Specialty Stories | Medical School Headquarters | Premed | Medical Student

By Ryan Gray, MD of Meded Media

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Description

Specialty Stories is a podcast to help premed and medical students choose a career. What would you do if you started your career and realized that it wasn't what you expected? Specialty Stories will talk to physicians and residency program directors from every specialty to help you make the most informed decision possible. Check out our others shows at MededMedia.com

Episode Date
72: A Community Neonatologist Shares Her Specialty With Us
24:01

Dr. Leslie Pineda is a private practice Neonatologist in Orlando. We talk about her inspiration to go to the NICU and what she likes, dislikes, and more.

Jun 20, 2018
71: An Academic Pediatric Cardiologist Shares Her Specialty
39:26

Session 71

Dr. Serena Sah is an academic Pediatric Cardiologist in the California area. We talk about what drew her to the specialty, what she likes about it, and more. Serena has been out of training now for three years.

By the way, do you know of someone whom you think would make a great guest on this show? Email me at ryan@medicalschoolhq.net.

[01:25] Her Interest in Pediatric Cardiology

Serena enjoys working with kids so she knew she wanted to do Pediatrics. She had a six-month-old cardiac patient that had an interesting physiology. Knowing nothing about cardiac disease, she was freaking out and that encounter with the patient was what really got her intrigued by the physiology of the heart. Additionally, pathophysiology made sense to her. She likes being able to figure out the causes of the disease. Going through medical school, she initially didn't have that interest in Cardiology as much as when she encountered that experience. She thought she would do general pediatrics at first but she already had the mindset of going into cardiology.

She admits her intern year was rough and thought of not going any further. But that rotation in cardiology and her interest just peaked again. She also considered neonatology which had intensive care to it. Still, she was interested in the cardiac patients.

[07:11] Traits that Lead to Being a Good Pediatric Cardiologist

Serena says you have to enjoy working with kids and being around kids a lot. Understand that pathophysiology is interesting to you. Some of these kids can get pretty sick so just having a sense of calm under stressful situations.

"You have to be able to know that you'll see kids of both spectrums of severity of illness. You have to be comfortable in that kind of environment."

[08:25] Types of Patients and Her Typical Week

A lot of the patients that get referred into their clinic are teenagers with chest pains, fainting spells, arrhythmia, or minor heart diseases. She would also have a portion of patients where she does neonatal surgery or infant surgery where patients are born with a single ventricle. They would need to have a series of operations and you need to follow them throughout their life. Basically, it's a good mixture of people who have cardiac-related symptoms, heart murmurs, and those diagnosed during their neonatal period and she just follows them through.

Of her patients who come in already diagnoses, Serena calculates it's about quarter to a third of them and she's just following them up. The next quarter to half of them are people that come in with symptoms and they diagnose it. Also, a quarter of them get screened but get discharged without any cardia diagnosis.

Serena works at an academic institution with a large group of cardiologists or pediatric cardiologists so majority of their time is spent on outpatient. Then they do a rotation of inpatient service a week at a time and it happens less frequently. Her typical week would be one to two days of outpatient clinic. She reads heart ultrasounds for 2 to 2 1/2 days of the week. She also does a couple of half day sessions of administrative time or research time.

[12:37] Academics vs. Community

Serena chose academics over community for convenience. She felt she could go either way. But she enjoys teaching trainees. In fact, she looked to both places but it just worked out that her home institution had a position that opened up so she grabbed it. And it worked geographically.

"It wasn't the only thing I was looking at, but it ended up being where I was at."

[13:40] Doing Procedures, Work-Life Balance, and Taking Calls

As a pediatric cardiologist, cardiology is one specialty in pediatrics that is a medical specialty but provides a way for you to do hands-on things. They have a specialty in catheterization and put on cats and heart stents. You can also go into cardiac ICU as a subspecialty which is a third level of training. Then you can do a lot of procedures. Doing ultrasounds is not invasive but these are two subspecialties within pediatric cardiology where you get to work with your hands.

Serena says she has a very demanding position from a clinical standpoint so there's a lot of clinical work involved. Being in a larger group, their call schedule is more spread out. So she's not on call as much versus as she were in a smaller private practice group. That being said, she still wishes she had more time for family and things outside of work.

They usually handle home calls. They do have fellows that do first call where they're screened and their just escalated to them. So they rarely go to the hospital when they're home at night. But during service, they would also cover the weekend which means going to the hospital to round and be there if there are emergency situations. Their fellows also take phone calls so they go in if they need to.

[17:07] The Training Path to Pediatric Cardiology

After four years of medical school, you match into residency for Pediatrics. Then the application cycle has changed since she applied. You have to apply in your second year so you know where you're going by the end of your third year as you graduate from residency. But they've just changed the fellowship application cycle. You apply on your second year and then match in the fall of your third year. Pediatrics is three years and Cardiology is another three years. If you want to do the subspecialty within Cardiology, the trend is to have another year or two of training. Then there's five to six different subspecialties within Cardiology - Heart Failure, Transplant, Imaging, Electrophysiology, Catheterization, and ICU.

Some are also doing a fellow, fourth year, in Hypertension so it makes six years all in all. Others do Preventive Cardiology since there's growing obesity in the younger population. There's Cardiac Genetics.

"There's seven or eight subspecialties that you can potentially train for as an extra year of training if there's something specific in Cardiology that you want to do."

Serena says the more competitive fields are neonatology, critical care, or PICU within pediatrics to match into since a lot of people want go into it. But generally, all are pretty competitive although she doesn't really have the numbers of it.

[21:50] Bias Towards DOs and Working with Primary Care and Other Specialties

Serena doesn't see any negative bias towards DO in general. As with working with primary care, she feels for the pediatricians seeing a lot of patients. When they see referrals from pediatricians, it's difficult for them. So if there's something they're uncomfortable with, then pass them onto them. But they don't mind seeing patients that need to be seen to help the general practitioners figure out who needs further care.

Other specialties she works the closest with are the ICU people, neonatology, pediatric ICU, general pediatrics, hematology-oncology, nephrology, and GI.

As with special opportunities outside of medicine, she knows of several pediatric cardiologists who have gone medical mission trips to help different places and countries. They also have people who work with developing technologies and devices. Research is also one since genetics is becoming a big field that people are interested in that relates to both bench research and genetics research.

"Genetics is becoming a big field that people are interested in." 

For nonclinical things, there are opportunities for teaching. For Serena, her job is more clinical so it's most of what her know. That said, there are people that do AI type of technology that incorporates cardiac information.

[30:57] What She Knows Now that She Wished She Knew

Serena says she has a conflicting view of things. She loves the action of intensive care but she dreads it at the same time being a stressful situation since patients have various outcomes. So she loves and dreads it at the same time. She finds herself gravitating more towards the outpatient stuff where she can be involved in the action but not as directly.

All this being said, she wished she knew more about call in general in that it can be pretty rough during residency and training.

What she likes most about her specialty is thinking through the heart diseases and diagnosing them. She likes being able to educate the family about it which she finds fascinating and rewarding. She likes being able to work the families and helping them through the process.

What she likes the least on the flip side is handling difficult cases and if there's nothing they can do for tough conditions as well as that feeling of being responsible even though you're not if the outcome isn't good.

[35:27] Major Changes in Pediatric Cardiology in the Future

Serena says there's a lot of new technology being developed within interventional cardiology and imaging. They're working a lot with 3D stuff, printing or imaging modalities. They also work very closely with bioengineers. So if you're thinking about going to medical school, Serena says having this background helps. And if you're already in medical school, just be aware of all the technologies up and coming that are potential things to explore going into it.

"There's a lot of emerging technology that will come into play very prominently in the field."

Although she loves medicine and the intellectual stimulus of it, but if she were to go into medicine again, she would still be in pediatric cardiology. If she didn't go into medicine, she would probably be into graphics design or any design-related field.

Finally, her advice to those who are considering this specialty is to be persistent as cardiology training is difficult. Persevere and maintain your motivation and persistence, Have an attitude of learning everything as much as possible within your training time. It's a great field and a very interesting and fulfilling and rewarding field. The process is long but there's a lot of rewards that come out at the other end.

Links:

ryan@medicalschoolhq.net

May 30, 2018
70: Private Practice Sports Medicine from Family Practice
41:07

Session 70

Dr. Daniel Clearfield is a Family Medicine trained physician who specializes in Sports Medicine. Listen to how he got into the field and what he loves about it.

First off, The Premed Playbook: Guide to the MCAT is now available on Amazon, Kindle, and Paperback. Just a reminder, you don't have to have a Kindle device to read a Kindle eBook. You can use a Kindle app on every device you have. It's $4.99 for the Kindle at this point and $9.99 for Paperback.

Please help us find guests for this show. If you have physician friends, family, and people you work with whom you think would be a good guest here on Specialty Stories, where we also haven't covered their specific specialty and setting, shoot me an email at ryan@medicalschoolhq.net.

Listen to The Premed Years Podcast Session 273, especially if you still have some questions about osteopathic medicine. Dr. Daniel Clearfield is a family sports medicine physician who's been out of training now for seven years. He used to be in Academics nut now is in Private Practice. He's going to talk about his specialty with us today.

[02:00] Interest in Kinesiology

Daniel found Kinesiology as a major in college during his Sophomore year. He started studying mechanical engineering but didn't like it. Then he started doing Kinesiology and just loved it. At that time, he was already a personal trainor and learning about the anatomy and biomechanics exercise and physiology. Trying to figure out how he can continue with it, he found there were different paths you can take. A lot of people in his major ended up becoming coaches or personal trainors. Others started looking into physical therapy as well as other paths until he found primary care sports medicine as something that appealed to him the most during externship. Although he was open-minded to other specialties, it was still something he was passionate about and it was what he ended up doing still.

"It was like that whole scope of family medicine where you can see from cradle to grave. You're not really limited as to what you can see or do."

Daniel did consider different specialties but what really drew him to sports medicine is the fact was being able to see patients of all ages. Plus, the fact that you're not limited to what you can see or do. In some sense, you will have a limited scope. That being said, Daniel says primary care sports medicine allowed him to delve into all of the different things that can involve a family doctor they might see from a broad scope of things, and focusing more into the sports/ movement aspect. Daniel also shares that one of the things he sees a lot of physicians suffer burnout from is noncompliance of patients, who are just apathetic about doing things to better themselves.

"One of the things he sees a lot of physicians suffer burnout from is noncompliance of patients."

[06:10] Traits that Lead to a Good Sports Medicine Doctor

Daniel says that you have to be a personable as you'll be seeing a wide range of patients. And although you don't have to be an athlete to be a sports medicine doctor, it helps. Daniel's main sport in high school was wrestling. He has also done football and other different sports. He experienced suffering from a lot of sports injuries so he's able to empathize more with his clients.

"Being an athlete, having that mindset, that definitely is something that helps in sports medicine. Anybody who was an athlete gets that mentality and is able to better connect with their patients."

In fact, Daniel recently attended the annual sports medicine conference and he saw that everybody was in great shape.

[08:00] Types of Patients

"I tell people I'm not a surgeon.I'm not looking to try to do surgery. I know my limits."

Daniel says he covers patients from toes to nose. He will see anything from broken stub all the way up to nose fracture. He sees fractures, dislocations, etc. He tells people he's not a surgeon. In fact, an ankle fractured patient was referred to him today and knowing his limitations, he referred it over for a surgical evaluation. He explains that most fractures don't have to go see an orthopedic surgeon necessarily since they know how to manage this type of things. That said, he sees the common sprains, strains, fractures, dislocations, concussion.

Daniel has become recognized as one of the concussions experts in his area (north Texas). And he considers this as both a blessing and a curse. Although he knows what to do with it, some of the cases they have to deal with are so complex. What Daniel really likes about how mentally stimulating his practice can be. And just like any part of medicine, it's a lifelong learning experience. So he still keeps on learning, teaching, and going to conferences. And this is the reason his scope of practice continues to grow.

"Unless you really limit your practice, you're going to be challenged. You're mentally going to be very stimulated...just like any part of medicine, it's a lifelong learning experience."

[11:20] % of Patients Coming In Who Are Already Diagnosed

Daniel actually corrects this question as to how many patients are coming to him with a diagnosis that's correct and need further verification. He adds that it sometimes depends on who your referral source is and what setting you're in.

Daniel also says he's able to figure things out because he reads and learns a lot. He has even seen patients that have been to the Mayo Clinic, were not diagnosed there, and he was able to figure it out. Not the best diagnostician, but he admits he's pretty good who can figure out some things others can't.

[13:15] A Typical Day

Daniel has a variable schedule but he works 5 days week with a 40-hour week schedule. This is part of his routine. During football season, he would start working Friday nights and if needed, he'd go to a training room with the athletic trainors at one or more of the high schools he covers. He covers them at least once a week to try and go see some of the athletes just at point of care at the school. Outside of football season, his schedule varies depending on events happening around his area. He does have plenty of weekends where he's free but there's also plenty of time that he'd be working at tournaments.

"There's plenty of times where I have my weekends free but there's plenty of times that I find myself working at tournaments."

A lot of these events he's just volunteering at. It's a mix of being a wrestler and loving those combat sports and being a team doctor with USA wrestling and judo. He found himself covering those events when they come to Texas. It's a passion that he enjoys. He likes to bring medical students and residents so they can experience and see what goes into the mindset of the sports medicine doctor covering those things.

There would still be times that he'd be doing a procedure on every single patient in a single day. Other days, he would not be doing any procedures all day long. More commonly than not, he'd be doing procedures. For example, he did 11 procedures from 8:30am to 2pm.

[16:20] Taking Calls and Work-Life Balance

Daniel doesn't take calls and he says it basically depends on the kind of practice you're in. He's the only sports medicine doctor in a family clinic. Typically, there'd be a call one night a week and then a weekend call once a month, which isn't that bad. But for the most part, he doesn't get too many calls and never had any really serious calls that he had to go after. One time, he recalls getting a call and he was out in Colorado rock climbing with his friends. He was half way up the mountain, heard his phone ringing, so he had to stop what he was doing. So he answered the call while he was about 100 feet up in the air. Not the smartest thing, but a cool story to tell.

Back when he was also teaching, they would also be in a similar call which wasn't too bad. Orthopedic surgeons realized there were three of them not orthopedic with two sports medicine doctors and one of his colleagues was a primary care sports med. They also had one physiatrist (PM&R) doctor with them. None of them took the ortho post operative call from the hospitals but they took any of the clinic call. So they had to divide it into clinic call and hospital call. They weren't part of the hospital call.

Daniel says he has enough time for family. Being a single father, he has full custody of his daughter. Looking at the type of job he's in, he makes sure he has time to watch his daughter grow up and be there for her. This is a huge priority for him. Earlier in his career he'd always say family was first but there was a time especially while he was going through his divorce where he was just investing his time in his work because he didn't want to go home. So he began shifting his priorities when he got custody of his daughter who is his absolute number one. So he set up his schedule in a way that affords him a lot of time to be spent with her.

[19:05] The Path to Residency Training

Going through medical school and you know you want to be a sports medicine doctor, it's good to start doing some coverage opportunities especially when you're in your first couple of years because that where's there's a lot of opportunities.

"It's good to start doing some coverage opportunities especially when you're in your first couple of years because that's where there's a lot of opportunities."

This means getting on the sideline for football games, showing up at pre-purchase patient physical events. Make sure you go out there and be in boxing or wrestling tournaments. Get saturated with those sports medicine experiences in your first two years to figure out if this is something you're interested in doing. Initially, Daniel wanted to do a sports medicine rotation but he knew he had to figure out what he really wanted to do and where he wanted to go. And once he figured out he wanted to do family medicine in his third year, then he figured out where he wanted to go. He then used a lot of his elective rotations in fourth year to do auditions all over the country before he was able to settle on a good program for it.

"The thing is sports medicine is not a primary specialty, it's a subspecialty."

Currently, there are six different paths to primary care sports medicine that you can take - family medicine, internal medicine, emergency medicine, pediatrics, physical medicine & rehabilitation. Then in the osteopathic world, you can do neuromuscular medicine/osteopathic manipulative medicine.

From the neurology end, there's one program at the University of Michigan where they have a sports neurology fellowship that you can do from there. For orthopedic surgery, after you do a five-year ortho residency, you can do a 1-2-year  sports medicine fellowship from there. For physiatry (physical medicine & rehabilitation), they have their own specific sports medicine program as well. Then you can do either a primary care sports medicine fellowship or a physiatric sports medicine fellowship.

Additionally, before you can be a good sports medicine doctor, Daniel says, is that you need to be good at whatever your primary field is because you're going to branch off from that.

"You need to be good at whatever your primary field is because you're going to branch off from that."

As to competitiveness, Daniel describes the subspecialty as a pretty competitive one. He was fortunate to get into one himself but he really worked hard to set himself up to be a very good candidate. He has had mentees that has gotten sports fellowships and one of them he thought to be a really good candidate. But he didn't get in for whatever reason the first year he applied but got into second year and re-applied. He was persistent, went back and worked for a year. Now, he's out in practice and doing well.

That being said, you have to be able to groom yourself to be good. Show that continuity. Even if you did well on your boards but if you didn't show that kind of passion for this field then it's going to sway program directors from taking a look at you.

From a research standpoint, there are programs that have academic-type requirements where you need to make sure you have some sort of academic work. As a fellowship director back then, he made sure their fellows produce at least one case presentation and one research project and looking to get those published as well. At the very least, have a presentation you put together or a podium or poster presentation to make you a better candidate.

[25:35] Bias Against DOs

Daniel admits he felt discriminated as a DO in some places. For the most part, a lot of the ACGME allopathic programs have open arms and they openly accept DOs into their program. A couple they found were a bit restrictive where they would have wanted you to have gone through an ACGME residency program. Although this could already be changing with the ACGME merger happening.

"For the most part, a lot of the ACGME allopathic programs have open arms and they openly accept DOs into their program."

He adds that when he goes to national conferences that are both DO and MD, he finds that people that have buyer's remorse on their allopathic degrees are primary care sports med docs and physiatrists. They realize the value of learning the osteopathic manipulative medicine and that having that extra tool to treat people is so helpful. And so many of the athletes appreciate this. When he did his olympic internship at the Olympic Training Center in 2013, he would evaluate them and figure out what's going on. Then he'd do some treatment. So if you can treat them just with your hands, they would appreciate that just to shy away from taking any pill to prevent any controversies with regards to doping.

"Especially Olympic athletes, they love the fact that you can treat them with your hands because they don't want to take a pill."

[28:30] Working with Other Primary Care Doctors and Other Specialties

Daniel explains a lot of people think they can't refer over to sports medicine or that patients think the same thinking they're not athletes. They think they only take care of athletes, primarily elite-level athletes. But he says to them that anybody who moves as an athlete, they can practically see anyone who has aches and pains. There's a little crossover into the pain management realm here too. They can do things other than pharmacologic means only to be able to keep them moving and active. He sees a lot of their arthritic patients that need therapy and rehabilitation. Mostly, it's about looking at their whole kinetic chain. They try to see where they have deficiencies and what is transferring their energy through their body that doesn't enable them to do certain activities or what's keeping them from being active.

He further believes that family medicine should have a panel of patients and they should be lifelong patients. What he likes other primary care doctors to know about what they do, there is actually so much to learn. Daniel now has a broader scope of things and he now has a better look at how to get people moving and get them active.

For instance, in tendinopathy, he was aware of three things that he could do to treat chronic tendon injury or an acute tendon injury when he was just going through residency. But after going through fellowship and being out in practice for several years, he can probably name 16 things off the top of his head that he could do for chronic tendon type of injury.

Other specialties they work the closest with include physical therapy and athletic trainers, rheumatology, and orthopedic surgeons.

[34:15] What He Wished He Knew that He Knows Now

Being a kinesiology major, one of the paths he could have taken is an athletic training path and become a certified athletic trainor while he was going through his undergraduate degree. He thinks this would have been cool. Just having a little bit of that knowledge was something he would have wanted. He also wanted to learn more of how to run a business and if there's a combined MBA program, this would be a very good thing as well. This way, you'd be able to manage your business in your practice and be able to manage your money better too.

"I see plenty of people who are awesome at what they do but they're not awesome at managing their finances."

What Daniel likes the most about being a sports medicine physician is that he can sleep well every night knowing he's doing the best for his patients. He's helping people to the best of his ability and he has good humility about what he knows and what he doesn't. He knows he's doing his best to try to keep his patients moving and keeping them active. He likes all those little wins.

"Medicine can be a frustrating to be in but if you know you really want to do this, you have to be passionate about it. You need to know that this is what you love."

And if he had to go back and do this again, he would absolutely. But what he likes the least on the flip side is that they're volunteering so much at events that he'd describe it as not a very lucrative field. Also, he practice with very good ethics and morals so he doesn't do things just to do them. He makes sure it's medically necessary. He has seen sports medicine physicians that do things similar to him but doing them irresponsibly. But he makes sure patients need those type of things. All this being said, he is comfortable and happy.

[39:20] Final Words of Wisdom

Daniel recommends to premed students listening to this who might be interested in sports medicine is to find a sports medicine mentor and just maintain good contact with them. Just check in and make sure it's still something you're passionate about. Make sure that you're doing the kind of things that set yourself up for this type of future. And just get involved. Volunteer at events and find events. As with him, he actually created an event to be able to cover the sport he was passionate about. And this was how he became s team doctor with USE Wrestling which was one of his dreams and he made this happen!

Links:

The Premed Playbook: Guide to the MCAT

ryan@medicalschoolhq.net

The Premed Years Podcast Session 273

May 16, 2018
69: Private Practice General Orthopedics and More
37:22

Session 69

Dr. Pamela Mehta is a general private practice orthopedic surgeon. She has been out of training now for ten years and has been in private practice for two years. We get into a great discussion about what led her to private practice, post-training, types of patients, and what she likes about orthopedics. We talk about what it's like to a be a woman in a male-dominated specialty and much more.

By the way, The Premed Playbook: Guide to the MCAT is going to be available very soon. Written with Next Step Test Prep, we will soon be putting it up on Amazon and other stores as soon as possible. Go to MCATbook.com to sign up and be notified. Also check out our other books The Premed Playbook: Guide to the Medical School Interview and another one coming up in August is The Premed Playbook: Guide to the Medical School Personal Statement.

If you have any suggestions for physicians whom you think would make great guests (only attending physicians), shoot me an email at ryan@medicalschoolhq.net.

[02:00] An interest in Orthopedics

Initially, Pamela didn't expect she wanted to be a surgeon because she expected she was going to find herself in primary care, her primary reason she went to medical school. In fact, she saw herself as either a pediatrician or family medicine doctor. And during her third year rotation, she put trauma surgery first, with the intention of just getting it out of the way since she wanted to practice so when she gets to the family medicine, internal medicine, and pediatric rotation, she will be in good position to get good letters.

During her first day at the trauma surgery rotation, she just couldn't believe how excited she was. She was amazed by how the ER doctors, surgeons, and nurses were working together to get the patient up into the operating room as efficiently as possible. And when she was asked to scrub in, Pamela says she will never forget that feeling. From that day on, she made a complete switch and decided she was going to do surgery.

"I could not believe how excited I was and just the adrenalin that was pumping when trauma came into the trauma bay."

It was actually a blessing in disguise when she had the whole year to figure out where she was going to do her fourth year sub-I's in. This gave her time to choose which clinical subspecialty she wanted to do.

[06:15] Pushback as a Female Surgeon

Pamela admits that when she was still attending USC, she got told many times by other orthopedic surgeons, residents to instead do other specialities like radiology or anesthesia or PM&R. And she she didn't really understand why she can't do it as well. And she was told orthopedics was difficult in terms of lifestyle or having a family.

Good thing, she went to a very supportive residency in Columbia University in New York City and out of the six people in her class, two of them were women and the class right before them, four were women out of the six.

She felt really protected in that she never felt she was a woman there in terms of feeling discriminated against or not taken seriously. However, it was a different case when she began entering into the workforce. When she started interviewing for jobs, she faced a lot of the discrimination.

"If you are a female and you want to go into a male-dominated specialty, you absolutely should but you do have to have a thick skin. That's life."

Pamela adds that having a thick skin is important being in a male-dominated specialty. In fact, sometimes you even have to be more perfect than your male counterparts. Because when you slip on something as a female, there are those that will think it's because your'e a girl.

[09:00] Patient Types and Her Choice to Do General Orthopedics vs. a Subspecialty

Part of the reason she loves orthopedics is she loves taking care of children, young adults, and seniors. She treats fracture work when people break their bones and they have to go to the ER and can't walk. She handles patients with sports injuries as well as arthritis patients, especially older patients that can't walk or are debilitated, for which she does joint replacement surgery as well.

Pamela thinks it's rare for a resident to graduate and not do a fellowship especially in the more competitive environments like the bigger cities. But she just likes general orthopedics. She likes the bread and butter orthopedics. She likes taking care of all kinds of issues from sports injuries to fracture work to arthritic patients. So she took the leap and decided not to do the subspecialty. Finding a job wasn't that much of a difficulty for her too.

"Once you're in your job, you really learn so much on the job in your first couple of years as an attending and a brand new surgeon that the fellowship stuff doesn't matter as much."

From a marketing standpoint, once you're out of practice, Pamela suggests it's in your best interest that if you're in a big city, you have to be able to market yourself as a certain subspecialist.

[11:35] Private Practice

Pamela recalls being in a large group composed mostly of men. And once she had children, she realized it was very difficult to work in a large group of men. They didn't seem to understand if she needed to drop or pick up her kids. So she was looking for that flexibility to do what she wants and when she wants it on her own terms.

"I just really wanted the flexibility to do what I want, when I want on my own terms."

Ultimately, she made her decision after her second child to go out into private practice. Not an easy decision to make though considering she already had a job that had a stable paycheck and great benefits. It was definitely a risk she decided to take, considering too she was confident that she had several years of experience and the surgical volume under her belt. And so the rest is history as she's now practicing for about two years. Being her own boss, she calls the shots as to when she wants to see patients and when she wants to do cases. She may be a lot busier than she was before, but it's all on her own terms (and she's making more money now than she did as well).

[13:40] Diagnosis in Patients Coming to Her

Pamela says mostly anyone that comes to them still needs a diagnosis. She often has patients that have been either to the primary care doctor, a chiropractor, a physical therapist, etc. Oftentimes, they'd come up with some idea but they don't have the answer yet.

Pamela says that they mostly have to diagnose the patient from beginning to end. In orthopedics, Pamela explains that there's not a lot of non-operative care that you do before you actually do any kind of surgery.

Additionally, Pamela explains that because orthopedics is not a big part of medical school and a lot of primary care doctors don't actually know how to diagnose these problems. So there are patients coming in diagnosed with carpal tunnel syndrome in their hand, for instance, and really, what they have is a trigger finger.

In some ways, it's always much more complex because sometimes you're being led in a different direction from what says on the referral than when the patient comes in and you have to start from the beginning and not really trust anyone else's diagnosis.

"There are patients coming in diagnosed with carpal tunnel syndrome in their hand and really what they have is a trigger finger."

Pamela recommends to primary doctors to carry with them The Handbook for Fractures. Also, it would be better to shadow an orthopedist at some point in your residency training. She has tried as a private practitioner to go out in the community and give out her numbers, telling primary are doctors that they can always reach her if they have any questions.

Building a relationship with an orthopedist in town as a primary care doctor is a good idea too to have someone to pick their brain and ask things.

And out of the percentage of patients they end up taking to the operating room, Pamela would say 70% when she used to work with that large group. There were a lot of layers of primary care/physical therapy/PM&R that was seeing the patient before they finally got to orthopedics. On the other hand, Pam thinks that if you're in private practice or in academics, the percentage can be at 30% to 40%. This being said, she explains you never say no. You see anyone and everything. So you're less protected when you're out in private practice and not part of the large multi-specialty group.

[17:50] Typical Week, Taking Calls, and Work-Life Balance

Now that she can do whatever she wants, she has a set schedule. Mondays would be her OR days. Tuesdays to Fridays would be clinic days with a mix of procedure work, doing injections and regenerative medicine like PRP and stem cells. Then closer at the end of the week, she will do a second OR slot where she'll take some fractures that have come through on call or thru the ER.

In terms of taking calls, Pamela says that if you decide to affiliate with certain hospitals and usually they'd ask you to take ER calls.  This means you're on call a few nights of the month. Although you can do as little or as much as you want. If you're a part of the group in private practice, you will join up with some other colleagues and take group call for your private patients that come through your office. Pamela is part of a larger call group of eight but she considers this as pretty light and not anything too crazy. Although it becomes a little bit more intensive if you're affiliated with a large trauma hospital where you're in-house and doing a lot of fracture work over night.

"Usually when you're brand new, you want to take that ER call because that's how you get some patients into your office."

Pamela believes she has enough family time. Her husband is an ortho spine surgeon so he thinks there's balance that comes with that. They work together in terms of fitting their schedules in. They also make sure they block weekends for family time. She takes her partnership with her husband some credit for being able to manage their work-life balance.

[21:30] The Path to Being an Orthopedic Surgeon

It basically takes four years of undergraduate training and then four years of medical school. Usually in the end of your third year and beginning of fourth year, you have to do an orthopedic rotation usually your home program. Then you can choose to do a couple sub-I's away.

Pamela applied to about ten orthopedic programs and went on about six or seven interviews. She matched to Columbia where she did a five-year program. Their first year was a mix of general surgery and orthopedics. Then PGY-2 year is what they call their ortho intern year so you're like the scut monkey and you do all the consults in the ER. Pamela describes this as your most work-intensive year. The rest of your three years are focused on operating and operative skill.

You can then choose to do a fellowship. All orthopedic fellowships take one year. Pamela thinks this is good since it shouldn't really be that long. Examples of fellowships available are spine, sports, joint replacement, hand, foot and ankle, and peds.

Pamela explains that if you want to be competitive in residency since this field is highly competitive, you have to honor your rotations in your third year as they look at that. Then get good letters of recommendation. Do well on your boards. In fact, when Pamela had pretty average board scores and when she got those board scores back, many people told her to take a year off and do some research or switch gears. But she was pretty determined so she pit three places to do her sub-I's and really hustled her way through to leave a good impression on people. Hence, she was able to get more letters.

If you have good board scores, that doesn't make you a shoe-in but it does help you chances quite a bit. But if you don't have good board scores, it's that much more important to just impress people a lot and get really good letters.

"If you don't have good board scores, it's that much more important to just impress people a lot and get really good letters."

[24:30] Bias Against DOs

Pamela says that that one of the best orthopedic surgeon in that big group she used to be a part of was a DO. He operated better and more efficient than any of the rest of them. He was the most revered and the go-to guy for questions and opinions. Currently, she works with an orthopedist in town who's also very well-trained. All this being said, she really doesn't think there's much bias at this time. It really doesn't matter that much anymore once you're out in practice.

"Any place that is that unaccepting, whether you're a female or you have children or you're a DO, then that's not really a place you want to be at."

She adds that people could be caught in the idea that we have to be in the best place, but it doesn't work like that. It has to be a place that's going to support you in your endeavors.

[26:20] Working with Primary Care and Other Specialties

Pamela recommends to primary care physicians is to get the x-rays done as it's very hard for them to evaluate patients without them. You can also get someone started on physical therapy unless it's a broken bone. It's nice to get knocked out of the few non operative treatments before sending them to a specialist. It's all about making a little effort to give patients a little bit of treatment before they get to the specialists.

Other specialties they work the closest with are pain management, PM&R, and internal and family medicine.

Whether there are special opportunities outside of clinical medicine, Pam says there's the whole medical legal world where people ask for you to review charts. So there's a lot of personal injury work you can do. It can run a whole gamut of doing an independent examination. There's a lot of things you can do outside of clinical medicine in terms of just dealing with traditional insurance companies.

Another nice things with orthopedics is they have a lot of sports games so you can go to the local high school and junior high schools or community colleges and ask if they need someone to come and be there on the sidelines for the games.

[29:20] What She Wished She Knew and Her Advice to the Male Doctors

What she knows  now that she wished she knew back then was that Pamela found herself so naive and energetic in medical school. She thought it wasn't a big deal she was a female even if people were hesitant about it. It was okay for the most part but she did wish she had more female colleagues instead of all men colleagues all the time. There's only 5% of them female orthopedic surgeons practicing outside residency. In training it's about 14% and they dropped down to 5%. She sometimes feels this is a little bit of a struggle, not feeling the camaraderie that many female-dominated specialties have.

But in terms of the actual work, she is happy about it. In fact, she couldn't imagine doing any other field. That said, she thinks that when you're in medical school and one specialty is not working out for you, keep an open mind to think about two or three other different specialties.

"Keep an open mind to think about two or three other different specialties."

Pamela says that the deterioration in numbers in female orthopods from residency to practice is more of a system problem. And unfortunately, there's still a lot of discrimination in medicine more so in the surgical field. This said, the way to do it is for men to really accept females into their "circle" and recognize they're a large part of the workforce and they have something to contribute. Pam suspects because this is the age people start their family and if people in the workforce aren't more open to that, this is something people need to accept. And we need to nurture that. People from training to stopping work is just a scary number and odd.

[33:20] Things She Likes the Most and Least

What Pamela likes most about being an orthopod is the variety of the things she gets to do. She gets to do big open surgeries and fixing things with plates and screws. She also gets to do smaller surgeries like just playing video games.

On the flip side, what she likes the least as with any other surgical field is infection and pus.

In terms of the major changes coming to the field, Pamela says orthopedics is a very dynamic field that there's new stuff coming all the time. They're improving all the implants they put in. There's a huge wave of regenerative medicine with stem cells and the different ways to garner those stem cells.

If she had to do it all over again, Pamela would still have done the same. Lastly, she wishes to tell students that this is a great field with a lot of variety. You get to operate and get to see patients in the office. You get to have fun with your colleagues. You get to treat patients that really want to get back to their active lifestyle. For the most part, they're generally healthy. Just show your passion and dedication for the field and you can achieve anything you want.

"If you're a medical student that struggles with low board scores, don't let it get in the way. You can do it. It's very possible to do it and even without taking the time off."

Links:

Handbook of Fractures

The Premed Years Podcast

ryan@medicalschoolhq.net

MCATbook.com

The Premed Playbook: Guide to the Medical School Interview

The Premed Playbook: Guide to the Medical School Personal Statement

Apr 25, 2018
67: What Does Academic Emergency Medicine Look Like?
31:17

Session 67

Dr. Elaine Reno is an academic Emergency Medicine physician in Denver. She talks about why she choose academics, her work-life balance and more.

First off, check out all our other podcasts on MedEd Media. If you're a premed student, be sure to take a listen to The Premed Years podcast, covering test prep, applications, essay writing and personal statement writing, interview prep and so much more. And if you have a suggestion for a guest here on the podcast, kindly shoot me an email at ryan@medicalschoolhq.net.

Back to today's guest, Elaine has a subspecialty in Wilderness Medicine, which is really not that big of a practice. Rather, today we focus on academic emergency medicine and why Elaine chose this.

Back in Session 2, we covered emergency medicine from a community perspective. In that podcast, we had Dr. Freess talking about community-based emergency medicine. This week, Elaine talks about being an academic emergency medicine, why she chose it, and much more.

[02:10] An Interest in Emergency Medicine

As a medical student, she did all the rotations but two things drew her which were Emergency Medicine and OB/GYN. She thinks they're both pretty similar being 90% routine and 10% acute crisis. Until she realized she likes the variety of Emergency Medicine. She also didn't like the operating room very much.

If you think Emergency Medicine is all about gunshot wounds and adrenalin rush, Elaine says that most chest pains are not heart attacks or that in most car accidents, the people are fine. Or that most weakness or tingling sensation is not a stroke.

"A lot of my day is much more routine than what most people think."

[04:05] Traits that Make a Good Emergency Medicine Doctor

Elaine explains that you're always going to need help, you're always going to need to talk to your specialty consultants. So you have to be a good communicator, and you have to be able to work with your specialty consultants. That being said, Elaine says how Emergency Medicine is like a team game where you have to be able to work in a team, with physicians, nurses, etc.

"Emergency medicine is like an extreme team sport I think honestly more than any other medical specialty. You have to be able to work in a team."

[06:00] Types of Patients and Typical Week

They see anything and everything on a day to day basis. The common things they see are flu, respiratory illness, chest pain, abdominal pain, headaches - the bread and butter of emergency medicine. People come in with symptoms rather than diseases and it's your job to figure out what's going on and what you need to do to manage it.

A typical week for them basically varies and she likes the variety of it even if other people hate that. Every week, her schedule is different and she likes it a lot. As an ER doctor, she mans the doors of the emergency room so she deals with everything that rolls in whatever it is during her shift. They do an extreme variety of cases everyday from chest pains coming from heart attacks and strokes from trauma patients, to cancer patients with infections or miscarriages or broken bones.

[08:05] Academic vs. Community-Based or Private Practice

What she likes about the Academics is primarily the teaching aspect of it. She likes working with the residents and teaching class for undergrad students. She likes teaching the course. She also describes the residents as very smart and if you can't keep up with them, you'd be on your toes. Nevertheless, she likes the learning and education that come with academics.

"I just like the academic flavor, there's constant ongoing learning every single day. I feel like it challenges me everyday to learn more and to be a better doctor."

[09:20] Is Emergency Medicine a Good Fit for You?

Elaine explains that they do a lot of procedures. They're not surgeons but more of like intensivists in the level of procedures they do. Although gastroenterologists and cardiologists  do more procedures than them. Family medicine doctors do less. But they do central lines and arterial lines. Occasionally, they also do intubation. That said, if you hated procedures, Elaine doesn't think emergency medicine is the specialty for you.

"If you really like the flavor of emergency medicine but didn't like the big procedures, you could do something like urgent care."

[10:20] Taking Calls and Work-Life Balance

Although they sometimes cover for doctors who call in sick, they don't really have to take calls outside of shift. No one calls them about patient care duty. And she likes the aspect of this a lot.

When it comes to shifts, she explains it's different for every doctor in every clinical practice. They work a certain number of shifts whether they work full time and whether they need to do other things like research or education so you would have to do less clinical shifts. This is a huge part of emergency medicine but specifically for academic emergency medicine and if you're interested in doing research, you can just work less clinical shifts. Having no patient population like a primary care doctor, you're able to do this.

Elaine just had a baby and when she was pregnant, she was forced to stop a little bit after having a difficult pregnancy. So she feels she has enough time with him on a day to day basis. She'd also do a whole day where she doesn't see him and then he'd have the next day off so she can spend time with him.

"I do feel like it's actually very conducive towards a family life. You have to be creative about how you make it work."

Nevertheless, Elaine thinks Emergency Medicine is very conducive towards a family life as long as you're creative. And if you feel like if you're working too much and that you're not having enough time with family, then you can always just step down and not work full time. In terms of making quality time, it's about making that quality time. She will always work nights, weekends, or holidays. Someone has to be on the ER on Christmas and Thanksgiving or New Years. This will be a part of her job for the rest of her life. And she's okay with it. But by the time she's with her family, they turn off their phones and prioritize being together.

[14:14] The Residency Path to Become an Academic EM Doctor

Elaine explains that EM is a three-year or four-year residency depending on where you go. Most of them are becoming four-year residencies. And most of those going into academics go through a four-year residency.

During your first year, you rotate through different specialties. You learn a little bit of everything and then spend more and more time in the emergency room as you progress through residency training.

She also describes the training as getting more and more competitive due mainly to it being conducive for having a good quality of life and having other interests. So she thinks it's getting more and more competitive every year.

Having been involved in the admissions side of things for the emergency medicine residency, Elaine's advice for students to be competitive to match into EM is about having that whole package.

You want to be getting good grades and excel in your clerkships. Do well not just in the one subspecialty you want to go into but in all of your clerkships. They also look at your extracurriculars, research, letters of recommendation, etc.

[16:18] Bias Towards DOs and Special Opportunities

Elaine thinks that the DO and MD match is becoming one soon. She works with DOs and she thinks the bias is slowly fading away. She adds that if the match merges, she thinks this is the right way moving forward. There will still be some inherent bias, she thinks, but she really doesn't think this is a big thing in where she's at or in her residency programs.

After residency training, there's also fellowships in Emergency Medicine like Toxicology, Global Health, Admin, Education, Ultrasound. Elaine did Wilderness Medicine with little Global Health.

For those EM doctors who do fellowships, a lot of them end up in academics. So if you do an education fellowship, you end up doing education work. For Toxicology, they end up being a consult service. With her diploma in Tropical Medicine and Hygiene, she works part-time at a travel clinic and does pre-travel advising coordination. She basically works with a pediatric infectious disease doctor where they work together to provide care for the whole family.

[20:00] Working with Primary Care and Other Specialties

Elaine thinks that if you want to send a patient to the emergency room, communication is key. They won't always know why primary care doctors would send their patients but she thinks the most important thing here is coordination, which must work both ways. Coordination is very important since they won't get to manage the patient long term and this provides the best care for the patient.

"A lot of times in emergency medicine, it's like a stop point in time. I'm treating that acute exacerbation of your COPD... but I'm not going to be managing this long term."

Other specialties they work the closest with include trauma, cardiology, intensive care units, etc. Special opportunities outside clinical medicine for EM doctors available would be education, research, ED doctors, full time researchers, administrative work, EMS directors.

[23:18] What She Wished She Knew that She Knows Now

Elaine wished she knew how much it would have affected her sleep having brutal rotating schedules which could be brutal on your circadian rhythm. She would have still chosen the same specialty. But she could have started taking melatonin earlier.

What she likes the most about being an EM doctor is the variety. And the least thing she likes is the circadian rhythm disruption.

[24:45] Major Changes in the Future of Emergency Medicine

Elaine personally thinks there's a greater goal of keeping patients out of the hospital. So they train with their social worker, physical therapists, mental health counsellors, case managers. They talk about what they can do to keep patients at home.

"The push to keep patients out of the hospital and away fro hospital-born illnesses and away from the complications that come with hospitalization is definitely there."

Right now, there is that protest against discharging diagnosis to deny payments. So if you're discharged diagnosis from the ER, they feel it's not an acute, life-threatening emergency and they'll deny payment. And this is something she's really advocating against. She thinks this is very unfair to patients. In an ideal situation, everyone has a great primary care doctor that they can trust and they can call and get access to the continuity of care.

Ultimately, if she had to do it all over again, she would still have chosen Emergency Medicine. Finally, her last words of wisdom for premed students and medical students out there is that medicine is a great profession but it has to be what you want to do. Make sure it's what you want, and not familial pressure or peer pressure. At the end of the day, you're the one doing this so make sure you're pursuing something you want to do. And if you don't know or are not ready yet, don't apply and just take the year off. Travel, work.

"Medicine is a marathon and it's like the longest marathon. It is not a sprint. It doesn't matter if you start med school when you're 22 or 25... make sure it's the right choice."

