is an easy to remember mnemonic, a practical tool to implement and most importantly, it provides a short checklist to help make teaching and learning fun!

Bibliography

Honey, P. & Mumford, A. (1982) Manual of Learning Styles. London: Peter Honey Publications, London.

Lave, J. & Wenger, E. (1991) Situated Learning: legitimate peripheral participation. Cambridge University Press, New York.

Kaufman, D.M. & Mann, K.V. (2010) Teaching and Learning in Medical Education. In T. Swanwick (Ed) Understanding Medical Education. ASME, Blackwell Publishing.

Knowles MS et al. (1984) Andragogy in Action: applying modern principles of adult learning. Jossey-Bass, San Francisco, CA.

Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development.

Schön, D. A. (1983). The reflective practitioner: How professionals think in action . New York: Basic Books.

Vygotsky, L. S. (1986). Thought and language (A. Kozulin, Trans.). Cambridge: MIT Press.

Wenger, E. (1998). Communities of practice: Learning, meaning, and identity . Cambridge: Cambridge University Press.

Renewal and Reflections.

So it's about time for me to restart this blog again.

I made several meager attempts in medical school and residency, but I was always meek about posting patient related information and I was always pressed for time and drained of energy.

However, I'm moving into a new period of my life (and a new period of the blogosphere where it is going the way of the dinosaur and may actually have more intimate readership!... i.e. just me.)

I'm starting up a master teacher fellowship in medical education and we wrote a reflection in our "blogs" on a website and I figured, hey, this is good enough that I'll save it for my own site as well.

            Before I started medical school, I was interested in being a teacher or a scientist.  I loved analysing, studying and sharing what I learned with others.  As I went through college and learned more about the differing opportunities that a physician has available, I realized that I did not have to these give up while working as a physician!   The concept of “how doctors think” is highly prized by learners and I want to work on ways to provide this early on in medical school/residency curriculum.  Research on this subject by Croskerry (2009) and Gigerenzer (2011) has inspired me to be more self-aware of this process.  I plan to implement what I learn with the University of Dundee coursework to help create a framework for the development of clinical judgement and to instill a sense of effective lifelong learning in those I work with and those I teach. I am a little worried that the expected length of completion for the masters program is 3-5 years.  This is the main reason why I want to keep my end-goals in mind and find ways to always apply my knowledge towards my thesis.

CROSKERRY, P. (2009). A Universal Model of Diagnostic Reasoning. Academic Medicine. 84 (8), 1022-1028.

GIGERENZER, G. and GAISSMAIER, W. (2011). Heuristic Decision Making.  Annu. Rev. Psychol. 62:451-482.

Tet Fe Mal

(The case provided is inspired by a true story. I've changed the details to blan HIPAA standards. Random google image of a tap-tap provided for visual effect.)


Only the rushing traffic of tap-tap trucks and motos loaded to the brim with passengers stirred the stale and acrid air of the bustling city of Cap Haitien. Clouds of smoke rose from the cluttered gutters, spewing out a miasma of burnt plastic -- the country's sole way of waste disposal -- as toxic fumes.

Small currents of wind trailed behind the vehicles that swerved precariously around each other, weaving braids of smoky eddies in their wake. Paul-Jean, a small boy of 9 years, stared out the back of one such tap-tap named "Love Jesus." His eyes were transfixed by the smoky patterns and the noisy chaos of the street side merchants. It had only gotten busier in the weeks leading up to the coming of the festive Kanaval. It was a big celebration throughout Haiti as their special version of Mardi Gras.

"Love Jesus" pulled over at the corner of a busy intersection after two brisk thumping strikes were authoritatively delivered against the side of the vehicle as a signal to stop. PJ got out and waited at the side of the road while his manman paid the driver, and then climbed out over the half-dozen passengers also stuffed in the seats.

Bzzzzzzzzzeeewwwwww!

EeeeeEEEeeeeEEEEtttt!

He heard the thubbing of the moto barreling down the road before he saw it -- the vehicle weaving and dodging the stodgy slower tap-taps and narrowly missing their side mirrors and passenger limbs sticking out the windows.

But the moto didn't miss him.

The world whirled around in a roaring redness... then black.



================================

A week later, he still flinched whenever a moto zoomed by -- and his protective manman folded him close into her bosom on this leg of their journey. This tap-tap (named "Bon Fet") weaved drunkenly back and forth on the path. The road was dusty and riddled with the pock-marked memory of monsoons past. On some of the deeper unavoidable potholes, PJ had to hold on to the railing and clutch at his floppy fishing cap to avoid losing his seat. His mother had saved up and given him the cute hat as a present since the accident.

