How NOT to start a nano reef

[Medical_Reef]

COVID affected us all in different ways. For me, it canceled my in-person rotations for medical school and effectively transitioned the last 18 months of training to a virtual experience (because catching babies virtually is totally the same thing as in person…). Because of this, we no longer had a compelling reason to stay in South Texas, and the current state of healthcare in the valley was dire enough that we knew the pandemic would hit the area hard. With this in mind, two little kids and living thousands of miles from our parents, we decided to pack up and head home to Utah to weather out the pandemic and finish school virtually.

As detailed earlier, this involved breaking my tank down and shipping out the corals I wanted to hold on to. We set up a coral quarantine tank for my incoming coral as all of the fish in my parent’s 120 had been quarantined while the tank itself had sat fallow following a velvet outbreak. I don’t have any great pictures of the 120 at this point, but it had been up for a couple of years and had fallen victim to a combination plague involving RBTAs and pocillopora. While they hadn’t completely taken over the tank yet, there were at least 12 bta scattered throughout the rock structure and 7-8 large colonies of self-propagated pocci, with dozens of smaller nubbins starting to grow. The rocks had been moved around a few times to get fish out and my parents weren’t super happy with the aquascape at this point. The sand was starting to look grungy, most of the other thriving corals were limited to zoas, mushrooms, leathers, and colt corals. The tank as a whole, while not unsuccessful and enjoyable in its own right, hit a major decision point; continue on the current path, letting the pocci and bta become dominant above everything else, or rescape and restart the whole system to control the invading species?

We seriously debated just continuing on the current path, with the addition of a few monti caps for the lovely scroll growth, as the tank was pretty much on auto-pilot and the outcome would be unique in its own sense. A tank fully grown with alternating rose bubble tip anemones and green pocillopora would have been an enjoyable sight, with movement and hard coral structures. However, they ultimately decided that a tank refresh was in order, and dry rock was ordered the very next day.

Seeing as I had freedom in my schedule and we were all stuck at home anyways, I was placed in charge of the tank reboot. Their only request was that the aquascape was designed in such a way for lots of coral placement, most likely big shelves. The prior tank had been started with live rock and sand, but this time we chose to go with dry rock and bare bottom, partially to allow for flow around the bottom of the tank to keep it clean, and also to control pests in the tank. Added bonus, growing coral on the bottom glass would just increase the amount of space we had for coral growth. I found aqua forest rock and it fit our goals to a tee; man-made and sterile, flat shelves, pink tinged, and easy to work with. It took me longer than I’d like to admit to design an aquascape I was happy with, but in the end I think it turned out pretty good and gave us lots of room with different elevations to grow coral. Once the structure was finalized and pieces cemented together with eMarco 400, I disassembled the aquascape and started it soaking in heated salt water with a little bacteria and ammonia boost.

While agonizing over the rock structure I also started the breakdown of the old tank. I had two goals; save clean frags of the coral in the tank with no pocillopora or aiptasia, and frag up the remaining coral to sell and help fund the reboot. A particularly fun challenge was trying to get all the BTA off of their rocks, and suspending them above water did not work. Luckily, I already had a quarantine tank up and running for my coral I shipped in, so as I fragged coral and found clean pieces, they went into the quarantine tank. We also started shopping for new coral, as the diversity in the tank was pretty minimal. Torches and monti caps were highest on our list, but then we just kept an eye out for other good deals or things that caught our eye, all the while only spending as much money as I was able to make selling frags from the breakdown. All of the coral was ordered and placed in quarantine with sufficient time to eradicate ich, while also allowing us to watch the frags on a daily basis and kill any aiptasia we saw and scrape off and glue any pocillopora spores.

Once the unwanted coral and old rock was rehomed, and the new aquascape finishing cooking from April 13th - June 1st 2020, we pulled the fish out and deep cleaned the tank and sump. Removing the sand was by far my least favorite exercise, and it was impressive just how much junk was hiding in the sand bed. We filled and rinsed the tank and plumbing with hot water and muriatic acid, drained, rinsed, and let dry fully. We also reworked the sump a little, added a few new baffles to switch from a filter sock method to a crash chamber followed by filter floss, and made room for a refugium. Ease of use was the sole driving factor. The new rocks went in, fresh salt water was made, and the fish were returned to the tank with only one casualty, our melanurus wrasse. We tried using a wrasse-den to hold sand for him to sleep in, but the engineer goby threw the sand out of the den as soon as it was filled and the wrasse couldn’t handle the transition to bare bottom.