Links:

MedEd Media

The Premed Years

PMY 02: What Is Emergency Medicine?

Mar 28, 2018
66: What is Reproductive Endocrinology and Infertility Medicine?
25:14

Session 66

Dr. Natalie Crawford, found on Instagram at @nataliecrawfordmd, is a Reproductive Endocrinology and Infertility (REI) specialist and she talks to us about it today.

Natalie is trained as an OB/GYN but did Fellowship training in REI. And if you're an OB/GYN resident listening to this and thinking whether REI is right for you, then take a listen.

Natalie has been out of fellowship training now for a year and a half. In her Instagram profile @nataliecrawfordmd, she shows the ins and outs of being an REI doc as well as being a mom and female physician.

Check out today's episode to find out why Natalie chose Reproductive Endocrinology and Infertility as well as why she actually chose to change residencies. She actually started off in one residency and then changed to OB/GYN after her first year.

By the way, we’re constantly in search of awesome specialists to be a guest on this show, so if you know someone you’d like to recommend, please shoot me an email at ryan@medicalschoolhq.net or message me on Instagram and Twitter.

[02:00] Interest in Being an REI Doc

Natalie actually had a hard time deciding what to go into during medical school. But she loved all the all the fields that involved clinical care of patients. She remembers just loving taking care of people in her third and fourth year. She had a hard time deciding but she ended up matching into Emergency Medicine (EM). She did a year of EM before she switched to OB/GYN. So she really didn't really know continuative care and taking care of patients for more than just one encounter.

Until she started having very brief encounters with them and feeling like something was lacking as a physician. When she realized this during her Emergency Medicine internship, she started seeking out some mentors and realized she really loved women's health and this led her to OB/GYN.

In her OB/GYN residency, she discovered a passion for the endocrine system and for patients struggling with fertility. Hence, this has led her to do REI. For one, she really loved the relationship with the patients. And they're not just brief encounters. Her new patient visits are 45 minutes long. So she gets to understand their history, both the male and female partners. She gets to understand everything they've gone through. So it's that having that type of connection with the patient and trying to see them from a point of being very low to being very high with the goal of pregnancy was what really drew her to the field. She also got fascinated by how all these hormones work together with all the feedback loops. She loves this part of the body and how it was puzzled that made a lot of sense.

"Patients who are struggling to start a family feel like they're missing out on something that most other people can achieve so easily."

[04:35] Her Thought Process in Figuring Out It was a Wrong Specialty

Natalie always encourages students to not be afraid. She was very fearful having heard many people discouraging her to go to OB/GYN because of the lifestyle. Or that she's not going to be happy in the surgical field if she wants to have a family. She wouldn't want to work that hard otherwise she'd never be a wife or a mom.

And that fear has led her to not wanting to do things even if she was really drawn to them. Not to mention, she didn't have any mentors who knew her well enough to give her the best advice. So her advice to students is to not being fearful of things and to find a mentor that can help guide you along the path.

"Find a mentor who can get to know you well enough and help guide you, either validate or put away some of those fears so you can make a decision that really sets what your goals are."

[05:50] Traits that Lead to Being a Good REI Doctor

Natalie describes OB/GYN as a notoriously difficult residency. That said, you need to have rally good work ethic. You have to be able to think quick on your feet and like taking care of patients. You should also be able to enjoy variety in that there's a lot of primary care, surgery. Some stuff are basic, there are also some stuff that are very emergent. If you like all of those things and like taking care of women as your base population, those that go into REI are a little more particular. They like details and are perfectionists. They love the O.R. and microsurgery. You have to be able to hone in some of the small minutia.

Before Natalie switched over to OB/GYN, she knew she wanted to do a fellowship. Compared to emergency room where you notice just a little bit about everything, she loves that a subspecialist knows everything about the smaller segments. You'd really be the expert. You're the end game that your peers come to when they have a question.

"I love that a subspecialist knows everything about the smaller segments. You'd really be the expert. You're the end game that your peers come to when they have a question."

Other specialties that she actually considered include maternal fetal medicine which involves high risk obstetrics, combining the mother/baby endocrine system and a lot of how disease plays into that. But she also likes REI a lot and she was drawn more to it because of the deeper relationship with the patient. She feels they're struggling more and they really rely on their doctor heavily. Moreover, it's a much more surgical-heavy side of the field.

[08:00] Types of Patients

Natalie has been trained in both reproductive endocrine and infertility (REI). The RE side includes puberty, abnormalities, abnormal menstrual cycles, absence of periods, and abnormalities like hair growth, thyroid. And then 90% + of what she does is all infertility. Infertility ranges from couples who have trying to conceive and just can't to couple who know they have a problem. For instance, the woman doesn't have a period or the man doesn't have very much sperm and they know about that. Sometimes, there would be same sex couples who just need help to be able to get pregnant because they don't have the gametes they need. Or sometimes it would be couples who are looking to preserve their fertility because they're going to go through cancer treatments or they want to freeze their eggs for social reasons.

They also do preimplantation genetic diagnosis of embryos. They have to screen embryos for either known genetic diseases or some just for aneuploidy, which she describes as a hot topic in the field right now.

In terms of the percentage of patients coming to her with a known diagnosis, Natalie says it depends on the field based on where you practice and what your population is. She has a lot of referring doctors in town so she works with a lot of the general OB/GYNs. Their style really varies. So if they like infertility, they tend to like to do the workup and then send the patients to her. That said, they come to her with that piece she already knows. If they don't, they can just come straight to her and she does the workup. So she estimates it at half and half for her patients - coming already knowing what's going on versus coming as a blank slate.

"Half and half for my patients either coming already knowing what's going on versus coming as a blank slate."

Moreover, she does a lot of patient education on a daily basis. Although she likes the investigation side of medicine, she really loves the counseling too. She likes to empower them to understand how their body works and their endocrine system works. She makes them understand why certain tests are being done and why they're doing such treatments and what outcome to expect.

[10:22] A Typical Day and Week

Natalie describes it being varied days for her. She has clinic time and O.R. time. IVF can happen at any time. Her typical week is M-T-T as full clinic days involving 45-minute long new patient consultations, 30 minutes of followup visits for patients in a variety of treatment stages, and a lot of ultrasounds. She does hands-on ultrasound for patients in the process of doing fertility treatments and then making plans for them to adjust to what they do. She starts clinic at 8:30 and finish at 5. If they have IVF procedures in the mornings, she can back it up earlier and start as early as 5 in the morning sometimes.

Wednesday is her O.R. day where she operates the whole morning. Then have clinic in the afternoon. Friday mornings, she does half-day clinics.

In terms of the operation side, it is mostly hysteroscopy, which is a minimally invasive surgery inside the uterus and laparoscopy, inside the abdomen, looking for things like endometriosis or ovarian cysts. She evaluates the fallopian tubes, ovaries, uterus, etc. She could also sometimes do larger surgeries like abdominal myomectomies where they really open up the abdomen and taking fibroids out of the uterus.

"Most of our surgery is day surgery, 90 minutes or less, quick procedures but very rewarding."

Natalie adds that there are some things they can control and can't control. When it comes to how a woman is going to respond to medications and how fast her body will grow to a point of having mature eggs, it varies for each woman. So they start their egg retrievals early morning so their clinic won't be impacted and they won't have to reschedule patients as much and so that they can get home at the end of the day. Some larger clinics have a dedicated IVF person and it won't start that early.

[12:52] Taking Calls and Work-Life Balance

In as far as taking calls, she would do a tradeoff during weekends so as she won't have to do calls. Her counterparts have 24-hour call in the hospital but she doesn't do that. So she will work every other weekend on Saturdays and if IVF happens then she would have to be there on a Sunday too.

Having two little kids, Natalie finds it as a constant struggle in terms of work-life balance. There are some days where the balance leans more towards the office and the practice and at other times it would lean more towards the family. This being said, she has a lot of flexibility with her schedule so she's able to block out three hours in the middle of the day and go to a school event or a party. She stresses the importance of being able to do this.

[14:05] The Path to REI Doctor Training

You would have to spend four years of OB/GYN residency and if you want to do REI, you have to do research during you residency in some of that time being a pretty competitive field. You also have to take your written and oral OB/GYN boards to become board certified. This is followed by a three-year fellowship in REI. It's a much easier lifestyle than an OB/GYN residency. It's 18 months of clinical time and 18 months of research. So the research is a huge part of becoming board-certified in REI. You have to have a significant project that gets published. You have to make a thesis and be able to defend it as part of your board certification for REI.

"If you want to do REI, you're probably doing research during your residency in some of that time because it's a pretty competitive field."

To be competitive for REI, what Natalie recommends to students is to go to a residency program that has an REI fellowship. It's a small field and that's what makes it competitive. So being able to work under people who are known in the field and be able to see how they practice is key. Get a letter of recommendation from them. Do some research with them. And these things carry a lot of weight. Natalie admits that one of the reasons she was able to match into REI was having a great mentor in residency. She did basic science research in residency and sh thinks this was what really helped her stand out by showing her dedication to the field. Nevertheless, go to a place that has those people and has that REI fellowship and it will make it a lot easier for you to match into the field compared to going to a residency that does not.

[16:10] Bias Towards DOs and Subspec Opportunities

Although Natalie has seen some negative bias, she thinks they just have to stand out even more than their alloapathic counterpart. The people she respects highly in the field are DOs. Although any bias will go away once you're in residency and you're working hard but that said, you just have to prove that it's something you want to do, largely by research, away rotations, etc., more than their equal counterpart might have to. Especially with the fact that DO schools are known to be a little less research-heavy than their MD school counterparts.

In terms of further opportunities to further subspecialize, Natalie says there are none. Once you've done all seven years of training, you can't get past that anymore. There are people who have their own other interests. For instance, some may be interested in clinical research or have a Master's in Public Health. Natalie has a Master's in Science and Clinical Research she obtained during her fellowship since she really loves clinical research. Some people take PhDs because they love lab work or do Master's in Business. But with regard to further subspecialization after REI, there is none.

[17:45] Working with Primary Care and Other Specialties

What Natalie tells to every generalist is to know what their own limitations are. If you like infertility, then reach out to them as they'd be happy to help them. But if this is something you don't like, don't feel like you have to do some things and don't be afraid to refer to a subspecialist faster.

"What I tell every generalist is to know what their own limitations are."

There are some patients she had wished had come to her earlier that she felt a generalist hang on to them a little longer. And she stresses that these generalists can't really send them too early since every patient is unique and different. So you don't really know what their journey will look like. If they're wanting to see a subspecialist, then don't hesitate to send them.

"You can't send them too early. Every patient is unique and different and you don't really know what their journey will look like."

Other specialties they work the closest with would be urology. In terms of other special opportunities outside of clinical medicine, majority would be in research. So you can typically be in an academic institution with research depending on what your interest is.

[19:33] What She Wished She Knew

What she knows now that she wished she knew before going into REI is that the one thing she didn't think she had as good as a handle on is how much the patients really need you. And the one thing that she could have focused on her day is that no matter what's going on at home is you really need to focus on the couple in front of you. Although she sees many patients during the day, but for those patients sitting right in front of her for a new patient visit, this is the thing they've been dreading. Nobody wants to come into the infertility doctor's office. Nobody looks forward to see her. Hence, trying to establish that relationship really early takes investing in the relationship from the very beginning. And she never really appreciated this earlier in her career than she does now.

What she likes the most about being an REI doctor is when couples bring their babies back to her, whom they've worked so hard for to achieve. It's seeing a couple who has made it through the journey. She compares it to a marathon where you make it to the end. And to see they're now a family or that their family has grown and how happy they are, and they can describe that it all makes sense to them now.

On the flip side, what she likes the least is the pregnancy loss. It's the rollercoaster of getting so close to where you need to be. You've achieved the pregnancy and you're seeing the baby grow and not succeeding for whatever reason. The heartbreak that comes from this is just amplified. And it's really touch when this happens after a very long journey.

"A lot of patients would say they'd rather not just get pregnant from any given treatment than have to go through the heartbreak of miscarriage."

[21:42] Major Changes in the Field and Her Last Words of Wisdom

Natalie describes genetics as a the hottest in the field right now, that being genetic testing of embryos. And as they've gotten better at this, they're starting to open up all new options for testing the uterus. The biggest that she sees on the horizon would be able to mature eggs inside the lab. Right now you can only mature eggs in the body and you can freeze them once they're mature. This is what happens with the egg freezing or in IVF, you can fertilize a mature egg. This is called IVM (In Vitro Maturation). And if you can get them from the immature to the mature stage inside the laboratory, Natalie says this will definitely change the game for them as this allows for IVF to be done in a safer way. This will allow more options for fertility preservation for patients with cancer, especially at a young age.

If Natalie would have to do it all over again, she would still have chosen being an REI doctor 100%. It's debatable whether she would have taken an extra year to do the Emergency Medicine residency but she would definitely do REI all over again.

Ultimately, her last words of wisdom for students out there is to find a mentor. Ask questions. And believe in yourself. Just because something is competitive doesn't mean that you can't do it. You just have to make it a priority and make sure that on a daily basis, you're making decisions that's in line with that priority.

"It's completely attainable, you just have to want it."

Links:

@nataliecrawfordmd

ryan@medicalschoolhq.net

@medicalschoolhq on Instagram

@medicalschoolhq on Twitter

Mar 14, 2018
65: How Will The Single GME Accreditation System Affect You?
11:21

Session 65

If you're an allopathic/MD Medical school, this may affect you a little bit, but not as much as this would affect DO students. In July of 2020, the AOA, AACOM, and ACGME will form a single GME Accreditation system.

What this means for DO students is something that not a lot of schools are warning their students of. So if you're a premed entering osteopathic medical school or you're a 1st year or 2nd year osteopathic medical student, this is something you need to hear.

By the way, be sure to check out all our other podcasts on MedEd Media.

[02:00] What the New System Means: Then and Now

Previously, there have been two accreditation systems - the AOA for the DOs and the ACGME for the MD residency programs and fellowships. As an MD medical student, you could only apply to ACGE (MD) residency programs. As a DO student, you could apply to both AOA and ACGME. As an MD student, you can only apply to one.

In July 2020, once this goes up and running, that restriction for MD graduates to only apply to ACGME programs will go away. The safe haven that DO students that have had with DO only residencies is also going away.

If you are a weaker DO student, with weaker board scores and weaker grades, weaker recommendations ore reviews through your clinical rotations, you may have potentially been sheltered and given a spot at a DO residency because there was this force field where MD graduates couldn't apply to these programs. And that is now going away.

[04:14] What You Need to Do as a DO

This is not a bad thing though. But what this will do is that as you are going through this process, and as you're going through medical school, you need to work your tail off and leave nothing behind.

"Leave nothing on the table as you go through this process."

Nobody ever says they've studied too much. The regret is only about not studying enough. If you're a DO student, you need to work your tail off. Crush your classes to give you the foundation to crush your boards.

When you went to medical school, MCAT and GPA were huge! But personal statements are super important as well as the extracurriculars and interviews. When it comes to residency, your Step 1/ Level 1 score would be the make or break aspect of your application. You need to interview well as the process in residency is completely different than medical schools. You need to have the board scores. You need to have the grades to do well in the match.

"If you're a weak DO student, you're now at a huge disadvantage because that protective program that you thought you would be safe at is now open to MD graduates."

[06:45] What This Does to IMGs (International Medical Graduates)

This actually applies to not just U.S. graduates. There are thousands upon thousands of international medical graduates, which are both U.S. citizen and non-U.S. citizen graduates applying to residencies every year who don't get the spot. A lot of these students are really good. But they're international graduates so they've always been a rundown than everybody else. But with this new system, as a DO student, your competition has just gone through the roof.

Time will tell as to how this will all play out. But there's a potential risk that weaker DO students are now going to be at a severe disadvantage for finding residency spots because of this influx in MD applicants into what has been known as DO only programs.

"Now is your time to turn your game up and work your tail off to do as well as you can."

[08:55] Work Your Tail Off!

You need to work your tail off in medical school. This goes both ways to MD and DO students. If you're still premed, you should be working your tail off too preparing for your application. Potentially, this has huge ramifications for DO students with the match and applying to specialties.

If you're starting osteopathic medical school soon and if you're first or second year in osteopathic medical school, hopefully this will open up your eyes to what may be coming with this "merger." It's not all roses and sunshine like a lot of osteopathic medical schools are painting it out to be. There could be some rough waters in the future for the lower, less qualified DO applicants to residency programs. Again, work your tail off so that you aren't one of those students. And make those residency programs want you because you have the stats that shine and you have everything else that goes along with that.

[10:30] We Need Your Help

We are currently struggling with finding physicians to be on this podcast. We need your help. If you know of physicians, as well as physicians you know know social media, whom you think would be great to be on this podcast, shoot me an email at ryan@medicalschoolhq.net. Send me their email address or their social media profile so I can reach out to them and invite them here on this podcast.

Links:

MedEd Media

ryan@medicalschoolhq.net

Mar 07, 2018
64: What is Private Practice Internal Medicine-Pediatrics?
25:48

Session 64

Dr. Lauren Kuwik is a Med-Peds specialist in upper New York. She shares with us her desire to go into Med-Peds vs other specialty and so much more.

Check out all our other podcasts on MedEd Media Network. We are constantly looking for people to guest here on our podcast. If you know a physician whom you think would be a great guest, reach out to them and give them my email address ryan@medicalschoolhq.net and have them contact me and we will get them on the show.

Today's guest is a private practice Med-Peds doctor. Med-Peds is internal medicine and pediatrics combine specialty. Lauren is now practicing for five years in Buffalo, New York area. And she talks all about her journey with us today.

[01:50] An Interest in Med-Peds

Lauren grew up knowing a doctor who was a family friend who ended up being her internist when she transitioned from her pedia rotation and she was Med-Peds.

Having always wanted to be an archaeologist and a teacher, she feels that Med-Peds allows her to be both. With internal medicine, in terms of the archeology part of it, you're always putting together clues to figure out what's going on with the patient. She loves the mental tenacity involved in internal medicine. While for the peds part, she loves children and thinks they're fun. She loves taking care of kids. And as with the teaching aspect, she loves educating patients on a daily basis. So she gets to do all the things she wanted to do together in one specialty.

"You're always putting together clues to figure out what's going on with the patient."

[03:08] Is Med-Peds Going Away Soon? And How It's Different from Family Medicine

With the generality of it with both internal medicine and pediatrics, she doesn't really see any risk of the Med-Peds going away over time. There's a need for primary care doctors and specializing in both really gives you the opportunity to be a better pediatrician and a better internist. People really like to have someone that they can see themselves and their kids. They're both the doctor to the mothers and kids. So Lauren thinks this specialty is really here to stay.

"Specializing in both really gives you the opportunity to be a better pediatrician and a better internist."

How is the specialty different from family medicine then? Lauren explains it's similar to family medicine or family practice where they take care of the whole spectrum from babies all the way to patients in their 90s or 100s. But they don't do OB, so they don't deliver babies. They take care of pregnant patients but they're not involved in their prenatal and delivery care. They do very little surgery. And while family medicine may do a couple of months in pediatric training, Med-Peds would have to do a full residency in pediatrics and they're board-certified in pediatrics. They can subspecialize if they want to. So any specialty comes out of internal medicine, out of pediatrics.

You can either subspecialize in the pediatrics and adults subspecialty or you can specialize in both. There are those that may want to take care of patients with compact heart disease as a kid. They're then repaired and now they're in their 30s. So there are people who will do a longer fellowship and combined internal medicine and pediatrics, cardiology and then they can take care of those people throughout their whole life. It's longer. If each fellowship in internal medicine or pediatrics three years, that's usually about a five-year fellowship.

Other people just do adult cardiology but because they're pediatric certified, they feel very comfortable with those cases. There are other ways to do that without doing it for five years. Nevertheless, it's a lot of training.

[06:00] Traits that Lead to Being a Great Med-Peds Doc

Lauren explains that you have to be willing to talk to people. You have to be willing to build relationships and be comfortable speaking with specialists. This will help your patients out in the future.

Additionally, you have to be able to apply knowledge to things that don't seem very straightforward. Some people like to have one specialty where they get a lot of deep knowledge in a very narrow pocket. You have to know a little about everything and be really willing to work hard.

Alternately, if you're someone that doesn't like to do a lot of procedures or like to be in an operating room, this is where you can do minor procedures that are not heavy. So this is a good fit as well.

"You have to know a little about everything and be really willing to work hard."

Aside from Med-Peds, another specialty that actually drew her was Emergency Medicine. In fact, she thinks most people in Med-Peds, at some point, considered a career in Emergency Medicine. For her, a couple of things impacted her decision. First being was that her mother was an emergency medicine nurse practitioner. She spent a lot of time volunteering in the emergency department. She found it to be so much fun with a lot of variety. But ultimately, she likes controlling her time. She doesn't mind an emergency every once in a while or dropping everything to take care of it. But she doesn't lots of emergencies going on at the same time. She doesn't like feeling flustered.  She really likes having control over her schedule in deciding the hours she wants to work without someone assigning those to her so she gets more time with her family.

[08:05] Types of Patients and Typical Day

Lauren sees a mix of patients from a one-day old baby to a 91-year old patient. She sees a mix of well visits or annuals. She sees people who are getting ready to go for surgery or those who come in for chest pain or for fever. It's just a variety of things.

A typical day for Lauren is getting to the office 30 minutes before she starts her day.  She'd do a lot of things between seeing patients like talking to her nurses, answering calls, checking labs, reviewing many documents, images, and sometimes prepping her notes in the morning. She sees patients in the morning for about three to four hours. And then she also sees patients in the afternoon. She has a late day where she's in the office until 7 at night, but she comes in at noon when this happens. So it's basically the same day just pushed forward.

Lauren explains that where she lives, she does more of outpatient care. But for most outpatient primary care doctors, are having their patients taken care of in hospital by hospitalists. So she only goes to the hospital for babies born to her practice at the newborn nursery. Most pediatricians have their hospitalists and the nursery sees their patients. That said, she reckons it at 95% out patient for her.

[10:22] Taking Calls and Work-Life Balance

Lauren takes calls one day a week. She might get one phone call usually. In fact, one time, she went almost three months with no phone calls on that day. Sometimes, she gets two or three. And every fifth weekend, she's on call. She gets an average of ten phone calls.

She doesn't necessarily have to be somewhere. She just has to be available by phone. If patients hear her kids talking, they know she's living her life. But it's not as time-consuming.

Lauren has three kids and two of them, she had during residency. However, with the kind of schedule she has, she feels like she has a lot of time with her kids.

"Anything after having two kids back to back in residency seems like a ton of time."

[12:05] The Training Path

As a Med-Peds doctor, you're taking a three-year pediatric residency and a three-year internal medicine residency. Then you're mushing them together into four years. Because of that, there's a lot of overlap especially in the first year about learning how to be an intern. A lot of the things that you learn are not really specific to one specialty or another.

There's not a lot of time for electives or research months. They have a lot of inpatient and intensive care unit months compared to a traditional pediatric or traditional internal medicine residency.

"There's a lot of overlap especially in the first year about learning how to be an intern and a lot of the things that you learn are not really specific to one specialty or another."

For Med-Peds, there's a national guideline that you have to hit to both finish your pediatric requirements and finish your internal medicine requirements. And Lauren doesn't think this is a modifiable thing. She feels lucky though because her clinic "assignment" was at a private practice and a community where the other doctors are really happy in primary care. It gave her a great introduction to life as outpatient primary care doctor and talked her into that role.

Lauren goes on to explain that Med-Peds programs are usually pretty small. She's from the east coast and most programs were 2-4 residents per year. Most people who graduate from her program would be one in the primary care. They only did dev specialty in internal medicine or pediatrics. And sometimes, they overlap stuff such as sickle cell care or cystic fibrosis care. She has seen people do both although she has no knowledge of the actual data. But speaking of her program, most people went into primary care.

Lauren doesn't think Med-Peds is competitive. She went to state school and interviewed at top programs but she didn't think it was particularly competitive. Primary care in general, she thinks, is not as competitive too. Although she wished it was more competitive, but she assumes it has more to do with salary.

"I wish they were more competitive. It probably has a lot to do with salary. I think they're the greatest field in the world, but not as competitive."

[16:30] Bias Towards DOs, Special Subspecialties, and Working With Other Specialties

Lauren doesn't really see any bias towards DOs. A lot of times, she forgets when she thinks about her colleagues that she did training with as to who went to DO school and who went to MD school.

As to what's not available to a Med-Peds doc to do a fellowship in, there might be people who do a Med-Peds residency and then do a fellowship that is just within one sphere, for instance, pediatric ICU. But the practice both in the pediatric and adult realm, she does see this happen. But there's not anything that's cut out. When she was rotating in pediatrics and internal medicine, most of the attendings are happy to have Med-Peds on their teams knowing they're pretty academic and they work hard.

Other specialties they work very closely with Cardiology, Oncology, Surgery, and sometimes Nephrology. Outside of clinical medicine, special opportunities would be telemedicine, college health, reviewers on different journals, etc.

[18:55] What She Wished She Knew that She Knows Now

Although not specific to Med-Peds, Lauren wished she knew so much more of how the business in medicine. Being a private practice owner and actively learning, she wished they taught this in medical school. She wished she got a wiser advice about her student loans before entering attending shift, although it's coming around and she plans on them being gone in a couple of years.

"I wish I knew so much more of how the business in medicine because I'm a private practice owner and I'm actively learning but I wish that they taught this in medical school."

What she likes the most about being a Med-Peds doctor is being someone's doctor. She likes taking care of families and she loves taking care of older adults in their 80s and 90s. She thinks there's so much to learn from them and she loves taking care of first time babies of families and guiding them through the process.

On the flip side, what she likes the least is the reimbursement compared to specialists. Although there's not a lot to complain about, it seems like it's a fact that they pay more for procedural specialties than they do for those people who hold their patient's hands and talk to them when something's going on. And she really thinks the reimbursement playing field must be evened out.

[20:15] Private Practice versus Academics

The reason she chose private practice over academics is having control over her own schedule and over how things run where she is. Additionally, you get paid more, you get to have a better schedule, and so you get a better quality of life. You get to have more say over how your practice runs and you're not having an administration telling you what to do.

Lauren recalls that in her particular practice for five years, the first four years, she was an employed physician. And then she became a Partner last year. And she basically realized she would never work for someone else for the rest of her life.

[21:35] Major Future Changes in the Field

Lauren mentions this thing called, capitation. It doesn't impact students but there's a change in the way that they're paying private practice. This is on a regional level, but a lot of insurance companies are interested in incentivizing in order to provide really good care to their patients. But then they pay you per month to be someone's doctor and they pay for sick visits when patients come in.

"There's changes in the payment structure for private insurance right now."

Overall, with the Affordable Care Act, this has not affected her practice in a negative way. So she's interested to see what happens in the new healthcare plans. Moreover, the one population she loves taking care of which are 80-year-old patients are on Medicare. They've worked so hard so you would want those to be available to those patients.

[22:55] Final Words of Wisdom

If she had to do it all over again, she'd still choose the same specialty 100%. Lastly, Lauren would like to impart to students that it's important to network and connect with attending physicians. Shadow them to see if this is something you're interested in. Most of them are really excited to share their specialty with people. So if you know someone that's a family friend or your pediatrician, or someone you met at a networking event for premeds, really take them up on the offer if they offer for you to shadow. Or reach out to them. Because they want to share that with other people who may be interested.

Links:

MedEd Media

ryan@medicalschoolhq.net

Feb 28, 2018
63: What Does the Family Medicine Match Data Look Like?
22:27

Session 63

In this episode, we do a deep dive into the numbers of the Family Medicine Match. How many spots are there, how many unfilled, and so much more.

First off, we need your help! We are in need of more podcast guest recommendations. We need physicians for this podcast. Shoot us an email at ryan@medicalschoolhq.net so we have more physicians to interview. There are over 100 specialties and we're doing both community and academic setting. So there should be over 200 episodes available there. I also want to do retired physicians and program directors. Yet we're only 63 episodes in. So we need your help!

[02:35] Match Summary

Data here is taken from the 2017 NRMP Residency Match Data. As far as number of positions offered, internal medicine is huge at over 7,233. Family medicine is the second largest and half as big, with 3,356 positions offered. Table 1 shows that 520 programs, more than internal medicine, but half the spots. So although it has more programs, it's half the spots. Hence, the programs are much smaller.

Interestingly, there were 67 unfilled programs. This means people were not applying to family medicine. While there are so many that are applying to internal medicine. This is probably because of the fellowship training that you do after internal medicine. Which means you can go to Cardiology or do GI, or do Pulmonology or Rheumatology. You can do a lot of different subspecialties after Endocrinology, after Internal Medicine. So even the International Medical Graduates (IMGs) want that opportunity.

"People are not applying to Family Medicine."

So out of 3,356 positions offered for Family Medicine, 1,797 U.S. Seniors applied fro those positions. Now, there were 6,030 total applicants for those 3,356 spots. Comparing this with internal medicine, they have over 7,000 spots and almost 12,000 students applying for those spots.

Just by numbers, you have more people applying for those Family Medicine spots than you do for internal medicine.

[06:35] Matches by Specialty and Applicant Type

Out of 3,356 positions, there are 3,215 filled positions and there were 141 spots that were left open. Of those, 1,513 were U.S Seniors, 132 were U.S. graduates - students who graduated from an MD medical school who may have taken a gap year to do research or travel. Or maybe they didn't get in the first time. There are 574 osteopathic students so a lot of them are going into family medicine.

Interestingly, there's a similar increase in osteopathic students going into internal medicine but there's only 690 of them. Nevertheless, this means there's a big opportunity for osteopathic students in family medicine. There's one Canadian and 658 U.S.-citizen international medical graduates, and 337 non-U.S. citizen international medical graduates. This is a huge discrepancy here with foreign grads applying to internal medicine at a way higher number than family medicine. There were over 2,003 non-U.S. citizen international medical graduates applying for internal medicine and getting into internal medicine, and only 337 in family medicine. And I really think it's that fellowship piece - just a wild guess!

"This is a huge discrepancy here with foreign grads applying to internal medicine at a way higher number than family medicine."

[08:40] Growth Trends (2013-2017)

Table 3 shows the increase in size from 2013 to 2017. Family medicine has gone up 11.5% every year over this four-year period. It's growing so it's a much needed primary care specialty.

Moving down to Table 8 is positions offered and percent filled by U.S. Seniors and all applicants from 2013 to 2017. Again, not a lot of U.S. Seniors are applying to family medicine. Out 3,356 positions offered, 45.1% of those spots filled were by U.S. Seniors. Internal medicine is lower at 44.9%. Shockingly, Pathology is way lower at 35.9% filled up U.S. Seniors. This suggests that U.S. Seniors are not going into Pathology, and in fact, it's getting less and less. In 2013, for Family Medicine, it's 44.6%, then 45% (2014), 44% (2015), 45.3% (2016), and 45.1% for 2017.

Table 9 shows how big Family Medicine is compared to all other specialties. Internal medicine is the largest specialty for students matching every year, specifically at 25.6% in 2017. The second largest is Family Medicine at 11.6%. This is followed by Pediatrics at 9.7%, another big primary care specialty.

"A quarter of all students matching matched into Internal Medicine and just 11.6% matched into Family Medicine. It's the second largest."

[10:48] PGY-1: U.S. Seniors and Osteopathic Students, Matched and Unmatched, and SOAP

Table 10 shows the U.S. Seniors matching into PGY-1 positions. The numbers don't hold up here for U.S. Seniors though compared to all applicants. Internal Medicine has 18.6%,s still the largest. But Family Medicine here is not the second largest and only falls third or fourth at 8.7%. Emergency Medicine is larger with 9.2%.

Osteopathic students (Table 11) keep the trend going with 23.5% of students matching into an allopathic Internal Medicine program, while 19.6% matched into Family Medicine. When you look at the previous number of all applicants, 11.6% of all applicants matched into Family Medicine but 23.5% of osteopathic students matched into Family Medicine.

"It seems like a good fit for osteopathic students who want to match into Family Medicine."

Figure 6 shows the percentages of unmatched U.S. Seniors and independent applicants. Family medicine and overall total unmatched of 25.3%, which is the fifth highest. The highest is Internal Medicine Prelim at 37% total unmatched. Second is Dermatology at 33.8%. Followed by Psychiatry at 30.8%, and then PM&R at 27.5% and fifth is Family Medicine. It has a high overall unmatched rate which is surprising considering there were so many programs that went unfilled.

Independent applicants are the majority of those unmatched with 40.9% and U.S. Seniors are pretty low at 3.5% unmatched.

"With so many open programs, the assumption is that they applied to not enough programs or they were very picky on where they were applying."

Table 18 shows the SOAP (Supplemental Offer and Acceptance Program). These is offered for programs with MD spots that need to be filled. Family medicine had 67 programs that went unfilled and 141 spots. All of those programs participated in the SOAP. 64 programs filled and there were 3 spots at 3 programs that went unfilled.

[14:05] Charting the Outcomes 2016

Table FM-1 shows a summary of all the data for U.S. Allopathic Seniors. Mean number of contiguous ranks means that those who matched ranked 10.7 programs on average. This means that those who matched ranked a lot of programs. And those that did not match only ranked 4.5 programs. So they were much more strict with the programs they ranked and that hurt them.

The mean USMLE Step 1 Score is 221 and the average is around 230 for this data. So it's a much lower score than average. Those that did not match was 208. So they're struggling with their USMLE score. With that low score, they probably didn't get interviews. And because they didn't get interviews, maybe they didn't rank the programs. So it's not an issue with being too strict with the programs they're ranking but it could just be an issue with their Step 1 score. Hence, they're not getting interviews in order to be matched to rank.

Mean USMLE Step 2 score is 237 for those that matched and 223 for those who didn't. Research experience is about the same at 2 and 1.7. Mean number of abstracts, presentations, and publications are the same at 2.6.

AOA members are 6.1% for those that matched and 0 for those who didn't. It doesn't mean though that you have to have AOA. It just means that the people didn't match didn't have it.

[16:38] Happiness, Burnout, and Compensation

Now, let's look into the 2018 Medscape Physician Lifestyle and Happiness Report. In terms of happiness, 30% of physicians are very happy,  outside of work is 12%, and extremely happy at 26%. As to who is the happiest, Family Medicine is in the lower half at 51%, within the range of 40%-61%.

As to which physicians are most introverted, Public Health and Preventive Medicine doctors are the highest at 48%. Family medicine is near the bottom at 37%. Radiology was at the lowest at 36%.

As to which physicians say they have three or fewer close friends, Family Medicine is near the top at 53%, Pathology is the highest at 58%. So this does not do any justice to Pathology and the stereotypes that come with Pathologists.

Looking at the 2018 Medscape National Physician Burnout and Depression Report, which physicians are most burned out, Family Medicine is near the top at 47%. Critical care is 48%. Neurology is 48%. There are a lot of specialties above 40%. The lowest is Plastic Surgery at 32%, along with Dermatology.

As to which physicians experience both depression and burnout, Family Medicine is still near the top of the list at 16%. OB GYN is the highest at 20%. As to which physicians are more likely to seek professional help, Family Medicine is again near the top of the list at 31%. Psychiatry is at 40%.

Moving on to the 2017 Medscape Physician Compensation Report, Family Medicine being a primary care specialty is right near the bottom at $209K a year. Just to compare it, the highest paid specialty is Orthopedics at $489K, more than double that of a family medicine doc, while Pediatrics is the lowest at $202K.

"When you say you can't make money going into primary care, it's not true. You don't make as much as somebody who's a specialist... but still very good money."

As to which physicians feel fairly compensated, even though Family Medicine is near the bottom of the list for compensation, they're up near the top half for feeling fairly compensated at 53%. Emergency medicine doctors are the highest at 68%.

Would a family medicine doctor choose medicine again? They're near the bottom half at 77%. The highest is Rheumatology is 83% and Neurology is the lowest at 71%. Which physicians would choose the same specialty? Interestingly, Family Medicine ranks second from the bottom at 67%. Internal medicine is the lowest at 64%.

Links:

2017 NRMP Residency Match Data

Charting the Outcomes 2016

2018 Medscape Physician Lifestyle and Happiness Report

2018 Medscape National Physician Burnout and Depression Report

2017 Medscape Physician Compensation Report

ryan@medicalschoolhq.net

Feb 21, 2018
62: What Does a Community Based Joint Replacement Specialist Do?
31:09

Session 62

Dr. Brock Howell is a community-based joint replacement trained Orthopedic Surgeon. We dive in and talk about his path and what you need to know about joints. Brock has been out of Fellowship now for two and a half years.

Also, be sure to check out all our other podcasts on MedEd Media Network.

[02:00] Interest in Being a Joint Specialist

Throughout his third year of clinical training, Brock had no clue as to what he wanted to do. Although he found himself in between medicine and surgery. He knew wanted to go into surgery, just not what exactly in surgery he wanted to do.

What he gravitated him towards orthopedics is that it's very tangible when for instance, you see a broken bone. And then it gets fixed. As opposed to things in medicine or GI where you tinker a bit and still have to wait for a result. Hence, there is that sense of instant gratification.

As to why he chose joint replacement surgery, he liked that it's not a small surgery so you get to walk away and look at an x-ray and be able to change someone's life. Plus, you can do it in an hour or less. It's not a scope procedure where you just look at the sutures. And seeing patients before and after the clinic makes him happy.

[05:05] Traits that Lead to Being a Good Joint Replacement Doc

Brock says you have to be comfortable around older population. In some instances, you have to be real patient when it comes to those kinds of your patients. They would usually try conservative therapy for a long period of time before the surgery.

That said, you have to be willing to go in and just make things work. You have to be able to adlib and be comfortable at times.

"Sometimes in the big revision surgery, you're not necessarily knowing what you're getting into and you just have to be comfortable getting into a giant mess and trying to figure a way to get your way out."

Revision surgery is where patient has already had a joint replacement. But for whatever reason, the joint replacement has failed. It could be that it's gotten infected or that the parts have come loose. A lot of times, you have to go in and deal with something someone else has been before. You may also have to get implants out of the bone whether they're grown into the bone like most hip surgeries or whether cemented in place. So you have to get implants out and deal with extensive bone loss. You'd have to get new implants in and use different types of implants into your normal primary or first time having a joint replacement surgery. So this is a big surgery and this can be tough.

"It's a big surgery. It can be tough. You can run into a lot of things real fast and you just have to think on your feet to get your way out."

[07:33] Situations Patients Need a Replacement

Patients who undergo joint replacement would usually have undergone arthritis in the joint, whether primary degenerative osteoarthritis or something post traumatic for whatever reason.

Brock often tells patients that it's not heart disease or cancer so it's not going to kill them. If they didn't have a joint replacement, they're not going to die. So he really doesn't rush anybody into it. He sees no reason to push someone into the replacement if they're not ready for it.

Most patients coming in complain that they're not able to do the activities they want to do. They can't walk anymore or play tennis. So he leaves it up to the patient to assess their quality of life and if they're not able to handle it, then they could have the surgery done.

[08:45] Community versus Academic

As to why he chose community versus academic, the major factor was proximity to his family. He's in his hometown that he grew up in and his wife's family is less than two hours away. Also, you're an employee in most university setting practices so he wanted more of the private practice model where he could control things more on a day to day basis.

Brock also cites the difference in the private practice as a joint replacement surgeon. You'd do a lot of primary joint replacements. You'd also be doing revision surgery but majority of the cases consist of primary.

A lot of times, academic joint replacement surgeons do a higher percentage of revision cases than they do primary cases. This is mostly due to the fact that they're paid differently than what a private practice surgeon would be. Plus, revision cases take more time. In some instances, he can get three primary surgeries done in the same amount of time it would take to do a big revision. And you're not going to be paid significantly more for a revision surgery than a primary surgery.

"A lot of times, academic joint replacement surgeons do a higher percentage of revision cases than they do primary cases."

[10:22] A Typical Day and Percentage of Surgeries

Brock would usually get up between 5 and 5:30 am. He'd go to the hospital to round if there are any patients. Mondays and Tuesdays will be his office days, seeing between 25 and 35 patients in the morning. He will do elective cases even at the surgery center or he'll have time to do one or two joints on a Tuesday afternoon. Wednesdays would be his big surgery day. He'd do 5-6 total joints. And every other Wednesday, he'd take calls so he'd leave his Thursday mornings open to do call cases versus other elective or non-urgent trauma cases like ankle fractures. Fridays, he does an all-day session of office.

Brock says he's dealing with joints in 60-70% of cases while the rest of it would be dealing with issues like knee pain. It doesn't necessarily end up in a joint replacement but it could end up in any scope. He'd also take a lot of call cases as well as carpal tunnel issues.

So his main surgeries are joint replacement (70%), arthroscopy of the knee (5%), and the rest would be trauma cases.

For joint replacement, most of the patients that show up in the office with arthritis end up with the joint replacement but it's just a matter of when. Some may want to do it immediately while others would try not to getting surgery done. So you'd be injecting them for two years before they finally decide to do a surgery.

"Most patients show up with really significant arthritis and have surgery and so it's just a matter of when."

[13:10] Work-Life Balance

Brock says having a work-life balance. He is married to an optometrist that works part-time and they have three boys. Although a lot of times, it is tough. There are some busy weeks but most of the time, he has plenty of time to do everything he needs to do.

[14:05] The Training Path to Become a Joint Specialist

Most orthopedic surgeons do five years of residency followed by a Joint Replacement Fellowship which is another year, for a total of six years of postgraduate training after medical school.

As to competitiveness, Brock describes it as being average. And that most who go through it usually matches but it just depends on where they match and whether it's high up on their list or not.

If you're interested in getting into joint surgery, Brock recommends trying to get some research done and try to do as much as you can joint replacement-wise. More than anything, you have to figure out Fellowship as to where you want to match.

"Fellowship is a game, trying to match where you want to match, trying to get into the residency you want to get."

This said, see if there are connections in your residency program to certain places you want to go. All it takes is picking up the phone and calling in a buddy or your fellowship director or a program director and that could get you a spot.

Again, do your research. Do well in all of the services you work on. Don't just focus only on joint nor be a bad resident when you're in trauma. Just be a great resident and do some research. Figure out a way to make the connection you need to make.

[16:25] Working with DOs and Special Opportunities

Brock says he has been around plenty of DOs that were great orthopedic surgeons. In fact, he knows some very prominent orthopedic surgeons in the joint replacement field that are DOs. Hence, it doesn't really matter to him. Although admittedly, there is some bias out there. And it's harder for DOs to sometimes into competitive fields of fellowships. At the same time, there are also some very friendly DO programs out there in orthopedics. Just get out there with anybody else and do well. So Brock says DOs should not be discouraged and just go for it. In the Fellowship he did, he had met some DOs that went through it as well.

