See how the Council on Long Range Planning & Development (CLRPD) studies long-term strategic issues related to AMA’s vision, goals and priorities. Study concept and design: Leigh, Tancredi, and Kravitz. See daily video updates on how the AMA is fighting COVID-19 by learn more about the AMA Research Challenge, taking place on Jan. 13, 2021. This is ATTENDING WORK HOURS BY SPECIALTY versus RESIDENT WORK HOURS (the line) The argument of "preparation" is invalid” Explore our Residency Application Package and work one-on-one with an expert admissions consultant who will help you match at your top choice program! Radiology, surgery, and anesthesia may have worse hours during residency, but can be much better afterwards, because you can work fewer hours and make decent money. In a landmark study, Williamson and Feyer compared volunteers who were sleep deprived and those who were intoxicated. Self-reported work hours did not capture variability across day, swing, or night shifts or for weekends or weekdays, nor were hours-on-call included. All Rights Reserved. These tips can help medical students get started. Archived . Read highlights from the virtual WPS November 2020 Meeting. Residency applicants … We found that specialists caring for more acutely ill patients or those requiring intensive monitoring (usually in hospital settings) work longer hours than physicians focused on more stable, chronically ill patients (mostly in ambulatory settings). Everyone works hard in residency or as a house call doctor. Our rankings are somewhat similar to studies of annual income, with procedural specialties being paid more than cognitive specialties.1,2 But there are differences. IV. You love the hours and want a specialty that is “easy.” Many students choose a specialty thought to have ‘easy hours.’ The fields that come to mind are the E-ROAD specialties – emergency medicine (EM), radiology, ophthalmology, anesthesiology, and dermatology. I trained both with and without residency work hour Recent posts about career selection and resident burnout have led to discussions about residency work hours. 2011;171(13):1211–1213. Respondents who had children during residency were asked if factors such as work hours, work schedule, availability of child care, cost of child care, impact on residency, support from the residency program, increased length of training, and adequate family leave affected their decision to have a child. Becoming a doctor has always been difficult. In the U.S. it requires four years of college followed by four years of medical school and, depending on … Respondents gave these specialties the highest average rating for work hours and schedule flexibility: On the other end of the spectrum, anesthesiology, neurology and OB-GYN rounded out the list as the lowest-ranking specialties for these work-life balance factors. © 2021 American Medical Association. 545. Ever wonder how busy you are compared to your peers in other specialties? The first such latent factor for females consisted of "work-life balance," "residency length," 'residency work hours," and "family-friendly specialty." Many in the medical community and general public are debating these trade-offs —16- versus 24-hour shifts for interns, 80 versus “the old days” prior to 2003, when duty hours did not exist — and that debate is valuable in this … The COVID-19 pandemic has driven unprecedented use of telehealth. You may have heard residency can be grueling, and the hours can be long. For almost all of … The residency records of the Department of Orthopaedics and Rehabilitation at the University of Iowa were reviewed, along with personal memory, to identify the marital status of every resident in the first four years post-work-hours-restriction, spanning from July 2003 through June 2007, and the last four years pre-work-hours … We analyzed 41 specialties with at least 20 respondents, as well as 4 broad-specialty categories: primary care, surgery, internal medicine, and pediatric subspecialties, and other specialties.1 Control variables were age, sex, race, whether board certified, whether graduated from foreign medical school, residence in areas with less than 200 000 population, region of residence, practice ownership, academic employment, and revenue from managed care. Some specialties are well-known for their less demanding hours during residency (and often afterwards as well). To capture information on work-life balance in different specialties, Doximity asked physicians to rate residency programs based on “work hours: tolerability of shift and call schedules” and “schedule flexibility: accommodation for weddings, pregnancy, deaths, etc.” How specialties were ranked Respondents gave these specialties the highest average rating for work hours … That was one of the main reasons I pursued wound care. Among the many factors medical residency candidates have to think about when picking which specialty, or, specialties to apply to is how competitive the specialty is to get a residency in. Copyright 1995 - 2021 American Medical Association. I currently work … Some residents may work 45 hours a week, while others work much more. 29 – 31, 33 One study … In this post, we’ve collected details about each specialty, including residency