We let the tank run with the lights on and no coral for a few weeks, though I will admit I don’t remember how long we waited, and then we slowly transferred all of the coral in. This was also a pain-staking process, as we hoped to only glue frags down once and leave them be. For added stability, my dad decided to upgrade his dosing regimen to aqua forest three-part with an automated dosing pump. I left in July to return to Texas to finish up some rotations and then came back in September to a tank that was doing well and growing nicely.

https://youtu.be/vcS5P8tbOZ4

Since rebooting the tank, we have had very few hiccups. I was worried that with the dry rock and bare bottom we would experience a severe ugly stage and significant coral death, but we avoided most of it all together. I attributed this partially to dosing vibrant (though with recent evidence this seems like maybe not the best idea) and KZ coral snow with cyano clean from the start of the tank, as well as getting the refugium on board fairly quickly. We also got our coral back into the tank shortly after turning the lights on, which brought diversity and stability along for the ride. The only thing that has been a consistent struggle for the past year and a half or so has been the refugium. It'spowered by an AI prime fuge, which we believe was a sufficient light, but the chaeto and other algae we would place in the refugium wouldn’t stay together, would break up and disintegrate, or just not grow. For a brief time, we sandwiched the algae between egg-crate sheets and made a pancake that we could trim and flip. However, after a big snail and emerald crab were found wreaking havoc on coral frags, knocking them every which way as they tore through town, they were sentenced to time in the sump and made short work of the algae. I think my dad is considering an algae scrubber but hasn’t pinned down the exact solution he is looking for. Other hobbies can also be distracting.

And here we are today with a pretty recent video showing good growth and happy fish. There have been a few coral casualties; one torch colony on the tip of torch island slowly retracted and died over a month. There is a chance the torch was just getting too much light, as I can’t remember what the par was at that point, but the other torches have been doing well. We also had a duncan colony that started to recede tissue from the base. I fragged it into as many healthy pieces as I could and all but one continued to recede and die. The lone, remaining duncan is hanging on for now, but we will see how it plays out. And sadly, I had a few really nice mushrooms that slowly melted away; a small colony of superman rhodactis and a small jawbreaker. A couple of coral have really taken off and are obviously happy in the new environment. One was a purple monti cap that we temporarily placed on a low rock ledge as we glued the other caps to the overflow, and then promptly forgot about. It quickly attached and thrived in its discarded state. It would be really interesting to test the par and see how much it is actually getting. One of the big stars up front is the pipe organ. When it was first put into the original tank, it was only a few very small polyps that we wedged into a rock crevice and hoped for the best. It grew substantially there and we were able to frag out a chunk of the brittle colony and start again in the reworked aquascape. It is front and center, adding lots of movement to the tank and really expanding as much as we will let it. I placed the hammers and frogspawn on one edge of it to hopefully keep it at bay, but we may have to frag it back soon.

https://youtu.be/qCGGnnemUFM

My crowning achievement, and what I am most proud of through this whole process, is the BTA island. This historically, unruly vagabond of the captive reef reigned destruction throughout the entirety of its prior habitat. But I believe that I have successfully cultivated a secure home that has discouraged further wandering and reigned in destructive tendencies. That is the next post!

 

[Medical_Reef]

This one should be shorter.

If you’ve spent any time on this forum, you know that bubble tip anemones are notorious for wandering around the reef and settling exactly where you don’t want them. I can’t be sure that I am the first to try this, but while looking for sand-solutions for the melanurus wrasse in the bare bottom tank, I found these wrasse dens.

Now it didn’t work for the wrasse at all, but I adapted it for a different purpose. I drilled an additional hole on the other side of the den and built a rock ledge around the wrasse den using aqua forest rocks and eMarco. Was going for a pride rock look and think I really nailed it. The worst part is I don’t have any pictures of the rock before it got wet, but I snapped a few when the btas were just put in the den.

The goal here was to build them a cave they’d love so much they never wanted to leave. And so far, it has worked marvelously. We started with 3 small nems over 18 months ago, and now they’ve split numerous times and exploded in growth. However, they never moved from the rock.