As other further subspecialties for joint replacement, Brock mentions the Joint Hip Preservation Fellowship. This gets you into the realm of doing hip sculpts or hip resurfacing. Some joint fellowships like WashU and University of Salt Lake City, Utah, they specialize in patients with hip dysplasia and other hip scopes.

[19:00] Other Body Replacement Options

Brock solely does hip and knee replacement but as far as joints that can get replaced include ankles, hips, knees, joint replacement in the spine, cervical discs, shoulders (three different types), elbows, wrists, and almost every joint out there can be replaced.

[20:10] Working with Primary Care Doctors and Other Specialties

What Brock wishes to tell primary care physicians out there is to not be afraid to treat the joint replacement patient conservatively. Moreover, understand that joint replacement patients can be totally normalized after joint replacements. No restrictions are needed and they could go back to doing whatever they can do and want to do.

"Joint replacement isn't signing up for sedentary lifestyle for the rest of your life."

Brock's practice is built up mainly of general orthopedic surgeons but usually they deal with a large amount of trauma they do at their facility. So he deals a lot with the anesthesiologists and general surgery trauma doctors.

[22:10] Special Opportunities Outside of Clinical Medicine

Being a joint specialist, there's a plethora of different companies to use and each company has different implants to use. They're always looking for joint surgeons who deal with a lot of joints and have a lot of experience doing joints to help them design better implants and design better instruments to put the implants in with. Or help and teach surgeons who may not have done joint replacement fellowship as to how to use their products better and what opportunities the products present to patients.

"There are a lot of design and teaching opportunities available in joint replacement surgery."

[23:06] What He Wished He Knew that He Knows Now

He wished he knew that not everybody does great. Even with the best of intentions, you can go in and do a joint replacement surgery and for whatever reason, a patient may not be happy with it.

There are some studies done that show characteristics in patients that they won't do well after joint replacement surgery no matter what. There are a couple of studies done like if you look at the patient's allergy list and the higher number of allergies the patient listed, lower patient satisfaction scores and other scores post-surgery.  Another study done where they put a blood pressure cuff on a patient's arm and it would blow up to 200 mmHG and have the patient rate their pain on a scale of 1-10. The patients who recorded higher pain with blood pressure cuff on actually had some of the poor outcomes after surgery.

[24:50] The Most and Least Liked Things and Major Changes in the Field

Brock likes the immediate gratification he gets before and after surgery. He finds it awesome to see someone with a horrible arthritic joint do their surgery and they can already walk 500 feet the next day.

On the flip side, what he likes the least about joint replacement surgery is some of the situations where patients are in a bad way. Whether the patient has a chronic joint infection you can't get rid of or when they're coming to you. Or they may have the perfect x-ray and they tell you everything but no matter what you do. It's just difficult to track some of the puzzles and figure out why are some of the patients are hurting and whether it's legitimate or not can be a struggle.

As to the major changes coming in the field of joint replacement, Brock mentions two things - 3D printing and robotic surgery. They use 3D printing to print on the back of the implant's actual bone that improves the quality of ingrowth. They also started designing custom implants that are shaped just like an individual patient's shape instead of a one-size-or-shape-fits-all implant. On the other hand, robotic surgery is starting to push towards the front. You can get a scan of the patient's affected joints and then plant a surgery ahead of time. Then get into surgery and take the knee or hip through a range of motion, stressing it and making adjustments to your plan before you make a single bone cut. A robotic arm attached to it will guide you and make sure you make the bone cuts exactly how you planned it before surgery. This makes sure everything is as precise as possible. This system is also used for total hips and partial knee replacement. Brock describes how it's such an exciting technology.

"It's all in the name of hopefully a better outcome for the patients."

Ultimately, if he had to do it all over again, Brock admits he asks this question all the time. There are days he would probably have done it again. And there are other days he did his best and the patient is not happy with their joint, and it's a tough day. So you just have to take the good with the bad. Nonetheless, he would still have chosen joint replacement surgery.

[29:11] Final Words of Wisdom for Medical Students and Residents

Finally, he wishes to tell medical students who may be interested in joint replacement is to make sure you try everything. But if you really have your heart set on something early, try to get involved in that specialty whatever it is. Try to do as well as you can on Step 1 and just get involved in what you're interested in because that's going to help you always when you're trying to get into residency.

As far as residents go, try to do well in all your rotations. Ask anybody for a letter and then try to figure out where you want to go and what type of fellowship you want to do. You may want to go to a fellowship where you watch another surgeon operate for a year or where you do all the operating for a year. Or something in between. See if there are any connections to those programs and start working on those connections.

"Start working on those connections."

Links:

MedEd Media Network

Feb 14, 2018
61: A Community Based Pediatrician Talks About Her Specialty
31:31

Session 61

Dr. Catherine Mcilhany is a community-based General Pediatrician. She joined us to talk about her position and her path and what you need to know.

We're constantly looking for guests that we can feature here in the podcast. It has been a challenge for us. Please shoot me an email at ryan@medicalschoolhq.net if you know any specialists that you would like to have on the show.

Back to today's episode, Catherine has been in practice now for 15 years. Several weeks ago, I talked with a rural General Pediatrician. So you get to hear some differences between rural medicine and a community-based, urban center general pediatrics.

[02:15] Interest in Pediatrics

It was during her third pediatric rotation that she realized she wanted to do pediatrics. She just had so much fun with the kids and that's what she liked about it. She admires the resilience of kids despite what they're going through.

"If you can have some fun almost everyday in some part of your job, it's totally worth it."

She did consider doing OB/GYN but then she got into rotations and realized she didn't want to be a surgeon of any type. She also thought about doing Med-Peds but she found the scope of family medicine was so broad that she was worried there would be so much to have to know all the time. She was looking for something narrower. And after doing her adult medicine rotations, she realized she wanted to stick with the kids.

That said, Catherine likes working with the parents. A big part of what they do is educating parents and sometimes, crisis management. She describes it as a little intimidating thinking that you're taking care of the most important person in most people's lives. Hence, you have to interact with adults as well.

[05:35] What Is Med-Peds?

Med-Peds is a combined specialty of internal medicine and pediatrics training so you would be fully qualified to do the full scope of adult internal medicine plus pediatrics care. So it's like Family Medicine except that you're not doing GYN procedures like Family Medicine might do. So you don't have the OB and some of the more specific GYN type.

[06:20] Types of Patients

In a day, he will see everything from a 3-day-old to a 19-year-old. She had seen a 19-year-old having some schizophrenic break to a diagnosed cancer. She does see a lot of healthy children. She works in a population of a fair number of kids who are really struggling in school. She sees a lot of behavior issues in her office. She also sees a fair amount of contraception counseling, sexually transmitted disease testing in teenagers. So it's an interesting scope of diseases that they see in pediatrics, which is quite opposite to what most people probably think that they're only seeing cold cases.

"The hard thing about pediatrics is that you'll see a lot of kids with the same chief complaint, but you have to be able to find the one that has something that's unusual."

Although children may have a chief complaint, the hard thing about it is that you have to be able to find the one that's unusual. Hence, you need to be well-trained in seeing a high volume of kids and always thinking who's going to be the "zebra out of all these horses."

[08:12] Community versus Academic Setting

Catherine admits having worked in an academic setting. But she knew she didn't want to do academic general pediatrics, which involves doing research since it wasn't really her interest.

Then when she went into general pediatrics to be a regular primary care pediatrician, she thought getting her feet wet and figure out doing it before she'd teach the residents. Although now, she's in the position where she has been doing it for four years now so she feels more comfortable.

[09:50] Typical Day and Procedures

Catherine doesn't do any inpatient or nursery-rounding. Her typical day starts at 07:55 am with her first patient. At her clinic, their schedules are about 24 patients a day. So she's doing any number of well visits or sick visits. But most weeks, she sends a couple of kids to the ER, or at least once a month.

In terms of doing procedures, Catherine explains the biggest opportunity is when you're working in a little bit of a smaller area where those doctors do a lot. In her office though, they don't do so much suturing just because of how their schedules are set up. So they don't have as much time to do those.

"If you're working in a little bit of a smaller area, those docs do tons."

But doctors in smaller areas do a lot. They do their own admissions. And if a kid needs a spinal tap, they'd do it. They'd do the inpatient side of things and go to deliveries. They stabilize infants how are newborns. So there's that big chance of doing procedures if you're willing to live in slightly small area. Whereas in large metro areas, it's a little harder mostly just because of the way practice is set up. Nowadays, there a lot more hospitalists around, which is a big change compared to back when she was still training.

[12:45] Taking Calls and Work-Life Balance

Catherine only take calls a couple weeks the whole year, which means she has a very nice setup. But this may vary from place to place. As in her case, she works for a larger group. It also depends on what size of community you're in.

Catherine says she has enough time for her family. She doesn't work five days a week, specifically that she has a couple of kids and one of them has a lot of medical needs. So she tries to balance those things.

But for most pediatricians, they're pretty aware that they have lives outside of medicine and they're pretty balanced.

Primary care, just in general, sometimes is tough because you will have to figure things out. And if the specialist you send someone to hasn't been able to figure it out, the patients go back to see you. That said, she likes primary care also because it's challenging. But the people that go into pediatrics are pretty much looking out for each other.

"Everyone knows that people have lives outside of medicine and they generally want to preserve those for themselves and for their colleagues."

[15:05] Choosing Where to Do Your Training

Catherine wanted to train at a setting with a charity-type hospital or public safety net hospital where she got to take calls and have a lot of responsibility since she badly wanted the experience. And that's where she ended up going. Also, because where she went to medical school had a large county hospital system, for which she went through a lot of those for her rotations.

"If you really don't know what you want to do and you're not sure if you'd want to go into some kind of subspecialty or not, go somewhere that has a strong program."

Additionally, go to a school that has a really good primary care focus and that the clinic structure is good. Sometimes, things can change so you want to make sure that you go somewhere that's a well-rounded, strong program.

Catherine adds that you should go to where it's going to make you happy. Think about where you're going to be happy and where you're going to fit in well because it's a long three years. It's a lot of calls and a lot of hours. Also, try not to go too far from your support network.

[17:05] Bias Against DOs and Common Pediatric Subspecialties

Catherine says she hasn't seen any bias against DOs. And coming originally from Oklahoma which has a very large osteopathic presence and she's from Tulsa, which has a very well-regarded osteopathic medical school, she's not seeing it. If this was a question 25 years ago, she would have said there was a difference. But where she trained, she really doesn't see it as an issue.

The other more common subspecialties for pediatrics are hematology, oncology, cardiology, and gastroenterology. Catherine stresses how there's a much larger academic emphasis in pediatric specialties that in the adult world. There's a lot fewer jobs in pediatric subspecialties that are non-academic.

"There's a much larger academic emphasis in pediatric specialties that in the adult world."

If you want to do hematology-oncology in pediatrics, you're virtually 100% looking at the academic curve. So there's just not enough population that support that kind of complicated work that needs a huge amount of technological subspecialty support like hematology-oncology which needs ICU and al these other subspecialists with it. So if you don't want to do academics and you desperately want to do hematology-oncology, pediatrics may not be the right choice.

[19:55] Her Message to the Future Specialists to Help Them Take Care of Patients Better

First, Catherine says that if it sounds like a really stupid referral, it may be that the parent would literally not take no for an answer. Conversely, if they're puzzled by something or there's a hole in the story that they can't figure out, understand that sometimes that they know a little more. And sometimes, as primary care doctors, they can fill in some of those gaps.. Or they can sort out why this family is so anxious about x, y, or z and they can't figure out why. So she wishes specialists to know that they can just call them. Especially that everything is on electronic medical records now.

"Sometimes we have some context that they may not have."

[21:20] Working with Other Specialties

The people she works with the most are ICUs, cardiology, infectious disease, dermatology, and GI. She doesn't use hematology too often which is good but she uses pulmonology a ton due to asthma cases. That said, they use a whole variety of specialties. But the one they need more of is developmental behavior pediatrics and mental health support. This is one part of pediatrics that Catherine thinks that they as general pediatricians end up trying to manage a lot more than they feel comfortable managing. Luckily, she gets great support from where she works but there's a lot of people out there that don't.

"We are seeing a lot of mental health issues too now on kids and teenagers and it has gone up a lot in the last 15-20 years."

Outside of clinical work, you can do MD/PhD Peds Hema/Onc, which was what her friend did and now does drug development.

[22:33] What She Wished She Knew

Catherine wished she had known how much better she would be once she became a parent. Again, she says it's an incredible responsibility and privilege to take care of someone's kid.

"It is an incredible privilege for someone to trust me with their child's health."

It's a tough job, but at the end of the day, pediatrics is great. At times, you may have to tell some bad news and it can be difficult. And she sort of knew this but she didn't really know this until she had her own kid.

What she likes most about being a pediatrician would be her patients and her colleagues. She considers them as being each other's tribe. Everyone she works with is very committed to population health of the children in the U.S.

On the flip side, what she likes the least is wrestling a one-year-old to see their ears. ON a serious note, she says the hardest thing is people who don't want to vaccinate their kids. She knows they care for their child and they think they're making the right decision.

[27:05] Major Changes in Pediatrics and Final Words of Wisdom

Catherine points out that telemedicine is a big issue right now. And she thinks some pediatricians get the "primadonna" type reputation but it's not true. The irony is they're the least interventionist with their own patients. So she really doesn't see how telemedicine for pediatrics is going to work.

If she had to do it all over again, Catherine would still have chosen to become a pediatrician. Ultimately, for premeds or med students interested in getting into pediatrics, Catherine's advice is to realize that it's the parents and not just the kid. Also, remember that it's always about what you're going to be happy doing. Compare yourself to other people going into it and when you do rotations. Think about could you work with these people. You want to make sure you could sign your patients out or trust your colleagues. Or if you feel like you could enjoy working with them.

"You really want to be in a field that not only do you really love the patients but your colleagues and you have similar and tuned personalities."

So don't just look at the work hours, the prestige, the money, etc. But long term happiness. You need to feel like you fit. Don't try to put a square peg in your round hole all the time even if you thought you're only going to do one thing. Be flexible and think about where do you really fit since you're going to work with them for a long time.

Links:

ryan@medicalschoolhq.net

Feb 07, 2018
60: An Academic Peds Pulmonologist Talks About Her Specialty
33:22

Session 60

Dr. Taylor Inman is an academic Pediatric Pulmonologist who is also a locums physician. She has been one and a half years out of fellowship training. We discussed her path into the specialty, what it's like, and much more.

Check out MedEd Media for more podcasts. If you have some premed friends, kindly tell them about The Premed Years Podcast.

If you have suggestions who would make a great guest on the show, please email me at ryan@medicalschoolhq.net.

[01:20] Interest in Pediatric Pulmonology

Taylor realized she wanted to be a pediatric pulmonologist when she got to her second year of residency. She always knew she wanted to get into medicine at a young age, having had Type I diabetes and getting diagnosed at five years old.

She has been exposed to medicine at a young age with her mom being a nurse and her dad having a PhD. So always knew she was going to do something in medicine.

Then when she got into pediatrics residency, she knew wanted to specialize. She likes interesting kids and she's been trying to figure out which interests her and pulmonology just fit the bill.

[03:27] Traits that Lead to Being a Good Pediatric Pulmonologist

Taylor describes that one of the traits that lead to become a good pediatric pulmonologist is being able to pay attention to details. Especially in pulmonology, there are a lot of details that you have to tease about patients to help optimize their treatment.

Another trait that can be a hard thing to learn is the ability to listen to families. Working together is important to figure out a plan. this being said, building long term relationships with patients and their families is very important.

"You need to listen to the parents who take care of the kids because a lot of times, they do know more than you do about their child's condition."

[04:23] Being a Locums Physician in an Academic Setting

Taylor says she actually fell upon her practice as a locums physician by chance. She trained in San Diego and her husband's family is in Las Vegas, where they moved after her training since at that time, they had a 22-month-old and a 3-month-old. She wanted a break so they needed to live somewhere where the cost of living was lower. Her plan was to take six months off, study for boards, take boards, and then start working locally. Only to discover that it wasn't as easy as she thought it would be to get a job locally in a pediatric subspecialty.

Then she found the locums position in Fresno, California where they're desperate for a pediatric subspecialist. They have a huge pediatric hospital with over 300 beds so they needed help with their inpatient service.

So Taylor travels to Fresno one week at a time where she gets on-call and does rounds. They pay for her rental car and her hotel. And she finds having a work-life balance and she's been doing this for about eight months now. So she works one week, and then have three weeks off to be home with the kids.

The hospital she's working at started their own pediatric residency only this year. They have residents rotating through. They can do a pulmonology elective and they can have residents covering some of their CF (cystic fibrosis) patients. But for the most part, most of the patients in the hospital are taken care of mainly by attending physicians along with the resident service. So it's nice to have that balance of residents covering for them at night.

[07:10] Types of Patients and Primary versus Consulting

Majority of their patients have cystic fibrosis. They do see a lot of asthma patients as well as chronic patients. They have a separate service for all the chronically ill patients and they do consult on them. When she trained back in San Diego, they were oftentimes the primary physician for these patients although they're dealing with multi-system problems. Other cases are patients with pneumonia, embolism-type stuff, and TB, bronch patients.

As a primary physician, you're in charge of everything - feeding, breathing, medications, discharge, etc. As a consulting physician, as a specialist, you just consult on your special field. She can make suggestion about other organ systems but she's primarily responsible for the lung organ system. A lot of times too, as physicians, they don't write orders for the patients since the hospitalists do that. But they make recommendations and then hospitalists get to decide to follow her recommendations or not.

"Primary in a hospital, when somebody is admitted, doesn't necessarily mean primary care doctor."

So you can have a specialty service and admit people to that specialty service.  That means there are other patients there that consult other specialties. Taylor explains that for cystic fibrosis patients, they are the primary physicians for the patients when they're in the hospital. She actually feels like they're their primary care physicians too, although they do require that their CF patients have a primary care physician outside of the pulmonologist. Unless they come in with a complaint for another organ system, these are different services and Taylor can just consult for those patients.

[10:53] Clinic versus Inpatient

Taylor illustrates how clinic setting is being a little bit more low-keyed than an inpatient. For clinics, it's nice to be able to get longer appointments. For instance, they can spend 45 minutes with an asthma patient for the first time. They'd figure out what's going on and what they can do to help.

CF patients come in one specific day where they have a multidisciplinary clinic with a social worker, a dietitian, a specific CF nurse, pharmacist, and respiratory therapist to all help with the care.

In regular pulmonary clinics, they see a lot of asthma and all different respiratory complaints. They take care of patients with sleep disorder, breathing, and sleep apnea. They also have patients who are on long-term ventilators at home or patients that have a tracheostomy that they care for.

"It's good variety of different things. No two days are ever the same in pulmonary clinic."

[12:10] Percentage of Patients Coming In

Taylor estimates 30-40% of the patients are new and the rest are follow ups requiring management. Especially once the asthma patients are stable, they try to have their nurse practitioners follow those patients up because there is such a high demand for pulmonologist in Fresno and there aren't very many pediatric pulmonologists. Because of this, she's seeing more of new diagnosis instead of follow-ups.

A typical day for Taylor would be getting to the hospital at 8:30 or 9 am, unless she has a bronchoscopy schedule where they're scheduled first thing in the morning. They'd do outpatient or inpatient bronchoscopy. Then she'd come in a bit later in the morning to check her CF patients. She looks through her list for new consults coming in. She reviews them on the computer the night before and then she'd see all the patients and talk with other specialists she's consulting with or on.

In the afternoon, she spends a few hours writing notes, which is her least favorite part of medicine. Then she'd get down around 5:30 pm depending on how the day goes But usually, she's out at a reasonable hour.

"I spend a few hours in the afternoon writing notes. That's really my least favorite part of medicine."

[14:15] The Training Path to Pediatric Pulmonology

The first step is to match into Pediatrics residency. After you do three years of Pediatrics residency, you match to become a Pediatric Pulmonologist. This happens in the Fall of your third year. This gives you more time to do some electives and figure out what exactly you want to do. Taylor adds that you have to know what you want to do by the beginning of your second year.

"It doesn't really matter where you do pediatric residency for becoming a specialist."

Pediatric pulmonology is an additional three years of training. And most of the pulmonology fellowships require a lot of research, which is good. At her fellowship, she had almost two years of full dedicated research time and a year of clinical time, spaced out over the course of three years. So she did mostly clinical her first year and mostly research on her second and third year.

For most of the pediatric subspecialties, most of them are three years in length. Pediatric neurology can be combined to become a 5-year instead of 6-year training program. Even pediatric emergency medicine is another three years of training. So it doesn't matter where you're going to, since it's going to be six years in total.

In terms of competitiveness, Taylor doesn't think it really is a very competitive field compared to other programs. When she was matching, half of the spots were unfilled each year because there are so many spots and so few people who want to go into pediatric pulmonology.

"If you have your heart set on going to one specific place, it may be competitive in a given year... but for the most part, if you want to be a pediatric pulmonologist, you can do it."

The reason for the few applicants being that the pay isn't that great in pediatrics. A lot of time you spend mastering your subspecialty and when you go out, your paying potential isn't that great. Plus, a lot of people who get into Pediatrics just aren't interested in pulmonology.

[18:15] How to Be Competitive for a Pulmonology Fellowship

Taylor recommends doing as much research as possible during your residency. Even if just writing case reports is better than nothing. Get to any research you can get involved with. She also mentions having great recommendation letters.

"Even if your research doesn't seem like it's going to apply to your field, it's still helpful to have the experience of research as early as possible."

Ultimately, it comes down to where you would work well and where you'd fit in well. She further adds that people who are smart and play nice with others can really go far in pediatric pulmonology.

[19:45] Bias Against DOs, Working with Primary Care and Other Specialties

Taylor hasn't really seen any negative bias towards the DOs since you're basically doing the same pediatrics training. So when you're applying for fellowship, you've already been working and doing the same thing for the last three years. So it doesn't really matter at that point.

In terms of working with primary care, Taylor says that she feels that 90% of refractory asthma patients they get from primary care doctors are non-compliant. They're not doing their meds and they're lying or they're not doing it correctly. But she gets how this can be challenging in gen peds when you're practice in jam-packed. Taylor points out that most of the poorly controlled asthma is all about taking the meds and taking them correctly. And she's happy to see those kids in her clinic. As well, she's happy she has the support staff to help call and find out if families are refilling their prescriptions and picking them up.

"For the primary care doctors, you're doing everything right. It's just a matter of the patients taking the medicine or doing it correctly."

And for their CF patients, they appreciate primary care doctors who are seeing patients when they're sick and really working together. Taylor admits that as pulmonologists, a lot of times, they don't have sick visit appointments. But parents will call them when they're sick. Although their obligated to do something, Taylor says it's nice to have someone lay eyes on the child and be able to tell them if they do look sick or not. This being said, they value the input of primary care doctors even for the complicated kids that they do a lot of management for.

In the hospital, other specialties they work the closest with include hospitalists, PICU, NICU, etc. With outpatient, they work with all the specialists in all different capacities. They work with ENT, Cardiology, GI, Allergy, Rheumatology, Hematology and Oncology.

[23:23] Special Opportunities to Further Subspecialize and Outside of Clinical Medicine

Taylor explains that you can do an extra PICU or NICU training. This would be an additional two years of training but she doesn't really know if doing this would make you better of an intensivist. The fields are split especially in Pediatrics. So they have each their own subspecialty. Moreover, Taylor doesn't like the lifestyle in PICU.

The opportunities outside of clinical medicine are endless for research. Fellowship requires a research project and most fellowships give you substantial time to complete the project. They really encourage you to continue research after you've completed your fellowship. This said, there are tons of grants you can write and funding you can apply for to do research.

The Cystic Fibrosis Foundation has all kinds of different funding pathways for physicians to do additional research.

"All the research you could ever want to do is possible in pediatric pulmonology."

[24:55] What She Wished She Knew and the Things She Most and Least Liked

Taylor admits there were times she was envious of NPs or PAs who started at the same time as her and they finished and are already working and making more than her as a resident even though they're the same age. And a lot of the NPs and PAs don't have to take calls as much as physicians do. But she's still glad that she went through it all. It wasn't easy. But now she's on the other side of things, no one can take that MD away from you.

There are still a lot of opportunities too as Taylor points out. You can go practice gen peds if you want to or do urgent care and take care of low acuity patients in the ER if you want to. So she's still happy she did it.

Looking back, she thinks it was more fun that she thought that it was. It's pretty cool that as a 26-year-old that she was admitting kids to the hospital and deciding treatment for them with a senior resident.

The thing she likes the most about being a pediatric pulmonologist is how fun it is. Most of their kids get better. Also, you get to know the families well and see the patients grow and get better and graduate from pulmonary clinic.

"Regardless of what you do, a lot of them will get better. So you don't have to be the smartest person to figure out what to do."

On the flip side, what she likes the least are having patients who are chronically ill and not going to get better. A lot of them eventually will have respiratory problems and breathing is the one thing that can make them live or die. So they end up being involved with families making decisions whether or not to place tracheostomy or place patients on ventilators. She says that a lot of times, it doesn't feel right making that decision. She also finds it hard if she doesn't feel like she agrees with the family. For instance, she sees that the patient is not going to get better but the family wants to have them live as long as possible even though they don't have a good quality of life. These are very challenging cases for her to see kids who are not going to get better and to know that they're not going to get better.

[28:35] Major Changes in the Field of Pediatric Pulmonology

For asthma, they have some new treatments for asthma monoclonal antibodies that will target to lower IGE and kids who have allergic asthma. They have made a big difference in treatments.She thinks there will be more specific, targeted therapies to come in the future.

Also, trying to use personalized medicine to classify patients with asthma and figure out what type of asthma they have or what specific medications will work best for them. Taylor reveals there a lot of stuff that are just on the cusp of discovery.

And it's a very exciting time for cystic fibrosis with all the new medications coming out. There are two drugs currently available and more drugs are on the horizon. She does hope the price of the therapies comes down soon too (right now, it's over $300,000 a year). Nevertheless, it's exiting to have new treatment options for their patients.

Ultimately, if she had to do it again, she still would have chosen Pediatric Pulmonology. Although at the back of her mind, she does wonder if she would enjoy being an endocrinologist. Having lived with diabetes her whole life has made her feel like she's an expert so it could be easier to make a difference in the field of endocrinology.

[31:40] Final Words of Wisdom

Taylor recommends to aspiring pediatricians or pediatric pulmonologists out there to try to get as much exposure as possible, even as a med student and resident. Try to get involved. Shadow in a clinic and see what kinds of patients are seen. It's a lot of fun and a lot of variety so it's a good balance of having excitement and seeing patients who are sick. And there's good work-life balance since they're not being called in overnight to come in and do procedures. As a mom. Taylor says it's a good specialty to pick.

"It's a lot of fun. It's a lot of variety. It's a good balance of having excitement and seeing patients who are sick."

Links:

The Premed Years Podcast

Cystic Fibrosis Foundation

Jan 31, 2018
59: What Does the Psychiatry Match Data Look Like?
22:44

Session 59

Looking at the Psychiatry Match data, it's easy to see that it is becoming a more popular field. I discuss all the data in today's Specialty Stories podcast.

Finding physicians for this show has been a challenge so we'd like to ask for your help. If you know a physician who would be a great addition to this podcast, shoot me an email at ryan@medicalschoolhq.net .

Go to medicalschoolhq.net/specialtiescovered and you'd find a list of physicians that we've already covered here on the show.

Today, we cover Psychiatry match data based on the 2017 NRMP Main Residency Match Data.

[03:20] General Summary

There are 236 programs in psychiatry. Comparing it with other specialties, pediatrics has 204 programs. So there are 32 more psychiatry programs than there are pediatric programs.

The total number of positions offered for Psychiatry is 1,495 spots. This means a little over 6 spots per program. Whereas pediatrics is much bigger with twice as many spots of 2,738 in 204 program. So it's almost 13 1/2 spots per program - almost double the size of psychiatry programs.

There were 3 unfilled programs in 2017 and the total number of U.S. Senior applicants for those 1,495 spots was only 1,067. These are the students at MD medical schools who are still in school, and not those that have graduated. So there were less students applying to those spots than there were spots available.

There were 2,614 applicants. It's almost 1,200 more applicants than there were spots available. This is still pretty competitive to apply.

Looking at the number of those that matched, only 923 of those 1,067 U.S. Seniors did match while over a hundred of those did not match into Psychiatry. It was only about 61.7% of those that matched are U.S. Seniors.

Looking at other fields that matched, Anesthesiology was 66.8%, Dermatology at 92.3%, and PGY-2 positions for dermatology is 81.8%.

[07:05] Types of Applicants and Growth Trends

Table 2 of the NRMP Match Data for 2017 shows the matches by specialty and applicant types.

For Psychiatry, there were four spots that went unfilled, 923 were U.S. Seniors and that's about almost 62%. 49 were U.S. Graduates. These were students who went to anMD school but had graduated already. Maybe they didn't get in the first time or they were just taking a gap year doing some research or travel, whatever.

"A good percentage of osteopathic students are getting into Psychiatry."

There were 216 osteopathic students, 166 U.S.-Citizen International Medical Graduates, and 137 non-U.S.citizen International Medical Graduates. There were four unfilled positions.

Table 3 shows the growth trends covering 2013 to 2017. Psychiatry is growing a bunch, about 5% every year. In 2017, it grew 5.2%. Table 7 shows positions offered and number filled by U.S. Seniors and all applicants from 2013 to 2017. There's an interesting trend in Psychiatric that it's becoming more popular among U.S. graduates. When you go back to 2013, it was only about 52% of the class who were U.S. graduates.

"If you're interested in Psychiatry, it seems to be growing. Hopefully there'll be spots for you as you continue down your training path."

In 2017, U.S. Seniors comprised 61.7% while in 2013, it was only around 52% and been going up year over year.

Table 9 shows you how big a specialty is int he grand scheme of specialties. Ophthalmology is a separate match so that's not included. For Psychiatry, 5.4% of all students who matched, matched into Psychiatry. Just to give you a scale, Anesthesiology was only 4.1%, Emergency Medicine is 7.4%, Internal Medicine is 25.6%, Family Medicine is 11.6%. OB/GYN is 4.7%.

[11:40] Osteopathic Students

And if you're an osteopathic student interested to know your chances, Table 11 will show it to you. 7.4% of all DO students who matched into an MD program, matched into Psychiatry. Compared to the rest, Family Medicine and Internal Medicine are huge, Anesthesiology is 5.6%, Emergency Medicine is 9.6%. So the ratios are very similar.

Figure 6 shows the percentages of unmatched U.S. Seniors and Independent Applicants who ranked each specialty as their only choice.

If you are only ranking Psychiatry, there's a total unmatched percentage of 30.8%. But don't let that scare you if you're a U.S. Senior. Because their unmatched percentage is only at 7.4%. 52.9% of those who are independent applicants (ex. DO students, U.S. citizen and non-U.S. citizen international medical graduates, Canadian students) did not match

[13:13] SOAP

Let's go to the SOAP (Supplemental Offer and Acceptance Program). There were four unfilled programs, when you look at the data. But interestingly, when you look at the SOAP for 2017, there were only three available positions. One of those positions was either filled or taken off of the board. So there were two programs with three positions available. And all three of those spots were filled through the SOAP.

[13:45] NRMP Charting the Outcomes 2017 - Contiguous Ranks

Based on the 2016 NRMP Charting the Outcomes, Table 1 shows the number of applicants and positions in the 2016 match by preferred specialty. Psychiatry has 1,586 spots, 2,134 applicants, number of all applicants per position was 1.54, as one of the highest on this list.

There are a lot of International Medical Grads and DO students are applying for these spots. Specialties like vascular surgery only has 56 positions and the total number of applicants per position is 1.91. The only one here above Psychiatry other than that is Neurosurgery which is 1.58. So there are a lot of applicants for those spots.

Chart 4 tells the median number of contiguous ranks of U.S. Allopathic Seniors. Those who matched in Psychiatry ranked 9 programs in a row; while those that did not match only ranked 5.

"You need to apply to a lot of programs and rank a lot of programs. That is the same across the board for every specialty."

Further down the report is Table P-1 is the summary stats for Psychiatry. The mean number of contiguous ranks for those who matched is 9.6 while those who didn't is 5.6. Mean number of distinct specialties ranked is 1.1 for those who matched and 1.3 for those who went unmatched. For those who did not match were a little bit wishy washy with their specialty choice.

[16:30] Step 1 and Step 2 Scores, AOA Members, and PhD Degree

Step 1 scores for Psychiatry is not as high as some of the other programs. Psychiatry has 224 for mean Step 1 score and 214 for those that did not match. For Mean Step 2 Scores, 238 for those that matched, and 226 for those that did not.

For AOA (the honor society for medical students) members, only 6.2% of the students who matched were AOA members while none of those that did not match were AOA members.

4.4% had a PhD degree and 0 unmatched had a PhD degree. You could look at that saying that you have to have a PhD degree to match into Psychiatry or you have to be an AOA member to match. But you have to look at the data yourself.

[18:00] 2018 Medscape Lifestyle and Compensation Reports

The 2018 Medscape Lifestyle Report shows the highest outside of work is 61% for Allergy Immunology and the lowest is Cardiology at 40%. Psychiatry is right in the middle at 51%.

But let's also look at the 2017 NRMP Main Residency Match Data. Psychiatry and mental health are at the bottom for burnout at 42% versus Emergency Medicine at 59%. How severe is the burnout, they're much lower at 4 on the scale.

"Not surprisingly, the question which physicians are most burnt out, Psychiatry and Mental Health are at the very bottom. They probably have some coping skills."

Which physicians are happiest outside of work and at work? Psychiatry is lower on the list with 66% happy outside, and 37% are happy at work. And they're found on the lower end of the scale.

Looking at the 2017 Medscape Compensation Report, Psychiatry is on the lower end. That's understandable because usually, the more procedure-heavy specialties are compensated more. Their average annual compensation is at $235K while Orthopedics is up at $489K. So that's a big difference. Pediatrics is the lowest at $202K.

However, they're getting 4% salary increase year over year. Slide 18 shows which physicians feel fairly compensated and Psychiatry is top 3 at 64%, next to Dermatology and Emergency Medicine (first).

Slide 38 is a question about whether they'd choose medicine again and Psychiatry is top 2 at 82%, Rheumatology is at 83%. 87% of Psychiatry also say that they would choose the same specialty again. The highest is Dermatologist and Orthopedics is next.

[21:38] Final Thoughts

As mentioned earlier, we are in need of more physicians to interview. Please help us find out which physicians are interested in coming on the show. Go to medicalschoolhq.net/specialtiescovered and see which ones have been done.

Links:

medicalschoolhq.net/specialtiescovered

2017 NRMP Main Residency Match Data

2016 NRMP Charting the Outcomes

2018 Medscape Lifestyle Report

2017 Medscape Lifestyle Report

2017 Medscape Compensation Report

Jan 24, 2018
58: What Does a Movement Disorder Specialist Do?
35:37

Session 58

Dr. Kathrin LaFaver is an academic Neurologist who specializes in Movement Disorders. We talk all about her job and what you need to know if you're interested.

Check out all our other podcasts on MedEdMedia Network. And don't forget to subscribe on whatever medium you have.

Going back to today's discussion is a movement disorder specialist who has now been four years out of training. She talks about why she chose her career, what it takes to become one, and so much more!

[01:54] Her Interest in Movement Disorder

Kathrin was a neurology resident and she got to shadow or do an elective in movement disorders. She found a great mentor and she was just fascinated by it, including the personal connections they formed. So from day one she knew it's what she wanted to do.

The great thing about movement disorders, Kathrin says, is that you see the problem in front of you. So you can often make a diagnosis as they come into the room. On the other hand, there are people with too much movements and you can describe and see what's wrong. Then you can make your own conclusions from just observing the patient.

"It's a really interesting specialty, a lot of treatments available, and the opportunity to follow people long term."

Ultimately, she enjoys the connection with movement disorder patients. Treatment-wise, the medication for Parkinson's disease that was discovered way back in the 1960's, it still remains as the mainstay treatment for Parkinson's disease.

[05:15] Traits that Lead to Being a Good Movement Disorder Specialist

Kathrin says you have to have good observation skills - seeing them, finding the pattern, and fitting them into the right category. Over time that you've done it for a while, it becomes natural to see those specific disorders, which may not be so obvious for someone who's not specifically trained in it. Other skills include being able to enjoy logic thinking and fitting clues together, which are actually things common to neurologists.

[06:40] Types of Patients and Cases

Parkinson's Disease is the mainstay for most people in this practice. Unfortunately, this disease has been on the rise. In fact, one in 37 patients is expected to have Parkinson's Disease.

"One in 37 patients is expected to have Parkinson's disease so it's actually a very common disease. Whether you do neurology or not, you're going to see people with Parkinson's disease."

Parkinson's disease affect people, young and old, and there are different treatments, both medication and non medical treatments. It also affects not only the motor system, but also sleep, mood, and other symptoms. So Kathrin says this is an interesting area to be active. There are a lot of things to be researched on and discovered.

Most common disorders spans the whole spectrum from age ranges such as dystonia, tourette's syndrome that often affects children and teenagers. Tremor can also be present in younger adults. Others would be genetic forms of movement disorders often presented in midlife. They also encounter other forms of dystonia as well as tremors.

Kathrin explains that many are still diagnosed although essential tremor and Parkinson's disease are so common. She says it's easy to tell them apart, but not everyone behaves like a textbook. So it's not always as easy.

"Surprisingly often, they're misdiagnosed either by a primary care physician or a neurologist who might not be very well-trained in movement disorders per se."

Being at a tertiary academic center, Kathrin says they do get patients where they have to dig deeper to look for the missing clues to get to the diagnosis. That said, she has challenging cases every week where they have to be thorough with their history and examination to get to the diagnosis.

[10:55] Academic versus Community versus Private Practice

Kathrin has always been interested in human psychology, and movement disorder was just so interesting for her. Although they're called movement disorders, they are so much more. All these disorders like Parkinson's disease and Huntington's disease have behavioral manifestations as well. Depression and anxiety for example, are common in Parkinson's disease. Anger and depression are very common in Huntington's disease, too.

"We're still just at the beginning of understanding all these diseases and finding better treatments and cure for them."

This said, Kathrin knew she wanted to be in a place where she can continue exploring and help contribute to gaining new knowledge about diseases.

[12:40] A Typical Day - The Parkinson Buddy Program

Being the director of the Parkinson's Disease and Movement Disorders Clinic at the University of Louisville, she spends 50% of her time in research. She's involved in several medication studies for Parkinson's and Huntington's. These are studies run in multiple sites across the US and Europe. This gives patients an opportunity to try new treatments or be involved in new treatment efforts.They're currently looking for treatment for anxiety affected by Parkinson's. So she doesn't see clinic patients. Rather, she's involved in teaching medical students as well as community outreach.

Three years ago, they started the Parkinson's Buddy Program where they team up first year medical students with Parkinson's patients in the community, This is an opportunity for these students to experience how someone with Parkinson's lives and what challenges they face in their lives.

So when they get paired with a patient, they get some mentoring sessions with her. But the goal of the program is to let them meet with the patient in social settings so they can explore and experience it. Kathrin is involved in other teaching community activities, fundraising, etc.

And the other half of her time, she does patients in the office.

Kathrin sees 100% movement disorder patients in the outpatient setting. All neurologists in their group the alternate call as well. One week every 2-3 months, she spends a week in the inpatient general neurology service. At this time, she'd supervise residents and see all patients with general neurology conditions like epilepsy, multiple sclerosis, etc. While all of his outpatient time is spent with movement disorder patients.

[15:50] Work-Life Balance and the Residency Path

Kathrin is married with two kids, ages 2 and 4. And her work is fairly busy. She explains her time outside of the hospital is spent with her family.

In terms of the path to being a movement disorder specialist, Kathrin outlines the process. First, you do the neurology residency which is usually a year of internships, one year of internal medicine, and three years of neurology.

"Movement disorder fellowship is actually not an accredited fellowship so the pathways are a little bit more flexible."

There are also fellowships that are one year, mostly clinical. And many are two years - one clinical and one research year. As well, there are some additional opportunities to get intensive training in deep brain stimulation surgery. This is a surgical treatment for mostly Parkinson's disease and essential tremors. Kathrin describes it as a teamwork where the neurosurgeon does the procedure and then the neurologist or movement specialist would do the programing and follow-up care for the patient. For Kathrin, she did one year of clinical fellowship in Boston. Then spent two years of research fellowship.

In terms of the competitiveness, Kathrin points out the shortage of neurologists. Some programs are more competitive than others. But if you're flexible with your location or willing to go, it's not really extremely competitive to get into a fellowship.

One of the challenges in the movement disorder sphere right now is the epidemic of Parkinson's disease coming upon us in the next 20-30 years. The trends she sees coming in the future is telemedicine, especially in rural areas, in the hope of meeting the demand for movement specialists.

[19:36] Negative Bias Against DOs and Special Opportunities

Kathrin doesn't really see any bias going on against DOs. Moreover, if you're interested in surgical treatment options like deep brain stimulation surgery, it requires special training.

[20:38] How Deep Brain Stimulation Surgery Works

The patient essentially gets a pacemaker for the brain. Electrodes get placed in targeted areas and in order to make sure this is done correctly, the procedure is done while the patient is on an anesthesia. Then the electrode is advanced and the patient wakes while a mapping is being done. Then they actually listen to the cells as the electrode is advanced. And this is how the actual training plays in.

"Cells and the different parts of the basal ganglia have all characteristic sounds."

Imaging plays an important role but most centers still do the microelectrode recording as additional means of finding the right location for these electrodes. Doing this procedure is a team effort - they have the neurosurgeon, the neuro electrode physiologist. Then a neurologist helps with listening to the cells and doing testing on the patient. If they're in the right spot, they turn the stimulation briefly on. Then they look on where the tremor gets better. So they're able to see immediate effect in the O.R. as it confirms that the space is the correct spot where the electrode is placed. Although results are not guaranteed, but there have been many cases where the tremor has really stopped. For many patients, it's a really miracle surgery.

[23:58] Working with Primary Care and Other Specialities

Kathrin's message to primary care physicians is to not be afraid of referring a patient to a neurologist or movement specialist. Because Parkinson's and essential tremor are so common, sometimes the internist or the primary care physicians become the main providers treating patients. And often, it works out just fine. But it's important for people without special training to realize the limitations and first-end treatment does not go so well. So if patient still experience the tremor, then they should not hesitate referring them.

In many cases, we really have very effective treatments which can make a huge difference and even for people in more advanced stages, treatments like the Deep Brain Stimulation Surgery may be an option.

"Don't hesitate asking for help for someone with Parkinson's disease or tremor and we can often make a big difference."