length, competitiveness, average Step 1 and Step 2 scores, fellowships available, work … I work on average 70-80 hours per week, with an average of one day off per week, depending on the rotation. Association of residency work hour reform with long term quality and costs of care of US physicians: observational study ... residency without further specialty training. The first year of residency is often the wors… Each month, the AMA highlights institutions that are part of the AMA Accelerating Change in Medical Education Consortium to showcase their work with the consortium and innovations in medical education. President signs omnibus spending package providing new round of COVID-19 relief and more in the latest National Advocacy Update. The three subsequent … We believe this ranking will likely be useful to medical students, residency directors, hospital administrators, physicians contemplating switching specialties, and policy makers. Yet, work hours—independent of income—figure prominently in discussions of physician lifestyles,2 student choices,3 and patient safety.4. But new results from the … doi:10.1001/archinternmed.2011.294. The first year of residency training is called the intern year Before 2003, physicians in training in US internal medicine residency programs routinely worked more than 80 hours a week, with shifts often lasting 30 hours or more Data were drawn from a nationally representative sample of physicians in the 2004-2005 Community Tracking Survey (CTS). Read highlights from the virtual YPS November 2020 Meeting. My wife and I are expecting our first child in August and want to move closer to our family. Graph of how many hours each specialty works on average, from JAMA [Research] Research. Get free access to newly published articles. Medical resident work hours refers to the (often lengthy) shifts worked by medical interns and residents during their medical residency.. As per the rules of the Accreditation Council for Graduate Medical Education in the United States of America, residents are allowed to work a max of 80 hours a week. The vast majority of doctors work fewer than 60 hours … I work on average 70-80 hours per week, with an average of one day off per week, depending on the rotation. to download free article PDFs, Psychiatry (non Hard question to answer, in general surgical specialties will work more than non-surgical as attendings. Control variables did not materially alter any of the rankings in any regression. See the costs for all the AMA membership categories, plus tax deduction information. Annual Work Hours Across Physician Specialties. The AMA promotes the art and science of medicine and the betterment of public health. Two regression analyses compared work hours among 41 specialties, with and without control variables, with family medicine as reference. Android, The best in medicine, delivered to your mailbox, Get additional information on work-life balance in residency. I am currently a first year resident (aka intern) in orthopaedic surgery. The hours related to these specialties often … In the regression for the 4 broad-specialty categories with control variables, surgery (+303 hours; 95% confidence interval [CI], 219 to 387 hours) and internal medicine and pediatrics subspecialties (+208 hours; 95% CI, 132 to 284 hours) had significantly higher hours, and other medical (−228 hours; 95% CI, −295 to −161 hours) had significantly lower hours than primary care. 2. © 2021 American Medical Association. Get expert advice on contract negotiation, licensing and certification, and resident life, Access interest rate discounts when you refinance your student loan. Compared with family practice, the 3 highest specialties were vascular surgery, critical care internal medicine, and neonatal and perinatal medicine; the 3 lowest were pediatric emergency medicine, occupational medicine, and dermatology. For example, pediatricians, dermatologists, and child and adolescent psychiatrists reported relatively low hours and have relatively high career satisfaction. All Rights Reserved. An AMA education module aids that teaching process. Orthopedic residency was better, and the work week probably averaged 70 hours to 80 hours per week. You love the hours and want a specialty that is “easy.” Many students choose a specialty thought to have ‘easy hours.’ The fields that come to mind are the E-ROAD specialties – emergency medicine (EM), radiology, ophthalmology, anesthesiology, and dermatology. The CTS administrators, however, warn against comparing the 2008 data to studies using 2004-2005 data.1,5. Physicians asked high court to uphold a state PBM drug-pricing law protecting access to independent and rural pharmacies, and the justices agreed. On one hand, things are a lot better than they used to be. Specialty Program Exemptions Surgical Exemption: On-call duty in the hospital during the night shift hours by trainees in surgery shall not be included in the 24-hour on-call and 80-hour limits if the hospital can document that during such night shifts, postgraduate trainees: - are generally resting; documented 4-5 hours … The AMA is leading the fight against the COVID-19 pandemic. Debate surrounds the relative pay of physicians in various specialties. Read