Now I may be counting my little chicks way too early here, but I am counting this one as a success. We may hit critical mass here soon and one will have to jump the rock to start a new pride, and I have some baskets waiting for them, but until they do we’ll keep at it. I’ll tell you what though, the clowns are loving Nem Rock.

 

[Medical_Reef]

Well, I wish I could say that I deviated from my prior trajectories and managed to successfully start my nano zoa tank, without any hitches, and am happy with the results. Alas, it was not destined to be so.

What I thought would be a fool-proof way to start a nano tank turned out to be nothing of the sort. The worst part of this journey is that I am still at a loss as to what happened. The best that I can guess is that in the process of blowing detritus off of the rock structure prior to a water change, it caused a nutrient spike that upset the zoas and they never recovered. Or an alternative, the distilled water I am buying at the grocery store to mix my salt is not the best option, but I didn’t really have any other choices. Or maybe in the simplest terms, my water change schedule just wasn’t adequate to maintain the tank, and despite the hardy nature of zoas, they could not survive my care. But, no definitive answers here.

With that, on to the show!

ACT 1: The ‘foolproof’ plan

For my medical training, I have had to make many cross-country moves in the past few years, and from June 2021 to June of 2022, I am living in the north east prior to moving all the way out to the north west coast. I was reluctant to go without a fish tank for this year, despite the knowledge I would be working 60-80 hours a week for the majority of my stay. Maybe I am a masochist, but I also wanted a little piece of the ocean to carry me through the winter. However, I knew that throwing together a fresh tank for just a year would have minimal success. My solution? Choose a hardy coral that can survive the nano tank environment and culture and curate the rock in my parent’s tank prior to moving, therefore hopefully avoiding a sterile tank start and the related complications.

Zoas were the obvious choice, and as luck would have it I had started to collect an array of zoas in Texas prior to breaking down the waterbox and moving back to Utah. These were some of my favorites that had joined the collection and were thriving in my parent’s tank: bowsers, AOIs, yoda, rasta, BBEB, king midas, Halle Berry, goblins on fire, and a few other less exotic varieties. My ultimate goal would be to take this tank into my new office in the North West, so I chose the marineland portrait 5-gallon for its small footprint and built a walnut and epoxy hood. I was inspired by some of the floating reef tanks I had seen around reef2reef, and thus adapted a frag rack I had lying around and glued on extra aqua forest rock chunks I had left over from the restart of my parent’s 120. Once the rock was all glued up, I let it mature in the 120 for a couple of months before adding on small frags of all my favorite zoas. I don’t remember exactly when the rock was in the tank, but from what I can tell it was in the tank by at least February 5th, 2021 and the zoas were glued on around the first week of May, once the uglies had passed.

[Zoa rock on the left in the 120]

I moved to the NE in June and the zoa rock continued to mature and grow until September, when it was shipped out my way. This was complicated a little by a leaky shipping box and an overnight stay in a fedex sorting facility before returning to the 120. But, the following week, shipping was successful and the tank was up and running. Little did I know that the shipping difficulties were a sign of things to come.

ACT 2: Zoa paradise

The floating zoa rock arrived somewhere between September 8-10th and was added to my little 5-gallon tank with no complications. The tank had been up-and-running for a couple of months with sand and a talbot’s damsel, named peach. While I could not get a hold of a par meter, I watched the BRS clips about the ai-prime and matched their spectrum and power settings for the desired par, and then powered down even a little further to avoid blasting the zoas with too much light. I erred more on the side of under-lighting the zoas than overdoing it, but maybe this is another place where an error was made.

The zoa looked fantastic within just a matter of hours, even with the shipping struggles, and all of the different colonies opened up beautifully. I was very pleased with how well they had grown in since I had left Utah, and the color combinations and full polypes were a great sight. I added a little clown goby who would perch on the top of the zoa colonies while the Damsel would inhabit the rock clusters on the sand bed.

The only hiccup I had early in the start was with the flow. I added a nero 3 for ease of use in the AI app, but it was obviously overpowered. The sand on the bottom was easily kicked up, and any little spec was capable of grinding the nero to a halt. This is a topic for another day, but I found it frustrating just how easily the pump would stop running, and it seemed to have scratched the plastic parts that rubbed against each other, only making the operation worse. I opted for pulling the sand out and going bare bottom with the hope that I could keep the flow high enough to send all the detritus down the overflow. This proved to be a little more difficult than anticipated, since the marineland was a fresh-water tank and did not have an ideal sump layout. I did my best to glue in some baffles and seal the strange second intake section on the back wall, but I believe it is just one more area of this build that suffered.