Other specialties they work the closest with are Psychology, physical therapy, speech therapy, and occupational therapy. Many centers, in fact, run special multidisciplinary clinics, where they have a monthly clinic for Parkinson's or Huntington's disease. People can see multiple specialists at the same time. This is very helpful in facilitating care for the patient as they try to streamline care. It also helps to get input from multiple specialties as to how to serve the patient best and work all together.

They also work with social workers in their clinic. Kathrin stresses the importance of understanding how movement disorder affects someone's work or social life in, especially in later stages.

Special opportunities outside of clinical medicine include research. Some have actually pursued a full time research career. Other options are private practice or working in academia. She adds your career can actually change multiple times throughout your life.

"Just being in medicine in general and being a physician, getting expert knowledge, you can really forge your own path and find your niche."

[27:55] What She Wished She Knew and Major Changes in the Field

Kathrin explains there are many changes in medicine. They can be burdensome and taking too much time. But as a medical student, you don't really see that side. Nobody will tell you that in the anatomy class. And in the real world, you spend a lot of time on the phone as you try to get your patient's medication approved due to insurance issues. And this is a hidden truth.

"That's a hidden truth right now that our physicians are maybe not as autonomous as we would like to be... oftentimes, insurances mandate the medications we can prescribe."

That said, Kathrin saw really no surprises from the neurologic side of things. Rather, it's about how you deal with the whole business side of medicine.

What she likes most about her job is working in a setting where she gets to see the patients, doing interactive trainings and teachings as well as research. There can be lots of challenging times but in the end, Kathrin says it's all worth it. Having success in one area can sometimes compensate for another disappointment so it balances things out.

Alternatively, what she likes the least are the regulatory burdens and dealing with insurances. She's hopeful though that this gets resolved in the coming years and physicians will gain a little bit of autonomy.

Major changes she sees in the field are developments in multiple areas. One is the Deep Brain Stimulation Surgery that has already been mentioned and that these could be more individualized soon. Another interesting area is genetics. They can now do a whole genome sequencing for $5,000 which was years ago, was unthinkable to do that. So there's more discoveries and insights to come in the future.

Additionally, Kathrin wants people to understand the interplay of environment and genetic factors and how that impacts complex disorders like Parkinson's disease and other movement disorders. Hopefully, we can learn more about how to intervene and really make differences.

Lastly, Kathrin says that if she had to do it all over again, she would still have chosen the same subspecialty.

[33:55] Last Words of Wisdom

Kathrin encourages students to do an elective in neurology. That said, there are lots of opportunities to get engaged in research. She has students working with her during the summer break. And this is a good opportunity to have a good hands-on experience. Also do a little research project like see someone in their day to day or get some patient contact. See if this is something that interests you.

Links:

Parkinson's Disease and Movement Disorders Clinic

MedEd Media

Jan 17, 2018
57: What Does a Pulm Critical Care Medicine Doc Do?
30:55

Session 57

Dr. Tom Bice is an academic Pulm Critical Care physician in North Carolina. We talk about his specialty and what you should be doing if you're interested in it. Tom has been out of fellowship for four years now.

By the way, check out all our other podcasts on the MedEd Media Network.

[01:03] His Interest in Critical Care Medicine

Not being able to decide on one topic, Tom knew he wanted to do a little bit of everything. And he has mild to moderate ADD. He also considered Emergency Medicine early on but he found he didn't enjoy people showing up at 3 am with significantly non-emergent problems.

So when he focused more on internal medicine, he was doing his rotations in surgery and medicine. Then he realized that all of the patients and disease processes that were cool ended up in the ICU. What cemented his decision was his OB rotation with a young 26-year-old lade with sickle cell anemia came in at 29 weeks and went to the emergency section. She ended up in the unit for several days and intubated, septic shock. He was a third year medical student at that time and he was the one from their team surrounding the patient. And he realized he loved every minute of it. In fact, the attending OB was one of those who wrote letters for his residency. Since then, he got hooked.

"I was hooked. Right away, I just love the excitement of the physiology and meeting a broad swath of knowledge about the various systems."

In short, it was the acuity that actually drew him towards what he's doing now. He had this notion that patients are going to need you when they come see you. But that's not always the case in the emergency medicine.

[04:55] Types of Patients

Being part of a large academic medical center, they have different ICUs for all the different patient types. As with Tom, he works predominantly in the medical ICU. But they also have the cardiac ICU, neuro ICU, surgical ICU, and cardiothoracic ICU (where he spent the first two years out of fellowship).

At medical ICU, they see patients with sepsis and septic shock of some kind. You also have those with liver failure, drug overdoses, and problems which you can't figure out what's wrong but they look real bad. What identifies all those patients is the need for fixing a deranged physiology.

Neuro intensivists tend to go through neurology or emergency medicine and then do neuro critical care. The cardiothoracic ICU uses a bit of everyone including anesthesia and critical care. Cardiac ICU does cardiology and pulmonary critical care too.

Tom explains that you get training during fellowship because your'e required to do so many months of ICU, that you can go and work in any kind of ICU necessary. Having done a lot of moonlighting during fellowship, and he saw that at the bigger community-based academic programs, intensivists rounds on all those ICU patients providing critical care.

[09:15] Typical Week

When Tom is o service, his typical week would be nighttime covered by the different intensivists where he is on from 7am to 7pm for seven days. And for the weekends, the ICUs have to have two attendings on so they split it between the two of them every other day.

Tom tries to keep his rounds short. And there's a lot of work that need to be done, procedures, consults, and activities for patients. Then before he leaves for the day, he ensures he has followed up everything and whatever action plans that needed to happen should have happened.

[10:35] Is It Procedure-Heavy?

Tom says it's a lot of procedures, with a caveat. To some extent, you can do as many or as few procedures as you want depending on how hands-on you want to be. But if you don't like procedures then it's not the specialty for you. Especially for the pulmonary side of things, they do thoracentesis and chest tubes as well as intubation, lumbar punctures, etc.

If you really don't like procedures, then it's probably not the specialty for you."

[12:00] Work-Life Balance

Tom says he has a lot of work-life balance, and this is the reason he chose academic over private practice. He probably would have enjoyed private practice critical care for 2-3 years. But he enjoys about 12 weeks of ICU time a year. And the rest of his time is non-clinical, doing research. His focus is clinical research so it's still patient-focused. But the 24/7 grind is not constant.

Nevertheless, when he's home, then he's really home. He likes the advantage of shift work. In fact, most of critical care is moving that direction around the country. In their state, what he notices is very much a day group and a night group. You're on when you're on and you're not when you're not. So it's easy to maintain balance that way.

"There is generally recognized shortage of people that are critical care trained and most of the hospital quality folks would prefer that there was a critical care trained person in the hospital 24/7."

[13:45] The Training Path

Tom cites a few options available now. When he started his fellowship, he knew he was going to keep doing research and stay in academics, he did his three-year internal medicine residency and then a  two-year critical care fellowship only.

Another options is for one extra year, you do pulmonary. This is mostly determined on whether you like clinic or not. People who do critical care only, tend not to have clinic obviously because there's no ICU followup per se. But if you want some of that longitudinal relationship with patients then you get to a little bit of both. That's why Tom also has a pulmonary clinic. This is three year after internal medicine residency, totaling to 6 years after medical school.

"There is no particular disadvantage to hiring a critical care fellowship only."

In terms of competition, Tom thinks it's getting more competitive, but it's not cardiology, or GI, or oncology. They get very competitive applicants every year at their program. He describes it as being competitive enough that requires some degree of forethought. He also thinks you have to have some research exposure if you go to an academic-type program.

[17:24] Negative Bias Towards DO Physicians and Special Opportunities

Tom has not seen any bias against DO doctors. In fact, a couple of his absolute famous attendings from residency were DOs that did pulmonary critical care. They've interviewed plenty of DOs. To them, it seems another way of getting the same training.

There are further subspecialization both in the pulmonary care side and the critical care side. Under pulmonary, there's interventional pulmonology which is more procedure-based. There are no formal NRMP matching programs for lung transplants but there are a few places that offer fellowship and subspecialty training in that. There are not set training programs, but they are niches within pulmonary medicine.

"As with everything, subspecialization continues to involve. There aren't formal training programs but emphasis or subspecialization has developed in recent years."

[20:10] Working with Primary Care and Other Specialties

Tom explains they do have interaction with primary care doctors in the pulmonary side. One of the balances they often run with primary care is the shortness of breath consultations, which cardiology and pulmonary like to point the finger at the other direction. His advice to primary care is to accept that both are probably wrong. And it's probably a little both of the lungs and the heart causing the shortness of breath.

Other specialties he works with include Nephrology. One-third of patients through the ICU require dialysis at some point. Tom also underlines the importance of having a good relationship with critical care trained surgeons, which are different from your general surgeons. Sometimes, it's knowing when not to take the patient to the operating room. And sometimes, it's knowing that you need to take a patient to the operating room, no matter what. He may also work with GI/Hepatology.

"In the medical world, having good relationship with your critical care trained surgeons makes a big difference."

Outside of critical care, there are other opportunities that are available. Pulmonary gets involved with high altitude medicine which also includes diving (low altitude medicine). Personally, he has had some experience traveling and training in resource-poor environments. Knowing how to provide critical care in those environments can be very handy.

You can also do research. Critical care is relatively a new specialty. So there's still a ton that we don't know about how to do things right, according to Tom. You can also do quality and leadership initiatives through that.

[23:40] What He Wished He Knew that He Knows Now

The one thing he didn't know as much early on about critical care is how much time spent with families of dying patients. He's glad though that it's something he enjoys having those conversations about end of life care and the expectations of what is going to happen.

"Most of our medical training leading up to, and including in residency and fellowship, is find the problem, fix the problem. There's just so much of the time where we just can't."

Tom stresses that unlike what they're taught during training to find the problem and fix it, there are times they just can't. And being able to have that conversation with patients or their families is really important.

This is a good message he wishes to send out to primary care doctors as well is to have those conversations in clinic early. But recognize that they're flexible and people change right up until the last minute.

[25:20] What He Likes Most and the Least and Major Changes in the Future

What Tom likes the most about critical care is that there's always something to do. It's always a busy specialty. There's always going to be sick patients. And the acuity never stops because if you're going to get one patient better. And there's going to be three waiting in line.

"Flu is one of the diseases that they know most of the symptoms of it, but they can just do anything later on and affect almost any organ system."

On the flip side, what he likes the least is that the ICU never closes. So you have to know that you're going to work in the ICU on Christmas and all the other holidays at some point.  Know that going in.

Although this has been growing over the last several years, you still see the inclusion of advanced practice providers like PAs and NPs in the ICU. This is primarily because of the shortage of critical care providers. It's a numbers problem that a number solution can help with.

Ultimately, if he had to do it all over again, he still would have chosen the same specialty. Tom wishes to tell students who might be interested to explore this field that they'd love to have you. Contact your local critical care doctor for rotation. It's a good time even if it's busy.

[29:30] Personal Takeaways

Most students that love a little bit of everything go to emergency medicine. Yet, there's also this subsection of students who love the high acuity stuff.

Go back and listen to Episode 2 of Specialty Stories where I interviewed an emergency medicine doctor where he revealed that the high acuity stuff only comprises a small percentage of an emergency physician's job. So if you like the high acuity stuff, and you like a little bit of everything, pulm critical care might be the specialty for you.

If you have a physician you want to be interviewed here on the podcast, shoot me an email at ryan@medicalschoolhq.net.

Links:

MedEd Media Network

ryan@medicalschoolhq.net

Episode 2 of Specialty Stories

Jan 10, 2018
56: How Hard is the Neurosurgery Match? A Look at the Data.
24:49

Session 56

Neurosurgery follows the rules of economics. There are very few spots, so it is really competitive to get into. We covered the NRMP Match data for Neurosurgery.

Neurosurgery is one of those residencies that are super hard to get into. Ryan has had an academic neurosurgeon previously on Episode 20 of this podcast.

Please subscribe to this podcast. We're on Spotify now! Check us out there as well as on any Android phone, or on Stitcher and Google. Nevertheless, the podcast app on the iOS is the best way to subscribe on an iPhone or iPad. You will also find all our episodes on the MedEd Media Network.

Let's dive into today's data...

All information here are based on the NRMP Main Residency Match 2017, Charting the Outcomes 2016, Medscape Lifestyle Report 2017, and Medscape Compensation Report 2017. Ryan walks you through the data along with some commentaries. So you will know what it means and what it looks like and what you should be thinking about if you're interested in Neurosurgery.

[02:30] Match Summary for 2017

Looking at Table 1 of NRMP Main Residency Match 2017 Summary, Neurological Surgery is how they list it. For this field, they have 0 unfilled programs. This means lots of people are applying for neurosurgery and they're getting filled. There are 107 programs. Comparing this to other fields, Emergency Medicine has 191 programs and Anesthesiology with 124 programs.

So for neurosurgery there are 107 programs and 218 positions. It's just over two spots per program. Comparing this to Anesthesiology, it has 124 programs and 1202 positions. This is almost 10 spots per program.

This said, there are not a ton of spots and programs for neurosurgery, but every program is super small on average. As you think about your journey, and you're dead set on being a neurosurgeon, all this data shows that you need to well.

"If you're dead set on being a neurosurgeon, you better buckle down for medical school...to make sure you have great board scores, great grades."

So for U.S. Seniors there are 212. Again, U.S. Seniors here means that it's somebody who's an allopathic/MD still a senior in school. So this doesn't include U.S. Grads who are now taking a gap year, doing research, or doing something else who have graduated.

There are 311 total applicants for those 218 spots. Through this episode, Ryan will discuss where these other 99 students are coming from. And out of those U.S. Seniors, 183 matched. So it's 83.9% U.S. Seniors matching in an allopathic medical school. This tells you that they're favoring students at allopathic medical schools.

[06:45] Summary of Students: U.S. Seniors, U.S. Grads, IMGs, Osteopaths

Table 2 shows where these students are coming from. Again, 83.9% of those that matched are U.S. Seniors. And 15% of those students are U.S. Grads. This means they probably took a year off or they didn't match their first time around so they did research or whatever. There are 2 osteopathic students and 4 U.S. citizen international medical graduates matched into neurosurgery.

Looking at this data, is going to a Caribbean school better than going to an osteopathic school? Thinking this alone is wrong. You can't draw these conclusions as to why the numbers say so. If all four of those students when to a DO school, they might have still matched because of who they are, not the letters after their name.

"You can't draw conclusions that says going to Caribbean school, Australia, or Ireland better than going to a DO school if you want to match into neurosurgery."

Non-U.S. citizens international medical graduates are 14 of those that matched. They are obviously strong students who crushed their boards that they were able to match almost as many students as U.S. graduates.

[09:22] Yearly Trends

Table 3 shows the yearly trend showing a slow, steady incline every year for the number of positions from 204 to 218 over the last five years. It's a 0.8% increase every year from 2013 to 2017.

Looking at Table 8 shows the number of positions offered and the percent filled by U.S. Seniors versus all applicants.

For 2017, 83.9% were U.S. Seniors and the numbers are pretty high every year. In fact, this is the lowest year since 2013. It's 92.6% in 2016, 89.5% in 2015, 91.7% in 2014, and 93.1% in 2013.

This tells you a couple of things. That for 2017, less U.S. Seniors matched percentage-wise for the total number of positions offered. This tells you that either there were less qualified students applying this year or there are more qualified non-U.S. Seniors applying this year.

Table 9 gives you scope of how big a specialty is. For neurosurgery only 0.8% of all applicants matched into neurosurgery. There are a total of 27,688 students and 100% of those students are matching. Another surgical subspecialty that is low is ENT with 1.1%. Not a ton higher but still higher.

"Out of the 27,688, only 0.8% of those are matching into neurosurgery. So it's a very, very small specialty."

[12:35] Unmatched U.S. Seniors and Independent Applicants, SOAP

Looking at Figure 6, Neurosurgery has an unmatched percentage of 20.6% so one out of every five students is not matching into neurosurgery. 55.4% of the independent applicants go unmatched. So it's a large percentage of that are non U.S. Seniors. Only 10.4% of U.S. Seniors are unmatched.

Comparing this with other specialties, plastic surgery is 16.3% for U.S. Seniors, Dermatology is at 13.8%. This is a high percentage but not the highest.

Table 18 shows the SOAP (Supplemental Offer and Acceptance Program). Neurosurgery had 0 unfilled programs so no neurosurgery programs needed to participate in SOAP.

[14:00] Charting the Outcomes 2016

Digging into the Charting the Outcomes 2016, looking at percent match by preferred specialty, Chart 3 shows that 76% of U.S. allopathic seniors matched into it. This the third lowest. Vascular surgery is 71%, Orthopedic surgery is 75%. This tells you that it's one of the most competitive specialties out there, at least for U.S. Seniors.

Table 2 talks about the mean USMLE score for Step 1 and Step 2 CK (Clinical Knowledge) versus CS (Clinical Skills). The mean USMLE Step 1 score for all specialties combined for those that matched was 233 and 230 for those that did not match. Keep these numbers in mind.

"To match, you have to rank a lot of programs. The more programs you rank, the higher the chance that you will match."

Chart 4 shows that in Neurosurgery, the median number of contiguous ranks is at 16 while those that did not match only had a median number of 11. So you need to rank enough programs to match. If you want to match, you cannot be very picky. Are these people not ranking programs because of location? Or prestige? Or are they not ranking programs because they just didn't interview there and decided not to rank them. So there are many questions there.

Again, the data is just data. You can't draw conclusions based on this data. We can only make some inferences and discuss what is behind these numbers. But there is no way of knowing specifically why the numbers are what they are.

[17:23] Ranking by Specialty and Step 1, Step 2 Scores

Ryan always tells students that if you want to be a physician, don't have a plan B of being a PA. Don't have a Plan B of being an NP. Don't have a plan B of using your Biology degree or something else. If you want to be a physician, figure out how to get there.

"Don't have a plan B of being a PA... If you want to be a physician, figure out how to get there."

Chart 5 talks about the mean number of different specialties ranked by U.S. Allopathic Seniors. This tells you that those who have a plan B did not match at a much higher percentage in most instances than those that didn't have a plan B. Looking at Neurosurgery, the mean number of different specialties ranked was 1.1. This means a  large majority of students only ranked neurosurgery on their rank list. The mean number of those that did not match was 1.4. It means there are more of those students putting in different, most likely, surgical specialties. If you're applying for neurosurgery, that means you like the operating room. This probably means you're applying for maybe general surgery as a backup. And that back up might hurt you. Psychologically, it might hurt you. And the data shows it leans that way.

Chart 6 looks at Step 1 scores. The mean Step 1 score for all specialties was 233. For neurosurgery, the mean Step 1 for those that matched was 249. Those that did not match was closer to 238. So you need to have great board scores to match into neurosurgery on average. The same thing for Step 2 scores. The mean Step 2 scores for all specialties was 244.8. For those that matched into neurosurgery, the number was upward to 251-252. For those did not match, it's closer to 242.

"You need to have great board scores, if you're planning on being competitive for neurosurgery."

[20:21] Scores, Research, Publications, AOA

Table NS-1 shows that Mean USMLE Step 1 Score is 249 for those that matched and 238 for those that did not. Step 2 Score is 251 for those that matched and 241 for those that did not match. Research experience is 4.8 versus 4.2. Number of abstracts, presentations, and publications for neurosurgery is 13.4 for those that matched versus 8.4 for those that did not. This tells us that research is very important for neurosurgery.

"Research is very important for neurosurgery."

The number of students that are AOA (the medical student honor society) based on grades, almost 33% of those that matched were AOA versus only 11.5%. It's not just about having the AOA label, but having the grades that made you competitive and that led you to AOA. It means having the grades to give you the knowledge to do well in the boards. So you can look at this thinking you have to be AOA but you have to have a solid foundation of scientific knowledge of all those courses you've taken in medical school. And this leads to AOA. But it also leads to great board scores. So it's not just AOA.

So 9.5% of those that matched have a PhD degree versus 7% who did not. Mean number of contiguous ranks is 15.7% of those that matched versus 10.2% for those that did not match. Again, you need to rank a lot of programs to increase your chances of matching.

[22:27] Burnout Rates and Compensation

Moving on to the data of Medscape Lifestyle Report 2017, Neurosurgery is not on the list since there are only a few number of them. And looking at Medscape Compensation Report 2017, it's the same thing, Neurosurgery did not have enough representation to be in this list.

Anecdotally, Neurosurgery is one of the highest paid specialties out there. If this is something that's motivating you, which shouldn't be, neurosurgery is up there. Based on the NRMP Match Data, it's very hard to get into neurosurgery. But if this is what you want to do, start now. Make sure you have a solid foundation of your classwork. Get AOA as much as possible and get great board scores. Get those connections to neurosurgery programs. Make a great impression as you go through this process.

Links:

MedEd Media Network

Specialty Stories Podcast Episode 20

NRMP Main Residency Match 2017

Medscape Lifestyle Report 2017

Medscape Compensation Report 2017

Charting the Outcomes 2016

The Premed Years Podcast

Jan 03, 2018
55: What Does Rural Pediatrics Look Like?
38:38

Dr. Ekta Escovar is a general Pediatrician in rural Texas. We talked about her desire to work in a rural setting and the benefits and challenges it presents.

Dec 27, 2017
54: Academic OB/GYN Discusses Her Journey to the Specialty
23:38

Session 54

Dr. Esther Koai is an academic general OB/GYN. Listen to what drew her to OB/GYN, what she recommends you do if you're interested in it and so much more.

She talks about her role, why she chose the specialty, and what you should be thinking about if you're interested in getting into OB/GYN.

Also, check out all our podcasts on MedEd Media. For suggestions of physicians you want interviewed here on the Specialty Stories, shoot Ryan an email at ryan@medicalschoolhq.net.

[01:07] An Interest in OB/GYN

Esther says she likes working with women as well as the comprehensive care OB/GYN's provide. She also loves surgery. Specifically, she loves working with women and women's issues, women's health, and women's sexual health. She does a lot of contraceptive counseling in the office. She finds a lot of women who may not feel comfortable of talking to their friends or mothers/family, or even a male provider about certain aspects of their sexual health. And they'll open up to a gynecologist or open up to someone listening specifically for certain things.

"It's a good mix of both the patient side, the continuity of care, and the surgical aspect of care."

She realized this was the path for her during her four year of medical school. She finished her OB/GYN rotation on the third year. It was towards the end of her third year that she applied to all of her neuro electives as she was going into neurology. Then her last rotation of third year was Pediatrics and she realized in the middle of that rotation that she was much more interested in the maternal fetal aspect of things. She missed the labor floor since she had so much fun at her OB rotation. So she ended up canceling all of her fourth year electives and reapplying for OB/GYN.

[03:47] Traits that Lead to Becoming a Good OB/GYN

Esther thinks that in order to be a good OB/GYN, you have to be a good clinician and have that clinical acuity. You also have to be able to act fast. Similar to emergency medicine where you have to be able to respond fast. You have to be able to recognize that this is an emergency and you've got to call your team in and all that.

Additionally, you have to be able to be flexible and be able to go between your OB and GYN patients. That means you have to switch back and forth from doing prenatal care to doing a paps smear and all of that.

As an OB/GYN, she can decide whether she wants to focus on GYN over the other and vice versa. She explains it depends on your department but you can say you can focus more on GYN and do more teaching. There are people who refer their hysterectomies to her.

"In order to be a good OB/GYN, you have to be a good clinician and have that clinical acuity."

[05:18] Academic vs. Community Setting

Part of the reason she chose to go into academic medicine versus going out in the community is her love of teaching. She loves teaching both her patients and residents and medical students, which you can only get in the academic setting.

They do a lot of grand analysis and statistics and a lot of academic activities sprinkled in throughout her week. And she enjoys those.

She did interview at a couple private practices but she found they just weren't for her. Part of it too is the thrill of just being in a high, action-packed, high risk academic center. Because you can see all the cool, crazy stuff out there. You get all the referrals for the intricate medical puzzles.

[06:37] Types of Patients, Typical Day, and Taking Calls

Being at a big academic center, Esther is seeing a wide range of patients. They're an accreta center so they see a lot of placenta accretas. They do hysterectomies. They have a Level 1 NICU. So they're able to deliver very premature infant. Their MFM (Maternal Fetal Medicine) team is well-developed so they have a larger referral base.

A typical day for Esther would be Mondays, she would have a morning off for paperwork. Monday afternoons, she precepts the residents in clinic. Tuesday mornings, they have their academic days - stats, rounds, etc. And they usually have their own panel in the morning and then in the afternoon, she precepts again and do continuity clinic. By panel, she means her own patients. So Wed-Thurs, she sees her own patients.

Usually, two Wednesday nights per month, she'd be on call. So she would be post call on two Thursdays. And then Fridays, she's in the hospital either doing labor and delivery cases and OR cases.

It's her personal preference to have clinics just by herself on days and with residents other days. She chose to be a clinic preceptor and she enjoys teaching and seeing patients with the residents.

Esther takes three overnight calls a month. One is a 24-hour shift on a weekend and the other two are 15-hour shifts. It's an in-house call where she's there with the residents. They see all the patients, triage them, and present them to her. Then she will go and reevaluate and go over things they may have missed or they may have not thought about.

"It can get pretty busy to where I get no sleep at all. And it can also be every once in a while, very chill and laid back."

[09:45] Percentage of Patients in the OR

For Esther, the percentage of patients that come from her clinic ending up in the OR is higher. During Wednesdays and Thursdays, she's at a site where she's the GYN consult. So all the patients she sees have already been screened by a family medicine or internal medicine provider. They refer them to her because they need additional workup of they're a little bit more complicated. So she only sees GYN patients that are more complicated on those days.

She thinks she has a disproportionately high number of GYN patients that she ends up doing procedures on. She estimates it would be a third to a half, she ends up looking for cases. Everything else is either medical management or routine.

[10:44] Work-Life Balance

Esther feels like she never has enough time for family. For her the work-life balance is what you make of. Like when you're able to utilize your vacations well. She has one weekend of call a month so she gets to spend time with family for most weekends. And she thinks this is better than if she were in private practice.

"Work-life balance is what you make of."

[11:25] The Training Path to Become an OB/GYN and Competitiveness

After medical school, you have four years of residency. Then if you want to specialize, they have two to three year fellowships including Family Planning, GYN Oncology, Maternal Fetal Medicine, Urogynecology, Minimally Invasive Surgery, Reproductive Endocrinology, and Infertility. Family Planning Fellowship involves contraceptive counseling, IUD placements, dilation curettage, dilation evacuations, terminations, etc.

Esther doesn't think it's one of the more competitive residencies. Rather, it depends on the program so she'd describe it as mid-range, much like Emergency Medicine. What they're looking for in applicants are those who are willing to put a lot of time and effort into the residency. It does suck up a lot of your time. As far as research and things go, they're not really a huge research center so applicants can do academic research at their program. But it's not the program that turns out into academic literature. But they're looking for people who are able to see a high volume patients and are willing to deal with patients with high morbidity and who are obese. They're able to deal with patients with multiple medical problems. They're looking for people who are ultimately going to be happy.

For someone doing an elective rotation as a medical student, it can be hard to look for these qualities. But part of it is just the general feel. The residents are pretty clear about whom they click with. So her first move is to usually ask the residents what they think of the applicant or the sub-I. She'd find out whether they seem interested or engaged or they just checked out in the corner.

"People always put their best face forward, or at least, should be putting their best face forward."

Esther explains that the mark of a good sub-I is someone who is just very much part of the team, very self-motivated, and somebody you would rely on just as much as your own intern.

[14:35] Bias Towards DOs and Working with Primary Care and Other Specialties

Esther hasn't seen a lot of negative biases towards DOs. And part of that is because one of their MFM's at their program who is highly respected and he ended up being the director of the department at their site, is a DO. That said, they haven't had any DO residents so she hasn't really encountered any other DO OB/GYNs. Alternately, she does see a lot of DOs in Anesthesiology and they're doing just fine.

What she wished primary care providers knew about OB/GYN to better serve their patients is that they knew more about contraceptive counseling for one. And in general, she wished more people felt more comfortable talking about and dealing with female anatomy. It's a daunting idea to people who don't routinely work in that field so it's something that people tend to shy away from. But there's nothing scary about it, Esther says. Other specialties she works the closest with include Urology, Emergency Medicine, Family Medicine, and Surgery.

"There are a lot of misinformed statements floating around out there about contraceptives."

[17:02] Special Opportunities Outside Clinical Medicine, What She Wished She Knew, and the Most and Least Liked Things

Special opportunities outside the clinical world for OB/GYN may include work in patient safety. They have so many obstetric emergency situations. So there are opportunities in patient safety in QI.

What she wished knew that she knows that you've got to really work really hard. But it's all going to be worth it in the end. The amount of knowledge that you gain and the amount of surgical prowess you gain are just unbelievable. It's so rewarding to be able to apply that on a day to day basis.

What she likes most about the job is the patient counseling. She likes having that sit-down conversation with them where she's able to connect with them and they understand things about their own health they may not have understood before. She adds it's an aha moment for every patient when they find out something they've never known before. She finds this very rewarding. And for selfish reasons, she says she loves doing surgery and for her, it's an immediate gratification.

What she likes the least on the flip side is chronic pelvic pain in terms of the types of patients and treating them and all the stuff that goes with it. She finds it cumbersome and difficult to treat. She thinks it's very multifactorial and patients usually get bounced around from place to place. Then they come to you very frustrated because they've tried everything.

[19:20] Major Changes in the Field of OB/GYN and the Future of Residencies

She thinks there's a lot of tracking going on and in other fields as well. Especially in OB/GYN where they're two very separate fields meshed together into one. And this is reflected a lot in the way that the entire field is moving both in the academic and in the private world. Before, you'd see more generalist doing both OB and GYN, but now you're seeing people doing OB only as laborists or GYN only in the clinic. And it's becoming more of a divisive field, Esther puts it. So this is the general trend of things and a lot of academic centers are doing it.

"You have your OB side and then you have your Gynecological side. If you weren't dealing with the same organs, they'd be almost totally separate fields."

Although she's not yet seeing this as of the moment, but potentially down the line, there is that possibility of students applying to OB-specific residencies and GYN-specific residencies. Esther says that if she had to do it all over again, she would still have chosen the same. She loves the people and the patients. She thinks it's a great field and it's fast-paced and can be very intense. But you can also make it very calm and inviting. So it's a very versatile field.

Lastly, she leaves the premed students with an advice to do it. Be enthusiastic. Be curious and ask questions. Seek out the puzzles and really dive right in. There's no better way to experience something other than just committing 100%. It's so rewarding to be able to talk to a patient and have them really hear what you're saying and have them light up.

Links:

MedEd Media

Dec 20, 2017
53: An Academic MS Specialist Discusses The Specialty
39:39

Session 53

Dr. Jacqueline Bernard is an academic Neurologist who specializes in treating patients with multiple sclerosis. She is a physician at OHSU (Oregon Health and Science University). We talk about the specialty and so much more.

Tune in every week to hear different stories of specialists even if you're interested in going into primary care. One of the questions I ask them is what they wish primary care doctors knew about their specialty. Also, check out all our other podcasts on MedEd Media.

This week, I interview Jacqueline who has been in practice now and out of her training for many years now. She has been in the community-based setting and is now back in an academic setting.

I was diagnosed with MS about three and a half years ago so this episode hits home for me. So we chat about her career as an MS specialist, what drew her to it, what keeps her happy, things she didn't like about it, and her advice to you if this is something you're interested in.

[02:04] What Do Her to Becoming an MS Specialist

Jacqueline says her interest grew in her. As a woman, her practice was getting referred a lot of female patients with neurological disease. And a large percentage of them were patients with MS. She realized very early on how this was a very compelling group of people. They were trying to educate themselves as much as they could about this disease process and what treatments are out there. This grabbed her pretty quickly once she was in the region of the country where it was disproportionately highly prevalent compared to other places.

Minnesota for instance, has a lot of MS cases. So it was the volume of patients she was seeing that grew quickly. Within a couple of years from moving to the state, this impacted her.

"MS is a very tricky disease. You have to be able to detect it. That's also true about Neurology in general."

Jacqueline explains how MS is a tricky disease and you would have to be able to detect it to figure out what's going on because it can relapse and remits. So you'd have to look at the circumstantial evidence. It might  involve various parts of the nervous system such as optic nerve, spinal cord, or the brain. So you get to see the impact of the inflammation in a lot of different ways.

The most compelling part for her is how people are able to manage it and how they bounce back and continue to really live with the disease. Another piece about it is that people with MS can have really severe attacks. Jacqueline says you can help them get through that and bounce back. Ans this is something that inspires her to help patients.

[05:45] Traits that Lead to Being a Good MS Specialist

Jacqueline says you have to be curious about the path of MS and having interest in all the different ways you can suppress inflammation. If you're interested in neuro immunology, Jacqueline things it's one of them most interesting parts of clinical medicine today.

"It's really an interesting disease to watch over the last 20 years because in the process of trying figure out ways to stop inflammation, a lot of science is being uncovered."

Jacqueline was initially drawn to Epilepsy seeing how it has interesting science and mechanisms. In fact, it's more interesting now that there are certain antibodies found to be associated with refractory epilepsy.

She was also interested in moving disorders, having had some of the country's best moving disorder specialties in their school. They actively engaged them into going rounds and invited them to hang out. They taught all the perils along with their fascination and passion about moving disorders. She specifically cited one of the editors of Handbook of Neurology who was their teacher - a big supporter of medical students. In fact, 10% of each class went into Neurology because of his teaching. Teachers have a huge impact in the way they bring the top of the live and how that inspires students. Anyway, she ended up doing MS which for her was workable for someone trying to raise a family.

"MS was more amenable to trying to have a career and a family."

[09:23] Patient Types and Over Diagnosis of MS

Classic patient demographics are those between the ages of 20 and 40, women to men ratio of 3:1. However, they're now seeing much more pediatric MS. These are cases of children down to age 10. They're also seeing first time diagnosis for people in their 50's and even in their 70's going to their clinic.

"It means that something about the way we live. Not for ascertainment but probably the prevalence is increasing. It also means people are living longer with MS."

That said, they have a huge age range of patients at the MS clinic across the country. And by ascertainment, we're not just getting better at testing and finding MS. Instead, there's more people developing MS. And now that we have an MRI machine in every corner, it's much easier. In fact, people are over diagnosing MS. This was at a recent meetings at European Clinical Trials MS Meeting in October saying this. Spots on an MRI does not equal MS. So it's important we make sure we're following criteria and that we're able to sit with a little bit of ambiguity until we collect all the appropriate data before we tell people they definitely have MS.

Three years ago, I was diagnosed with MS and it was a question of whether I have MS or was it something else. It's interesting to hear that there's a lot of over diagnosis. It seems pretty simple. It's not a test but a clinical diagnosis through the McDonald Criteria for MS.

Jacqueline explains that the good thing about this criteria is we could now incorporate MRI neurological information into out decision-making. Then use that to help us proof of dissemination and space and time. Those criteria are actually being decided upon for possible revision. She adds the need to be able to have clear evidence of dissemination in space and time. Otherwise, we're going to see more people having lumbar punctures to try to find evidence of abnormalities to help substantiate this. This being said, more corroboration will be needed.

There are the clinically isolated syndrome but even before that, people talk about radiologically isolated syndrome, which are spots on the MRI obtained for other reasons. And this is probably the most common reason people are having an MRI.

[13:55] Percentage of Patients Already Having a Diagnosis of MS and Typical Day

Jacqueline sees patients in the MS clinic as well as some general neurology patients. Most of the patients in the MS clinic have been given a diagnosis. They're asking for second opinion on the diagnosis or regarding some new treatments that may be out.

"75-80% of the patients they see in the MS center already have a diagnosis. 20% wonder if they have it or are worried they might have it. But most likely, they don't have it."

In the general neurology clinic, they get a lot of questions about numbness and abnormal MRIs. Some of them turn out to be MS but not all numbness equals MS and not all abnormal MRIs equal MS.

A typical MS day for Jacqueline may include having a medical assistant in the clinic with them. They have an MS-certified nurse and three fellows and several MS faculty. They get people roomed. They also have two city coordinators in the clinic, who see who could be patients appropriate for studies. They have 12-14 desktops in their workroom so they can pull the MRI results there and get a lot of discussions.

So Jacqueline sees 50-50 percentage of her time spent on MS versus general neurology. She also has another administrative role being the Vice Chair for Clinical Operations in her Department. She does a lot of work around access in the state of Oregon. She sees patients and learns about how they get referred in.So she's still trying to understand referral patterns, access, and improving it in every way they can.

[18:06] Taking Calls in an Academic Setting vs. Private Practice

In academic medicine, Jacqueline their calls to be a little different. A couple of weeks may be spent on the teaching service. Their residents are taking the call for the general neurology ward as well as the stroke service. When they're covering the neurology ward, they're not covering the stroke service. But for at least the first week of their two-week stint, they're covering the transfer service.

Any doctor in the state of Oregon, and sometimes the state of Washington, Idaho, or Montana can call into HSU if they have a neurology question. Or if they have a potential transfer. They take those calls. She describes the transfer center as very organized and data-driven that they call it command control. They monitor all calls that come in. Everything's recorded. They give advice and they may follow the patient. Or if it's a critical patient, they suggest they transfer the patient and their transfer center makes it happen if there's a bed available.

"Bed availability of course, is a problem at academic medical centers around the country."

Moreover, they partner with other community hospitals. Some of the less acute neurology transfers might go to one of their community partners rather than all the way into the university hospital. Her calls are intermittent during the day and at night for the first week of her two weeks. They also cover 24/7.

Jacqueline differentiates this from taking calls in private practice, which she did for a number of years. That would be you're on call 24/7 for a full week and you're taking primary call, mostly people you see in consultation on the same day or next. Or you get call from the ER for acute stroke or a huge hemorrhage.

As a neurologist, they're consultative when they're working in private practice. At academic institutions, they typically have a neurology ward where they do their teaching. So it's a little bit different. Typically, when neurologists go out of private practice, they're strictly consultative. They're not running a ward.

[21:44] Work-Life Balance

Her decision to leave private practice and go back into academics was that because her kids were getting bigger, she can spend more time running papers and grants.

"A neurologist spends, on average, five hours more per week outside of work doing computer back up work, five hours more per week than other specialties."

Jacqueline thinks there is a demand of time that is difficult to balance with having a family. It takes resources to raise a family. So it made more sense for her to cut back when her children were younger and then when they're older, she's now able to dedicate more bandwidth to her work.

At this point in her life, she considers herself busier than most people by choice considering the opportunity to take her leadership position. But she believes it's hard to achieve a balance when your children are younger.

[23:55] The Training Path

Typically, you can take a one-year or two-year fellowship after four years of general neurology. These are not yet funded in the same way a stroke fellowship would be funded for instance. So it's not ACGME-funded at this time. Most of their MS fellows find their funding either through pharma and other national MS society funders. They often go out and write their own application to entities that do fund. Jacqueline advises to plan this ahead of time.

"Essentially for any fellowship, you've got to be ready by about PGY-2 to start thinking about it for sure."

Talk to some people and places and so some electives. See if that's really what you want to do. Start to get your applications going.

The training is pretty popular as Jacqueline would describe. They would receive plenty of applications for their one or two spots they take each year. She thinks the MS prevalence has increased and the number of things they can do has increased. MS was also the place where they talk about neuro immunology which has grown so much. In fact, at the American Academy of Neurology, there's not just an MS section but they now have an neuro immunology section. They call their fellowship MS under immunology but it may by at some be split off and it will be either/or. A lot of these disorders are associated with unusual antibodies. So there are different ways to think about your fellowship.

[26:42] How to Be Competitive for Fellowship

If you're a resident interested in MS fellowship, during your PGY-2 when you're trying to get exposed to everything, set up some electives. This way, you can spend more time to expose yourself. Second reasons is to get people to know you and like you and write letters for you.

If you have a research interest which is hard to do in your PGY-2 year, but if you can think of something where you can do over your residency in that field, go ahead. Have at least some project you can submit as a poster or write a paper, a review or part of the chapter with your MS faculty. Inquire early as to what they're working on and where can you fit in.

"Get to know the faculty where you are so that they can tell you what you need to do, maybe get to like you, and try to help you stay there or write letters for you."

Another important thing is to try to present at meetings to help you get to see what other people are doing. Get inspired by them and that will help you determine whether you want to do the fellowship.

[28:27] Bias Towards DO and Working with Primary Care and Other Specialties and Special Opportunities Outside of Clinical Medicine

Jacqueline has not seen any bias towards DOs. She has worked with fellow who had osteopath training. They fit in absolutely with the other fellows.

What she wished primary care providers knew is that not everything that is white spots equals MS and that not everything that is none is MS. It's important to look for other entities and exclude other entities who are writing out e-consult guidelines to help our primary care doctors. At least, they do something to work up before sending patients over to them so they can help them know and also become more efficient and appropriate with their time and who they see in clinic.

"If somebody has numbness, do a good neurological exam."

That's why neurology is so important in medical student education so people can start to put together all this random cranial nerves and motor reflexes. Learn that so that you can do these exams. Maybe it's a peripheral neuropathy and it's not MS. Or maybe it's a migraine and not MS. So try to get a good neuro exam to get good history if you can.

Other specialties she works the closest with include ophthalmology, rheumatology, and hematology oncology.

Special opportunities outside of Clinical Medicine for MS specialists include pharma aspects. People can work in the lab and direct a drug development or in clinical trial design for potential drug candidates. Then those people putting drugs to the FDA. There are people who zoomed into pharma early in the career and they get an intensive experience getting a drug through the FDA. It's a 24/7 stuff where you have your SWAT team.

Others who have worked in the MS centers for many years can get scooped up and get offers to go to different pharma companies to run their different clinical development program.

[33:55] What She Knew Now, Women in Neurology, and Major Changes in the Field

Jacqueline says there are no guidelines being a woman and having kids. But if she had known it's going to work out then it would have been good. But she had no choice otherwise.

"As I look at women today, many women are choosing to have their children in residency and somehow that all works out just fine."

It's common to see women in neurology now that more than 50% of medical school classes are women. Interestingly, they have a disproportionate number of women applying to neurology in their region. This reflects that more women are in medical school.

What she likes most being an MS specialist is the patients being so compelling as well as the science. MS has really led a lot of interesting science. The neuro immunology has exploded over the last 20 years. It's a perfect mix of clinical with really interesting science. On the flip side, what she likes the least is generic to neurology, which is all the time they have spend on the computer. There are other people in the room with them that are from insurance companies. So it's a whole different field now. Still good, but a lot more has changed.

In terms of the major changes in the MS field, she thinks patient continue to be very educated about what they choose to take. She just hopes people can maintain their healthcare coverage so they can continue to get the access to important medications.

If she had to do it all over again, she would still have chosen the same filed. She thinks it's the most interesting filed, not to mention having great colleagues across the world. They're working hard to improve treatments and assessments. All the aspects of it is interesting.