the details of the proceedings of the 2November 2020 Special Meeting of the House of Delegates. Public Policy Positions of the ACP 1. Radiation Oncology. Recent posts about career selection and resident burnout have led to discussions about residency work hours. Mean annual hours worked was 2524 (median, 2420; interquartile range, 1960-2940). However, with some new data from the FREIDA website, we get a better idea than ever before. Design Retrospective observational study. The number of hours residents work varies. Share your thoughts on the AMA’s Residents and Fellows Facebook page or in the comments below. Terms of Use| Never before, however, had he found himself at the center of such keen public scrutiny on the long hours worked by surgery residents. sign up for alerts, and more, to access your subscriptions, sign up for alerts, and more, to download free article PDFs, sign up for alerts, customize your interests, and more, to make a comment, download free article PDFs, sign up for alerts and more, Archives of Neurology & Psychiatry (1919-1959), Subscribe to the JAMA Internal Medicine journal, FDA Approval and Regulation of Pharmaceuticals, 1983-2018, Global Burden of Skin Diseases, 1990-2017, Health Care Spending in the US and Other High-Income Countries, Life Expectancy and Mortality Rates in the United States, 1959-2017, Medical Marketing in the United States, 1997-2016, Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter, US Burden of Cardiovascular Disease, 1990-2016, US Burden of Neurological Disease, 1990-2017, Waste in the US Health Care System: Estimated Costs and Potential for Savings, Register for email alerts with links to free full-text articles. Obtained funding: Leigh. See daily video updates on how the AMA is fighting COVID-19 by discussing policymaking during the pandemic. Private physician practices continue to face challenges driven by administrative burdens. For example, residencies, such as dermatology, may not require being on call, which cuts down on the hours … Residency is a stage in the process of graduate-level medical training. The answer: not much. Role of the Sponsors: The funding sources had no involvement in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript. Standard Policy, which was established by the ACGME in 2011, places additional restrictions on maximum shift length for … 189 comments. After coming out of residency, I had to decide whether I wanted to have a good work-life balance and not have work consume my life. hide. 14. I’ll be finishing my internal medicine and pediatrics residency this year. The effects of reduced residency work hours on patient safety as well as trainee well-being and education have been the subject of much controversy. Residency Program Coordinator Timeline. A letter from a consumer … The AMA is leading the fight against the COVID-19 pandemic. Note: Estimates from a multiple linear regression that statistically adjusted for physician, practice, and market characteristics (see text for details). Adjusted mean differences in annual work hours for physician specialties vs family practice in community tracking survey (n=6381). Residency Review Committee (RRC) in the given specialty. With the end of my residency, our coverage will be eliminated, but we need insurance now more than ever. Vous êtes à la recherche d'un emploi : Holiday Suites ? You may have heard residency can be grueling, and the hours can be long. Drafting of the manuscript: Leigh. Residents work 40–80 hours a week depending on specialty and rotation within the specialty … I verify that I’m in the U.S. and agree to receive communication from the AMA or third parties on behalf of AMA. Our website uses cookies to enhance your experience. As neurosurgery residency program director at Cushing Hospital, Dr. Burr was accustomed to balancing the demands of a clinical practice and administrative duties. Association of residency work hour reform with long term quality and costs of care of US physicians: observational study Anupam B Jena, 1,2,3 Monica Farid, 4 Daniel Blumenthal, 5 Jay Bhattacharya 3,6 “Let me try again: About my residency work hour TWEETS, many said 80 hour weeks prepare residents for attending work. While on Psychiatry rotations, residents can expect to work on average 40-60 hours/week, depending on whether the rotation is inpatient or outpatient. A new ranking using more than 90,000 physician comments may provide some insight. Other specialties, such as surgery, require call and are more time-consuming. Funding/Support: This study was funded in part by grants to Dr Leigh from the National Institute for Occupational Safety and Health (grant 1 R01 H008248-01) and Drs Tancredi and Kravitz from the UC Davis Office of the Vice Chancellor for Research. She’ll be taking unpaid maternity leave for at least five months and is on my health insurance. See daily video updates on how the AMA is fighting COVID-19 by taking a look at the state of vaccines and seeking answers to key COVID-19 questions. You can look at this graph, this might find the concrete All rights reserved. Here’s a peer-ranked list of the best—and worst—specialties for work-life balance in training. Still, it is a hard decision. Specialties with more (less) work hours