Things chugged along pretty well outside of making adjustments to the sump area and removing the sand. Unfortunately, it didn’t last long, and it seems that a water change could have been my demise?

ACT 3: The mystery of the detritus.

This act opens on the zoa tank in late October 2021, thriving, but in need of a water change. There was some detritus on the bottom of the tank, but nothing overwhelming. Just prior to siphoning out some water, I opted to blow the rocks off. The resultant cloud was rather impressive, especially since I had turned the pump up enough to try and avoid settling debris on the bottom. What I believe happened, however, is that since I had positioned the powerhead below the floating rock on the back wall to cleverly hide it from view, it was doing a fantastic job of keeping the tank bottom clean while blowing the debri into the water column above the zoa rock, which would then settle onto the rock’s surface. Thus, when I turned the water flow off in the tank and blew the rock off with the turkey baster, the tank quickly became cloudy and took a good 15 minutes to settle out on the bottom before I could siphon it out. This irritated the zoas, which all closed up, but I assumed that once the water change was over and the flow was returned they would cheer up. Unfortunately, they never did make a recovery. Some of the colonies would partially open from time-to-time, but for the majority of the time since, they have stayed mostly closed and slowly receded.

I had a brief battle with invasive algae following this event, which I treated with a light spray of peroxide on the rock, and later with the addition of a tuxedo urchin. While the urchin managed to control the algae beautifully, the zoas still did not recover.

ACT 4: Isolate to recover, if possible.

I gave it time. Days turned to weeks, then weeks into months, and despite adjusting lights down, increasing the frequency of my water change schedule, adding live rock to add biodiversity, dosing different beneficial bacteria, changing fish food, and dosing iodine, the zoas did not return to their former glory. Most of the colonies are still hanging on, the pink zippers pretty consistently open but are an atrocious color. Only one or two of the colonies seems to have completely melted away. At this point, I admitted defeat and chose a different strategy, especially since the move was coming so soon anyways. I removed the fish from my tank on March 19th and entered a fallow period to quarantine the corals with the hope to get the zoa rock back to Utah and into my parents 120 again. Hopefully, if any coral tissue can survive until June, they will make a slow but meaningful recovery to their former selves.

But the question remains for me, what was the issue? Was it just a nutrient spike? Did the lack of sand in the tank decrease the stability, despite the fact that the rocks had cured for a while? Was the light the wrong intensity? Where do I go from here? The highest I ever tested the nitrate was at 25 and phosphate at 0.12, both of which don’t seem too startling on the surface. But possibly a sudden change had caused the major issue.

An unfortunate loss along the way as well, my Nero 3 made a short and quick demise of my poor little clown goby. One day, in an effort to get the detritus off the tank floor, I turned the pump up higher than I usually do and he made a wrong turn in the tank. So here is a post in memorandum of goomba, our clown goby.

I would still like to have this tank up and running in the NW and to take it into my office, but I am not sure what route I am going to take when the time comes. I have had great success with a rock-design in my parent’s tank that keeps BTA happy and in one spot, so I am thinking about a BTA and clown tank, but we will see. I am also considering giving up on the sump portion of this tank altogether, cutting out the divider and transitioning to an aquaclear for filtration. This would give the added benefit of more display volume while also providing a sump I can easily get off the tank and clean when necessary. Plus, I could run the refugium mod, which may add diversity and stability to the small tank.

For now, I’ll do weekly water changes on my coral-only quarantine tank and try and get the zoas back to Utah to recover. I was also gifted a goniopora frag, along with a mixture of sps, which will hopefully stay healthy until the move. I have little hope for the sps, but since they came out of a huge birds nest colony that was destine for the trash anyways, I couldn't say no.

Maybe the true problem here is the small size of the aquariums I keep going with and I just need to go bigger. While my budget is no better after the move, I will at least be in the same city for at least 4 years, hopefully allowing me some time to find a stable, enjoyable tank.

 

[Hermie]

I am a bit surprised you never used RODI water and/or did a ICP analysis.

