Medical education and clinical programs are designed with four pillars - clinical excellence, research, education, and administration. These apply whether you build and design an ultrasound program or division, a simulation program, a toxicology or pre-hospital program or even an academic department Resa Lewiss describes the four pillars of medical education and clinical programs using a quirky anecdote of four tragic, dramatic and ridiculous stories of childhood dog deaths. Clinical excellence is providing good patient outcomes. Ensuring that staff are well educated and surrounded by working and necessary infrastructure to they can provide quality care. It is a strong and tangible pillar. Research is self-explanatory and demonstrates a program’s credibility locally, nationally and internationally. It is more difficult to uphold, including writing, grants, abstracts and writing manuscripts. Education is what the medical community does, occurring in a number of settings including the lecture theatre and bedside. It is fun, interactive and in real time. Administration is less glamorous, and involves making sure processes work, relationships work and things work. Through the stories of her four family dogs and their demise, Resa illustrates the four ways pillars of medical educational and clinical programs fail. They fail through silent, indolent process – cancer. They can be derailed by others, people and processes who do not want you to succeed – homicide. The clinical program can be the architect of it’s own demise, not publishing, not researching and not conforming to standards – suicide Finally, they can become stale, irrelevant and outdated – old age. Join Resa Lewiss as she remembers the tragic dog deaths of her childhood and what they taught her about medical education and clinical program design.