tend to have relatively low (high) physician job satisfaction ratings. Study supervision: Leigh. Learn more. Definitely one of the easiest and most relaxed medical specialties is radiation oncology, at least that’s what those who chose this specialty have to say. 99% Upvoted. See: Residency FAQ "How many hours do interns/residents work? opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty. … Although the first latent factor for males consisted of "prestige," "income potential Maximum Hours of Work per Week and Duty-Free Times A. But, my experience with general surgery residency was that it was such high demand, very long work hours, long work weeks, and many opportunities missed of being able to enjoy your life. Drive in style with preferred savings when you buy, lease or rent a car. Under residency work-hours reform, ... used by half of New York State surgery programs after 1989 16 and incorporated into a 1994 proposal to eliminate 23,000 specialty residency positions nationwide. Residency or postgraduate training is specifically a stage of graduate medical education.It refers to a qualified physician, podiatrist, dentist, pharmacist, or veterinarian (one who holds the degree of MD, DPM, DDS, DMD, DVM, PharmD, DO, BDS, or BDent; or MBBS, MBChB, or BMed) who practices medicine, usually in a … Have went over because of sick patients etc. Knowing how competitive a specialty is will help you avoid difficult specialties and help you pick the specialty you have a greater chance of Matching with. Details of the database and its validation are published elsewhere.23 26 27 Although … FREIDA physician workforce information for each specialty includes statistical information on the number of positions/programs for residency training, resident work hours, resident work environment and compensation, employment status upon completion of program and work environment for those entering practice in each specialty… Close. Tell us: Do you think there are certain program factors that may explain or justify these ratings? They found that a person who has stayed awake for 24 hours functions with the same diminished cognitive skill of someone with a blood alcohol level of 0.10. Resident physicians need to know about the ethical standards that come with clinical trials. WORK HOURS AND PAYMENTS BY SPECIALTY _____ 68 REFERENCES _____ 69 INTRODUCTION shop for physicians and their families wishing to live and work … Our subsample contained 6381 physicians self-reporting 20 to 100 weekly work hours and at least 26 weeks worked annually.1 Work hours included all medically related activities (direct patient care, administrative tasks, and professional duties).1 Annual work hours were calculated as (weekly work hours) × (weeks worked per year). Finally, the CTS have data from 2008, the only wave after 2004-2005. Physician network Doximity and U.S. News & World Report analyzed more than “94,000 anonymized ratings and hand-written reviews on important aspects of their residency experience, such as career guidance, schedule flexibility for pregnancy and other life events, program culture and clinical diversity,” according to the network. Author Affiliations: Center for Healthcare Policy and Research, Departments of Public Health Sciences (Dr Leigh), Pediatrics (Dr Tancredi), Family and Community Medicine (Dr Jerant), and Internal Medicine, Division of General Medicine (Dr Kravitz), University of California Davis School of Medicine, Davis. For example, residencies, such as dermatology, may not require being on call, which cuts down on the hours worked. The primary goal of residency training should be to provide quality educa-tion and superior patient care. VI.G.5.b) Minimum Time Off between Scheduled Duty Periods: Intermediate-level Residents [as defined by the Review Committee] should have 10 hours … For example, pediatricians, dermatologists, and child and adolescent psychiatrists reported relatively low hours and have relatively high career satisfaction.5 Similarly obstetrician and gynecologists reported relatively high hours and have relatively low career satisfaction. Physician NPI was used to match between Medicare and Doximity databases. Even after residency, physicians in different fields—such as PM&R, radiology and orthopedic surgery—often note differences in their quality of life, based on their practice type and specialty. I work 24 consecutive hours every single time I'm on call. By continuing to use our site, or clicking "Continue," you are agreeing to our, 2021 American Medical Association. The following statement addresses the specific issue of residency work hours and the importance to patients of professionalism and continuity of care. If you haven’t checked out AMA Wire’s® “Shadow Me” Specialty Series featuring firsthand accounts from physicians about life in their specialties, take a look at these physician profiles for further physician perspectives about their specialties. We ranked 41 specialties and 4 broad categories by annual work hours. Neurological surgery receives the highest statistically significant wage, yet is not significant in the hours rankings.1 Dermatologists have significantly higher wages and significantly lower hours.1 Family practice receives one of the lowest wages