It doesn’t feel like that long ago that I landed in Philadelphia. In June 2021, just a few short weeks after finishing medical school in the shadow of covid lockdowns in Europe, I stepped off a plane with four bags to start my intern year at Pennsylvania Hospital. Applying for social security and fighting with PennChart in parallel, I spent three weeks living in West Philly getting bit by recluse spiders before moving into an empty apartment on Pine, fitted only with the broken couch left there by the previous tenant. At the age of 27, after 9 years in higher education, I finally had a real job. The fruits of that freedom sweetened as I watched more pieces make the space a home, a bed that cost me my entire first paycheck, then a table, and then some chairs, a rug, and a TV stand. Before I could even stop to think I was in the thick of residency living two weeks at a time, just trying to make it through to my next block. Having never rotated through an American hospital during medical school, there was not just a learning curve, I was in a learning crevice that angled sharply upwards, with a brittle rock-face that crumbled unpredictably. Eventually, I settled, just as we all do. Somehow all the time caught up to me, and here I sit, on a plane going somewhere, trying to catch my breath with the whirlwind of three years in the rear-view mirror.

Residency came to a close just the way I thought it would. My second last block, a vacation to Argentina with my co-residents, now bound by fire for life, was a smashing together of my personal history and the new life I built in the City of brotherly love. This came on the back of a two week block of nights mired by poor sleep and interesting cases, and was followed by my last attachment: two weeks in the clinic followed by a week of nights in the ICU with the new cohort of interns. New faces flooded the building, as bright-eyed and bushy tailed as I was when I started. They were eager to ask questions and be useful, with a future that felt equal parts frightening and exciting. Alongside the vigour of their entrance, the graduating class made occasions out of everything, with so many formal and informal ceremonies that by the end goodbye felt almost like a broken record. Fast and furious, life reverberated colour like the best days of a lifetime.

All good things come to an end though, and that’s okay. Time passes for everyone.

I am glad fate chose to push my boat in this direction, whether I had the strength to paddle or not. My mind calls back to some of the most potent memories, patients and families who I connected with, cases I found interesting, projects that brought meaning to my presence. But what I really think about most is the people. Pennsylvania Hospital is just full of incredible human beings, and I am eternally grateful to have walked the halls among them. There is an ethos to this place that defies any statistic, publication, healthcare metric, or program brochure. After all, a hospital is just bricks and mortar, what makes it is the people inside. This residency is a family.

I think of my co-resident seniors. Sofi, my Latina partner in crime who had my back since we met at Paddywhacks before intern year started, Bassam, charismatic and clever witted whose sense of humour disarms me at the best of times, Ajit, a noble soul trying to make this world a better place with a sharp mind and too many words, Goggins, the savviest clinician, who set an example without even knowing it, and Sangoi, one of the fiercest friends and hardest workers I have ever met. These people were a guiding light for me in the building every day, and I strive to live up to their standard as a clinician and a friend.

I think of my juniors. Wade, the purebred Dubliner, who will someday be a keynote speaker anywhere he goes, Olivia, the most beautifully bizarre and amazing person I have ever met, Colin, reserved and humble with the heart of a lion, Carl, whose presence alone brings a smile to everyone in the room, Igor, well-meaning and affable, being disgruntled in your company is truly impossible, Nasser, who has lapped me in so many ways its remarkable to think I ever had something to teach him, and Ali, the best of all of us, and the gold standard I would want for a doctor and a human. My heart bursts with pride to have once been your senior. Like a parent must feel with a child, watching you grow from frazzled interns into model physicians has been a privilege.

I think of my interns, those both advancing and just arriving. You guys are still growing. This building is in your hands now. Trust in yourselves the same way that we did.

I think of the formative attendings and teachers that I had in this period of unfettered growth. I thanked as many of you as I could find before I left. Your impact on your residents is far greater than you appreciate, and it is only through your good will that we find our love for this building in the way we do. I carry lessons with me that you may not even realise you gave.

I think of our nurses. The real healers. I have so much respect for what you do, and sometimes I ask myself if I missed my calling alongside you in the trenches. So many come to mind, Mackenzie, Jake, and the OG group on 4 cathcart, Jenna, Jess, and our incredible oncology team on 7, Rich and the rest of them in Stepdown, and then there’s the ICU, where I won’t bother writing names because it would take up the whole page. Thank you for being there when nobody wants to. Thank you for not giving up on patients, even when they’ve sometimes given up on themselves. You are my source of inspiration day in and day out.

I think of everyone else that props up us self-absorbed clinicians. Unit clerks like Kim with her frizzy hair and colourful socks who made this place what it was. Axillary staff like cath lab Pete, the friendliest man who ever lived. The staff at the clinic, Dom, McKenna, Sam, Sheena, you guys had so much patience for so much nonsense. Jorge, Dianne, and Trucy from the cafeteria, it was such a nice respite from my day to see your faces and share a smile. Our administrative group, Marialaina, the real MVP of Pennsylvania Hospital who endured so many idiotic requests from me in these years, Joy, the heart and soul of the department of medicine when I arrived, and Lejla, who in a short time has laid her footprints all over the program in the best ways possible. Without you, the house of cards falls apart. You are immense.

Lastly, I think about my patients. To be in your service has been and will continue to be the ultimate privilege of my lifetime. I think of those who moved on to the next life, and what an honour it was for me was to be part of this one. I think of my sickle cell patients, who will remain in those beds for eternity until a true cure materializes. I think of those waging the silent war with opioids, I only wish we could have done better for you. I think of all the floppy hearts. I think of those plugged into machines, aware or not, who trust their lives to us without a choice. I think of so many who humoured my questions, who waited patiently as I made teaching points from their suffering, who offered me solace in times when I was overwhelmed and trying my best but falling short. Without you, I am incomplete, a lost soul in the cosmos. Thank you for everything.

So in this last reflection I ask myself what I learned in these three years. Yes, I learned about management of heart failure and diabetic ketoacidosis. Yes, I also learned about sepsis and GI bleeds and Lupus nephritis. What I learned about most though, was how a hospital should feel. I learned what it’s like to wake up some days half dead, telomeres shortening, yet still excited to walk through Ben Franklin’s gate for another day of adventure with my friends. That to me is what medicine should feel like. That is what life should feel like.

So I thank you Pennsylvania Hospital, you have been kind to me. I love you forever. I’ll be back someday to make sure you don’t forget me. For now though, another chapter beckons. Dr Lopez Tiboni is signing off.

All my love,

Juan