 

[Medical_Reef]

I am a bit surprised you never used RODI water and/or did a ICP analysis.

It’s a fair point, one I considered. For water, I’ve found myself in a rural location without a good fish store, and I maybe poorly assumed that distilled water was sufficiently purified to be no issue. I also didn’t bother setting up an RODI system since it is such a short stay in a rental property. Still being on a tight budget, I tried to keep this as low cost as possible, and grocery store distilled water is nice and cheap.

I think an ICP test would be interesting, but I’ve also assumed that since the volume of the tank is so low, I could overcome any trace deficiencies with repeat large water changes. Maybe poor thinking, especially if a piece of equipment is damaged and leaching or something else is going on, but so far I haven’t felt compelled to do more than that.

 

[Hermie]

It’s a fair point, one I considered. For water, I’ve found myself in a rural location without a good fish store, and I maybe poorly assumed that distilled water was sufficiently purified to be no issue. I also didn’t bother setting up an RODI system since it is such a short stay in a rental property. Still being on a tight budget, I tried to keep this as low cost as possible, and grocery store distilled water is nice and cheap.

I think an ICP test would be interesting, but I’ve also assumed that since the volume of the tank is so low, I could overcome any trace deficiencies with repeat large water changes. Maybe poor thinking, especially if a piece of equipment is damaged and leaching or something else is going on, but so far I haven’t felt compelled to do more than that.

I know what you mean about trying to keep the budget as small as possible. With that in mind, the 60 dollars I spent on an RO Buddie system was the best money I could have spent on my reef tank. It saved me tons of trips to the grocery store and ensured my water was filtered to the level at which many reefers have success. I still remember taking home 10 or more gallons of distilled water from the store and I'm happy I don't have to anymore.

 

[Medical_Reef]

I know what you mean about trying to keep the budget as small as possible. With that in mind, the 60 dollars I spent on an RO Buddie system was the best money I could have spent on my reef tank. It saved me tons of trips to the grocery store and ensured my water was filtered to the level at which many reefers have success. I still remember taking home 10 or more gallons of distilled water from the store and I'm happy I don't have to anymore.

I love the stares I get in the checkout line. Almost makes it worth it.

I'll be putting in an RO/DI system for sure. I'd love to have a brute can of RO water and salt water ready at all times to make things easier on myself, but we'll see how that goes.

 

[Medical_Reef]

And with the post updates, I am all caught up. And now, just a few photos. Cheers.

 

[Medical_Reef]

Alright, it’s been a bit, but I’ll start slow. I need to work on my writing, maybe this is a good venue to try that out.

Much has changed. Thankfully no more kids hitting tanks with hammers, though my daughter did try to catch a “nemo” with her fishing pole. I’ve moved, I’ve lost fish, had some great success, and most recently lost an entire tank due to a winter storm. More posts to come later, but for now an update on probably the single most successful thing I have done in this hobby; the anemone rock.

My dad’s 120 has gone through some struggles since the reboot, partially due to waxing and waning tank maintenance habits, but the anemone rock has done its job remarkably well. We didn’t have any wandering anemones until the rock was completely overrun and there was just no space for more splits to prosper. I attribute part of this success to the BTA strain that is in my dad’s tank, as it has literally been there since the beginning. Through every tank crash, cleaning, restart, or other problem, these nems have continued to live and thrive, and daresay may be one of the hardiest strains out there. Maybe there is a commercial benefit here…

Progress pics!

It is hard to tell from the pictures, but the anemone rock has grown to larger than a basketball when fully extended. It is pretty incredible that it lasted more than 2-years before we had any wandering anemones, but all good things come to an end eventually. The last two pictures show some anemones that have abandoned the mothership for greener pastures and most likely will not be returning home.

It isn’t clear what the future of this tank might be, though it may be the inevitable outcome that we worked to prevent with the tank reset in the first place – complete bubble tip take over. At least we got rid of the pocillopora!

 

[Medical_Reef]

Next for updates is the 5-gallon marine portrait nano tank that at one time looked so beautiful. Sadly, the zoa rock that I curated in my parent’s tank never recovered and I lost all but 1 or 2 frags from that rock. I still don’t have an answer for that unfortunate loss. The tank looked fantastic, and then following one water change the zoas closed up and never opened again. I didn’t see any signs of infection, zoa pox, and you would think any contaminant would be completely addressed with fresh salt water, but it never made a difference. I even brought the rock back to Utah when we moved from Vermont to Oregon for the next step of training and placed it back in my parent’s tank, hoping to salvage some of the zoas, but it made no difference.