[38:01] Final Words of Wisdom

Jacqueline says that by 2025, they are predicting neurology desserts in at least five states because of the graying of the population. So there are more neurodegenerative disorders. So there's job security in MS.

And if you're in general neurology, you can see MS and other things too. Parkinson's, Dementia, migraines, etc. You get to see a variety of people and lots of different kinds of diseases that help affect the nervous system and impact families hugely. Neurologists impact patients everyday.

Links:

MedEd Media

European Clinical Trials MS Meeting in October

McDonald Criteria for MS OHSU (Oregon Health and Science University)

Dec 13, 2017
52: A Look at Pathology Match Data, and Lifestyle Reports
22:44

Session 52

This week, we're diving into the match data and cover Pathology. Interestingly, Pathology is a small field that seems to be losing interest among graduating U.S. seniors according to the data.

I'm digging into the results of the NRMP Residency Match Data 2017. As you're going through the process, you can understand what this data is telling you and what you should know to help you better plot a path.

[02:40] General Overview

Table 1 shows the match summary. Let me clarify first that the U.S. Seniors for the NRMP match data means U.S. students in an allopathic/MD program who are still in school. So a student could have graduated from an allopathic program and now applying to residency. Maybe they didn't get in the first time or took a gap year for some reason.

Caribbean students and international medical grads, foreign and U.S. citizen international medical grads are not counted as U.S. Seniors. DO students are not counted as U.S. Seniors.

Back to the data, there are 159 programs in Pathology with 601 spots. It's a very small specialty. Just to give you a comparison, Anesthesiology has 1,202 positions with 124 programs. So it has less programs but double the spots. This said, Anesthesiology has much bigger residency programs than Pathology.

Unfilled programs for Pathology is 33. It ranks up there with a lot of other programs that go unfilled. It's interesting to know why this is.

U.S. Seniors who applied are 232 out of 601 spots. Let's say out of 150+ medical schools in total, only one and a half students per medical school are applying to Pathology. So it's not a lot of senior medical students are applying to Pathology.

There are 876 total applicants for those 601 spots. Even though there were more applicants than positions, they still went unfilled. Out of the students who filled Pathology, only 36% were U.S. Seniors and 91% of all the spots were filled. Pathology does not have PGY-2 positions and it doesn't have any physician positions here.

"It's a good number of programs, but very small programs."

[06:25] Matches by Specialty and Applicant Type and Trends

Table 2 of the NRMP Match Data 2017 shows the matches by specialty and the applicant types.

Out of 601 spots in Pathology, only 545 were filled. This data is only pre-SOAP.  Let's see if they filled the programs after the SOAP.

Out of the 545 filled, there were 216 U.S. Seniors who were accepted. There were 25 U.S. graduates, 32 osteopathic students, no Canadians, 57 U.S. international medical graduates, 215 non-U.S. citizen international medical graduates, and 56 unfilled spots.

Table 3 shows how many spots are available each year from 2012 through 2017. Every year, it goes up by 2.1% or 2.2%. So it's a slow steady rise in the number of spots available.

Table 8 shows us the number of positions offered and the percent filled by U.S. Seniors and all applicants from 2013 to 2017. There was a dip from 2015 to 2016. The number of U.S. Seniors that filled those spots went from 45.1% in 2013 to 42.9% in 2014, then 46.6% in 2015 and down to 42.8% in 2016, and further down to 35.9% in 2017. There's been a pretty sharp decline of U.S. Seniors filling up those spots.

"There are less U.S. Seniors who seem to be interested in going into Pathology."

Table 9 shows the number of all applicants that matched by specialty from 2013 to 2017. 2% of all students that matched, matched into Pathology. Anesthesiology is 4.1%, Emergency Medicine is 7.4%, Family Medicine is 11.6%, and Internal Medicine is 25.6%. Orthopedic Surgery is 2.6%. It's the only one that's close to compare Pathology with. Neurology is 1.7% and Medicine-Pediatrics is 1.3%.

[10:42] U.S. Seniors, Osteopathic Students, Foreign-Trained Physicians

Table 10 shows U.S. Seniors that matched by specialty. 1.2% of U.S. Seniors matched into Pathology. This is less than last year of 1.5% and less than a year before at 1.7%.

Table 11 shows osteopathic students that matched. 2.1% of all osteopathic students matched into Pathology in 2016. While it was only 1.1% in 2017. There were 51 in 2016 and 42 this year, 2017. It was 44 in 2015 (1.9%) and 51 (2.4%) in 2014, and 2.4% in 2013. So it's going down dramatically over the years.

"If you're an osteopath and you're interested in Pathology, there's another sharp decline in Pathology for osteopathic students."

Table 12 shows the foreign-trained physicians that matched by Specialty. There were 272 foreign-trained physicians who matched into a PGY-1 spot for Pathology. It went up to 4.1% in 2017 from 3.3% in 2016. But the number of U.S. trained physicians is going down.

[12:20] Unmatched U.S. Seniors and Independent Applicants Who Ranked Pathology as Their Only Choice

Figure 6 shows the percentage of unmatched U.S. Seniors and Independent applicants who ranked their specialty as their only choice.

Pathology is high up on the list for total unmatched applicants at 23.3%. That's because there's a large contingent of non U.S.citizen foreign medical graduates applying to pathology. Hence, the large percentage of unmatched total applicants. 33.5% of those are unmatched independent applicants, which are anybody other than U.S. Seniors. Only 5% unmatched U.S. Seniors.

Looking back at Table 1, there are a lot of spots for a little number of U.S. Seniors applying and yet 5% of them still were unmatched.

There could be a number of reasons why they didn't match. It could be that they didn't apply to enough programs. Or it could be their board scores were terrible. It could be that they didn't have enough research experience. It could be that they didn't have enough exposure to Pathology when asked why they wanted to be a pathologist.

That's what residency is all about. So you can ask yourself whether you can work with this person for 80 hours a week for the next four or five years.

"It's all about getting to know that person who's sitting from you on the table during the interview."

[14:40] SOAP

There were 31 Pathology programs that participated in the SOAP for 54 positions. If you look at Table 1, there were 56 positions that went unfilled. So two positions magically disappeared.

After the SOAP, there were only 22 programs that went filled and 45 spots were filled as shown in Table 18 of the NRMP Match Data. So even after the SOAP, there were 9 positions still available. In 2016, there were 14 programs for 24 spots and all of those spots were filled.

"It's telling me there are not a lot of qualified candidates for Pathology out there if these programs are going unfilled."

[15:55] Charting the Outcomes 2016

Let's go to the Charting the Outcomes for U.S. Allopathic Seniors 2016.

Looking at Table PTH-1, the mean number of contiguous ranks means how many students ranked before leaving a blank spot in their rank list.

Those who matched had 9.9 contiguous ranks. Those who did not match only had 5.1. This shows that you have to rank enough programs if you want to match. If you're restricted by geography or some other reason, you need to be aware there's a good chance you won't match because of that.

"You need to rank enough programs if you want to match."

The mean USMLE Step 1 score is 233 for those who matched and 210 for those who didn't. There's a very low Step score for those who didn't match versus those who did. Mean Step 2 score is 243 for those who matched and 225 for those who didn't. The mean number of research experiences is 2.8 for those who matched and 2.4 for those who didn't.

Mean number of abstracts, presentations, and publications is 5.9 for those that matched and 7.6 for those that didn't. Maybe they spent too much time writing abstracts and not enough time studying for the boards.

Percentage of AOA members is 13.3% for those that matched and 0% for those who went unmatched.

The percentage who graduated from one of the 40 U.S. medical schools with the highest NIH funding is 37.6% for those that matched and 12.5% for those who went unmatched.

Those who have PhD degrees have 22.4% for those that matched and only 20% for those that did not match.

[19:20] Medscape Lifestyle and Compensation Reports 2017

In the Medscape Lifestyle Report for 2017, Slide 2 shows the physicians who are the most burned out. Pathology is near the bottom at 43%. Psychiatry and mental health are the lowest at 42%.

Slide 3 shows how severe is the burnout and Pathology is near the top at 4.4. It's a random 1-7 scale and all of them are between 3.9 and 4.6.

Slide 18 shows which physicians are the happiest at work and outside of work. Pathology is pretty low for at work at 36% and 66% outside of work.

In the Medscape Physician Compensation Report 2017, Slide 4 shows the average annual physician compensation. Pathology is in the middle of the pack at $293K a year. Pediatrics is the lowest at 202K and Orthopedics is the highest at 489K.

Slide 5 shows who's up and who's down year over year. Pathology is higher up at 10% increase along with Orthopedics. Pediatrics is the only one that went down year over year.

Pathologists feel fairly compensated at 62% as shown in Slide 18. Emergency Medicine is the highest at 68%. Slide 38 shows only 76% of pathologists said they would choose medicine again. 83% is the highest with Rheumatology and the lowest is Neurology at 71%. And for those who would choose the same specialty (Slide 39), Pathology is at 85%.

Links:

NRMP Match Data 2017

Charting the Outcomes for U.S. Allopathic Seniors 2016

Medscape Lifestyle Report 2017

Medscape Physician Compensation Report 2017

Dec 06, 2017
51: What is Neuro-Ophthalmology? How Do You Become One?
20:20

Session 51

Dr. Bryan Pham is a community based neuro-ophthalmologist who is fresh out of training. He discuses the field and what drew him to it and so much more.

First off, please check out all our other podcasts on MedEd Media.

[01:30] Interest in Neuro-Ophthalmology

Bryan recalls having a difficult time in his neurology residency that got him disenfranchised.It was the end of his first year in neurology, which was the beginning of his second year that he had a very busy workload without a real break.

And the next rotation coming up was neuro-ophthalmology. And for him, that rejuvenated his love for medicine and for neurology.

He likes the wide variety of disease being able to see all different areas in neurology represented within neuro-ophthalmology. There are strokes that affect vision and there are movement disorders of the eyes.

My wife, Allison, is also a neurologist and I remember in her first year of neurology is her second year of postgraduate training. And then your junior of neurology, she was destroyed that year. So this is not an uncommon thing. So expect this if you're going into Neurology.

"The first year of Neurology, the PGY-2 year, tends to be the most difficult for everybody."

[03:07] Traits that Lead to Being a Good Neuro-Ophthalmologist

Bryan says that to be a good neuro-ophthalmologist, you have to take the time to think over the patient. It's a cerebral field. Not too much in terms of procedures, but he likes the mystery of patients and trying to figure that out.

Being a neuro-ophthalmologist, you're not actually operating on patients or conditions. Bryan explains that there are also neuro-ophthalmologists that do additional training in occulo-plastics.

Other specialties in the running for fellowship training, Bryan also considered neuro-intensive care. But he realized he doesn't really like terribly sick patients and the intensity of it.

[04:42] Types of Patients and Neuro-Ophtho versus Ophthalmology

Bryan describes that one-third of the brain volume is dedicated to vision. We see essentially everything that can affect vision that doesn't come from the eye itself. These could be strokes affecting areas of the brain causing vision loss as well as different abnormalities.

"Anything that affects the brain can and often does affect vision."

Bryan explains their bread and butter diagnosis is a condition called idiopathic intracranial hypertension or pseudotumor cerebri. It is where the pressure in the brain builds up that it can lead to vision loss when it puts pressure on the optic nerves causing them to swell. Nothing in the eye itself is abnormal, the problem is further. So any conditions where the eyeball itself is normal but the vision is affected would be appropriate for a neuro-ophthalmologist.

Bryan says he often gets referrals from his colleagues in ophthalmology but he also gets a few from primary care physicians.

[06:17] The Residency Path

There are two ways going to residency. One is the neurology residency and the other is an ophthalmology residency. Because it's a non-surgical subspecialty, it is an option through neurology. You do the typical neurology or ophthalmology residency and then followed by a year of fellowship in the neuro-ophthalmology. But it's a nonsurgical fellowship.

The joke in Neurology is finding the lesion and knowing the location, or localizing the lesion. But then not being able to do anything about it. In Neuro-Optho, there are also common jokes related to this.

But Bryan clarifies that there are some things that they're able to treat and cure. One example is benign paroxysmal positional vertigo.

Nevertheless, Bryan admits their subspecialty is the "diagnose and adios!"

[07:50] Typical Week and Community versus Academics

Currently, Bryan deals with 80% general neurology and 20% neuro-ophthalmology. There are neuro-ophthalmologists that do it full-time but they generally consist of essentially a full day of clinic.

There are consults they need to do in the hospital depending on the setting. In academic centers, you have more inpatient consultations.

"The nature of their subspecialty lends itself better to an academic setting just because there are a lot of ancillary testing available."

What really drew him to community versus academic setting is the absence of research. Bryan doesn't like the need to be constantly churning out research as well as the politics of climbing the academic ladder.

Bryan's typical week involves 100% clinic for neuro-ophthalmology. In his practice, the inpatient consultations are handled by the general ophthalmologist on call. And if they have any issues, they will refer them to him to be seen in the clinic.

[09:30] Taking Calls and Work-Life Balance

In terms of taking calls, during his fellowship, Bryan served through phone call. He remembers having done it twice in the middle of the month during his fellowship so it was very manageable.

The residents would call him whenever an issue came in. A typical emergency is a condition called temporal arteritis, characterized by an inflammation in the blood vessels on the side of the head. This can present vision loss or impending vision loss. This is one instance they have to act quickly to get the appropriate treatment started.

Bryan describes having a great work-life balance, more so now that he's out of training than he was in training since you'd have to be 24/7. Nevertheless, he has always thought he'd do things around the city and not have to worry.

[10:55] Neuro-Ophtho Fellowship Programs

Bryan describes there is generally one fellow a year at an institution, although some may have two. But only one program has three fellows a year. So it's a very small community. If you go to a fellowship and you're the only one, you are really are 24/7 for that year.

Bryan describes this can get better over the course of the year. Through the middle and end of the year, the residents are well-seasoned so they tend to wait until the morning to call rather than 2 am.

In terms of competitiveness, Bryan says it varies by the year. During his year, they had most of the spots filled. The following year, which is this year, they have a lot of open spots available.

"It fluctuates but certainly not difficult to land a spot."

If this is something you're interested in, Bryan's advice to become competitive is to make it to their national conference called NANOS (North American Neuro-Ophthalmology Society). Because it's a small community, everybody knows each other and so get your face out and meet the other neuro-ophthalmologists out there. Bryan thinks this is the best way to get ingrained in the field. It's all about networking, which I'm a huge believer of.

[12:45] Bias Towards DOs and Special Subspecialty Opportunities

Bryan says a lot of the leaders in NANOS come from osteopathic medical schools.

Moreover, Bryan mentions other opportunities out there to further subspecialize. Johns Hopkins, for instance, does the neuro-otology fellowship where they focus on dizziness. He further jokes that it has its own punishment. Other groups have their own niche as well such as those specialized in the people. Others focus on eye movement abnormalities and eye movement recordings. There are also those that scale in for more vision loss disorders.

[14:30] Working with Primary Care and Other Specialties

What Bryan wants primary care doctors to know is that examining people with your own eyes is important. There are things that can wait in neuro-ophthalmology so his advice to primary care docs is to not be shy about reaching out to them whenever they're concerned about any issues. If it's not appropriate for neuro-ophthalmology, they will direct your otherwise. But they're always willing and open to answering any questions.

"Examining people with your own eyes is important, no pun intended."

Just like general neurology where there is the need for the primary care physicians to know a good neuro exam, you need to know how to look at an eye or the retina. You need to get some sort of differential going. Bryan recommends resources like the online database called NOVEL (Neuro-Ophthalmology Virtual Education Library). They have examples of all the things you need to read about going to medical school.

Other specialties they work the closest with are neuro-surgery, neurology, and ENT. Special opportunities he sees outside of clinical medicine would be clinical trials. You can look into treatments for some of these neuro-ophthalmic diseases. It's mostly clinical practice as the end game.

[18:50] What He Wished He Knew and What He Likes Best About the Field

Although he is still relatively new to this, there is an end game. During his fellowship where he'd like to call it quits, he was glad he didn't at this point.

What he likes about being a neuro-ophthalmologist is the variety of cases. There's a little bit of different areas in neurology in neuro-ophthalmology. So everyday, there is something new to learn, specifically the continuity of patients. What he likes the least, on the flip side, is the charting.

In terms of any major changes that he sees in the field, it's still a relatively new subspecialty. So he feels there are two peaks for the neuro-ophthalmologists practicing out there. The first generation is starting to get through their retirement now. And there's this newer generation that's coming through. This said, there will be a lot of turnover in terms of the field. They will be losing a lot of their mentors. Nonetheless, he doesn't think this will change the practice of neuro-ophthalmology.

"There will be a lot of turnover in terms of the field. We will be losing a lot of the mentors that we had."

If he had to do it all over again, Bryan would still choose the same specialty. Finally, Bryan leaves with some words of wisdom.

He recommends students to come to a neuro-ophthalmology clinic and check it out. He never thought about it before his rotation. And here he is now!

[18:40] Last Thoughts

I actually didn't know that the majority of neuro-ophthalmologists out there were diagnostic physicians. They don't operate. When I think of ophthalmology, I think of a surgical subspecialty. But when you add that neuro on the front of it, then you lose the surgical part of it and you don't get that training.

Finally, please share this podcast in your Facebook group for your class (if you have any) or if you have some sort of email list or email group. Please let them know about this podcast.

If you know anybody who is a physician and should be on this podcast, shoot me an email at ryan@medicalshoolhq.net and we will make it happen.

Links:

NANOS (North American Neuro-Ophthalmology Society)

NOVEL (Neuro-Ophthalmology Virtual Education Library)

ryan@medicalshoolhq.net

MedEd Media

Nov 29, 2017
50: How Can Breastfeeding Medicine Fit Into Your Practice?
24:12

Session 50

Dr. Kristina Lehman is a Med-Peds doc who specializes in Breastfeeding Medicine, helping new moms and new babies through the struggles of breastfeeding.

Check out all our other podcasts on MedEd Media. If you're a med student and you want to be prepared for what's coming, we have a boards podcast coming up for Step 1 and probably Step 2 in the future.

Back to today's episode, Breastfeeding Medicine is one of those fields that really gets down into a "super" niche which is pretty awesome. Kristina is a Med-Peds doc who has taken some further specialty training being a breastfeeding physician.

While the breastfeeding side of her practice only comprises about 25%, still this is worthwhile to talk about as a stand alone podcast. This will give you the information you need if this is something you're interested in. Out of training now for about ten years, Kristina is practicing in an academic setting.

[02:13] Her Initial Interest in Breastfeeding

Kristina's interest in breastfeeding sparked when she had her first child. She always knew she would breastfeed and when she had her baby, she thought she had no idea what she was doing.

So she began researching until she just grew more passionate about it. But the turning point for her was when she discovered the Dr.MILK group, a breastfeeding group. MILK stands for Mothers Interested in Lactation Knowledge. She realized there were people out there who actually are pediatricians and lactation consultants.

Before this, her training focus was in internal medicine and pediatrics. She did a med-peds residency. Coming out of it, she wanted to do primary care and she started in an academic setting. She joined the faculty at where she trained to do Med-Peds Primary Care.

[04:00] Lack of Coverage on Breastfeeding During Pediatric Rotations

Kristina explains that a lot of times, experiential learning comes down from our attendings. Because doctors don't do a great job at breastfeeding, they're not likely to advise their patients well, too. To add to that, there is a lot of formula marketing in pediatric residency. A lot of the AAP stuff is sponsored by these companies.

"We know that doctors don't necessarily do a great job breastfeeding themselves. And that when they don't do a great job, they don't advise their patients very well."

That said, AAP now has a curriculum where they recommend breastfeeding but still it's not widespread. Also, there are a lot of issues with breastfeeding in terms of other specialties telling that infectious disease antibiotics are not compatible with breastfeeding. So when a mom has a complication, she has to stop breastfeeding or pump and dump. Kristina thinks doctors should just really go back to medical school.

[05:40] Traits that Lead to Being a Good Breastfeeding Medicine Doc

Kristina cites the primary things to be a good breastfeeding doc are wanting continuity of care, being a good listener, and wanting to know what's going on. Kristina says the need to integrate and see what's happening to both the baby and the mom. Think about what's going to be best for both of them.

"You can sit there and talk about what's really important for the baby but then that can lead mom to the wayside."

Kristina adds having good problem solving skills is helpful. More importantly, you have to be interested in women and women's health. You shouldn't be afraid of breasts since the breasts are a big part of the practice. She admits there are people that are actually scared of that a lot of times.

Kristina says that are male lactation consultants. It's obviously a female-dominated field. But if you're a guy and you're super interested in helping women then it's like male OB/GYNs. There are a lot of women that see male OB/GYN and they have a good reputation.

[07:37] Other Specialties that Caught Her Interest

Before going to Med-Peds, Kristina was interested in OB/GYN. She loved prenatal visits and all the outpatient stuff that goes with it. She hated surgery and being up at night. So she realized quickly that it wasn't the right specialty for her. That said, she has always been interested in the women's health aspect of things.

Within primary care, she was happy just to do straight up primary care. She loves the variety of seeing both kids and adults. And when she found Breastfeeding Medicine, she was happy she had the opportunity to focus on the academics. She was happy she could get to work on it with medical students and residents. She had the opportunity to work on curriculum development.

[08:30] Types of Patients and Taking Calls

On a daily basis, she deals with regular breastfeeding stuff. She's able to give more evidence-based information and more support for the day-to-day latch and milk supply. When she has a more specialized referral, she gets varied cases. For example, a baby that hasn't latched since birth. Or it could be a baby that was in the NICU so he/she was formula-fed so they have a hard time getting back to the breasts.

Sometimes too, moms are having a hard time with milk supply so she helps them troubleshoot how to make this better. Although there are really moms that have insufficient glandular tissue which never developed from puberty so there isn't enough milk supply. She also deals with other issues like cracked and bleeding nipples or mastitis.

"Most of the stuff is just the day-to-day maintenance of breastfeeding that moms just need a lot of support."

Kristina doesn't do any of the inpatient stuff such as taking calls. But she wishes sometimes though that there was somebody on call. They recently had a mom that had a wound infection. She was in the hospital and got switched around in antibiotics, specifically Cipro. The doctors on the service talked to the pharmacist and the pharmacist said it wasn't okay to breastfeed with it. They told the mom that she had to pump and dump. And so for ten days, she had to pump and dump. Then the mom came to her a bit later. But they would have been able to take care of that early on. She didn't actually need to pump and dump since there was no indication for that.

Moreover, mastitis would be an urgent thing but not necessarily too urgent for you to really drive to the hospital just to see it.

[11:10] Erring on the Side of Safety

Kristina explains there's a lot of stuff that says benefits outweighs risks. But very few places actually consider a mom's plasma level and what level gets into the breastmilk. Therefore, how much is the baby ingesting and how much of that ingested amount would the baby absorb into their bloodstream?

There is the infinite risk center run by a pharmacologist that has gone through all this. But doctors prefer to err on the side of safety. But Kristina points out there is more risk of clogged ducts and mastitis if you're pumping. Throwing milk away is just heartbreaking too. There is also the risk of that formula to the baby if the baby is formula-fed.

"Basically, nobody feels comfortable with the information that is out there saying it's okay to breastfeed."

[12:37] Work-Life Balance

Kristina describes having a good work-life balance. Her husband is also a hospitalist in internal medicine. So financially, they're in a good spot but they're also busy. They have two kids. She started full-time and as they're having kids, she has worked herself down to 50%. Currently, she's working herself back up with some nursery work. Nevertheless, this has allowed her to have some good work-life balance.

Similar to primary care, you're not on call and you're not going to the hospital necessarily. It's mostly an office-based work.

[13:24] What It Takes to Become an IBCLC

Kristina notes that to become an International Board Certified Lactation Consultant (IBCLC), there is an international exam that anyone can take. But there are different pathways depending on your background. The nurse or a doctor has a different pathway than a lay person off the street that wants to get it.

It requires some health and science background classes. As a doctor. you have to do 90 hours of lactation coursework. And you have to have a thousand clinical hours. Fortunately, those aren't supervised. So if a OB/GYN wants to become an IBCLC, they can use the time they talked for prenatal and postnatal counseling. Their hospital rounds can count too if they took care of mastitis or if they've worked with support groups. All those hours can add up.

Once you have those hours, you take the exam and then you're given this gold standard of certification. You're reputable and the community is having that level of knowledge and experience.

Another program is the Healthy Children Project, the certified lactation counselor. And this is how Kristina actually got her start. She did a 40-hour course. You do an exam and then do a little certification.

"Technically, anybody can do it. It's just having that evidence-based information. Make sure you're learning the right stuff."

There's also the Academy of Breastfeeding Medicine that has the fellowship track where you get an FABM designation. They're also working on a more clinical-based fellowship in the future.

Kristina also adds getting knowledge from mentorship and working other people and getting those other certifications.When it comes to billing, Kristina bills not as a lactation consultant but as a physician.

[16:20] Working with Primary Care and Other Specialties

Again, Kristina recommends making sure that what you know is evidence-based. See if there's somebody in your area that is more specialized. See if they're listed on the Academy of Breastfeeding Medicine's website or there's a doctor in town that's IBCLC. This way, you know who to refer to if you're having issues. Secondly, it's nice to reach out to them and talk about it especially if you have any questions.

"Search out that extra bit of training so you can be the best resource for your patients possible."

Other specialties she's working with are ENT and Peds in Dentistry. Kristina says it's nice being trained both in internal medicine and pediatrics since she's self-sustaining. She can take care of the mom and the baby.

But if you're a pediatrician and doing breastfeeding medicine, you'd probably be working with internal medicine or OB counterpart to help you with some of the mom stuff. Conversely if you're an OB/GYN, you'd have to work closely with pediatricians to take care of the peds stuff.

Other special opportunities outside of clinical medicine would be academia and research. They sponsored fourth year medical students to do some pre-residency lactation work. She also worked on the curriculum development for the interns in the pediatric residency. She does nursery rounds so she does teaching there.

Research-wise, there are a lot of opportunities in terms of curriculum and teaching development and the biochemical science behind breastfeeding.

[18:55] The Most and Least Liked Things About Breastfeeding Medicine

Kristina has been so enriched with the experience personally that bringing it on to other moms is helpful. She likes the fourth trimester concept when they help moms realize that those first couple of months of motherhood are really overwhelming and exhausting. So being able to support moms through that is enriching for her. She likes watching those kids grow and develop and the parents become parents and learning the parenting kinds of things.

"For me, the biggest things is helping those moms meet their goals and raise cool kids."

On the flip side, she finds it frustrating how little other people understand about the field. When people do or say things along with their lack of knowledge can affect how they take care of patients.

[20:17] Major Changes in Breastfeeding Medicine

Kristina hopes they can get a more dedicated fellowship or clinical track for this niche. We are in the day and time when breastfeeding is becoming more than the norm. So moms are initiating a lot more and are being more successful. Along with that, we see more moms struggling or having issues that need the support. Unfortunately, Kristina admits the lack of infrastructure for them at this point in time.

Things have definitely been a lot better. But she hopes to continue to see more changes with that like paternity leave for instance.

[21:20] Breastfeeding versus Formula-Feeding

Kristina points out that it's important to let moms know that there are going to be challenges and they need that support system. So find that support system and make sure you know what your resources are. She often tells parents to never give up on their worst days. Reach out for help when you need it.

"I often tell parents too, never give up on your worst day. You're going to have bad days. You're going to have bad moments."

Breastfeeding also has a lot of health benefits for moms that we don't usually look at. It actually reduces the risk of breast cancer, diabetes, heart disease, hypertension, multiple sclerosis, etc. So there are lots of benefits for moms as well. So there should also be a focus not just on the baby but also on moms.

[22:35] Final Words of Wisdom

If this is something you're interested in, Kristina recommends checking out the Academy of Breastfeeding Medicine. They have a great website with a lot of great protocols there which are evidence-based.

If you're a woman and interested in this, look up Dr.MILK group. They have over 10,000 members on Facebook. They welcome even those who are not breastfeeding but just want to learn more about breastfeeding.

Lastly, be open to the fact that you may not get a lot of training about this but it's super important and there are opportunities out there to learn more.

Do you have any ideas for specialties or if you know any physician whom you think would be great guest on this podcast, shoot me an email at ryan@medicalschoolhq.net.

Links:

MedEd Media

Dr.MILK

IBCLC

Healthy Children Project

Academy of Breastfeeding Medicine

Nov 22, 2017
49: What Is Pediatric Radiation Oncology? (It's Not Radiology)
43:56

Dr. Victor Mangona is a private practice Radiation Oncologist specializing in Pediatrics and Proton Therapy. If you're interested in Rad Onc, listen to this!

Nov 15, 2017
48: What Does the Pediatric Residency Match Data Look Like?
28:55

Session 48

Pediatrics is a primary care specialty. Usually, primary care spots are easy to match into. Does pediatrics keep up the trend? We’ll dig into their data.

The reason for this episode is to give you an idea as to how hard or easy it is to match into a specific specialty. I'm getting all of this data from the NRMP Match Results and Data for 2017.

An overview: When you're in medical school, you apply to match into residency in the U.S., through an algorithm-based system. The three people who created this algorithm won a Nobel Prize for it.

It's not a usual job application where you apply to 40 places, get interviewed in all of them. Then whoever wants you offer you something you say yes or no. With residency matching, you rank based on what programs you like. And the programs will also rank based on who they like. And the magic happens.

[02:47] General Summary of the NRMP Match Results and Data for 2017

Table 1 of the NRMP Match Results and Data for 2017 shows the general summary. Pediatrics for categorical slots have 204 programs and there are 2,738 different positions available.

"Categorical means you are going for all three years to that program."

They have a pediatrics preliminary (PGY-1) slots. So maybe for those who didn't match into a categorical, you can apply for a preliminary slot to make sure you're going somewhere. In this episode, we're covering mostly categorical.That means you're applying to one program for all three years for your pediatric residency.

Comparing it with other specialties, Family Medicine has 520, Internal Medicine has 467, Psychiatry is 236. So there are more psychiatry programs than there are pediatric programs. Surgery is 267.

Number of unfilled programs based on Pre-SOAP.  SOAP is the Supplemental Offer and Acceptance Program. The students who match in SOAP are not counted in this chart here. There were 13 programs that went unfilled in the 2017 match. That means they have at least one spot left.

Out of 2,738 positions offered, there were only 2,056 U.S. Seniors applying for those programs. So almost 700 spots available for U.S. Seniors assuming your qualified for the spot. This does not count the number of DO students applying for these programs or the number of international medical graduates. The total number of applicants is 3,763 so there are a thousand more applicants than there are spots available and about 700 less Seniors. This implies that there are a lot of international graduates likely applying for the spots.

"This is an MD data. The U.S. Seniors in this chart means students at an allopathic medical school."

Of those that matched, there were 1,849 U.S. Seniors. There are still 200 U.S. Seniors that applied and did not match. Why? There could be several different reasons for that. Their board scores were terrible. Pediatrics is not a board-heavy specialty but it doesn't mean you can bomb your boards and match. Or maybe they're a bad interviewer or didn't apply to enough programs.

Again, 700 fewer U.S. Seniors were applying for the spots but a thousand more total applicants than there were spots available.

[08:50] Table 2: Matches by Specialty and Applicant Type

Table 2 of the NRMP Match Results and Data for 2017, out of 2,738 positions, number filled 2,693. That's 45 spots that went unfilled. U.S, Seniors that matched were 1,849. So there were 889 left for other applicants. 24 went to U.S. Grads.

Again for this data, U.S. Seniors are students who are currently at an allopathic medical school. A U.S. grad is somebody that's already graduated from an MD-granting medical school. These could be students who didn't know what they wanted to do so they did more shadowing or research. Or these could be former students who didn't get in previously.

Moving on, there were 361 allopathic students that got into a Pediatrics (Categorical) residency and two students were Canadian.  It doesn't mean a Canadian at a U.S. school means a Canadian graduate. When you look at the overall numbers, only 7 total Canadian graduates got into a PGY-1 position and two of them went into Pediatrics.

There were 204 U.S. IMGs (International Medical Graduates). This is somebody who's a U.S. citizen who went to an overseas school - the Caribbean, Israel, Australia, Scotland, or wherever that may be. And 253 were non-U.S. citizen international medical graduates. Lastly, there were 45 spots that went unfilled for the Pediatrics (Categorical) rotation.

"Good for allopathic and U.S. IMGs since there's still a big opportunity for you to go into Pediatrics."

[12:13] Trends in the Match Program (2013-2017): Growth, PGY-1, Osteopathic Students

Pediatrics is growing pretty substantially to about 10% every year from 2013 to 2017. 2013 started off at 2,616 and there were 2,738 in 2017. It's between 9.5% and 10% growth year after year.

Figure 5 of the NRMP Match Results and Data for 2017 shows just how big Pediatrics is. Internal Medicine has the most positions offered followed by Family Medicine and Pediatrics is third at 2,821 and 2,775 of those were filled, and 1,880 were filled by U.S. Allopathic Seniors.

Table 8 shows the Percent Filled by U.S. Students and All Applicants. In 2017, 67.5% were filled bu U.S. Seniors. And in 2013, 70.2% were filled. It has gone down a little bit for the last couple of years. It's not a huge shift but it's showing you that it's roughly the same every year.

"When you look at the average total PGY-1 slots being filled by U.S. Seniors, 60.6% is the average based on all of them."

Table 9 shows that 9.7% of all applicants matching into a PGY-1 specialty are categorical Pediatrics. Just for comparison, Family Medicine is 11.6%, Internal Medicine is 25.6%, OB/GYN is 4.7%.

Table 11 shows that 12.3% of all osteopathic students an allopathic PGY-1 position program match into Pediatrics. Family Medicine is 19.6%. 23.5% of osteopathic students match into Internal Medicine.

[16:37] % of Unmatched U.S. Seniors and Independent Applicants and SOAP

For this data, independent applicants refer to IMGs and osteopathic students. For Pediatrics, the total unmatched is 12.4%. The unmatched independent applicants is 30.5%. It's very heavy with independent applicants. Unmatched U.S. Seniors is only 2.3%.

In comparison with other specialties, Internal Medicine/Pediatrics shows 0.5% of U.S. Seniors are unmatched. Surgery (Prelim) is 1.3%. Surgery-General is 9.6%. Neurosurgery at 10.4%; Orthopedics at 15.1% for unmatched U.S. Seniors. So pediatrics is relatively low as you would expect.

Table 18 shows the programs and positions filled in the SOAP program. SOAP (Supplemental Offer and Acceptance Program) is for students who didn't match in the first go round. This used to be called Scramble.

There were 12 programs in Pediatrics that did not fill and participated in the SOAP program. 44 positions were available and all spots were filled through the SOAP program.

"In Table 2, it looks like there's unfilled spots. But that doesn't count the SOAP and filling those spots through the SOAP."

[18:44] Charting the Outcomes in the Match 2017: Apply Broadly

Now, we dig into the Charting the Outcomes in the Match for U.S. Allopathic Seniors in 2016. It displays the information a little bit different so it's very interesting to look at.

Chart 4 shows the Median Number of Contiguous Ranks for U.S. Allopathic Numbers. For Pediatrics, students who did not match only have 3 programs contiguously ranked. While those that matched ranked 12 programs.

"This is going to be the theme of matching or not matching for every specialty. You need to rank enough programs to match."

This being said, you cannot be super selective with programs where you're applying to match. You have to apply broadly. Just like medical school where the average number for the AMCAS applications is 14-15 as well as for DO schools. The same goes for your rank list when applying for residencies. The biggest mistake you can make is not ranking enough programs.

Chart 8 looks at the Mean Number of Research Experiences for U.S. Allopathic Seniors that matched and did not match. The numbers are almost identical - 2.4 for those who did not match and 2.5 for those that matched.

Chart 12 shows the percentage of U.S. Allopathic Seniors who are members of the AOA. In pediatrics, 16% of the Seniors that matched are members of AOA (Alpha Omega Alpha), the U.S. MD Premed Honor Society for Medical Students. In comparison with other specialties, Dermatology is 53%, Plastic Surgery at 52%, and ENT at 45%.

"AOA is very much tied to the more competitive specialties."

[22:44] Mean Number of Contiguous Ranks, USMLE Step 1 and Step 2 Scores

Still looking into the Charting the Outcomes in the Match for U.S. Allopathic Seniors in 2016, PD-1 (Page 159 of 211) shows the summary statistics on U.S. Allopathic Seniors  for Pediatrics.

The mean number of contiguous ranks for those that matched is 11.9 and for those that did not match is 4.0. Again, you have to rank enough programs.

Mean USMLE Step 1 Score is 230 for those that matched and 207 for those that did not. Mean Step 2 Score is 244 for those that matched and 224 for those that did not match.

Graph PD-1 (page 161 of 211) shows the curve of the probability of matching which is around 64% if you only ranked one program. 70% for two programs. Roughly 75% for three programs. 83-84% for four programs. The more programs you rank, the better your chance will be, even up to a 100% of matching at around 13 programs ranked.

[24:14] Medscape Lifestyle and Physician Compensation Reports 2017

The Medscape Lifestyle Report 2017 looks at which physicians are most burnt out. Slide 2 shows that Pediatrics is right above the halfway point at 51% with Emergency Medicine as the highest at 59%.

As to how sever the burnout is, Slide 3 shows that Pediatrics is on the lower end at 4 on a scale between 1 as the lowest and 7 as the highest. Which physicians are the happiest? Slide 18 shows Pediatrics is higher up at 36% happiest at work and 70% happiest outside of work.

Based on the Medscape Physician Compensation Report 2017, Slide 2 shows that overall, Specialties earn $316k while Primary Care (where Pediatrics is a part of) is $217k. Who has the highest average annual physician compensation? Slide 4 shows that Orthopedics is at $489k and Pediatrics is the lowest at $202k.

If you've listened to our previous episodes where we talked to pediatric specialists, on average, they say they're always paid less than their adult counterparts. It's still a great salary though.

"On average, they all say that pediatric specialties are always, always, always paid less than their adult counterparts."

Slide 5 shows Who's Up, Who's Down and Pediatrics is the only one that went down by 1%. Interestingly, even though Pediatrics is the lowest paid specialty, more than half of the physicians feel compensated at 52% as presented in Slide 18. In Emergency Medicine, 68% of them feel fairly compensated while Nephrology is the lowest at 41%.

Would you choose medicine again? Slide 38 of the Medscape Physician Compensation Report 2017 shows that the highest is Rheumatology at 83% and the lowest is Neurology at 71%. Pediatrics is at 78%, right in the middle of the pack with everybody else.

Slide 39 shows who would choose the same specialty again. Dermatology is the highest at 96% where they say they would choose the same again and Internal Medicine is at the lowest at 64%. For Pediatrics, 81% of them say they would choose the same specialty again.

[27:44] Final Thoughts

If you're interested in going into Pediatrics, these are great information to figure out what you want to do with your career moving forward.

Additionally, if you know a physician that you want me to talk to, shoot me an email at ryan@medicalschoolhq.net. I'm always looking for a guest for this podcast. If know someone on Facebook or Instagram, reach out to them and let them know about me. Put us in contact.

Links:

NRMP Match Results and Data for 2017

Charting the Outcomes in the Match for U.S. Allopathic Seniors in 2016

Medscape Lifestyle Report 2017

Medscape Physician Compensation Report 2017

ryan@medicalschoolhq.net

Nov 08, 2017
47: What Does Vascular Surgery at an Academic Setting Look Like?
48:25

Session 47

Dr. Westley Ohman is an academic Vascular Surgeon in the St. Louis area. We discuss why he chose academics, what makes a good vascular surgeon and more.

Good news to all premeds out there! We have a new podcast called Ask Dr. Gray Premed Q&A. Or if you know someone who's a premed, point them to the podcast as well as all our shows on MedEd Media.

[01:54] Interest in Vascular Surgery

Westley had exposure to vascular surgery from an engineering standpoint as an undergrad. But it wasn't until late in his third year and going into his fourth year with his sub-I's that he had world-class mentors from the cardiac and vascular side of things. He was fortunate enough to be guided in his decision making. They supported him going into vascular seeing that's where his interest and his skill set lie more than on the cardiac side.

He likes the interventional approach where you can treat aneurysm in one room with two small needle pokes in the femoral arteries and then patients go home the next day. Then in the next room, you can be doing an open aneurysm and the patients can stay for a week. You're deciding which patient benefits from which and really try to master both open and endovascular surgery.

Westley is fortunate enough to where his mentors would let him manipulate the wires when it was safe to do so even as a medical student. So his appetite only went from there.

Other specialties in the running as he was going through his sub-I's were cardiac surgery and cardiac interventions which he found interesting. But he can't explain but the technical aspects of doing a fenestrated aneurysm appealed more to how he approaches problems and think about things. He also thought about neurosurgery more on the endometrial neurosurgery as opposed to true neurosurgery.

[04:50] Traits that Lead to Becoming a Great Vascular Surgeon

Westley sees spatial reasoning more so than any other surgical discipline. They do open surgery anywhere in the body. So you have to understand not just where the blood vessel runs but where's the nearest muscle insertion or origin. Understand how you're going to be able to tunnel your bypass graft or how you're going to get exposure to that artery. And in the belly, understand where the important organs live as well as be able to manipulate the space in terms of where you're going to run your bypass.

"I really demand for technical precision. Vascular surgery has a way of humbling you."

In short, you have to know every inch of the body to be able to successfully operate on somebody. He even jokes in medical school that he's a practical radiologist. They know the anatomy from looking at pictures, but this is his practice on a daily basis.

[07:00] Types of Patients and His Decision to Stay in the Academic Setting

A big portion of the patients they're treating are the end stage renal patients. They do access creation or maintaining functional access through dialysis or revisions. They also treat peripheral arterial disease that comes along with the disease brought about by end stage renal disease. Your average VA patient encapsulates a lot of vascular surgery from a general standpoint. They're the smokers, the diabetics, the ones that don't necessarily take the best care of their body. So they get peripheral arterial disease or aneurysm. But from an academic standpoint, he also gets a lot of the referrals for infected endografts, aneurysms, in and of themselves.

As to his thought process behind choosing academic versus community setting, he looked at jobs for both academic and community settings. One of the things that made him stay in the academics was a job available for him. When you're going through looking for a job, the academic jobs are always posted about 4-5 months after the private practice jobs.

"No one truly knows when an academic job is going to pop up because of the difference in funding cycles."

The complex endo interventions entail pushing the limits of what they can do from an interventional approach or minimally invasive approach while still doing right to a patient. It's very easy to do something to a patient but determining if it's the right way to do it. They also have to consider limiting the physiologic stress on aortic surgery patients. And this is what kept him in the academics.

Moreover, he has always wanted to be a big aortic surgeon having found the disease processes in terms of aneurysm and dissections fascinating. And a lot of the smaller hospitals and mid-sized hospitals just don't have the resources to support the very sick and very challenging patient population. Westley clarifies it's not the fault of the hospital. It's just not their mission or their buildup. And it takes a very specific type of place to do it which he always saw himself doing as a surgeon.