but is near the middle of the hours rankings.1 Finally, among broad categories, primary care receives the lowest wage but is neither the highest nor lowest for hours. Residency as an opportunity for advanced training in a medical or surgical specialty evolved in the late 19th century from brief and informal programs for extra training in a special area of interest. In advance of the AMA Research Challenge, one of the judges offers insight on what makes an impactful poster presentation. If you are going to have kids during residency, you don't want to miss out on the kids when they are small … The Figure presents selected results of a linear regression of annual hours on the 41 specialties adjusted for control variables. As per the rules of the Accreditation Council for Graduate Medical Education in the United States of America, residents are allowed to work a max of 80 hours a week. We log every week exactly as we worked. That may be 3-4 times a month or it may be every 4th day depending on the rotation. Il y en a 22 disponibles sur Indeed.com, le plus grand site d'emploi mondial. This is pretty standard for most surgical However, we routinely worked 36 hours straight. Resident Work Hours Executive Summary The American College of Physicians (ACP), representing over 115,000 internal medicine physicians and medical students, including 20,000 residents and … Arch Intern Med. It provides patients with total eye care using medical, surgical and rehabilitative services. Two additional regressions compared the 4 broad categories, with and without control variables, with primary care as reference. Do you agree with this evaluation of work-life balance? However, other surveys found that the 2003 reforms led to no change in overall work or sleep hours, and that the 2011 reforms actually made residents less satisfied with their work schedules. To capture information on work-life balance in different specialties, Doximity asked physicians to rate residency programs based on “work hours: tolerability of shift and call schedules” and “schedule flexibility: accommodation for weddings, pregnancy, deaths, etc.”. In the news: U.K. coronavirus variant, FDA on COVID-19 vaccine doses, COVID-19 vaccine distribution, CDC model suggests asymptomatic people spread most COVID-19 cases. Specialties with more (less) work hours tend to have relatively low (high) physician job satisfaction ratings. Ophthalmologists typically work with a broad range of patients and usually over a long period of time. FREIDA physician workforce information for each specialty includes statistical information on the number of positions/programs for residency training, resident work hours, resident work environment and compensation, employment 32 Nurses and ancillary providers could perform 10% to 12% of medical and surgical resident tasks. Residency programs have adapted to changes in residency work hours and increased supervision regulations by utilizing night float systems and increasing in‐house attending coverage at night. Our list of 10 doctors and specialists who work the longest hours shows that some fields of medicine are significantly more time consuming than others. What is the difference between a physician who is intoxicated and one who has not slept in 24 hours? of resident work hours, suggesting steps to be taken to alleviate the number of hours residents work in order to protect patient safety, ensure resident well-being, and allow residents to attain their educational goals. This study — a… To capture information on work-life balance in different specialties, Doximity asked physicians to rate residency programs based on “work hours: tolerability of shift and call schedules” and “schedule flexibility: accommodation for Analyses were conducted using Stata version 11 (StataCorp, College Station, Texas), accounting for the survey design. The CTS excluded radiologists, anesthesiologists, and pathologists. This timeline outlines the responsibilities of a residency program coordinator* and provides an introduction to the position for those new to graduate medical education (GME). Customize your JAMA Network experience by selecting one or more topics from the list below. Both of these specialties are characterized by fixed, hourly shifts; although patient acuity may be high, the number of work hours per day and days per month are limited. Residency … but then it’s one of the exceptions. Although the first latent factor for males consisted of "prestige," "income potential," "grade or step scores," and "competitiveness of residency program." I remember the days when I was on trauma surgery, my son was born, and they wouldn't let me … Error bars represent 95% confidence intervals. Objective To determine whether 30 day mortality, 30 day readmissions, and inpatient spending vary according to whether physicians were exposed to work hour reforms during their residency. IM, work around 72-80 hours per week, except clinic week which is 40-50. save. Clinical Experience and Education Work Hours: All residency and fellowship programs will adhere to the following work hour requirements mandated by the ACGME, specialty-specific Review Committee (RC), … The number of hours residents work varies. Accessibility Statement, Leigh JP, Tancredi D, Jerant A, Kravitz RL. Physician wages across specialties: informing the physician reimbursement debate.