I was left back in the same place I had started at; I had a unique, 5-gallon nano tank and a custom wooden cover, a cross-country move, and a chance to start over. Best of all, I had rocks that had been wet a long time; I may have lost the coral, but I still had cycled, mature rocks that were (hopefully) ideal for a reset and a solid foundation for a new tank. I kept those rocks in salt water for the move to Oregon, and bided my time to design and restart the desktop nano, and this time it was coming to work with me. Training as a resident physician can be challenging. You never feel like you have a space of your own while you work tirelessly in the hospital, always moved from one broom closet to the next, writing notes for the billing department and placing orders for your patients. My time on the in-patient wards at the hospital was, thankfully, only one very-long year before I transitioned to my specialty training in oncology, in a department with my own personal space, and a desk that I could move into. It feels silly to admit, in my early 30s as my debt continues to grow, that I was so thankful to have a desk at work that was my own. A place that I could hang a Taylor Swift poster and keep my own little slice of the ocean next to me, along with a healthy stash of snack, but it takes that long to have any autonomy in medicine. And while I had a space to work, I was also starting over in a new field I knew very little about, and honestly had little-to-no autonomy because I needed the direct supervision. But my tank was going to be there to cheer me up. My broom closet was upgraded to a longer, interior office space I shared with five other resident physicians, and whatever medical students they stuffed in there, but at least we would have a window into the sea.

While not super relevant to the design of the fish tank, it paints the picture for just how excited I was to start this process again and take it to work. Maybe not having learned a lot from prior mistakes, as I didn’t have a great answer for the zoa failure, but this was going to work this time. I redesigned the cycled rock I had around the now-familiar ceramic fish hideaway as a place to keep anemones safe. Though, ironically, this time it would prove to not work perfectly. For a brief period of time, the 5-gallon tank actually housed 12 bubble tips, as a heretofore unmentioned tank at home went through an unexpected bacterial bloom and the nems had to be temporarily housed. It wound up handling the anemones like a champ. It was also rather entertaining to watch that many tentacles in a small space, filling the view and perfectly fulfilling the clown fish. But the following is a picture-series of the 5-gallon tank progression.

Once the tank at home stabilized, the anemones went back home and the office tank grew in beautifully. My biggest game-changer this time around was a dedication to weekly water changes. I set-up a home-filter system that allowed for easy access to ready water. Coupling together a couple of trash cans to an RODI system under the laundry room sink, I always had 15-gallons of RODI and 30-gallons of mixed salt water ready to go. Taking this step out of the water-change decision removed the biggest hurdle from this chore, and was especially helpful since I had to haul the water change to work if I wanted it done.

With a weekly water change of one gallon a week, coupled with the HOB filter with miracle mud and a little carbon as protection, the tank has chugged along remarkably well. For the first time, I generated a truly stable fish tank that supported thriving coral and coralline growth, with the added bonus that I saw it everyday at work. One of the most rewarding visuals was watching a fresh frag plug, with bone-white epoxy holding it in place, quickly get taken over by the thriving purple coralline in a matter of days. Scraping the rounded edges of the display glass was annoying, but with a tank this small and a single rock structure, it was easy enough to remove the rock and clean around it during water changes. The HOB filter was annoying at times. Though relatively quiet as trickling water goes, when it is 14 inches from your head it can be heard. Easy enough fix using a manual sprinkler-timer outlet set to run at night when the room was empty. The little power head provided all the flow it needed during the day. Stability was also accomplished using an ink-bird temperature controller and a gravity-fed ATO that I trained my co-residents to refill when I was gone.

I’m proud of this one. I’m proud to have provided a stable tank for the many occupants, including two clowns, Neisseria and trochus snails, as well as a little conch who happily cruised around his little domain. The corals are growing wonderfully and the tank is easy to maintain. I am in the process of dealing with aiptasia and vermatid snails, one with injections of Aiptasia-X while the other pest needs a more direct, plier-breaking approach. But I’ll keep this under control and keep the tank running, coral growing in nicely, and continue to provide a little piece of serenity for our small, windowless room of physicians in training.