[11:10] Percentage of Patients, Typical Day, and Taking Calls

Westley says two-thirds of his patients come in already diagnosed with a caveat. If he'd do thoracic outlet syndrome, they have one of the biggest, if not the biggest, thoracic outlet syndrome referrals in the country. Nearly 100% of those patients come in with a diagnosis in the ballpark. But for the remainder of his patients, he will get referrals from the hematologists or the rheumatologists. Once you get outside of the pure simple cases, you see patients in end stage renal disease and they need access or they've been smoking and they have peripheral arterial disease. So there are a lot of esoteric diagnoses they made in an interdisciplinary process.

"There are days in my clinic where the diagnosis is made for the patient before they get there."

This said, 25%-33% of his patients are usually an interplay between himself and another consulting physician where they bounce ideas off each other. But a lot of his diagnosis are not made from subtle physical exam findings. They're important but they're a more imaging-driven specialty.

Westley can't say there is a typical day for him, which has been a selling point for him. But if he's on call at a major center, he could get a ruptured and aortic aneurysm and go do that. While he could also deal with a gunshot wound to an extreme median having to figure out how to reconstruct or what conduit to use. But it's very easy to start your day with one procedure and then going to a different procedure. And then you bounce back upstairs to either do bypass or belly revascularization.

Outside of clinic days, he doesn't really know what comes his way. Because even if he's not on call, if they happen to get swamped and being pulled into other cases. So being able to be flexible and offer the full toolkit really allows his day to be as variable as the hospital needs him to be or as he wants it to be. He takes one and a half days of clinic per week so he basically spends more time in the OR or the cath lab or the interventional suite.

Westley describes being one of those rare groups with ten partners, nine of which will take call. So it ends up being a one in eight or so calls. He'd be on call a weekday, usually every other week. Then he'd have a weekend call every other month. For him, this is better than it was when he was in training. Outside of those large groups, it's easy to be in a Q3, Q4 call.

That said, he's in a major referral center so although it's an infrequent call, it's still a very busy call. Half of his calls, he's operating most of the night, if not all of it, and still running the full day the next day. And the other half, he's interacting with the referral line or fielding inpatient consults that don't necessarily need to go to the operating room. But students should expect that there are going to be emergencies going into vascular surgery. Not a lot of their cases is that when something goes wrong can be sit on until the next morning.

"Going into vascular surgery, there should be the expectation that there are going to be emergencies."

[16:52] Work-Life Balance

Westley still finds having life outside of the hospital. He's married to a fourth year general surgery resident. They have a toddler and two dogs. It's tough. But since he's finished training, their life has gotten significantly better. Regardless of what his wife is doing, he has time for what he wants to do in terms of family and career.

It's about finding that right balance and for them, that right balance is a wonderful nanny who helps them out. This allows them to stay in the hospital late on a rare night that you need to.

[18:03] The Training Path to Vascular Surgery

Westley explains that there are two routes. One is the traditional two-year fellowship after a five-year general surgery program, known as the 5+2. There's also the 0+5, which is 5 years of some amount of general surgery and a lot more vascular surgery. His program did it half and half for the first three years and the last two were only vascular, This allows you board certification only in vascular surgery.

From this, you can go on to do fellowships in cardiology or critical care to augment what you can offer. Westley comes from a 0+5 program where he could whatever he wanted anywhere in the body that he needed to be. I don't think either pathway is the right way. I don't think there's a wrong way to go.

He noticed that his co-fellow who came from general surgery training when he started his fourth year, was more comfortable in the belly. But by the end of it, they were roughly equivalent. And he felt he had stronger interventional or endovascular skills. That because he didn't learn laparoscopy whereas he did.

"It really takes some soul searching from the student as to which pathway they think is best for them."

According to Westley, all of his friends who have done general surgery and the vascular don't touch a laparoscope. And in fact, he's more likely to touch one than they are just by accident.

Regardless of the setting, Westley stresses the importance of the quality of the training program. There are 5+2 programs that will prepare you for a very successful private practice. And there are some 0+5 that will prepare you for a very successful academic, doing the big cases and vice versa. He thinks that each program has its own individual strengths. When he sat down six years ago to make his rank list, his first three were integrated programs and his fourth was general surgery.

He would recommend students to figure out what you want from there and what you want your life to look like. They may not know that and think 5+2 is the way to go since they have their general surgery to fall back on. It's not a bad decision. But it's a mindset that a lot of vascular surgery is moving more towards 95%-100% vascular surgery. This is because of what they can do and how they can do it expanding every year.

In terms of competitiveness, Westley describes it as fairly competitive. He thinks there are slightly more applicants than there are spots. And in terms of the 0+5, when he applied, it was more competitive than dermatology. They still have 80 programs per one spot per year and they interview about 20-25 of them. And for the fellowship, the numbers are a little smaller.

A big debate going on is that a lot of the 0+5 programs were born out of the big academic centers. Michigan was the first to have it as well as Pitt and Dartmouth, which are big names in vascular surgery. At WashU, they keep both pathways open. They're committed to matching one for each pathway per year. Part of that is having complementary learning that makes for a better learning environment.

Then there's always the big academic centers that don't have the 0+5. And the biggest leaders in vascular surgery right now say they will hopefully never have a 0+5 at their program. So even though it's been out for almost a decade now, it's still a very polarizing topic for some of the very senior people in the discipline.

[23:50] Advice to Students to Become Competitive

Just like for everything else, Westley says it comes down to having a reasonable Step 1 score. It's going to be a very easy, quick, and dirty screening outlet. Another thing is that vascular surgery being a small field, doing a sub-I is absolutely critical. This allows you to get your name in the door in different places. And if you can, you get letters and phone calls fro not only your home institution, but other institutions as well. So this goes a long way towards building a competitive application. Especially at 0+5 level, it shows exploration and an interest. There are also people falling out of the pathway and having an empty spot for the next x number of years where you're supposed to be training. Being able to show you know what you're getting into goes a long way. This is something they look for when they're interviewing applicants.

"Vascular surgery is a very small field and I think more so than general surgery...doing a sub-I is absolutely critical."

[25:30] Bias Against DOs and Subspecialty Opportunities

Westley doesn't see any overt bias against DOs. They've interviewed some DOs in the last couple of years. It's just that a lot of the big programs for vascular surgery aren't associated with an osteopathic school. This is an extra hurdle the student has to go through. They have to show they're investigated and they have the commitment. And if they can show that, then they could go further than the allopathic student who comes from a program that might have a great reputation for vascular surgery but didn't necessarily show as much interest or build a competitive application packet.

In term subspecialty opportunities within vascular surgery, there are several ways to make your niche. There isn't any formal ACGME fellowships. But as he said, what comes into anyone's mind is there is advance aortic endografting fellowships. Cleveland Clinic has one as the Mayo Clinic, which they've rolled out as a complex aortic reconstruction fellowship. UT Houston also has it, which is where he went to medical school. These are big aortic referral centers so they attract the aortic "super" fellows to learn those techniques.

Moreover, Westley says it's very easy to build a very heavy thoracic outlet syndrome practice if that's where you want to make your mark. Because if you can do it well and show consistent outcomes, those are patients that will come to you. And the referrals will come to you as well fairly easily. A lot of people in the community end up either specializing or treatments for venous reflux. Those are disease process that he thinks they've undersold as a society or medical profession. There's always one guy in town who's that carotid surgeon just like the thyroid surgeon that get good outcomes with your carotid procedures. Referrals will also continue to come as well. But in terms of established training pathways, there aren't any besides the aortic surgery.

"Beyond the general training, it's just kind of how you want to market yourself."

[28:50] Working with Primary Care and Other Specialties

Westley wishes to thank primary care physicians which he considers as his very best friends.A lot of the medical management of vascular patients is driven by the primary care physician. Whether in terms of following the JNC guidelines and the AHA guidelines in terms of the best medical management. About a third of his clinic patients, he ends up getting or giving a phone call to the primary care physician to pick their brain about it. He thinks it's underrecognized. In a large portion of society, everyone thinks about carotid disease and stroke but lower extremity and peripheral arterial disease and critical limb ischemia are fairly quick to pick up in terms of simple questions. These are quick and easy things that can prompt a referral to him and really impact the patient’s overall lifespan.

"A lot more medical management happens in vascular surgery than a lot of the other specialties."

Other specialties he works the closest with include the cardiac surgeons, nephrologists, hematologists, trauma team, radiology, and primary care. He is fortunate where the turf war was fought by a generation before him so he no longer has to fight them. But they do interact a lot with the interventional radiology colleagues in a congenial relationship and not antagonistically. The same think with interventional neuroradiologists that have made a name for themselves in the intracranial work. They do most of the extra cranial carotid disease. If those issues had not been settled, Westley admits it would have been different.

As far as limiting their scope of practice in the future, Westley doesn't really see this coming. He thinks a lot of the blame for the vascular being open for other specialties is they've done a poor job defining what's the best treatment option for this disease process. And the interventional cardiologist or interventional radiologist has the skill set to treat those patients as equivalently as he does in terms of cutting a wire across the lesion. Or whether it could be putting a balloon or a stent.

Westley believes a way for vascular surgeons to really sell themselves is that mindset of having multiple skill sets. But also think whether they're burning any bridges. If they can define who benefits from what procedure, and also market themselves as being the one-stop shop for lower extremity work. Either they protect their patient population or start to grow it. He won't sit and tell that there aren't interventional radiologists that can do phenomenal work in the peripherals. Or that the cardiologist can't do a good work in the renal segment for instance. So he thinks it as not only someone who can put a hole in an artery or fix a remote artery, he can also make an incision and provide a definitive fix to that problem.

[35:49] Opportunities Outside of Clinical Medicine

The first thing that always comes to mind is a lot of early advances in the industry. The first stent was developed by a physician (not a vascular surgeon). And a lot of the newer stent grafting was pushed by a vascular surgeon or helped developed by a vascular surgeon. Where he's at, they have a very large industry presence and they’re very active on clinical trials. The IP world for vascular surgery or devices in general has changed. Before, they'll just run with it and sit back and collect royalties. But those easy-picking days are gone because they really want to see an idea almost brought to the market. This could be in terms of the background studies, safety and efficacy studies.

Some of his partners are working on small drug molecules and working with industry from that standpoint. One of his former partners who moved on from the University of Michigan was big in "nanotherapeutics." They're pushing the envelope of how they can augment devices with small drug molecules to bridge the device industry and the pharmaceutical aspect of it.

"From the policy standpoint, vascular surgery hits on a lot of different disease processes that unify different body areas."

Moreover, he knows other vascular surgeons who have tried to move into more of a healthcare policy standpoint. They don't only look at the cardiovascular system but also the cardiology or nephrology world. Westley believes there has to be a healthy relationship with industry right now in terms of devices, balloons, grafts, and stents.

[39:15] What He Wished He Knew and What He Likes the Most and Least

When he was in training, he would curse the middle of the night and thought he should have gone to a place that's not a major level 1 trauma center. He really doesn't like operating that much in the middle of the night.

"Looking back on it, I really see that the trauma situations were really the ones where I grew the most as a surgeon."

And in that moment, he was tempted to curse and throw an instrument. And as he looks back, he thought that was actually an opportunity to learn how to approach new problems. He thinks it really made him a better surgeon. Would he pick vascular surgery all over again? Westley is absolutely sure, but just with a caveat that there are going to be a lot of nights and late days if you're going to do the big cases. If you want to design your practice to where you are treating venous reflux all day, then you're not going to have any inpatients. And you're going to live a very comfortable life. So it depends on what you want.

What he likes the most about being a vascular surgeon is being able to treat any disease process outside of the head and the heart. Because it always keeps his days different. And he really enjoys interacting with not only other surgical disciplines but also other medical disciplines. And in terms of approaching and managing those problems. Not every patient that comes across him needs an operation. But almost uniformly, he'll be interacting with either the primary care physician or some sort of medicine subspecialist to help provide some input on the disease process. He would still be treating patients even without a scalpel or without a needle.

What he likes the least is not operating at night. He often jokes with his trainees but there really is nothing more humbling than vascular surgery. He finds it very demanding from a technical aspect. Sometimes, he finds himself losing more sleep now as an attending than he did as a trainee. He's worried about whether it's okay enough to where he can leave the operating room or does he need to work on the problem. He likes the challenge but it's starting to wear on him. So he's starting to explore with his senior problems as to how to deal with it. Not to wear him down but to motivate him to either do better in that moment or do better for the next patient.

[43:05] Major Changes in Vascular Surgery in the Future

Westley explains that there's always going to be turf wars and he thinks that should be a call to better ourselves and better define ourselves. There's always going to be pushing the envelope. Fifteen to twenty ears ago, the only way to treat aneurysm was a big belly incision. Then they got to a groin cut downs and rudimentary endovascular devices. Today, he can do a complex paravisceral aneurysm through a procedure that at the one month follow up, you can't even tell they had an operation from the outside.

That said, the explosion of minimally invasive techniques is going to allow more and more people who say they have the skills with wires and catheters to come into their "turf." It's going to be up to the next generation to show that they can do it a lot better and here's how.

Eventually, all hardware fails. It's just a matter of whether or not the patient lives long enough for the device to get fatigued. Westley adds that as all hardware fails, it's only a matter of time until the device can get fatigued. In which case, they'll require an open conversion and you do want them to be at a major aortic referral center. It's not just about putting in the equipment but being able to manage all the complications that come from it. This is where vascular surgeons are going to help be able to define themselves.

"It's not just putting in the equipment, it's also being able to manage all of the complications that come from it."

[45:30] Final Words of Wisdom

Westley says vascular surgery is one of the more dynamic and rapidly changing surgical disciplines not only in terms of who they can treat and how. But also, pushing the envelope of what may be inoperable now. Ten years from now, you may already have a very simple device or very simple fix that you may very well be a part of developing. It's not for everyone. But people who will love this are those who welcome the technically demanding challenge or the opportunities of the spatial challenges that come along with vascular surgery. If you're good at it and you have inclination towards it, you're going to love it.

Especially for the general surgery resident who may only do it as an intern or a second year, not to see as a full breath and just be taking care of the patients. It's so much more than that once you get into the operating room. If you have the opportunity to rotate as a senior, by all means you should. It is night and day from just managing them post-operatively or sewing a simple fistula. And he was quick to discover there's no such thing as simple fistula, which he thought it was as a second year resident. When you're doing the more challenging cases either technically or intellectually, it's incredibly rewarding even though the patients may be challenging at times.

"When you're doing the more challenging cases either technically or intellectually, it's incredibly rewarding."

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Nov 01, 2017
46: What Does a Private-Practice Based Neuroradiologist Do?
42:25

Session 46

Dr. Narayan Viswanadhan is a community-based Neuroradiologist in the Tampa area. We discuss why he chose the community, what his day looks like, and much more. He has been out of fellowship training for three years now.

Also, check out all our other podcasts on MedEd Media Network.

[01:15] His Interest in Radiology and Neuroradiology

When applying initially for residency, he applied for internal medicine into several programs. And as he was doing his sub-internships, the was drawn more into radiology. What he likes most about internal medicine is coming up with the differential diagnosis. He likes figuring out the root cause of the problem. But as he kept going into internal medicine, he was going further away from it. And during his radiology elective, he realized he enjoyed being the diagnostician or the doctor's doctor. And this was what drew him into radiology.

"I really enjoyed being the diagnostician or the doctor's doctor kind of thing. That drew me to radiology."

Moreover, neuroradiology got him as he was continuing his radiology residency. He enjoyed the anatomy and the complexity of it. He found it an elegant system and so he thought it was something he was fascinated with. And with the crossroad between technology, anatomy, and medicine, this is what made him go into neuroradiology.

Other specialties drew him were those with modalities overlaying with MRI. He enjoyed musculoskeletal imaging. He thought sports medicine was interesting since he loves basketball. They also had a strong training in body imaging and having that strong background, he thought it would be a good opportunity to do further fellowship training in neuroradiology.

[03:55] Traits that Lead to Becoming a Good Neuroradiologist

Narayan thinks that you initially have to have a strong knowledge base with a detailed and comprehensive understanding of anatomy. There are so many anatomic structures you have to be aware of.

"You can't play the game if you don't know the players. That's definitely the case for all of radiology."

Additionally, you have to have a good background of anatomy, physiology, and pathology. Narayan thinks radiology is a long residency which takes seven years in total. Attention to detail is also another critical thing. You need to think about not just common stuff but esoteric stuff can easily come into play which makes a big difference in patient outcomes. You also have to be an effective communicator. You will be working into interdepartmental conferences with neurologists, neurosurgeons, primary care doctors, ENT doctors, and oncologists. So it helps to have that personality that can effectively communicate. It's nice that they can feel you're somebody they can go to and rely upon to provide the best care for the patient.

[06:05] Community versus Academic

Narayan was actually torn between going into community and academic settings since he applied to an array of both settings. He did a two-year neuroradiology fellowship. People who do this are more inclined to do academics. And he actually thought this was the career path he was going to choose since he enjoyed working with other residents, medical students, and fellows.

"Typically, people who do two-year fellowships are more inclined to do academics."

However, he felt he was going to miss a lot of the aspects of radiology that he grew to love including body imaging and procedures. So while he thought of both avenues, in the end, he didn't envision a career where he was going to focus on one sub-specialty for the rest of his life. And this is because he enjoys all the different aspects of medicine.

[09:15] Percentage of Practice, and Patient Types

Narayan explains that the beautiful thing about being a neuroradiologist working in a general setting is that while he has a niche, he also has the ability to a little bit of everything. This is from a diagnostic standpoint as well as from a light interventional standpoint. He feels he gets to utilize a little aspect of medicine he studied which still affects his day-to-day work.

As to what percentage of his practice is neuroradiology, Narayan would say that a third of his time is focused on neuroimaging. This includes reading MRI, brain CT, advanced imaging. Sometimes they do some profusion at some of their hospitals.

A significant percentage of the cases they read are patients with back pain (surgical or low back). Other patients that go in have issues with headaches and trauma. When he was still doing residency in Albert Einstein Medical Center in Philadelphia, they saw significant amounts of bullet-related and other types of trauma related to that setting. But now they see more of motor vehicle accidents. So their bread and butter would be routine imaging.

Moreover, they also have a cancer center. They have a neurooncologist in the community. So they see cases like gliomas and glio tumors, both initial presentation and follow up on those patients. This can include different therapies as well as evaluating and monitoring responses to treatment. Other cases are demyelinating disease and disorders like followup temporal progression or response to therapy.

From the ENT standpoint, they typically see patients (pediatric and adult) for hearing loss. They get CT for the temporal bones or MRI of the internal auditory canals to look for varying causes. They also see head and neck pathology such as tumors of the oropharynx or upper area digestive tract and after-treatment followups. These being said, it's a broad scope amidst a focused niche.

"Even in the community, several clinicians and consultants prefer to have neuroradiologist lead specific studies."

But Narayan points out that even in the community, clinicians and consultants prefer neurologists to lead specific studies. Because of that added level of training, it significantly impacts patient care.

[12:36] The Impact of Neuroimaging Mimics

Narayan is doing a lecture for radiology assistance and one of the things he has in the training is neuroimaging mimics. This could have a significant impact. One of the cases he would show is the case of  a subacute infarct which was diagnosed as a tumor. If somebody interprets it as a tumor, the neurosurgeon may do a craniotomy. But if the imaging can overlap that infarct, that's a big difference in treatment.

Another area which can mimic a tumor is called tumefactive MS. It's a demyelinating lesion but it looks like a tumor. And it does have some subtle imaging findings but it's important for the radiologist and neuroradiologist to distinguish these things.

"It has significant implications on what they decide to do and patient outcome."

[14:14] A Typical Day, Taking Calls, and Work-Life Balance

Narayan describes his days as very varied at his practice because they rotate between hospital-based and outpatient practice settings. But since he tends to go about 50% of the time to hospitals, they will start with the inpatient list. Having a big practice, they have a big ER and inpatient mix. So if he's just assigned to ER rotation, he will just focus on ER. But his typical day would be reading anywhere from 100 to 150 studies.

"A typical day for me might be reading anywhere from 100 to 150 studies."

In his current practice, a third of it would be neuroimaging related studies which include CTs of brain, MRI of the spine, the temporal bone, the head and neck imaging, tumor followup. The rest of it would be bread and butter - abdominal pain, pancreatitis, appendicitis, and other routine cause of abdominal pain and complications for patients and inpatient settings.

As a radiologist, he also does some light interventional procedures. He sees this as a nice break since he gets to interact with patients. He does paracentesis, thoracentesis, lumbar puncture, myelogram. He also does some biopsies at his particular setting. This is actually geographic in nature as to whether the subspecialty radiologist does this. But at his practice, even the specialty radiologist will do things like lung biopsy or participate on the drain.

Because of this mix, Narayan enjoys his day-to-day setting yet he still gets to concentrate on one particular specialty.

"We also just serve a large community so it makes for a busy day but we get through the work and try to do a good job."

Narayan takes calls about once a month. They cover both days on the weekend. Because of the broad practice setting, they have many different physicians and many different types of call. But they'd typically go in and cover one set of calls, say focus on ER and others may focus more on inpatient and ER. Again, it depends on the location, the time of year, and the time of season. Nevertheless, he describes it as being quite busy. The volumes are high. Imaging utilization it seems can sometimes be high. Not to mention, they serve a large community so it makes for a busy day.

Narayan can say he has a good work-life balance. Having three kids, he sees them as his priority. And choosing this specialty allows him to spend time with his kids.

[18:25] The Training Path and Matching

"The training path, you have to know initially that it's a long one and you have to be prepared for that."

Narayan's great piece of advice is to try to be patient and try to reach that end goal at the outset. Take it one day or one step at a time. After premed, you do four years of medical school. Then you do a year of internship - either preliminary year in medicine or surgery or a transitional year. This is followed by four years of diagnostic imaging or diagnostic radiology.

During your third year of residency, you would apply for a fellowship in neuroradiology. It's either a one or two-year fellowship. Narayan thinks majority of the fellowships are one-year training programs. But some still have two years.

In total, that's seven years of training after medical school.

In terms of competitiveness in matching, it comes in waves. It also depends on some academic centers where some are more competitive than others. But by and large, most radiology residents will secure a neuroradiology fellowship. In his case, Narayan submitted a rank list for residency. And most students would rank within their top three or four choices. And most get between eight to ten interviews. So he would describe it as competitive but not as difficult as getting into medical school.

As a medical student interested in neuroradiology, Narayan recommends a few things to be competitive. It also helps during your fellowship interview to talk about certain highlights that you've had in the field that others may not have. This could mean participation in research related to neuroimaging. Narayan did a lot of posters and mini-abstracts related to neuroradiology he'd present at national meetings like the American Society of Neuroradiology.

So think about pursuing research-related activities or even educational activities. He went to a very strong didactic residency focused on residency education. He would teach junior residents and they would have medical students come and rotate. He would create lectures on certain neuro topics. There also had opportunities to teach the CT and MRI technologists different aspects.

"Participating in research, educational activities are all good steps to take to make yourself most competitive."

[22:33] Bias Against DOs and Other Subspecialty Opportunities

Personally, Narayan doesn't see any bias against DOs in the field. He doesn't actually realize whether one is a DO or an MD since it's not something that comes into fruition on a daily basis. That said, it doesn't matter whether you're an MD or DO.

Once you're a neuroradiology fellow, other opportunities to further subspecialize include focusing on areas like functional MRI, profusion and imaging related to stroke or tumor, pediatric neuroimaging, pediatric neuoradiology, and pediatric neuro interventional radiology or neuro interventional radiology.

So three additional areas in subspecialization may be pediatrics, head and neck, or neuro interventional. For many people, after their one or two years of diagnostic neuroradiology, they would do an additional year of pediatrics. Or if they're interested in doing interventional radiology, it's an additional two years of interventional neuro training. There are also those that exclusively wanted to focus on head and neck, so there are some places you could do additional training for a year.

Moreover, in the practice setting, it depends on what path you want to create.

[25:30] Working with Primary Care and Other Specialties, and Special Opportunities Outside of Clinical Work

Narayan wishes primary care physicians to know that they're trying to provide the best, high-quality reads for their patients. Sometimes, with the increasing turnaround time demands and increasing volumes, it can become difficult. But he always does his best to provide the most accurate report in a timely fashion.

But also, the more information neuroradiologists can have, the better report they can provide. If they could give additional history, this could be very helpful in localizing and targeting their search in finding pathology.

"The more information that we can have, the better report I can provide."

Other specialties they work the closest with include neurosurgery, neurooncology, and ENT doctors - being the three main areas they work with. Narayan also stresses that it's good to have a good rapport with other surgical or clinical colleagues. A lot of times they'd just call each other on the phone. They frequently communicate so they can provide quick access to each other. Oftentimes, it helps to have that interdisciplinary relationship to further improve the care of the patient.

Narayan thinks there are many different avenues to pursue like the pharmaceutical industry. You can help to evaluate certain disease or therapies and drugs and response. Sometimes it's helpful to have someone with an imaging background and taking that into the pharmaceutical industry world. You can help evaluate both drugs and other contrast agents in response to therapy. He has also met neuroradiologists who have taken on working in fields like public policy. That said, he thinks the opportunities are endless.

[29:11] What He Wished He Knew

Narayan says he wished he knew it was a pretty challenging road. He thought it would have just been something he was going to do. But he never really anticipated the number of years it would take collectively. He never thought about the number of examinations he was going to take. After the three steps to get into medical school, there were also three board examinations. Then there also used to be the notorious oral board examination. Plus, after neuroradiology, there was another subspecialty boards he took called the Certificate of Added Qualification (CAQ) in Neuroradiology provided by the Board of Radiology. But the unique thing about neuroradiology is the endless educational cycle where it never ends. He's actually learning and reading to this day. And no matter how much you read or study, there's just so much body of knowledge that continues to change.

"No matter how much you read or try to stay on top of it, there's just so much body of knowledge that continues to change."

Plus, in the advent of artificial intelligence, some people may be hesitant. But Narayan sees this as an interesting opportunity to work side by side to help AI make them more effective and more accurate. So although it's an exciting field, he just didn't think he was ready for all the challenges.

He also mentions a poster the ABR does that highlights the fourteen years of training that takes to become a neuroradiologist. It has the picture of the brain that shows each area and during which step they're in. Indeed, it's a long road but he's still glad he chose it.

[32:43] Major Changes in the Future -  AI and Machine Learning

Narayan says that if there's one body of people that are scared and thinking their field is going to end is radiology. But looking at their different radiology meetings and the leaders in their field, they're actually embracing machine learning. They think of different ways to have it improved. They already have steps in machine learning in terms of working with them. He found that while it's good in some areas, it has limitations inn others. So it just works in complement with the radiologist.

Majority of the time, he thinks it's not the most accurate. There are some nuances to it that is not quite there yet. But there are definitely areas he can see where it can help them. This said, he thinks we should be embracing the leaders in the AI and tech companies. He thinks it would be nice to help the computer think about different algorithms and about the way they interpret the brain. Because some cases don't always nicely fit into some sort of algorithm that a computer may be able to pick. But for day-to-day portable chest xrays, it's a useful adjunct.

Also, as you do more and more and read more and more, you start to learn some subtle patterns.

"There are some areas the brain is still pretty good."

[36:34] What He Likes the Most and Least

What he likes most about being a neuroradiologist is finding things on people that's not always expected. He likes to provide the answer to a patient's problem as early as possible. While many times it's obvious to find something, it's rewarding to find them. And really this affects the patient’s cure early on in the disease. A lot of times, they always look at the whole study. But in fellowship, he remembers reading the MRI, the lumbar spine for back pain. But he had to define a Wilms tumor in the kidney. And the patient was able to get that resected and cured. And sometimes, you're the first one to notice that. He finds nodules when looking at shoulder xrays or just different pathologies all over. And the more you look, the more you find. So he finds this especially rewarding.

On the flip side, what he likes the least about his subspecialty is the difficulty of multitasking. You can be looking at a complex case and then you'd have to juggle that with taking a phone call from a technologist for instance. But he tries to resist the temptation to rush through things. So he just takes it one case at a time. That said, you still need to be able to multitask.

If he had to do it all over again, Narayan would still have chosen the same path. It goes in waves, but overall he's happy the path he chose is a wonderful career. It's one where you can have a tremendous impact on, both working with other clinicians and other doctors and also impacting the patient.

"You may not really get recognition from the patients but it's rewarding when you find stuff."

[39:45] Final Words of Wisdom

Narayan leaves us with some pieces of advice. Something he learned from his mentor is "we got to get the list cleaned up." But you have to always remember that it's a list of patients. It's people's individual problems. They're going through certain conditions. So it's your responsibility that while you need to get the work done, remember that they're patients. It can easily get lost in that mentality of just cleaning up the work. Just stay grounded. Be patient. And try to learn and do as much as you can.

For the medical student, and you might already know you wanted to be a neuroradiologist from day one, it's important to get knowledge in other areas. In fact, Narayan recommends that you do less in neuroradiology throughout your medical school and residency training. Because the more you understand what other specialties are looking for and what they want to know, the better neuroradiologist you're going to be. Same thing with doing more. Increasingly, you're going to be doing more procedures and be versatile. So doing your training, try to learn as much as you can.

[41:46] Like This Podcast?

Did you enjoy this episode? Shoot me an email at ryan@medicalschoolhq.net. I welcome any suggestions or specialty that you would like to come on the show. Better, send me a name so that I can interview him or her.

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Oct 25, 2017
45: What is a Cardiac Anesthesiologist?
30:48

Session 45

Dr. Maninder Singh is an academic Cardiac Anesthesiologist. He's been out of his fellowship now for four and a half years. And he's in a large academic medical center in Cleveland, Ohio. In our conversation, we talk about everything that you need to know about the field.

Check out The Premed Years Podcast Episode 256 where I interviewed the dean of the brand new medical school, Carle Illinois College of Medicine. Also check out all our other podcasts on MedEd Media.

[01:35] Why He Chose Cardiac Anesthesiology

Being the medical student that loves everything, he was interested in every rotation he was on. And he found that anesthesiology was the perfect mixture of everything. So it was more of a decision of exclusion where after he excluded everything else, the only one left was anesthesia.

What really drove him to the specialty was being close to the fire, and it gets ugly really quickly, then you get to control things and everything gets back to normal.

Cardiac was fun for him too. He always had that interest in cardiology because of the physiology. So it's the level of understanding and the impact you can have on the patient in an acute setting. Not to mention the outcomes you get to see right away were the things he was attracted to cardiology.

What really drew him to anesthesiology over emergency medicine is because the days are a little more regimen from a standpoint that he was able to have more control over his schedule. It made more sense to him back them.

[05:15] Traits that Lead to Becoming a Good Cardiac Anesthesiologist

"Being a team leader, regardless of the setting is the most important trait."

Maninder cites the traits that lead to becoming a good anesthesiologist such as being a good leader and a good communicator. Also, you have to be confident in your skills. He best describes it as being closest to the fire without being inside the fire. He also mentions that cardiography has become huge in the last five to ten years.

[07:10] Why Anesthesiology Subspecialty is Important

Maninder explains having a subspecialty gives you different options within the field. And from the patient population standpoint, it's different when you're putting a four-old-baby to sleep versus a 30-year-old athlete with an ACL tear to sleep. And versus a 90-year-old person with another severe condition to sleep. So it depends based on the type of surgery, the comorbidities of the patient, etc.

"You need a certain group of people that get advanced training in that particular field to provide the best care for the patient."

The field is changing dramatically with all the procedures they have available. So it's nice to be an expert for that exact procedure and that exact population.

[09:10] Types of Cases

Maninder cites cardiovascular as the number cause of death. From a cardiac standpoint, cases they deal with are bypass surgery, issues with valves. Moreover, congenital cardiac patients are living longer now so they see them in their adult lives.

From a heart failure standpoint, there is a huge shortage for heart transplant organs. As a result, lots of people are placed on assist devices until an organ is available.

50% of their cases are cardio-thoracic which includes lung surgery as well. And some cardiac surgery which is half bypass operation and half of which are valve replacements or valve repairs.

[11:06] Community versus Academic and Taking Calls

There are lots of community-based programs that are busy and have a huge demand for cardiac anesthesia. It used to be that after the surgeon does the surgery and comes for bypass, and now you call the cardiologist to the operating room to take a look at the valves. So you bring another physician provider into the room. Now, you've taken cardiology out of the operating room.

Maninder says this is one of the reasons to be in academic is that the acuity of patients you see are a lot sicker. The operations you're doing are much sicker.

"You get to teach residents which also would keep you on your toes and keep your skills up to speed."

In terms of taking calls, they take one weekend day call per month which is about 24 hour-in house on a weekend. They they'll do anywhere from one to two weekend days, which is usually a sixteen-hour call. You go at 3pm and stay until 7am. A cardiac call ends up being a home call. There are 25 of them so they end up having to do it one weekend a month for calls, which is a big academic practice.

[13:20] Work-Life Balance

Maninder says it's one of the main benefits of being in anesthesiology is that you get to live a more structured life. Cardiac is one of the busiest subspecialties out of all subspecialties in anesthesiology. But it's pretty well-balanced.

"One of the benefits of being in anesthesia, your life is a little it more structured."

It's also center-specific. So they would do one case a day and they're done by 2-3 pm. By that time, they finish their paperwork and then be home by 4-5pm. And probably go to the hospital by 7am. So he still gets to have dinner with his family and take care of his kid.

[14:25] The Path to Residency and Fellowship

Out of medical school, you will apply for an anesthesia residency. It used to be advanced which is some sort of general training. And a transition year from general surgery to medicine. And then you have three years of dedicated anesthesia training. Then the cardiac fellowship is one additional year where you deal with high intensity programs. You basically do multiple cases a day while getting good at providing anesthesia for patients in terms of anesthetic management. Then you try to become sufficient and be certified in doing cardiography. So it's five years in total.

Maninder describes matching to not as terribly competitive in general. Chronic pain and cardiac are the most competitive. Pediatric is getting more competitive as well. But certainly, it's much easier to get into cardiac anesthesiology that it is to get into anesthesiology.

For students interested in doing cardiac anesthesiology to stand out, Maninder recommends to learn the residency program you're in. Shadow a cardiac anesthesiologist to see what they're doing. Understand the intensity to see if this is the right field for you. If you have the intensity and the dedication and the desire, Maninder says you will succeed no matter what. You can do research or anything that's going to help you in your anesthesia residency. This shows that you're really interested in the field.

"There's understanding the intensity that goes with it and seeing if this the right field for you."

[17:10] Bias Against Osteopaths and Working with Primary Care and Other Specialties

Maninder sees no roadblocks for osteopaths who are looking into taking this path. He has met multiple cardiac anesthesiologists that are DOs and he finds them phenomenal and even better. He has trained with DOs and he has trained DOs. At least on the East Coast where he did his training, he didn't see any bias against DOs.

Sometimes, they do work with primary care providers depending on the situation. Other specialties he works the closest with include medicine, surgery, all kinds of surgical subspecialties, pathology, psychiatry, internal medicine, endoscopy, GI bleeds, and just about every subspecialty there is.

[19:33] Special Opportunities Outside of Clinical Medicine

Maninder doesn't see a lot of opportunities outside of clinical medicine but there's teaching on one hand.

But if you wanted to go into the industry, Maninder admits all the big stuff is coming out. The big thing right now is the percutaneous valves they're doing. it's probably the only research going on relating to valves. There's a lot of percutaneous devices coming out for patients with atrial fibrillation. And a lot of things coming out related to assit devices for patients with heart failure. That said, the industry is booming as more and more procedures are getting available and people are getting well.

"Cardiac anesthesia and cardiac surgery is booming because of all that's going on in the industry."

[21:02] What He Wished He Knew that He Knows Now

Just the intensity of it at times is what he should have known before. Because you don't appreciate it while you're in the moment. And you only appreciate it when you have a nice easy day or case. So at times, he thinks the intensity gets a little bit too much. But even if he had known that, he still would have gone through the same.

What he does now during intense situations to remind himself that there are things that you can't fix. You do the best you can. You have to have all your algorithms so you don't miss anything. Just be a good leader and be a good communicator. Make sure you don't leave any stone unturned. Be loud and clear

"It's okay to ask for help from the standpoint of just having a fresh set of eyes."

[22:52] What He Likes the Most and Least

Maninder's favorite part is echocardiography, which is essentially one of the main reasons he got to do his electrocardiography elective as an anesthesiology resident. This was the time when he was still considering between pediatric and cardiac anesthesiology. And so it was the last thing that made him switch over to cardiac anesthesiology.

On the flip side, what he likes the least is not having enough cases. Not enough crazy cases. But he's quite sure that will change when he's 50 years old. But at this point, he says it would be nice to do more craziness.

[24:05] Major Changes in the Future and Collaboration Between Specialties

A lot of devices are coming up in the cardio scene like microregurgitation when patient would have to go in for an open chest procedure. Now, they can do a percutaenous device so the patient can go home the same day or the next day. They do the procedure on valves. They started with aortic valves and now they're doing mitral valves. These are the patients that are high risk for all the long rehab that goes with an open heart surgery.

They're doing more and more assist devices for the heart transplant patients waiting for an organ to come in. When the organ comes, they'd come in and call them essentially a bridge therapy, which is a bridge to their transplant.

Moreover, there's a lot more management for atrial fibrillation, which are high risk patients for stroke, secondary to atrial fibrillation. And who has contraindication for being on anticoagulants. They have procedures to close up the atrial appendage so patient don't have to be on anticoagulation.

As cardiac anesthesiologists, they don't deploy the valves directly but they are an integral part of that. For example, they identify the appendage for the cardiologist or they are finding exactly where to put the valve in. Too deep or too shallow, the valves are not going to sit exactly where you need it to sit. This is all guided by electrocardiography. And this is what's going to help a cardiologist and a surgeon do the procedure.

"Even though we are not actually deploying the valve, we are actually telling them exactly where to deploy the valve."

As a result, it makes you feel like you're a big part of the team because they rely on the information you're telling them. This is a concrete example of collaboration. Maninder also likes to tell his residents that they are the eyes of the surgeon. Sure, there is pressure, but you need to back yourself up and train the best possible way you can. And there are times when you have to make those big decisions because they need you.

[28:50] Final Words of Wisdom

If Maninder had to do it all over again, he would still have chosen cardiac anesthesiologist. Lastly, his advice to students interested in the field is to just do it. Don't think twice about it. It's one of the best specialties. From a job security standpoint, you're doing something that not many anesthesiologists can do in terms of cardiography. You've gotten all this training so make sure you're always in demand. Be prepared to work hard and people will appreciate your hard work. You will essentially become the go-to person for every sick patient, for every big case, and for managing patients. And if you don't shy away from those things, then it's the best field you can possibly go into.

[30:06] Last Thoughts

If you're thinking about anesthesiology, take a look at cardiac anesthesiology. Find a cardiac anesthesiologist to shadow. It's the best next step you can take on this journey.

Links:

The Premed Years Podcast 256: A Look at Carle Illinois College of Medicine with Dean Li

Oct 18, 2017
44: A Look at Academic Pediatric Neurosurgery
46:05

Session 44

Dr. Michael Egnor is an academic Pediatric Neurosurgeon based in NY. We discuss his long career in the field and his thoughts about what you should know. Michael has been out of fellowship training now for 26 years and is currently a faculty member at Stony Brook University.

Also, check out MedEd Media Network for a selection of podcasts to help you on this journey to becoming a physician.

[01:25] His Interest in Medicine

When Michael was very young, his mother had a brain aneurysm that ruptured. She survived but she had some neurological sequelae. So even when he was young, he was already involved with neurosurgeons.

He thought that to be a neurosurgeon was the pinnacle of what one could accomplish in terms of profession. Moreover, he found medicine fascinating. He recalls that he read a book Not as a Stranger back in high school. It was a novel about a doctor but the title just fascinated him. The title actually came from a passage in the Chapter 19 of Job in the Bible. Job was asked how he deals with all of the horror he experienced and all the terrible things he has seen. He knows what he's going through ultimately will allow him to see life and actually to see God, not as a stranger. That is if you would come to know him and what it means to be him in an intimate way.

"To be a physician, you get to see in an intimate way what life is all about and understand what it means to be a human being."

He was also inspired by Dr. Christiaan Barnard who was the first surgeon to perform a heat transplant. He recalls seeing the news about it as a kid and got fascinated by it. He is specifically fascinated by congenital heart defects. As well, the  brain fascinated him. That said, he knew he wanted to be a doctor and a surgeon, just not sure as to what kind.

Then he went to the army in high school because he needed money to go to college. He served as a medic in the army for three years. And getting accepted to college, it gave him a deferred admission so he started college when he was 20. Right after college, he went to medical school. Being older going to college, he considers himself being more focused than some of his classmates. He knew what he wanted to do so he worked really hard to get into medical school.

Out of medical school, still undecided between neurosurgery and cardiac surgery, he started general surgery internship in Mt. Sinai in New York. And halfway through his internship, he realized he wanted to do neurosurgery. He knew that 20-30 years down the road, he would still be fascinated by the brain and not as much by the heart.

So he applied outside of the match. He called neurosurgery programs.They needed a resident at the University of Miami so he went there with his newly married wife. He spent six years in Miami, training in neurosurgery and came back to Long Island where his wife's family is from. Then he got a job at Stony Brook as one of the faculty.

[05:50] Brain versus Heart

Not that the heart isn't a wonderful topic of research, it struck him as a fascinating machine. But with the brain, he thinks you can take the knowledge much further. The other thing that enthralled him was neuroanatomy and how the brain was structured. To him, it was like almost as I if he was learning a secret to what life was all about and it was in the structure of the brain. So he felt the brain would keep him interested indefinitely. While the heart for him was to mechanical for him.

"Almost as I if I was learning a secret to what life was all about and it was in the structure of the brain."

[07:17] His Path to Pediatric Neurosurgery

He didn't get out of training as a pediatric neurosurgery, He did general neurosurgery but he has always liked pediatrics. He likes the patients and has a fair amount of empathy for parents. He also has a personality for it. And in some ways, he thinks neurosurgeons and pediatricians are thought a being at the opposite ends of the spectrum of medical personalities. Pediatricians tend to be warm, nice people who are nice to the family and patients. Neurosurgeons are thought of to be egostistical and dysfunctional people who just operate like crazy. But these stereotypes are not entirely true.

Pediatricians respond well to neurosurgeons and vice versa. What happened at Stony Book was for a couple of years, they didn't have a pediatric neurosurgeon. Since pediatricians like him, they sent him a lot of patients. So the chairman of pediatrics ultimately asked if he was willing to just become a designated pediatric neurosurgeon. And so he agreed.