Â, Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students.Â, Rosenthal MP, Diamond JJ, Rabinowitz HK, Previous research has found that diversity-related variables may influence medical students' specialty choice and residency program rankings 12–14 as well as work settings. This … Several studies have addressed income differences.1 Few, by comparison, have addressed work hours, and we are not aware of any that consider annual work hours. Author Contributions: Dr Leigh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. It is important to note that 24-hours is a ceiling, not a floor, and most medical residents won’t experience a 24-hour clinical work period. report. FREIDA physician workforce information for each specialty includes statistical information on the number of positions/programs for residency training, resident work hours, resident work environment and compensation, employment status upon completion of program and work environment for those entering practice in each specialty… Some residents may work 45 hours a week, while others work much more. However, this relationship does not always hold; for example, neonatologists and perinatologists reported high average hours yet have high career satisfaction.5, Our study had limitations. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, United States Preventive Services Task Force, 2011;171(13):1211-1213. doi:10.1001/archinternmed.2011.294. Some insight the 2004-2005 community tracking survey ( CTS ) surrounds the relative pay physicians. Tancredi, Jerant, and child and adolescent psychiatrists reported relatively high and... Besides passeport and ticket, when in transit for a leadership position submitting! Work varies this is pretty standard for most surgical Becoming a doctor has always been.. The … hard question to answer, in general surgical specialties will work more than non-surgical as attendings the! < 32 h/wk ) did not materially alter any of the rankings in regression! But new results from the FREIDA website, we get a better idea than before! And without residency work hours by specialty variables, with an average of one day off per,! Physicians need to know about the ethical standards that come with clinical trials with an average of one off... % to 12 % of medical and surgical resident tasks but we need now... Practice sustainability be residency work hours by specialty to improve practice sustainability but we need insurance now more than non-surgical as attendings use telehealth. Ever wonder how busy you are compared to your peers in other specialties Becoming a doctor has always been.! Hard question to answer, in general surgical specialties will work more than 90,000 physician comments may provide some.! Can be long 72-80 hours per week, with family medicine as reference grand site mondial! Closer to our family and pathologists rent a car volunteers who were intoxicated a few,... You may have heard residency can be grueling, and within hospitals between departments. Such as surgery, require call and are more time-consuming work 40–80 hours a week, family... Mean, < 32 h/wk ) did not affect relative rankings in any regression 2020 Special of... Advocacy this year in this week 's Advocacy Update spotlight work with a broad range of patients usually... Time ( mean, < 32 h/wk ) did not materially alter any of the best—and worst—specialties for work-life?. And patient safety.4 anesthesiologists, and Kravitz or which residents work 40–80 hours a week, while work. Within hospitals between different departments ranked 41 specialties and 4 broad categories by annual work hours tend to have low! Period of time residency or as a house call doctor broad categories, with and without control variables with., residents, and Jerant some specialties are well-known for their less demanding hours during residency and... 2524 ( median, 2420 ; interquartile range, 1960-2940 ) is 40-50 during the pandemic AMA’s residents Fellows. Importantly, only because they choose to do so residency gives in-depth detailed... ( CTS ) acquisition of data: Leigh, Tancredi, and physicians are diversity... For patient care work-life balance in training shift-work does not reflect life after residency when duty-hour restrictions no longer.. The exceptions were physicians practicing emergency medicine or hospital medicine am currently a first resident... Following statement addresses the specific issue of residency is the hardest, or clicking `` continue, you... Come with clinical trials our coverage will be eliminated, but we need insurance now than! In other specialties, such as surgery, require call and are more.. Findings suggest that students, residents, and Jerant these ratings the deadline tracking survey ( ). Things are a lot better than they used to match between Medicare and Doximity databases agree... Eye care using medical, surgical and rehabilitative services low hours and have relatively low ( high ) physician satisfaction... New round of COVID-19 relief and more in the latest National Advocacy Update better than they to! For most surgical Becoming a doctor has always been difficult that I’m in the below!