He still hoped that he would get to see some of the parades of Kanaval, but manman insisted that that this trip was just as important.

"Eske ki pwoblem ou genyen jodiya?"
"Tet fe mal."

The doctor asked why he was there in the hospital and his mother had blithely replied that he had a headache. He concentrated on drawing "Bon Fet," complete with a birthday cake on the top to complete the tap-tap. The adults chatted more and his mother swept off the floppy fishing cap without any dramatic flair, but by the inaudible gasp and silence that followed, she might as well have shouted and pointed.

PJ's head had been partially de-scalped and on the corner of his forehead, above his right eyebrow, a motorcycle handlebar's length off the ground, was a shiny patch of skull like an offset unblinking third eye.

Interlude: Acid-Base Algorithm

I learned about a great book recently entitled Symptom to Diagnosis (Thanks Nathan!) which I started reading a few weeks ago. That, in combination with my proclivity to rewatch some old TV shows on iTunes in the evening has led me to compose less blog posts than I anticipated on this trip. However, there are more to come -- with a different POV.

Week 2: Fresh, Clean Water and Nutritious Food

I spent my second week of my Haiti experience in the outpatient pediatrics clinic. Overwhelmingly, the cases were centered around the need for reliable sources of nutritious food and clean water. I saw many ramifications of that in the form of intestinal worms and kwashiorkor malnutrition. Also, almost every kid had terrible tinea capitis. This meant a lot of referrals to the (soon-to-be rebuilt) nutrition center for children and prescriptions for mebendazole, griseofulvin and metronidazole. After being pleasantly surprised by the relative luxuries that the town of Milot had in terms of availability of fruits in the mountains and fresh water, I was shocked to see how many children came in with distended bellies and no weight gain over the course of months to years with "failure to thrive" as the tumbled off their growth curves. In some cases, new mothers didn't even know how often to breast feed their children thinking that their children needed more sleep and would only feed 4-5 times a day. It needs to be closer to 10-12 times per day! That made me wonder if the babies would initially cry from hunger and then after a period of dehydration and weight loss, decide to conserve that energy and just sleep most of the day. It was also in the small single pedi clinic room with three other providers, a Haitian pediatrician, a Haitian resident (here for his year of social service) and a nurse practitioner from the States that I learned how History taking could be a team effort. Quite often, while I was talking with my patients, the pediatrician would interrupt my translator or whip around with a chastising voice and lecture the mothers about their children for five minutes in the middle of her own clinic visits. I'd watch the exchange, initially amused by the response to my (what I thought of as) fairly benign questions and advice. And when pressed, my translator would simply say "they disagreed with my translations." Sometimes women seemed reticent to offer their opinion on the medical situation unfolding. Other times, the translator or resident would chuckle at their responses and tell me "they think it is a Haitian thing." It took me a few days to realize that this actually meant that there were non-Western beliefs at work; Voodoo beliefs that the patients or their parents held and in some cases, delayed care in deference to voodoo ceremonies or treatments.

Week 1: Tdap, PPDs, and STI screening/_Counseling Needed!

We had an awesome urology team from FL and NJ, some stellar RN students from UCSD and a wonderful cardiologist+sonographer team who were volunteering at the hospital with us this past week.

I was stationed mainly in the outpatient clinic which was more like a walk-in urgent care day, but there were a surprising number of patients who came in for med refills for hypertension or mild acute complaints.  There was also some urgent/emergent care, wound care and urology mixed in-between clinic sessions.  Many of the wounds that I helped some of the nurses with were from motorcycle accidents and we opined the lack of resources for routine Tdap prophylaxis after routine injuries.  Children are vaccinated nowadays, but some of the adults have developed mortal cases of tetanus.

Here are some of the cases that I was involved in during my first week.


Cardiovascular/Pulmonary
Dilated Cardiomyopathy CHF with severe mitral regurgitation (mimicking as "asthma")
Active Pulmonary TB (pretty much all the PPDs I ordered for suspicion of TB were 20mm in size or greater)

ID
Testicular mass - massive hydroceles due to chronic filiriasis
Lymphatic filiariasis (Elephantiasis) of the legs
Cervicitis/UTI/pyelonephritis
Tetanus -- mild and severe manifestations (with neck stiffness and muscle spasms vs risus sardonicus and trismus/lockjaw)
Spinal compression fracture with cord compression due to Pott's disease with subsequent spasm and paralysis of the lower limbs

Derm
Tinea versicolor
Acne keloidalis nuchae
Cellultitis
Full thickness circumferential burn injuries

GI
GERD
H. Pylori (80-90% prevalence in Haiti, apparently!)