So there's a way to get boarded in pediatric neurosurgery outside of the fellowship track.It was a matter of submitting case logs for several years and taking a written exam.

[09:30] Traits to Lead to Becoming a Good Pediatric Neurosurgeon

Michael explains it's a blend of two very different species. Pediatricians tend to be people who are warm, nice people. They love kids and want to take care of them. Neurosurgeons are egotistical people and surgically oriented.

This path is great if you find you love the surgery and are fascinated by the brain. You like some of the technical challenges of neurosurgery and on the other hand you want to take care of kids. For example, you find conditions like hydrocephalus to be very challenging and fascinating from a scientific standpoint.

"It's a hybrid of two different ways of practicing medicine."

Neurosurgery is an interesting specialty. As much as he has met the nicest people who are neurosurgeons, there are those who are crazy too. Michael says, neurosurgeons have to have some degree of almost irrational confidence in their abilities. It's something normal human beings don't want to do. You're taking tumor out of someone's brain where you stand a reasonable chance of killing them if you make a mistake. It's not something even people who are inclined to surgery have a particular comfort of doing it. So you have to be fairly egotistical to do this for a living.

And how does one pull that off in the real world? Neurosurgeons have different ways of doing it. Some neurosurgeons just concentrate on being technically as good as they possibly can. Others are psychopaths in a non-criminal way. What Michael means is some of them don't take into account the humanity on the other end of the operating table. they just do the job as well as they can and then if it works out, great. If not, they'd call out the next patient.

Some neurosurgeons limit their practice so that they only do things they feel comfortable doing. While others don't put it together well at all and don't do such a good job.

[12:25] Types of Cases and Patients

As a pediatric neurosurgeon, a large fraction of his practice is children with hydrocephalus. And he follows them into adulthood so he also has a fair amount of adult patients.

Michael mentions the issue in pediatric neurosurgery that pediatric neurosurgeons who work in adult hospitals question as to where they will follow their pediatric patients when they grow up and become adults? Some pediatric neurosurgeons who work in children's hospitals can't do that. This is because patients can't be cared for at the hospital they work at. In Michael's practice, he deals a lot with hydrocephalus in both children and adults. He also deals with hydrocephalus in older people. He sees elderly people who have normal pressure hydrocephalus. Other cases he deals with are brain tumors, Chiari malformations in both children and adults, as well as syringomyelia in their spinal cortices. He also sees patients with craniosynostosis, infants with deformed skulls, and of course, trauma both adult and pediatric.

As to what percentage of patients coming to him that already have a known issue, Micheal says it's a very common scenario to see a child with brain tumor. And the pediatrician feels a lot of guilt about it because almost a child who has brain tumor has several months of symptoms. And pediatricians work up a child with some vomiting and headache. And after 1-2 months of evaluation, they get scanned and the tumor is found.

And so he tells them that in some sense, the neurosurgeon has the easiest job because virtually, patients come to him already with scans showing what's wrong with them. The primary care people, the pediatricians, or the internists for adults have a tougher job because they see a large volume of patients. Only a small fraction of them have serious problems. Then they have to find the ones who have the serious problems.

The major issues he faces are: is the patient's diagnosis responsible for the patient's symptoms? This can be tricky. People can have headaches from the chiari malformation and don't need surgery.

Michael finds it a challenge to sort out whether the symptoms of the patients are really caused by the disease identified on the scan. You have to be sure since the remedy you're offering is surgery. You want to make sure you're operating for good reasons.

"That's one issue I face quite a bit is making sure the diagnosis is the cause of the symptoms."

[16:25] Typical Week of a Pediatric Neurosurgeon. Taking Calls, and Percentage of Patients Ending Up in the O.R.

Michael describes his week since it basically depends on whether the hospital has a lot of trauma or not. But his typical week would be that he'd be on call once or twice during that week at night. He takes a general surgery call.

During the day, he has two operative days a week. On average, he takes 2-5 cases a week. He has 2-3 half-day clinics a week where he sees 15-20 patients per clinic. He has some academic time, usually one and a half days a week where he writes papers. They don't have residency in neurosurgery so he's a residency director for a program without a residency. This said, he's in the process of applying for residency. He teaches medical students as they rotate through the service he teaches and in the ethics class.

Of the patients he sees in clinics, only a relatively small percentage, about 10%-20%, go to the operating room. Many of the patients he sees are follow-ups after the surgery. Many of them are children with shunts he sees annually. They don't need surgery but he sees them manually. It's very important that if you have a shunt for hydrocephalus, you have a neurosurgeon that knows you. And that you know them and that they neurosurgeon is always available to you. He finds that annual visits keep everything fresh so they know each other.

Common cases would be a kid who bumps his head on the baseball field, has a mild headache and gets a scan. And something would be seen on the scan that has pathological significance but the primary care doctor sends the child to him.

Most of the calls he takes would be coming to the hospital for surgery. They don't have residents so any surgery is done by the attending. They have physician extenders but he still has to come in and do the surgery. Nowadays, generally, residents don't operate alone so even if they had residents, he would have to come in. About a third of his calls, he would have nights coming in.

[19:45] The Path to Pediatric Neurosurgery, Competitiveness, and Research

Basically, neurosurgery residencies have been for five or six years including the internship year. That's followed by a year or two of fellowship, if you want to do it. This past two years, the ACGME and the residency review committee (RRC) for neurosurgery have standardized neurosurgical training. Now, it's a seven-year program including a year of fundamental clinical skills, which used to be the internship. And then six years of explicit neurosurgical training.

Now they try to fold in the fellowship experience into the seven-year residency. So you don't have to do fellowship after you do it during the residency.

There is research involved in neurosurgery. In fact, programs are required to have a research curriculum, whether it's training or research methods. Residents are expected to be academically active, to publish during their residency. And programs are reviewed by the RRC based in part on the research output of their faculty and residents.

"It's a major emphasis in the residency review committee in neurosurgery to foster research in neurosurgery."

Although he doesn't have the numbers, Michael thinks that half of the applicants get into programs. He would rate it as moderately competitive. It's a small specialty with about a hundred programs in the country. There are a whole lot of people interested in going into it but his sense is about 50% of applicants get in.

As to the reason for it competitiveness, it appeals to a fair number of people, particularly people who are highly motivated. You have to really want to practice medicine at a fairly intense level to want to get into neurosurgery.

Moreover, people may be attracted by the status or the financial aspects. Most neurosurgeons do fairly well financially. And there aren't enough people repelled by the volume or nature of the work.

"It's fairy popular given what a small specialty it is."

According to my data, there are are only 218 physicians. Michael agrees this is just about right. Pediatric neurosurgery is one of the less popular neurosurgical specialties. Within the neurosurgical profession, popular subspecialties include spinal neurosurgery, general neurosurgery, vascular. The reason for this is people don't like dealing with shunts. Many neurosurgeons, too, don't like dealing with kids or with families. Another reason is pediatric neurosurgery doesn't pay as well as other neurosurgical specialties.

It seems to be a general rule across all pediatric subspecialties is that the pay isn't as good as it is for adults. But Michael points out you don't go into it for the money.

[24:00] How to Be Competitive for a Residency Spot

Besides being a good student and being a human being which always help you, Michael cites two things students should focus on. First is research. Have some publications appealing to a neurosurgical residency program. The second is to have some hands-on experience particularly with the programs you're applying to.

When he was a resident in Miami, they took two residents a year. There was an unwritten rule that one resident was taken based on the CV and the other based on personal experience. When somebody would rotate through their service, you get to know them personally.

It turned out that the people who did the best in the residency were almost the people who had rotated to the service and who they knew personally. You're going to work with the resident for seven years in fairly intimate ways in the middle of the night, saving lives, and doing all these stressful things. You really want to be somebody who you know you can work with, somebody you can trust and stand with for seven years.

"The residency in neurosurgery is so long and it's such a stressful process. It's almost like a short marriage."

Michael suggests that for people interested in neurosurgery, try to arrange external rotations at the programs you're most interested in applying to. This way, when your application comes across their desk, they would know who they're dealing with.

Nevertheless, the research is a big deal. But the programs have a lot of stress on them from the ACGME and from the RRC to have residents that do research. It's one of the criteria by which re-certification of the program is determined. Plus, if you already have an established researcher in your program, it's more likely for them to make their program look good. That said, having a research background is very appealing to programs. In the long run, having research background makes you a better resident and a better neurosurgeon.

[26:45] Biases Against DOs and Subspecialty Opportunities

Michael's personal experience with osteopaths has been uniformly positive. Some of the best doctors he knows are osteopaths and his personal doctor is an osteopath. He thinks osteopaths are great doctors generally.

He also knows that osteopathic programs have been brought into the ACGME. There are osteopaths at neurosurgery programs that do well. Although now, he's not sure how it's working into allopathic training. But osteopathic students are in an excellent profession and they can be very good doctors and very good neurosurgeon.

In terms of other subspecialty opportunities, there is a boarding process for pediatric neurosurgeons. Although they're not ACGME-certified. So there are boards but they are not same status as the neurosurgery boards or the internal medicine boards. Beyond that, he's not aware of any certification process. But there are pediatric neurosurgeons who have particular interest in areas like hydrocephalus, epilepsy surgery, vascular, tumor. So you can develop a niche within the pediatric neurosurgery world.

[28:50] Message to Pediatricians, Working with Other Specialties, and Turf Wars

Michael says it's nice for neurosurgeons and pediatricians to become friends in terms of personal relationships. The pediatrician knows you personally. He gets a lot of calls from pediatricians just asking common sense questions. He finds that in the relationship between pediatricians and neurosurgeons, it's nice to form long-term friendships. In return, there are also situations where he calls the pediatricians. He will have a patient who has a neurosurgical issue but also has some pediatric issues. Then he'll speak with pediatrician about helping them out with that.

Michael works a lot with other specialists like intensivist both adult and pediatric, orthopedists, otolaryngologists, and neurologists.

For somebody who wants to go into neurosurgery because they're interested in doing spine surgery, Michael explains that in general surgery, most of the operative stuff is spinal. General neurosurgeons deal with spine in generally 80% of their cases. And most of the spine they do overlaps with orthopedics. Most general surgery particularly in private practice deal with spine. And there are movements right now in general surgery to relinquish cranial privileges if you're a private practice neurosurgeon. Many of them find that the cranial surgery, because it only forms only a small fraction of the cases they do, it does form a very large fraction of the difficult situations they encounter. So it's not just worth it. Also, it makes the call much worse. If you're doing cranial neurosurgery, you're called in at night for that subdural in the ER. But if your practice is restricted to spinal neurosurgery, you don't have to be called in for the cranial problem. So many of pediatric neurosurgeons restrict the practice of the spine. He actually has a friend in Florida who has been doing this for fifteen years. It makes for a very nice practice.

In terms of overlap with orthopedics, Michael sees a lot of them. He never thought of it as something very competitive although his spine colleagues might feel differently about that. But they have a good relationship with their orthopedic colleagues at Stony Brook. The difference in the work they do is that neurosurgeons don't tend to do congenital deformities with scoliosis. On the other hand, Orthopedists don't do intradural surgery.

"Kids with scoliosis still tend to be treated only by orthopedists and not by neurosurgeons."

[35:10] What He Wished He Knew Now

Michael doesn't think he would have done anything differently. He thought a lot about it. He likes pediatric neurosurgery. He is very interested in hydrocephalus from a research standpoint. Most of his research is in hydrocephalus dynamics and the cranium related to it.

That said, there are tons of specialties within neurosurgeries that are great including spinal neurosurgery, tumor neurosurgery. But each of them has their drawbacks.

For spinal neurosurgery, you have to want to deal with spine patients who can be very difficult to deal with. They're in chronic pain. So it should be something you like doing. Michael finds it's not for him.

Tumor work is fascinating but many of your adult patients are dying. And to go into clinic everyday and see patient after patient with terminal illness is a hard thing to do.

Cerebrovascular neurosurgery is very powerful specialty now with a lot of good work but they deal with some very difficult clinical situations. And the call can be brutal because you're taking call for strokes.

Functional neurosurgery is great work for people who are fascinated by the intellectual aspects of epilepsy and movement disorders. But you have to have a certain personality to do that. Functional cases are very detailed, high tech cases that you have to like doing.

[37:15] What He Likes the Most and Least about Pediatric Neurosurgery

Michael likes fixing shunts. Even some pediatric neurosurgeons don't like that too much. But he finds hydrocephalus a fascinating condition. He's very interested in the dynamics of it and thinks there's much we don't understand about it.

Hydrocephalus is the one neurosurgical condition where you can come into the hospital near death and walk out of the hospital a day or two later just fine. You can come blowing a pupil and go home in two days if they fix your shunt in time and the pupil comes down. In hydrocephalus, you can get incredibly dramatic results. I find managing shunts to be frankly challenging.

"Doctors who deal with critically ill patients the most are neurosurgeons as much as any."

What he likes the least about his specialty is seeing patients not doing well. This something all doctors need to deal with to some extent. Even if an objective observer wouldn't think of the outcome as a mistake, you still hold it in your heart and hod it in your head. That if you could have done something differently, could this patient have done better. Michael adds that one of the most important things about being a neurosurgeon is that you have to deal with the outcome. A neurosurgeon who has a major complication of 1%, you're a good neurosurgeon. A good complication rate for major cases. But if you're doing 200 cases, it means that two patients a year are going to have major complications. And if you're doing it for 30 years, there are 60 people out there who had major complications that's your responsibility and you live with those faces in your head. So he tells students going into neurosurgery is you have to be able to deal with that. That can be hard. In fact, some neurosurgeons quit. And some do dysfunctional things. They drink. They take drugs. They become egotistical creeps. They have different ways of dealing with that. Some become religious. Some limit their practice to things they can do safely. But you deal with stressful cases and bad outcome and dealing with litigation which is every neurosurgeon's pain. It's hard and it's a major part of the stress neurosurgeons go through.

"Over the years, you get faces of people in your head who didn't survive or who were hurt for whom you feel some responsibility."

There's a neurosurgeon named Henry Marsh who wrote a book called Do No Harm. He is a very prominent British neurosurgeon and did doctors tend not to. He wrote a book about all his bad outcomes. So the book wasn't about how gifted he was and all the great successes he had. Although he was a great neurosurgeon, the book was about his catastrophes. It's a very honest book. Michael recommends this book to people thinking about going into neurosurgery.

[41:50] Future Changes in Neurosurgery

The most dramatic change that's occurred in neurosurgery during his career has been cerebrovascular surgery with endovascular techniques. The ability to treat aneurysms with endovascular methods to treat AVMs and strokes. None of that was possible when he was training so this has been a real revolution. It primarily affects endovascular neurosurgeons but it's still a big change.

In terms of pediatric neurosurgery, he's not seeing much changes except that they're seeing a lot less spina bifida than they used to. Due to folate supplementation in bread and milk and other foods, it's reducing the incidence of this condition. And also, prenatal diagnosis. Many of these babies are being aborted prenatally.

There's a lot of research in tumors but the basic management of tumors has not changed all that radically. In spine, there was a study done back looking at which neurosurgical operations are under performed and which are over performed. They felt that functional neurosurgery was under performed. While the spinal surgery was over performed. So the reality is there are more people having spinal surgery than really need spinal surgery. Many people could recover from their spinal problems with good physical therapy and non surgical management.

What's he's concerned about over the years is that insurance and the government will decide to reimburse spine in a much lower level and be much more stringent in the reimbursement which would affect neurosurgery in a very profound way. Because most of their income stream comes from the spinal surgery.

[44:10] Michael's Final Words of Wisdom

Consider this path if it's going to something that's going to be in your heart, it's your passion and not something you do for money. You also have to take into account the emotional stress that comes with dealing with people's lives on an intense personal level. He didn't actually feel this stress until he became an attending. You're going to have patients who don't do well so you have to have the psychological and spiritual resources to deal with that.

"You have to take into account the emotional stress of dealing with people's lives on such an intense personal level."

Links:

If you have suggestions on people we should have on this podcast, shoot me an email at ryan@medicalschoolhq.net. We're looking for great guests!

MedEd Media Network

Not as a Stranger by Morton Thompson

Do No Harm by Henry Marsh

Oct 11, 2017
43: Community Based Interventional Cardiology
36:23

Session 43

Dr. Venkat Gangadharan is a community based Interventional Cardiologist. We discuss his interests in cardiology and his thoughts about the specialty. He also gives his opinions on the latest changes in our healthcare system regarding reimbursement cuts as well as turf wars between specialties.

Also, check out all our other podcasts on the MedEd Media Network, including The Premed Years Podcast, The MCAT Podcast, The OldPreMeds Podcast, and The Short Coat Podcast.

[01:08] Interest in Cardiology

Knowing he wanted to be a cardiologist right on his second year of medical school, Venkat did what he could to figure out. By the time got into residency, his mind changed and considered things like pulmonary critical care or cardiology. Then he got the chance what the cath lab was like and got to see what they do when they treat heart attacks. And he got sold right then.

He's the type of guys that likes instant gratification in terms of treating patients. He wants to see them get better right then and there. So he found doing cardiology and interventional cardiology was the way to go. He knew he wanted to do interventional cardiology by his second year of cardiology fellowship. He recalls applying everywhere across the U.S. He thinks it was the toughest thing being one of the several thousands trying to get the same position. He has interviewed in at least ten different places. It was so difficult for him that he finally ended up matching in a program at the last minute. He decided to take it and to him it was the greatest decision ever.

"No matter how competitive you are, you're one among several thousands that are trying to get the same position."

What he really likes about cardiology is the physiology behind it. Plus, it required some amount of critical thinking and problem solving. But at the end of the day, there were define medications for certain purposes. There are risk factors you know you could treat. And the problems had definitive treatment modality and cure to some extent. Basically, he's fascinated by how the heart works.

[04:40] Traits that Lead to Becoming a Good Interventional Cardiologist

Venkat cites some traits in order for one to become a good interventional cardiologist such as being dedicated and hardworking. You need to be analytical and be able to think on your feet. In the cath lab and you have a patient's life in your hands, there are probably a million different decisions running through your head.

With so many things running through your head, you just have to choose the right one and make sure the patient gets through it no matter what. With heart attacks, for example, the chance of people dying from it is so low nowadays. Everybody has got a chance. Compared to back in the days during the infancy stage of interventional cardiology, there were no facilities to treat people. There was no place to send them.

“With the technology we have, there's not one person in the country that should not have the chance to live at the hands of a cardiologist.”

That said, you have to be able to think outside the box. You have to be analytical and mechanical. Venkat explains that interventional cardiology is all about physics and the give and go.

Additionally, having that adrenaline junkie kind of mentality is an edge. When you're taking an emergency call, you will have to wake up in the middle of the night to have of your faculties all ready to go. Drive to the hospital. Then have all of your fingers ready to go to and adept to put a stent or fix a blood vessel to fix a person's life. You need to love the rush for you to be able to mental faculties to take care of that problem in the wee hours of the night.

[07:22] Private Practice versus Academic Setting

Venkat explains the reason he chose private practice was being the easiest choice at that time. There are far more private practice physicians at that time than there are academic positions. Second, you have to have a certain mentality and persona to be an academic interventional cardiologist compared to a private practice physician.

"I wouldn't say it's money driven per se, but I would say it plays a huge role in the decisions you make when it comes to the job you pick."

As a private practice physician, you have the ability to dictate your own life as well as the ability to treat your own patients. You have the ability to learn things at your own speed without having to answer to anyone else but your own practice. These were what Venkat was looking for.

[09:07] Types of Patients and  Typical Day in His Life

As an interventional cardiologist, Venkat sees everything from valvular heart disease to atherosclerotic vascular diseases. It's truly mind boggling that the amount of coronary disease that is out there and how young a person can be by the time they get affected. Venkat finds it humbling to be doing intervention in a 34-year-old when you're the same age as he is and living the same kind of life he is. For him, this is eye-opening and it makes you realize how life is short and you need to take good care of yourself. So when he things sees on the screen, it makes him think twice. It's surprising to see how bad people's arteries could be at such a young age.

As a private practice physician, Venkat says it's tough being just an interventional cardiologist. So he also practices a lot of general cardiology and interventional cardiology, But his mind is always focused on what he can do to fix something.

He gets to the hospital around 6 or 6:30 in the morning and do some rounds. If anyone comes in with a heart attack or he's on call, he drops whatever he's doing and go and save that life. Then he goes to the office or clinic and trying to recruit patients to your practice so you can maintain a lifestyle and a career.

"It's very rare in private practice to find a position where you just do interventional cardiology."

You have to be ready to handle any situation presented to you. Venkat takes emergency calls about three to four times a week. Being a young doctor, his practice is made up of only two interventional cardiologists. He usually gets a call about three times a week. But not all private practice is like this. The larger the private practice, the less call that you're going to take.

From a general cardiology perspective, he takes calls once a week and he does one week in the month. Initially, when he started out, it was pretty rough not realizing it was this much work. But Venkat explains that you will get used to it.

[12:21] Work-Life Balance

Venkat thinks having that work life balance is a million dollar question. Over the past three years, he had thought about what life was like outside of his work and the balance he had between work and his home life. He has a two-year-old son who misses him all day long. There are plenty of days he'd feel bad about coming home late or working as much as he does. But at the end of the day, being a young physician and knowing this is your career, this is the time to make a living. This is the time to earn for your family. After which, you can decide what's going to work for you and where you want to spend your time more.

[13:33] The Path to Interventional Cardiology Residency and Fellowship Training

Once out of medical school, you decide to make an internal medicine residency. When he was applying, he looked for decent cardiology fellowship knowing it was what he was going to do. The likelihood of you getting into the cardiology fellowship at the residency program you trained at is better than one than you'd get at another place.

This is followed by another three years of cardiology fellowship. At this time, you're introduced to cardiac catheterization and different aspects of interventional cardiology. Also around the second year, you also make the decision if you want to become one and start applying to interventional cardiology fellowships.

The difference between interventional cardiology fellowship applications and the general cardiology fellowship applications is that many of those programs are paper applications. This means you have to seek them out. Find out what their application process is. Do every step you can and apply. Then follow up several times if they've received your application.

"Try to hone in on the programs that you really want to be a part of."

Things they would usually look at are your degrees of research you've done during fellowship, your progress in testing during fellowship and training, and where you trained which goes a long way.

As to why he thinks matching into interventional cardiology is so competitive, Venkat believes it's one of the more rewarding cardiology fellowships. The number one killer of people in the world is heart attacks. And interventional cardiology is essentially designed to treat those. So the amount of people applying to be an interventional cardiologist are far more than the people applying to be an electrophysiologist or a nuclear cardiologist. And for electrophysiology in particular, the testing is very difficult. It requires someone to be very cerebral and a mentalist to handle that kind of profession.

[16:18] Bias towards DOs, Subspecialty Opportunities, and Turf Wars

Venkat actually has not seen any bias towards DOs. In his own practice, he has a partner who is a DO. He took a very long way to become what he is today. But he's a successful interventional cardiologist.

"At the end of the day, the MD and the DO designation is just a designation. The person you are is the physician that you are."

Venkat adds that you can be an MD and be an awesome physician. You can be a DO, and still be an awesome physician. He really doesn't think this has any weight in terms of whether you have a chance of being an interventional cardiologist or not. It's about what you do with the time you spend and the training you spend that makes who you are.

In terms of subspecialty opportunities after interventional cardiology, Venkat explains there is a new development in structural heart disease. In the country, there's only a handful of programs that are accredited structural heart disease fellowships. The ACC and the AVIM have yet to recognize a designated fellowship for this.

Coronary heart disease is not the only thing that plagues people, Peripheral vascular disease is also what plagues people. So there are specialized fellowships to do a training in endovascular work. Venkat explains that as interventional cardiologists, they're actually an interventional cardiovascular physician. So the vascular aspect of things is largely untapped and majority of that training can be obtained after a fellowship.

Venkat also admits having turf wars brewing between cardiovascular and vascular surgery. When it comes to peripheral vascular disease, it's a turf war between a vascular surgeon, an interventional cardiologist, and an interventional radiologist. He adds there are programs out there with long, trusted interventional radiologist to do the procedure or long, trusted vascular surgeon to do the procedure. As interventional cardiologists, they are making the push to take that on themselves.

"The breadth of peripheral vascular disease is so poignant in this country. There's opportunities everywhere."

But Venkat says that you won't see many private practice interventional radiologist or private practice vascular surgeons doing a lot of endovascular work. Majority of them have some sort of academic affiliation. You will see a lot of private practice interventional cardiologist doing all of that work.

[20:10] Working with Primary Care and Other Specialities

Venkat wished primary care physicians knew the breadth of disease they see and the complicated nature of disease present in their patients. He really wished they would understand the medications they use to treat these conditions. Unfortunately, Venkat lives in a place where managed care is a strong push in the area. By this. primary care physicians are limited in the medications they can offer their patients. Many of them end up changing the medication he places his patients on. Or they deny the stress test or deny the arterial ultrasound the patient needs to gather some more information for their complaints. It actually blew his mind when he first got there. But that was the reality. And in the three years there now, he still couldn't grasp the idea where primary care physicians are literally dictate a patient's life regardless of the symptoms the have.

"I still couldn't grasp this idea where primary care physicians are literally dictate a patient's life regardless of the symptoms the have."

Venkat describes it's like the patient has to show up in the hospital to get the real care they deserve. They go to their primary care physician because six times out of ten, they're going to get denied. This is saddening. Venkat says he had to rescue people at death's door when they could have been rescued two years earlier.

Other specialties he works the closest with include pulmonary and critical care, infectious disease, and nephrology.

[23:28] Special Opportunities Outside Clinical Medicine

Venkat explains that the more senior you become as an interventional cardiologist or cardiologist even, the opportunities outside of medicine start to open up. When you're a part of a large hospital system and you have a good relationship with the hospital administration, most of those avenues are open for you.

One of his partners is the chief of internal medicine in the hospital as well as the chief of cardiology at the hospital. It's a rotating door when it comes to that position.

"Cardiologists are often taken in high regard because we have our fingers in every aspect of things."

Other cardiologists have also migrated to other industries. His mentor has left interventional cardiology practice of 45 years and is now engulfed in an industry that promotes one of the products he helped design and bring to market. So you have the opportunity to migrate over to an industry and be a speaker and teach the world about what you do.

[24:55] What He Wished He Knew and What He Likes the Most and Least

Now knowing what the process is like to get better framed in what he does, he wished he probably should have sought out an extra fellowship at the end of his one year of interventional cardiology. Had he known the amount of opportunities out there, he probably would have given it a better shot.

Secondly, although a private practice physician, he wished he had given academic interventional cardiology a strong push at the time he was making the decision for a job. He never knew it was this busy. But he's a young guy so he's pushing through it.

What he likes the most about being an interventional cardiologist is doing procedures. He loves working with his hands. He loves the adrenaline rush of fixing a heart attack. For him, waking up at 2 am is not difficult. If he could save a life and they'd walk out the door the next day, alive, he feels he has done his job for the day.

"To me, the procedural aspect of this whole profession is what makes the best thing everyday."

What he likes the least, on the other hand, is the bureaucratic aspect of it. Running a private practice or trying to develop a career as a private practice physician is very difficult. Unless you have the business know-how or the business acumen, it's difficult to make yourself well-known in the community that has several people just like you. But it does teach you what the business of medicine is like.

"One of the things we lack as residents and fellows is that nobody ever told you what the business of medicine is like."

Reality is that everything costs money. Everything you do, you need to earn something from it. And you need to be happy doing what you do in a day in and day out basis. So you need to find a place that gives you the opportunity to grow as a physician. But it should also give you the security that you know this job is going to keep you happy for years to come.

[28:00] Major Changes Coming in the Field

One of the major changes that is likely coming over the next year or two is that CMS is bundling payments when it comes to cardiac procedures and cardiac diagnosis. For instance, myocardial infarction which used to be differentiated in terms of medications and procedures are now going to be bundled under one big heading called myocardial infarction. So the payment you're going to get is going to be far less than what you've gotten in the past.

Over the last five years, Venkat explains how the field has been largely affected by the reimbursement and the cut in reimbursement. They've lost almost 40%-50% of what the normal reimbursement would be for a regular procedure. So it's not becoming more cutthroat in their field to do more work, find more patients, and treat more disease since you're not making as much as you used to.

This is going to get worse as time goes on, Venkat suspects. Eventually, private practice is likely going to dissipate depending on where you live and hospital-employed physicians and hospital-employed practices are going to predominate in this country. The reason for this is because hospitals are able to negotiate their deals with insurance companies and pharmaceutical companies than a private practice will. So if you want to make a decent living, you might end up becoming a hospital-employed physician.As for Venkat, he's holding up for as long as he could but he's aware that it's just around the corner.

"Hospital-employed physicians and hospital-employed practices are going to predominate in this country."

[30:40] Reduction in Reimbursements

CMS stands for Center for Medicare and Medicaid Services. Venkat personally thinks it doesn't make sense to reduce the reimbursement. At the end of the day, these procedures are being done by physicians who are taking the time out of their night to stay awake in order to save a person's life. The procedures continue to stay arduous. They don't get any easier. Although there's technology available to treat these conditions, these procedures don't happen in 30 minutes. It takes an hour or as long as four hours. So the work, stress, and the difficulty of your general lifestyle continue to exist and never change. Hence, reducing the reimbursement for these procedures is fostering an idea that medical management is better than risking your own life trying to do something.

Venkat has seen a lot of his partners who were interventional cardiologists 30 years back when things were great. It changed the way they practice based on the reimbursement they're getting. He raises this question that, "why would you go and try to do something whether to save a person's life or to be good at what you do, when the government and insurance companies don't feel like it's necessary and don't feel like you should get paid for it?"

Venkat thinks this kind of mentality is coming out a lot in newer graduates. The older generation is also catching up to it and realizing they can't make as much as they used to. So it's throwing a big stress in many of these private practice groups.

"The idea of newer graduates to think that they're going to get paid like they did 30 years ago, it's never going to happen."

Venkat's advice to the younger generation is that if you want to be an interventional cardiologist, you're doing it because you love what you do. Don't do it for the money because it's happening everywhere.

[33:22] Final Words of Wisdom

If he had to do it all over again, Venkat admits he would still have chosen interventional cardiology - 120%.

For students thinking about becoming an interventional cardiologist, Venkat explains that cardiology is a specialty that is going to continue to grow. It will continue to become the most prevalent disease in this entire world. If your heart is in cardiology and you truly believe that you want to help people and the adrenaline rush is what you live for, interventional cardiology is the way to go. You're going to love working with your hands. You're going to love the equipment they use. And it's only getting better. You can do things with heart arteries that people couldn't even fathom 30 years ago. The things your'e going to be doing is just unimaginable. Research keeps happening and happening. So if you love cardiology and you love what you do and you live for excitement, you're not going to be disappointed.

[35:02] Last Thoughts

Venkat is the first cardiologist on this podcast. I hope to bring you many other subspecialties within cardiology so you can get a great picture of what cardiology looks like for you, possibly in the future. Our goal is to find all these different specialties and talk to them and find out what their job is like. So as you're going through your training, you get a better picture of what life for you will look like. You will hear what physicians like about their specialties and what they don't like about it. This will help guide you on your journey to choosing your specialty.

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MedEd Media Network

Oct 04, 2017
42: Academic Neuromuscular Neurologist Talks About Her Specialty
44:18

Session 42

Dr. Vanessa Baute is a Neuromuscular Neurologist. She has been in the academic setting for the last five years out of her fellowship training. We discuss what drew her towards it, what she likes and what she doesn’t, and much more.

Also, check out all our other podcasts on the MedEd Media Network.

[01:16] Her Interest in Neurology and Neuromuscular Medicine, Patient Types, and Procedures

As a medical student, Vanessa was completely blown away by cranial nerves and their complex, visual system. She would read about it and study it and it didn't feel like work. The neuromuscular part evolved from having good mentors in the area for neuromuscular medicine. She enjoys doing procedures as well as the patient population. Not to mention, there was a fellowship spot available.

She still sees general neurology patients as with her inpatient work. She considers 75% of her practice as neuromuscular, which is a good chunk. Although she also sees patients having issues of neuropathic pain, different forms of neuropathy, and other neuromuscular diseases. She likes the variety of cases as well as the teaching part of it.

Some of the procedures she does to patients include occipital nerve blocks with ultrasound guidance, carpal tunnel injections with steroids, EMGs (which are a big part of her practice), skin biopsies, lumbar punctures, BOTOX for migraine and facial spasms.

"A big part of my practice is procedural."

[04:34] Traits that Lead to Becoming a Good Neuromuscular Neurologist

Vanessa cites some traits that lead to becoming a good neuromuscular physician would be the ability to stay with the patient through the journey and explain every step of the way. Every patient is going to be different so you have to be able to tailor your approach. It's not always black and white.

[06:20] The Misconception about Localizing and Being Able to Do Anything About It

Vanessa gives her take on the concept of localizing but not being able to do anything about it once you localize it. She thinks of this as a misconception considering the number of genetic therapies coming out as well as a whole slew of medications used to treat disease.

When you think of neuropathic pain and other forms of pain in neurology like headache or disc diseases, this brings on a whole holistic, integrated approach they can offer patients. This involves lifestyle medicine.

"There aren't many times in my career where I feel I can't do anything for a patient."

By this, Vanessa means doings things like walking with them in trying to figure out their diagnosis. For her, the ultimate goal depends on the person. Some people don't want to take a pill to have everything fixed. For other people, their healing journey is figuring out what's going on and how it's affecting their family. How can they live with it? Is their doctor going to be with them? Are their doctors listening to them? So she sees a lot of these in her practice just counseling patients.

"Even if I can't figure it all out in one visit and fix everything, that's not really a lot of people's goal."

Nevertheless, Vanessa assures there are cures for epilepsy as well as medications and treatments for MS. They have a lot of good treatments apparently. So she feels that her patients could be empowered. And maintaining their neurologic health, it's not always a big neurologic disorder they're coming with.

[08:40] Other Specialties She Considered

Vanessa describes herself as a happy person so she likes everything. She knew the complexity of neurology but she also loved her prelim medicine year. in almost everything she rotated through. She knew though that surgery wasn't for her even if she likes procedures. Funny as it may sound but she actually broke the sterile field on her first day of surgery rotation when her pants fell off.

She likes hematology oncology and found it's similar to neurology in some ways in terms of its complexity and the diversity of diseases. She loved the nephrology rotation, but not the acuity part of it. She is not a neuro-intensivist, but more of looking for bread and butter ways to look at preventive medicine.

Nevertheless, there was nothing strong enough to pull her away from her chosen field.

"There cannot be anything in this life other than a neurologist."

[10:52] Types of Diseases, and Followup Care

Vanessa considers her bread and butter neurology practice as a lot of peripheral neuropathy, neuromuscular junction disorders (ex.myasthenia gravis), cervical disc disease, lumbar disc disease, weakness, or a referral for motor neuron disease, ALS or an ALS variant.

Being an adult neurologist, she doesn't see children with muscular dystrophies. But they do have patients with adult muscular dystrophies such as myotonic dystrophy and imb-girdle disease.

In some of her general neurology practice, she deals with headaches and migraines where she gets lots of referrals for. She also notice how this has recently increased with the levels of stress as well as dietary influence. But she finds this exciting because of good treatment and good counseling options.

According to Vanessa, in most days, even if it's difficult news and diagnosis, she's still able to instill hope in them and offer them all the different treatments. She walks with them in the path which she finds very rewarding.

There are several instances where she does followup care when the patient comes to her already with diagnosis of ALS for example. About 80% of her patients come in having seen somebody, whether another neurologist or primary care doctor. Somebody has already labeled them and thought they had a certain diagnosis.

This is something she always harps on with education is going blind. It doesn't matter what somebody else had said because today is today and they're clearly here in our office. They always question the diagnosis whether right or wrong. We don't know what was happening when that person was in that doctor's office. They look at how the patient was diagnosed, the workup, the labs, the CK and the ENG report. They think from a critical standpoint if those were the things they would have measured. She always teaches her students to take a critical look at how these diagnoses are made.

"Some of the treatments are heavy-hitters and even just the labeling of the diagnosis. So we want to make sure."

And sometimes, they're able to take that diagnosis away and label away. And a lot of times, for a better one. For instance, Vanessa explains how ALS can be difficult to diagnose initially. So it's a big thing to tell somebody they have ALS if they don't or vice versa. So they take their time with all the information. Oftentimes, they repeat some of the tests until they both the physician and patient would feel good.

[15:27] Typical Day

As a neuromuscular surgeon, every single day is different. But she does this on purpose since she likes to be doing different things at different times. But a typical day for her would be a neruomuscular clinic. She works with neuromuscular fellows.her favorite part of the job is being able to watch the process done by the fellow or the trainee.

Vanessa also enjoys catching up with the patients. She sees from five to eight patients in a half day. And then the rest of the day is spent giving lectures to students or practicing integrative neurology. She does a lot of work in education, specifically, curriculum design, nutrition counseling. She also does a little bit of research.

[17:05] Academic versus Community Setting

Vanessa chose academic versus community-based setting for the primary reason that she loves the educational aspect of it which involves a lot of teaching. She also likes the mentorship. Medical training is challenging. And her personal experience with that stayed with her. It's almost traumatizing and hard.

"The educational standpoint is so redeeming. I can be there with the student or whoever it is I'm talking to."

She just can't imagine not having this part of it. Another thing about academics that she loves is being able to see a complicated neuromuscular patient and she can talk about it for two hours. She can talk about it with whoever - patients, doctors, nurses, colleagues. They can conference about the case and talk about it forever.

[19:03] Percentage of Patients She Does Procedures On

Vanessa mentions having a few sessions of EMG lab in procedures. Apart from her clinic, she has sessions devoted solely for procedures. So does separate her procedure clinic and her patient clinic. In her patient clinic where she sees patients, about 40% of them are ordered a procedure on - something with a needle. Then she will put them in her either procedure or EMG lab clinic which comprises half clinic and half procedure ratio.

A lot of her patients in procedure clinic are those who were people she met in the community. Not everybody likes procedures but since she loves them, she is known for it. So her colleagues will refer the different procedures to her.

"The referral base is good and I like being the person that is known for doing these procedures."

[20:49] Taking Calls and Clinical Coaching

Vanessa hardly takes any call otherwise the call she takes is voluntary. She still does a bit of inpatient service and that where she takes a call. She does this primarily because of the teaching aspect. Their calls are a mandatory process. She does four weeks per year of general inpatient neurology. A lot of this is neuromuscular cases like myasthenic crisis, Guillain-Barre, or transverse myelitis, etc. She sees this as an opportunity for her to get exposed to the residents and do a lot of bedside teaching, physical exam review, and clinical coaching. With clinical coaching, she partners with a third year medical student and kind of takes them under her wing. She goes and sees patients and watch them do history interviews. Then they'd have a feedback session afterwards. The call she takes is home call, which she has taken as a junior faculty. So likes to keep it fresh and keep up with the educational part of things.

[22:22] Work-Life Balance

Vanessa admits she tries to have a good work-life balance. Her goal is to show up at work and do something so fun that it doesn't feel like work.

"My goal is to show up at work and so something that's so fun that it doesn't feel like work and then go home and be at home."

Her goal is to use her training and what she's passionate about and what she loves, feel good about it, and then go home and be able to have that part of her life just as important. This is another thing she thinks a lot of people struggle with because you're not going to be an MD all the time. Your other roles are important too. She stresses the importance of focusing on those roles too as much as we're in the MD role. Nevertheless, the transition is challenging as we try to just sweep in. Know that you don't have to fix everything.

"You're not an MD all the time. It's important to be whatever other role you play in your life."

[24:22] Neuromuscular Fellowship, Bias Against DOs, Subspecialty Opportunities

Vanessa describes neuromuscular fellowship as not being very competitive in the sense that a lot of programs are looking for neuromuscular fellows. They're trying to recruit good fellows. There have been changes in the reimbursement in the last five years, specifically with EMG reimbursements. She's not sure if this motivates people to not go into neuromuscular medicine. Although it shouldn't because Vanessa stresses that if you're not loving what you do, it doesn't matter all - getting reimbursement or how much you're getting paid - if you're not into it. But this may have some influence in it. Again, she wouldn't consider it as a very competitive fellowship.

In terms of bias against DOs in the field, she doesn't really see this. Many of the fellows they trained are DOs. Vanessa says DOs have a lot to offer and a lot to bring to neuromuscular medicine. She finds it as a unique background even if she's not  DO. But she's heard a lot about it from the people she works with and she acknowledges how beneficial DOs are.

"DOs bring a lot to the table, especially with the manipulation, the musculoskeletal component, and anatomical component."

In terms of subspecialty opportunities, many will do just either neuromuscular fellowship with research. Most would do neuromuscular fellowship in one year. Some people will do a clinical neuro-physiology fellowship with several varying months of neuromuscular EMG training.

If you're interested in something specific after that, it's normally within that fellowship that you're going to get that training. In many cases, she knows people who went back and did something specific within neuromuscular medicine. Some people spend more time doing EMG while others spend more time looking at neuromuscular junction disorders.

Neuromuscular ultrasound is an emerging field, which is something she teaches at workshops and meetings. She noticed that more people want the training. There are different courses available for this - muscular dystrophy for instance.

[28:00] The Path to Neuromuscular Fellowship

From graduating medical school to being a neuromuscular neurologist, you do your first year or transition year as your first year of residency. You look at all the specialties and then you have three years of neurology. Most programs are front-loaded. Your PGY2 year may involve taking a lot of inpatient calls or seeing acute stroke - things like high-acuity neurology. Then it tends to get more clinical in most programs. You may also be exposed to EMG. It's rare to have EMG exposure early on in neurology residency although there are definitely programs able to do that. EMGs are mostly outpatient and most residency training is patient.

After your three-year neurology, you go into your one-year fellowship. Sometimes, this can extend to two years especially if you're interested in research opportunity.

[29:35] Working with Primary Care and Other Specialties

When Vanessa sees referrals from primary doctors, she wished they knew the neurologic exam. Sometimes she takes a referral over the phone asking about a neurologic questions. They would describe a neuromuscular disease to her and she would as how their reflex is doing. And then they say they didn't learn it. She considers this a travesty.

This is where Vanessa thinks clinical coaching is very helpful for students. Getting your neurologic exam down no matter what specialty you're going into. And basic things are important such as doing reflexes.

A great resource for learning this is the book Neuroanatomy Through Clinical Cases by Hal Blumenfeld. And practice this with your friends and family. Then have your neurology rotation. Do neurologic exams and have a neurologist watch you do it and coach you through it at least once. Record that. Take notes on that. And a neurology resident would be happy to do that too.

"Everybody needs to have some form of neurology exposure and medical training."

So one of Vanessa's biggest pet peeves is people not knowing if the patient has reflexes or Guillain-Barre. She would want them to at least know the level of sensory loss, especially if it's a spinal cord lesion. It's not that complicated but just a matter of education. It's a matter of learning that and practicing. Vanessa again stresses the importance of knowing the neurologic exam early in your training.