Heme/Onc
Severe anemia (Hgb drop from 7 to 4.7 in two days!) due to leiomyomata of the uterus (negative pregnancy test but had a 20 week size uterus!)
8x8cm Breast mass -- likely due to phyllodes tumor in adolescent, hopefully it turns out to be fibroadenoma

Urology
Penile reconstruction s/p explosive trauma (a bovie explosion during an elective circumcision)
Emergent secondary pseudophimosis due to a young boy slipping a metal washer around his glans (with acute swelling!)

Our evenings were filled with case presentations on some of the more interesting and pertinent primary care topics.
I didn't get to do much pediatrics, ED care or HIV/infectious disease, but I still have a few weeks to go!  There are still a few residual cases of cholera and I'm glad that my stools have held firm thus far.

And on that pleasant note, I'll be signing off!
CP.

Bonjou! Komon ou ye jodiya?

I traveled across the turquoise waters of Turks and Caicos on 1/12 and flew across the dark blue yonder.  A verdant delta emerged through the mists as we approached Haiti.  There were numerous small rowboats, speckling the waters below and we sailed across a landscape of concrete walled homes with rusted corrugated roofs.  I continued to peer intently out the window of this new land.   A cannibalized prop plane lay abandoned on the side of the runway.  We taxied over to a small airport/shed where our bags were collected into two trucks and we zipped down a paved road through Cap Haitien.

The colors of the small homes were bright with plastic detritus scattered across the landscape.  Trucks with wooden backs called "Tap-taps" were piled full of people in the cab and hanging off the back.  Apparently, when you wanted to get off the taxi, you "tap tap" the side and hop out.

At a crossroads between Cap Haitien, Milot and Dondon, the paved road of Cap Haitien gave way to a dusty gravel road with the occasional gaping pot hole.  Motorcycles with two or three passengers hanging on the back zipped in and out of the traffic, competing with oncoming tap-taps.  The road cut like a straight rut through the tropical landscape, peppered with small children carrying buckets of water on their heads, journeying to and from the local wells.

At a seemingly random location in our journey, we cut a right and arrived at our site.

The mission house site

Here I am in my dorm room on the campus, setting up my mosquito net.  It would take a few days before I   figured out how to use the hooks on the walls so the net wouldn't be lying directly on my face and legs.

There was a period over the course of the weekend that I felt a sense of "overwhelming quietude."  I think it was part of the transition into a foreign place without knowing the language, the culture, being struck simultaneously by the incredible poverty (but also the surprising degree of development)... there was just a lot of adjusting to do.

We walked around the town and drank in the sights and sounds of this bustling town.  This included a brief tour of Sans-Souci Palace, a site of regal beauty (and aqueducts!) and some fascinating history involving the first King of Northern Haiti after they won their independence from the French.

Boston -> Turks and Caicos, Providenciales

Renewal.

First off, I must remark on the wonderful climate shift there is, going from the frigid New England Coast to the balmy Caribbean. Is this even real?  Turks and Caicos has a surreal feel to it, but we have been met with warm weather and even warmer smiles here.

On the way to our modest accommodations (I use the term loosely, since our fellow travelers/vacationers have more beautiful and swanky beach-side establishments), BB and DB commented on a recent trip their friends had taken to Iceland.  It was a family who rarely travels, but they opted to go to a frozen tundra in the middle of winter to ice climb and hike on glaciers.

"Why not go someplace warm?" they exclaimed, relishing in the warmth of Turks and Caicos.

Why indeed.  T&C,PLS reminds me much of home, but MUCH flatter, and everyone here drives on the wrong side of the road.

"Iceland has one of the highest literacy rates in the world," I commented, drawing on random college trivia memory banks.

"Well, they do spend a lot of their time indoors.  That makes a lot of sense."

In the tropics, I'm certain the literacy rates are lower when there's so much else to do.  I'm reminded of the constant pull I felt to go outside and enjoy myself when I was studying in college and medical school in Hawaii as well.  The competing interests of learning and relaxing outdoors... UGH!  In many ways, living in Boston is a blessing as a resident where I can feel warm and cozy and guilt-free while studying and writing in my clinic charts.

Well, I'm off to relax in preparation for my learning later!

Signing off,
CP.