Aside from primary care physicians, other specialties she often works with include neurosurgery, orthopedics, hand surgeons, physiatry, PM&R, and rheumatology.

[34:18] Special Opportunities Outside of Clinical Medicine and What She Wished She Knew

There are also special opportunities outside of clinical medicine in terms of advocacy and administration within the hospital. It's a general personality trait as she describes it so it's not only unique to neurology. There is also a big split between a clinical role and a research role.

What she knows now that she wished she knew about her specialty is that reassurance. So had she seen this practice she has going on where she unites neuromuscular medicine with integrative medicine with education and mentorship, she'd be relieved.

"Everything feels very intimidating when you're in training and you don't see how it can be."

They've also had some surprises in the field with genetic therapies, spinrasa (nusinersen) and intrathecal administration for SMA. These are new things on the horizon. Looking at herself as a fellow looking at her now, she'd probably be surprised how fulfilling neurology can be as well as neuromuscular medicine. She'd be surprised in how far you can really go. Just keep going one day at a time. Keep going. Keep working. And you're going to be landing your dream job.

[37:05] The Most and Least Liked Things About Her Specialty

What she likes the most about being a neuromuscular neurologist is her colleagues and the chance to be able to work with the neuromuscular fellows. They have two fellows for year so they get to be intimate in their learning which she finds very rewarding. She loves how she's able to make a difference in the patient's lives while educating.

What she likes the least is paperwork. Again, not unique to neuromuscular medicine. She finds it challenging to implement and get people in the room, coordinating the referrals, and scheduling. Unfortunately. medicine has pitfalls in terms of bureaucratic processes which aren't what you want to be doing. So she tries to minimize this by building a good team and having meetings with everyone.

"Every person is essential. I'm only as good as my support staff... we all have to work intricately as a team."

[39:37] Major Changes in Neuromuscular Neurology

Vanessa notices that for muscle diseases, they have traditionally done their muscle testing and muscle biopsies in certain cases. Now, with genetic testing, they're able to talk to a patient. Send off a gene test. Then you may no longer be needing a muscle biopsy. They're not exactly there right now but hopefully, more innovations and drug therapies are coming out soon.

If she had to do it all over again, she still  would have chosen neuromuscular medicine with integrative medicine. For Vanessa, the two have to go hand in hand. She loves the patient population, her trainees, and her colleagues. She adds it's something you can tailor to what you're interested in. And if you know what that is in your own life then you can ask for that. Go for that. And you can make your practice really rewarding.

[41:25] Final Words of Wisdom to Students

Vanessa encourages students who like neuroanatomy and have done neuro rotation, or even if you're just curious if you're going to like it, go shadow a neuromuscular neurologist. And if you think it's challenging, it is! They're not easy. But don't get discouraged by that. As long as you like it and you're dedicated to it, know yourself and know what you're interested in and just go for it.

[42:42] Last Thoughts

One of the biggest takeaways for me during this interview was how much she loves procedures. As a neurologist, it's finding the ability to do procedures. Typically, neurology isn't considered to be a very procedure-heavy field. But she has found a niche for herself in doing these procedures because that's what she loves to do.

If you're thinking about something and disappointed because it's not very procedure-heavy, think again. You might be able to find a niche for yourself. And do the procedures you want while also seeing the pathologies and treating the patients that you want. If you know somebody who would be a great guest here on the show, please shoot me an email at ryan@medicalschoolhq.net and we'll try to get them on the podcast.

Links:

MedEd Media Network

Neuroanatomy Through Clinical Cases by Hal Blumenfeld

Sep 27, 2017
41: A General Pediatric Neurologist Discusses Her Specialty
33:28

Session 41

Dr. Denia Ramirez is a general academic Pediatric Neurologist. She talks about her journey to becoming a pedi neuro doc and other things about her specialty. Several weeks ago, we had a pediatric neurologist who specializes in headache medicine. She has been out in practice now for five and a half years after her residency in pediatric neurology. She is in a combined academic and community setting at the University of Tennessee Medical Center (UTMC).

Check out our other podcasts on the MedEd Media Network to help you on your journey to medical school.

[01:33] Her Interest in Pediatric Neurology

When she did her pediatric residency in Costa Rica, she got amazed by how a child gains milestones. She got interested in how things changed, and how they can shift from being so little and happy to somebody and completely against anybody who's a stranger at eight or nine months old. Her father-in-law was also a neurologist. It was around that time when she met her husband. So she got to see more of what a neurologist is not only inside but outside. This is basically what sparked her interest in neurology.

Other specialties that piqued her interest include emergency medicine. She realized the demands and the amount of time she was going to be out of home if she decided to go that route was probably too much for her. Since she still had to take care of family and do other things as well.

[03:20] Traits that Lead to Becoming a Great Pediatric Neurologist

First of all, you'd have to like kids. Not only for peds but also for adult neurology, you have to know your neuroanatomy. You have to know your localization well and learn the process in which we're taught to think to try to reach a diagnosis. More often than not, you're going to hear people you have to be smart to do this or that subspecialty.

"You have to like it. You have to enjoy it. You have to be dedicated. That holds true for any single subspecialty you get yourself into."

For Denia, one of the most wonderful things is when she's in clinic, she's essentially being paid to play with kids. She loves what she does and she loves talking to kids. She loves talking to parents. She loves to work with them and this makes her job much easier.

[04:40] Types of Patients

Denia says she sees almost anything. Child neurology has been a relatively new thing. She gets kids with epilepsy and the whole spectrum of those kids. There are those who come every six months. She helps them walk through the process and helps them until they outgrow it. She also sees kids with severe brain lesions or have genetic epilepsies. They also see kids with headaches. A lot of very normal kids who had one or two febrile seizures and parents are understandably worried and concerned about what that means. They also see kids with developmental delay with learning problems or kids struggling in school. Everybody wants to make sure that they're not missing something that is bigger. They see kids with neurodegenerative diseases. They see a lot of other different things like difficulty in walking, kids with ataxia, and so much more.

"The nice thing about pediatric neurology that is a relatively small field, there's not a lot of us."

Being a very small field, Denia says how they're so open and very supportive of each other regardless of the training program. And as much as they want kids with movement disorders to be seen by a movement disorder specialist, for example, but you don't always have that luxury. You reach out for them but you continue to take are of those kids.

[07:00] Generalist vs. Subspecialty and A Typical Day and Work-Life Balance

Denia cites three reasons for choosing to generalize instead of specializing. First, she has already done her residency training once back home and she'd have to repeat it. She felt she was at a point where she really needed to be more productive and do something. Additionally, she likes the idea that she gets to have all sorts of patients. Melinda adds she doesn't want to be stuck in a small bucket of things she sees over and over. She likes that she can see almost anything.

"The diversity continues to be a good stimulation for my knowledge, for my learning, and for continuing learning."

A typical day for her would be doing rounds. They don't have admitting services but they have consulting services. For the most part, she sees patients at East Tennessee Children's Hospital, not affiliated with UTMC.

Then she holds clinic between 10 and 11 am. She does reading and goes through a couple of journals to see if there is anything new that can contribute to her knowledge. Then in the afternoon, she sees patients. At the end of the day, she normally checks the charts for the next day. She finishes her notes and then her day is over.

She describes 50% of her time is spent doing clinics and another 50% is on doing rounds. Half of the time would be spent in the hospital. Some days, if they don't have any consults. she spends mornings catching up with any undone work. She'd call patients and see patients in the afternoon.

In terms of taking calls, she's available when it's needed but she doesn't have to be available. At the University of Virginia where she was at recently, they'd do one week of call. Some of them did more weeks of the year, some did less. It basically varies depending on your track. And then on the week you're on call, you have to be available for your residents 24/7 for the entire week.

Denia says having good work-life balance. As anything in medicine, you have to be organized at it. As long as you're organized, as long as you keep your priorities, you can do it.Denia still gets to cook everyday and go out on weekends. They don't have kids but if she had kids, she still thinks she'd be able to do things with her children.

"In peds neurology, once you're comfortable with it, it's easy to get yourself into that process."

[12:14] The Residency Path of a Pediatric Neurologist

The classical path includes two years of pediatrics and three years of neurology. In those three years of neurology, you'd do a year of adult neurology and then the last two years are allocated for pediatric neurology. So it's all five years in total. Some people join a program after they've decided they wanted to do pediatrics. They've finished the whole three years of pediatrics and then they'd do the next three years.

Another path available to some is you can do a year of internal medicine, a year of pediatrics, and then the three years of neurology, whether adult neurology or pediatric neurology. There are some residents who start as adult neurologist and really like pediatric neurology. For them to be eligible to sit for child neurology, they're required to do an extra year of pediatrics aside from the year of internal medicine they've already done. Then they''ll have to do a year of child neurology and they're done. This path is a little bit longer.

Nowadays, most programs have the five-year path. When Denia started, there weren't that many programs that would give two years of pediatrics and three of pediatric neurology. You had to go into two different programs. Some pediatric programs didn't like it because they were losing the resident. But most of the programs now have the options where they can do five years as a pediatric neurology resident.

You can be dual certified in pediatrics and pediatric neurology if you do two pediatrics and three neurology years. But you have to make sure you meet the criteria that the AAP has established for you to be able to sit for the peds boards. The reason people like to be dual certified is because some still like to be able to do pediatrics.

"Some stand-alone children's hospitals would ask you to be dual certified in pediatrics and pediatric neurology."

Denia cites what her mentor told her that there is so much shortage that you end up not using your pediatrics board even if you're eligible to do it. As for Denia, she doesn't think she would sit for the boards in peds. And what she has heard from those who did it, is that they're not sitting through the re-certification. Unless you're doing it for a daily basis, you're going to end up studying for a test.

[16:51] Is Matching Competitive?

Although competitive, Denia says there's plenty of opportunities. Pediatric neurology is a well-held secret. It could be because the five-year training may seem so long. But it really isn't as Denia would describe it. If you want to get into a field, you can get into a very good program with good letters of recommendation. But not to a point where there's one slot and 500 people are fighting for it.

[18:10] Bias Against DO's and Other Subspecialty Opportunities

Denia hasn't seen any bias against DO's, speaking for her field.

"There's no bias. If you're good, you're good. We don't mind how you ended up finishing med school."

Once you're a pediatric neurologist, there are other opportunities that you can specialize in including movement disorder, neuron EQ, and neuropedic critical care, pediatric neuromuscular, neuro immunology, epilepsy and neuro physiology, neurodegenerative diseases and white matter diseases, and mitochondrial and genetic diseases.

When she was interviewing and trying to make her decisions to what she wanted to do, her mentor gave her this advice.

"Once you're done, you essentially can do whatever it is that you want to do."

And her mentor was indeed right. He also told her she can go wherever she wants to go since she's needed everywhere. And Denia thinks he's been right about that. She has a lot of friends in the field who have gone through different paths. And they're equally successful. It's a field that is very supportive and has a lot of opportunities.

[21:35] Working with Primary Care & Other Specialties and Special Opportunities Outside of Clinical Medicine

Denia explains that you need to work with them on getting rid of lot of myths regarding headaches. They see a lot of headaches. And they see a lot of children with headaches who could be handled at the primary care level. Another thing is when do you refer a child for seizures and when do you use your skills to reassure the parents that those are not of concern?

Ultimately, Denia advice is that when in doubt, grab the phone, Give them a call. They're always available. Don't order tests because you're worried that you don't know how you're going to interpret the test. You're opening a can of worms for you and for that family.

Other specialties she works the closest with include developmental peds, genetics, NICU, and PM&R. And in terms of special opportunities outside of clinical medicine, there are people doing outreach and volunteer work. In the next five to ten years, Denia sees telemedicine being one of the fields that is going to develop within neurology. This gives you the opportunity to still see patients in a different schedule. This would be great for parents who want to stay longer at home. Or for those who don't do well being in an office for certain amount of time. That said, you can provide the care from the convenience of your house.

There are also opportunities working for federal agencies such as FDA. An ongoing discussion within the field is how they can diversify as pediatric neurologists in the way that other colleagues have.

[25:35] What She Wished She Knew and The Most & Least Like Things

Denia wished she knew how much the medical field was going to change then it would have helped her anticipate some of the things that came as a surprise to them. For example, how to measure for productivity. This not only touches pediatric neurology, but medicine as a whole. She also wished she would have taken a little bit more time to do all the things she wanted to do before going to med school. So she tries to pass this onto her students and to the residents.

"You need to take time for yourself. It's okay to take breaks."

What she likes the most about her specialty is working with the kids. She feels it's fulfilling to see how kids don't feel well and they let you know where they don't feel well. And then they'd feel better and start to recover. Knowing you've helped and have made a difference in their life is gratifying. What is equally gratifying for her is to see how kids, in the midst of difficulties, continue to push. They're fighters. It's amazing to see how they never give up.

"It's amazing how they never give up. Kids never give up. And that is extremely touching."

On the flip side, the least liked thing about her specialty is to deliver bad news. For years, she has tried to develop within her field in terms of research to say that she may be delivering bad news but people are doing something about it. She's trying to be part of the change so they can finally say what they can offer. You're going to have to walk the parents through the process of thinking that their child's life is going to look different than what they envisioned. But that's okay and you're there to support them.

The one field she doesn't particularly enjoy is neuro oncology. So she tries to stay away from it as much as she can. But if she had to do it all over again, she still would have chosen pediatric neurology.

[29:40] Denia's Advice for Premeds and Med Students

Denia recommends grabbing every opportunity you have to observe and shadow someone in the community. Try not to go into the hospital. It has the most extreme cases and it's not going to give you a good idea or a real perspective of what child neurology is and has for you.

For medical students, Denia recommends that if you're doing your peds neurology rotation, make sure you don't stick to the inpatient. Make sure you also go to outpatient. If you have an interesting patient as an inpatient, talk to your attending physician to let you get involved with it. Make sure you do a rotation. Make sure you express your interest and you're ready to get involved. Take as much as you can from those rotations.

"Get a good perspective of what the field has for you because it's broad."

[32:45] Final Thoughts

Tell me what you think about this episode and shoot me an email at ryan@medicalschoolhq.net. If there's a particular specialty you'd like to hear sooner, rather than later, shoot me an email again. And if you have somebody you wish to recommend for me to interview, hit me up!

Links:

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ryan@medicalschoolhq.net

Sep 20, 2017
40: A Private Practice Obesity Medicine Doc Shares Her Specialty
34:14

Session 40

Dr. Alexandra Sowa is a private practice Internal Medicine physician who specializes in Obesity Medicine. She talks about the specialty with us in the podcast.

This is a specialty that is relatively new but very important, In the United States and around the world, obesity is becoming more of a problem. But here in the U.S., obesity and being overweight affect two-thirds of our population. Our guest today is trying to change that as an Obesity Medicine specialist.

For more stories, tips, and strategies you can learn as a premed or nontrad or you’re preparing for the MCAT, check out all our other podcasts on MedEd Media.

[01:17] Interest in Obesity Medicine

Not having any idea what it was, Dr. Sowa first got interested in it when she was sixteen years old. It wasn't a specialty then but she was part of one of those scholar med invitationals in Washington, D.C. A speaker named Dr. Pamela Peeke gave an amazing speech about prevention and the role it plays in good medicine. She remembers walking away from that event wanting to go into public health. She knew it was she was meant to do. She wanted to prevent the disease.

So in college where she went to John Hopkins and took a double major in public health and writing. But she struggled with the idea of doing traditional public health on a mass scale or the med school. Until she decided she wanted to get into medical school and do prevention. But it wasn't a thing when she was applying but it was always something that she carried with her. So when she finally found Obesity Medicine in the middle of her internal medicine residency, that was it! She wants to manage disease and prevent it from progressing to the main diseases we think of in internal medicine like hypertension, diabetes, sleep apnea, and osteoarthritis, cholesterol problems. She wanted to get to the cause of it.

[03:17] Traits that Lead to Becoming a Good Obesity Medicine Doc

Alexandra cites compassion and openness as important traits to becoming a good obesity medicine doctor. There is an intense amount of stigma around treating, managing, being a person who carries excess weight.

"You need to be aware of how difficult it can be to be a patient who is overweight."

She uses the word obese and she's proud to proclaim that she's an obesity medicine doctor. You need to know that comes with many years of beating yourself up with how much you weigh and people treating you differently. Doctors, even a lot of times, are vocal about hating that population of people.

So again, you have to be compassionate and be willing to be open to understanding that it is a disease. It's multi-factorial. It's not a lack of will power that leads someone to have excess weight. Additionally since it's not a well-established field, you have to be cowboy. It wasn't until 2011 that The American Board of Obesity Medicine was formed and formalized. And it got streamlined under a board process. So there aren't many specialists

You have to be risk-taker. Think outside the box. Carve your own path in that regard. Another foundation to any specialty is just being really good at your primary training. Alexandra is an internist and she believes you still need to be a really good generalist to be a good specialist.

"You still need to be a really good generalist to be a good specialist."

Meanwhile as Alexandra was still going through her training, another specialty that was pulling her was Endocrinology. She thought she was going to be an endocrinologist. She thought managing obesity and the diseases comes along with it. And the only pathway is endocrine. Sometimes she would wish to have a little more training in it so she won't have to refer to an endocrinologist. But she's still happy she did her formal training.

[06:07] Types of Patients and Running a Private Practice

Alexandra sees a lot of patients with diabetes. Most doctors don't know there is a way to manage most people who are Type II diabetics with diet. She also sees people with fatty liver or joint pains and sleep apnea. All these problems are related to excess weight. She see overweight people to morbid obesity. She also sees people with normal weight but have metabolic abnormalities like really low HDL's and high LDL's. They are pre-diabetics and they just want to know what they can do to prevent the progression of the disease.

Alexandra decided to run private practice since she likes the idea of ownership of her practice and her patients. She likes the autonomy and being able to create her own schedule. She's able to create the relationships with patients she wants. And she felt that in her previous practice, there was just that focus on the bottom line. She had to see a lot of patients per hour. 

"In obesity medicine, you just can't do it effectively in a 20-minute slot. So you sacrifice what you're offering to patients."

There are five FDA-approved medications for long-term use in weight loss. And if you offer a 20-minute slot, you can write a prescription in 20 minutes. But you can't do much of the really important work and the counseling. You can't have a personalized discussion about diet and exercise. You can't talk about all of the things that go into how and why you're eating a certain way. Or what their goals are. You can't do that effectively, kindly, and compassionately in twenty minutes. So she decided to go on her own and practice medicine the way she wanted it. And the only way to do it is to do your own practice.

[09:20] Gaining Knowledge of Nutrition

One of the biggest complaints about physicians is they don't know enough about nutrition and diet. Alexandra says this wasn't taught enough in medicine. In residency, you're taught to check the BMI and tell them to eat less and exercise more. There was one clinic that was focusing on nutrition and it was within the bariatrics clinic. And this was the only exposure she got.

But when she had found this field, she sought out board certified experts. She was lucky enough to get to rotate with a well-renowned doctor, the godfather of the field. He started doing research back 25 years ago and has been a pioneer in making the field. So it was an eye-opening experience for her being able to work with him and being exposed to his clinic. That's when she started to realize that it can be in the form of the diet or pharmacology.

The diet piece came in more after residency and as she was working toward her board-certification. She just started reading. And she was reading outside of the traditional textbooks given to her in her internal medicine residency. She attended conferences and made connections with people doing diet modification in ways that blew her mind.

Down at Duke, Alexandra says they have an amazing multi-disciplinary group that does diet in different ways. They have low calorie diet or ketogenic diet (low carbohydrate diet). They also have meal replacement diets. So they tailor-make the plan just for the patient and what works for them.

Because of this, she has become much more in control of the diet plans she creates for patients. She doesn't use nutritionists nearly as much as she did when she started out. She feels like it's something she needed to teach herself so she could have that great relationship with patients. And it's working out really well.

[12:15] A Typical Day

Alexandra believes you have to think about what you want your life to be like. She has made a conscious decision to split some of her time up into boxes. She's a mom of two so two of her days are spent at home. This means some of her office work is done in the mornings. But MWF, she's in the office and comes in at around 8:30AM. She starts seeing patients at 9AM. And in her new practice, she's dedicating 40-60 minutes with each patient that comes in. So she's no longer seeing 20 patients a day.

Aside from seeing patients, she does admin work. She's doing a lot of meal plans and a lot of virtual correspondence with patients. She does coaching along the way. Every two weeks, she would check in with the patient if they're doing well or they're dieting or exercising. It's a nice reminder to patients so they feel that their doctor is invested in this with them.

She's also building up a new practice so there's a lot of learning a new skill set. She's a small business owner now too so there's accounting and lawyers. She has to deal with insurance and stuff. These take up a little bit more of her time now since she's at the start of her business. Nevertheless, she thinks it's a good balance.

[14:48] Talk About Insurance Reimbursement, Taking Calls, and Work-Life Balance

Alexandra admits insurance companies don't reimburse very well. So she has decided to step out of the insurance model so as not to compromise her care for patients right now. But she hopes that as more data come out and as more companies realize that it does make a big difference in ten to twenty years. That if they're able to take 10% body weight off an obese person, they're preventing a slew of diseases. So a lot of money is saved. And maybe they would realize to focus on a specialty. But as of the moment, it's not so great.

"I have made a conscious decision to step outside of the insurance model, just so I don't have to compromise my care."

In terms of taking calls, Alexandra has a partner as an internist and obesity medicine doc, and they're doing 50/50 call. But in obesity medicine, there aren't a lot of emergencies. She does use medications and it's rare that someone has a reaction. Sometimes too, when they're dealing with a specific bariatric population where they just had surgery, that might warrant some urgent follow-up. But it's not something with a very out-of-office hours burden

As to having that perfect balance, Alexandra still doesn't know the answer. But she has a made a few big decisions on prioritizing her family. She also thinks men and women shouldn't be afraid to talk about this. Doctors train for a very long time and females are going to have a baby somewhere along the way. Alexandra had her baby at the end of her third year of internal medicine residency. While being pregnant that year, she decided not to apply for fellowship and to pursue this path.

So the first decision she made was to step outside of training to have a little more control of her hours. She chose a job right out of residency where she didn't have to work five days a week. Her second son is now one year old. So Alexandra made her own hours and decided and when and how much or when to work.

"On one hand, you've got to work a lot owning a business but it's working for myself and that makes me feel it's all worth it."

[18:44] Training for Obesity Medicine

Alexandra stresses the importance of obesity medicine being that two-thirds of our country make up obese people. This is a huge underserved population. That said, Obesity Medicine covers the whole umbrella of anyone treating anybody with excess weight to lose and doing it in a thoughtful and trained manner.

The field of Obesity Medicine includes a variety of specialties including surgeons, pediatricians, internists, family medicine, and OB GYN. So it's not just limited to Internal Medicine. You can actually sit for the boards with any specialty.

To give you a better understanding, Alexandra explains the American Board of Obesity Medicine was founded in 2011. They created a track out of training which means you have to be board-certified in a primary specialty. Then you have to accrue a certain amount of credits and attend conferences over about a two-year period.

Another option is the fellowship. When Alexandra was looking to be certified a few years ago, there were not many fellowships. But the field is now exploding. In New York City for example, the number of fellowships has grown from zero to four.

So in order to get into Obesity Medicine, the first path doesn't require doing a fellowship and the other is to have a fellowship. But she believes a fellowship would be great. It gives you the opportunity to have access to learning from more seasoned mentors.

"The test is pretty hard so you really have to put all of your effort into being a self-learner."

Nevertheless, The Obesity Society and the Obesity Medicine Association have fantastic, ongoing lectures and conferences. You get to have access to new content. They're also creating their own journals. Alexandra recommends learning and soaking everything you can so you just grow with the field as it grows.

[22:30] Working with Primary Care and Other Specialties and Special Opportunities

When asked what she would have wished for primary care physicians to know about the obese and overweight population is that it's not a lack of willpower. She says this is the number one misconception that makes patients so disappointed in the healthcare system.

They've been told what to do traditionally, but it isn't working for them and their bodies. She explains that obesity, excess weight, or metabolic disease is multi-factorial and it goes all the way back to how much your mom gained during pregnancy, the kind of birth you had, etc. It's not just calories in and calories out. And so she encourages the doctors and medical students out there.

"It's not as simple as this traditional model that we've always learned. It's complex and there are new ways of tackling it."

Alexandra adds that you should try not to be close-minded. She believes words like diet doctor, medication, or diet has gotten a bad rap or connotation. People roll their eyes and think it's a fast fix and not true. She adds everyone is different and everyone should be treated in a different manner.

Other specialties she works the closest with include Endocrine and Bariatric Surgeons. Also, in her field outside of Obesity Medicine, because of her interest in training in nutrition, other specialties include gastroenterology. She sees and treats patients who have IBD and help them to manage bowel disease with specific diets and ways of eating and looking food as medicine.

In terms of special opportunities outside of clinical medicine, Alexandra sees this as a great area to write for education. Not every person has to go see an obesity medicine doctor. A lot of people can make some of the changes of the tools they have on their own. So anyone interested in writing or doing Facebook live video. She sees a huge opportunity for people to connect with the public at large with the information that the specialty provides people with.

[26:27] What She Wished She Knew About Obesity Medicine and the Most and Least Liked about the Field

Alexandra wished she had been more aggressive in creating research content within the field and connecting with mentors. It actually took her a while to find other people who were in the field. She realized out of her training now that people are happy to connect and they're happy to help you, especially in this field because they're so passionate about it and they want to see it continue to grow at the rate it has.

"People are happy to connect and people are happy to help you."

What she likes most about her specialty is the ability to change other people's lives. She has helped people who for years, have not been able to take off a single pound or worse. Or she has helped those who have gained and gained weight when nutritional medical system has failed them. They come to her and they start losing weight for the first time in their lives. They've taken off their medications and they cry for joy when they come back to see her. It's the first time someone treated their obesity as a disease. Treating that way, they're able to co-manage all their other diseases and reverse some. This is something very profound. In fact, her patient sent her a valentine's day card saying it was the best valentine's day present one can have. That year, she lost 50 pounds.

Conversely, what she likes the least is you can't fix everyone. So it's hard work. It takes time. And it's emotional and complex. Alexandra's dad is a hand surgeon. When he takes someone for surgery, he knows he's going to be able to fix them. If not, he manages expectations. But this is not the same with obesity medicine. You can't guarantee what everyone would become when they come to you.

"We're just here to make you a little bit healthier, and the weight that comes off is bonus."

This is how she approaches every patient. But she knows some people can still be disappointed. It's tough. There is no fast fix. It's hard work on all fronts. And this can be disappointing.

[29:24] Major Changes in the Field and Some Final Words of Wisdom

In terms of major changes she sees coming in the field, we're going to see novel treatments. This field of understanding that gut microbiome is really going to change obesity medicine. So there's a lot of fascinating basic research that is going to translate quickly into clinical medicine. She hopes that in her career it goes from five medications to a hundred. And that they can really target them into each individual patient.

If she had to do it all over again, she would still do it.. Lastly, she leaves some medical students with some pieces of advice. Listen to that little voice inside of your head that led you into medicine in the first place. She didn't even know this existed but there was something in her since she was sixteen that said she wanted to prevent disease. Her greatest motivator was to prevent disease and her getting to this now is fulfilling.

Follow your guts and think outside of the box. It's easy to become so inundated by the routine and all the years of schooling you need to do. Although important, it can be exhausting. You don't get to use the other side of your brain. So think outside of the box. There are opportunities outside of the traditional academia. You can carve out a little niche and patients will be so thankful.

"When the right patients find you, they're so thankful that you were there because you'll be offering something different."

[33:16] Last Thoughts

Check out Dr. Alexandra Sowa's website www.alexandrasowamd.com. Hopefully, this episode has helped you. Maybe this opened up your eyes to the specialty that you've probably never heard of before. This is the very goal of this podcast. If you know someone who can come to this podcast, just shoot me an email at ryan@medicalschoolhq.net

Links:

MedEd Media

The American Board of Obesity Medicine

The Obesity Society

Obesity Medicine Association

Sep 13, 2017
39: Academic Pain Medicine From an Anesthesiology Background
38:13

Session 39

Dr. Bunty Shah is an academic Pain Medicine Physician at Penn State. He completed his residency training in Anesthesiology. He shares the specialty with us.

Back in Episode 17, we interviewed a community-based pain medicine doc who came from a radiology background. So you get to hear some differences between these two episodes.

Bunty has been out of fellowship training now for two years. He now serves as the Associate Program Director for the Fellowship at Penn State.

If you haven’t yet, please check out all our other episodes on MedEd Media Network.

[01:33] An Interest in Pain Medicine

When he was in his surgery rotation in medical school in his third year, there was no actual anesthesiology rotation. But it was built into the surgery rotation. It was by chance that he actually encountered anesthesia during his surgery rotation. He met an anesthesiologist during third year rotation in medical school. He learned that anesthesiology was all about an interplay between physiology and basic sciences. It was very procedure-oriented and he enjoyed it. That was his first experience with anesthesia. And so he decided to pursue that.

He also wanted to do emergency medicine initially being formerly an EMT. He thought emergency medicine was very exciting. He still thinks it is but the finds anesthesia to have combined all the different specialties he was interested in. He could be a cardiologist, a nephrologist, an ICU doctor, and all these things at once in the operating room.

As far as pain medicine goes, he didn't know anything about it back in medical school. It was a subspecialty so he didn't have much exposure to it as a medical student. It wasn't until his CA two year being his third year of anesthesiology as a resident. He rotated through the pain management clinic and he saw all the different procedures done for pain of different causes. It married what he likes about anesthesia which is procedures. A lot of the procedures they do in anesthesia are carried over to pain medicine such as skills when doing epidural injections. So this gravitated him towards the pain medicine.

Another thing he liked about pain medicine that was missing when he was doing anesthesia was having more face-to-face time with patients while they're awake and talking with him. The other thing about anesthesia was he would do a case and take of a patient for one surgical procedure and not see them again. He considers this as a good thing in the grand scheme of things. Because it means they improved or did well.

"I like the continuity of care I get with some of my patients in pain medicine and establish relationships that is more long-lasting."

Again, it's the patient interaction along with the procedures that led him to pursuing a career in pain medicine.

[04:54] Learning Hand Dexterity and Other Skills

Bunty says you have inherent coordination skills to be able to do these procedures but you do learn by practicing. So the things that to some degree, it can be taught. But the most important thing to be masterful with procedures is understanding your limitations. You have to develop an overall sense of safety, knowing when you can advance a needle, and when you have to be a little bit more cautious. You have to understand the relevant anatomy. He recommends to medical students and residents that knowing your functional anatomy is very important to doing procedures.

"Knowing your functional anatomy is very important to doing procedures."

Bunty adds that your knowledge of the anatomy is your road map for doing a procedure. Aside from having dexterity and manual skills, your knowledge of the anatomy is a major factor in making sure you can do a safe procedure for a patient.

[06:13] Community vs. Academics

Bunty chose to stay in Academics because he likes to teach. He believes that if you can teach something, you can do something. He chose to stay at a program where he trained both in anesthesiology residency and in his pain medicine fellowship. Currently, he's the Associate Program Director for the Pain Medicine Fellowship. He is tasked with training fellows going to go out in practice within one year.

So he has the opportunity to shape these fellows to some degree. He also has a hand in the patients they treat since he's responsible for teaching them. For him, this is a tremendous responsibility and it's one he doesn't take lightly.

He feels humbled to know that they are shaping fellows who are going to go out and practice pain medicine on their own. They're touching other patients through them. And this is the major motivating factor for him.

Another reason he stayed in academics is he's able to get exposure to educational resources he wouldn't have gotten elsewhere. Because they're a training program, they have educational conferences. They have journal clubs where they review relevant articles. They're always learning. Not to say that you're not always learning in private practice, but he feels as an educator, the impetus is on them to do as much learning as they can.

"It's my responsibility to teach others so I need to stay abreast of developments in my specialty."

[08:15] Traits that Lead to Becoming a Good Pain Medicine Doctor

Bunty cites some traits that lead to becoming a good pain medicine physician. One is patience. As an educator, you're working with fellows and residents who may have limited exposure to some of the procedures and conditions they see at the center. You can't do everything yourself so you need to be able to teach the fellow. Allow them some autonomy at times but within a safe window. Other traits include inquisitiveness and curiosity.

[09:20] Types of Patients and A Typical Day

Being a major referral center at central Pennsylvania, they see a wide variety of cases and conditions. But being a large part of what they see is back pain, especially low back pain but also pain from the cervical spine and thoracic spine. They see a good deal of neuropathic pain related to conditions of the nerves and nervous system. They deal with things like neuropathy related to diabetes. They also treat pinched nerves of the spine which is considered neuropathic pain. They treat them with injections and medications.

Additionally, they also see pain from other causes like cancer pain, arthritis of the spine and knees. They treat pain of all sorts and kinds. If there's a condition that's painful, they see it.

A typical day for Bunty starts at 8 am when he arrives in the clinic. He has half a day of procedures that would include ultrasound-guided procedures, fluoroscopic-guided procedures, which would be x-ray-guided procedures. The second half of his day is seeing new and return patients. He works them up for different conditions and making recommendations about medications or possible procedures to help alleviate their pain.

In cases when there are case conferences or journal clubs, he stays a little bit later until 6 or 7PM. But a typical work day for him is anywhere from 8am to 4:30pm or 5pm.

[11:35] The Academic Side

In terms of the academic side of things, they have medical students and residents and fellows. They are with them for a year at a time. They have several different rotations, most of which, are in the pain clinic. But for about a half a year, they rotate out of their pain clinic and onto other services such as spine surgery, palliative care, psychiatry, neuroradiology. So they get exposure in these other areas that are also relevant to their specialty.

Their residents are part of the anesthesiology department and they rotate one month at a time. They come initially in their clinical base year, which is the first year of anesthesiology residency. And they return during their CA two year, which is their third year residency.

The occasionally have a resident from neurology coming to their clinic and they also have fellows who rotate with them from rheumatology and orthopedics. They also have medical students rotating with them about every month or so.

"A lot of different people coming in from different backgrounds but it's an educational experience for everyone."

[13:25] Percentage of Patients that Go to the O.R. and Taking Calls

Bunty estimates that 60% of their patients or maybe even 70% are patients who may benefit from a procedure and who are offered a procedure. The remainder of these patients are managed more conservatively with medications, physical therapy, sometimes pain psychology. It's a very multi-faceted approach. Especially in light of the opioid epidemic, they try to really approach issues from all different angles to really maximize benefit and minimize any harm they can cause to the patient.

In terms of taking calls, Bunty takes a minimal amount of calls. He has a group of five physicians. So he takes call one in every five weeks. His call consists of seeing in-patient consults on days when he's on call. So gets a call one week at a time from Monday thru Friday. If he's seeing patients in the morning, after lunch break, he sees inpatient consults in the afternoon. This allows him to actually get out by 4 or 4:30 PM. The rounds on patients who have nerve catheters or epidurals on the weekends. It takes anywhere from 1-2 hours and he's free for the rest of the day when he's taking home call for that entire week (Monday-Sunday).

If there are issues, they are first fielded by their fellow and if they have questions they can call him. Then they address these issues. Typically, they do this over the phone and it's only rare when he has to come to the hospital to take care of an issue. So he gets to have a good work-life balance and this is another motivator as to why he chose this specialty.

"For the most part, the call is not very bad. It does allow a good work-life balance in my opinion."

[16:05] The Path to Pain Medicine

Pain medicine is a subspecialty, initially created within anesthesiology. However, it is a specialty which can be entered via several different routes.

The traditional one is anesthesiology which is a four-year residency. Then that is followed by one year pain medicine fellowship. So pain medicine fellowships are all one-year long.

Neurology is another route as well as Psychiatry, Emergency Medicine, and Physical Medicine & Rehabilitation (PM&R). These are specialties through which one can enter pain medicine. By and large, most candidates are coming from anesthesiology and neurology. Currently, they have three fellows in their program. Two of them are PM&R and one is Anesthesiology. So the fellowship doesn't differentiate between what residency they came from. There aren't separate pain medicine fellowships for different specialty backgrounds. It's all one and the same.

In terms of treating patients, having one specific background doesn't necessarily give them an advantage over another.

"Depending on the specialty you come from, you bring a different skill set."

Bunty thinks PM&R residents and fellows have excellent examination skills of the musculoskeletal system. They come with good skills as far as procedures and ultrasound. They have a good understanding of the musculoskeletal system as far as dynamics and conditions that affect the system.

On the other hand, Neurology residents and fellows come with a very good understanding of the neurologic bases for pain and neuropathic pain states. They're very well-versed in conditions like headaches.

Anesthesiology residents come with very good understanding of analgesic pharmacology, basic physiology, as well as procedural skills as far as ultrasound goes. In anesthesia, they do a lot of peripheral nerve blocks and epidural injections. So Bunty thinks everyone brings something different to the table. That said, he wouldn't say one particular specialty is better than any other. In the end, he believes all of their fellows regardless of the specialty they originate in become excellent fellows. They're all on par with each other as far as becoming good pain physicians.

[19:37] Competitiveness in Matching

Bunty describes the Pain Medicine Fellowship as being quite competitive to match into. There are a number of pain medicine spots but it does happen to be one in high demand. One reason is particularly because the work-life balance is good in the specialty. You have an applicant pool that consists of candidates from multiple different specialties that may also contribute to the competitiveness of matching into the specialty.

Being an associate program director, what he looks for in competitive applicants are strong academic record including good examination scores, and in-service examination scores, as well as board exam scores. He looks at the character, particularly assessed by interviewing the candidate but also reflected in the letters of recommendation. He looks for personality that will be compatible with working in a team.

"Pain medicine is a team specialty that requires compatibility with working with members of other specialties, nurses, ancillary staff."

Other traits include being inquisitive and having a good work ethic. He also adds that it's very hard to judge someone on procedural skills. You haven't seen them do procedures but instead, he looks into their experience in pain medicine. He sees if they've done rotations in pain medicine and what sort of procedural exposure they've had. And they also look at the letters of recommendation. Bunty uses the interview to see what the candidate's personality is like. He also tries to understand the candidate's motivation for pursuing a career in pain medicine.

[22:55] Subspecialty Opportunities and Working with Primary Care and Other Specialties

When you finish an interventional pain medicine fellowship, Bunty explains it's pretty much as specialized as you can get. One can also do another fellowship but Bunty explains this is pretty much where you end your training. Nevertheless, learning being a lifelong endeavor, you'd be required by the specialty to do CME (Continuing Medical Education). He thinks it's a good idea to go to conferences and meetings to continue your learning. But as far as fellowship training goes, there's typically no further subspecialization for pain medicine.

In their pain clinic, Bunty describes a good relationship with their primary care colleagues. They have a good mutual understanding of what they can offer as pain medicine specialists for patients. He thinks it's important for primary care doctors to understand that they really strive to provide multidisciplinary care for their patients. Understand the indications for procedures like epidural injections. Understand that opioids are really the last resort and not proven in many studies to confer long term benefit in chronic pain. This is a major thing he'd like most primary care providers to understand.

He also stresses that in terms of the use of adjuvant medications in the treatment of pain, it's important to think outside the box as far as pain medicine treatments go. Lastly, understand the benefits of physical therapy and pain psychology such as cognitive behavioral therapy and biofeedback techniques. The interplay of all these things in the treatment of pain and the holistic approach they give to patients is very important.

Other specialties they work the closest with include primary care, neurosurgery, and orthopedic spine services since back pain plays a large part in why patients come to see them.

[27:01] Special Opportunities Outside of Clinical Medicine

If you're interested in research and has a PhD, there's a large need for research in pain medicine. Especially in the midst of opioid epidemic, research into the mechanisms of pain regulation and treatments are large areas that need a lot of research focus.

What he wished he knew about pain medicine going into his training is how daunting it is to understand how low our success rate can really be.

"For a lot of patients, even a small amount of relief can translate into a larger change in the quality of life."

Now he appreciates it when he sees patients with a small increase in functionality or decrease in pain levels and how impactful this is in a patient's life. This is something he didn't appreciate early on which he does now.

What he likes about being a pain physician is the ability to make a difference in patients' lives. Many patients come to them after having tried multiple different medications and even procedures. He starts from the beginning and he starts to understand why the patient is there. Sometimes they only want to be listened and to be validated in their thinking about their pain. Many patients are inappropriately labeled as medication seekers and so it's important to understand what the patient is saying. He takes the opportunity to really listen to the patient and get on the same page with them and what he can do for them.

On the flip side, his least favorite part is getting coverage in certain procedures, doing peer-to-peer, and working with insurance companies which can be frustrating. He does his best to reach out to them and get procedures approved but there are times when he's not able to do so. Nevertheless, this does not diminish his enthusiasm for the specialty.

"In any specialty, there's going to be some degree of dissatisfaction with working with insurance companies."

Bunty clarifies that there are times when you can all insurance company for a peer-to-peer. You call someone from a completely different specialty. They often have policy guidelines to which they're obligated to adhere to. For instance, he has a colleague who did a peer-to-peer for a spinal cord stimulator. The physician he spoke with in the insurance company was a pediatrician. So you may not always speak to a pain physician although you will very often. It just depends on any given day that you may speak to someone from a different specialty. Then you argue your case to have it covered.

[33:06] Major Changes in the Future

Bunty illustrates a larger emphasis on procedures to treat pain and a move away from the prescription of opioids. Again, he stresses the importance of this since many people are dying from opioid abuse or misuse and overdoses related to this. It doesn't take a lot to appreciate the enormity of the situation. Many times, prescriptions are filled especially after surgical procedures or even dental procedures or oral surgical procedures. These pills don't fall into the right hands. Patients with multiple co-morbidities which may include cardiovascular or respiratory issues on opioids are at risk for overdose as well. He adds the general lack of study supporting the long term benefit of opioids in the treatment of chronic pain. Then you realize now there might be more harm from these medications. This is mostly for the treatment of non-cancer pain. This said, opioids have a long standing track record for being helpful in pain related to cancer. Still, you have to think out of the box and think about adjuvant medications and use the the World Health Organization ladder that emphasizes the use of weaker opioids and adjuvant medications (NSAIDS) before escalating to stronger opioids.

"Many people are dying from opioid abuse or misuse and overdoses related to this."

So what Bunty sees in the future is a renewed emphasis on the procedures to treat pain and pain psychology and physical therapy. He sees approaching the patient from a multidisciplinary way of thinking. Moreover, spinal cord stimulation is an exploding field. They now have high frequency stimulation applied to multiple painful states. They include neuropathic pain from complex regional pain syndrome. They're also having discussions about treating visceral pain with spinal cord stimulation. These stimulators use high frequency that don't depend on paresthesia. So the technology is opening up to many patients who previously would have never tolerated these vibrations. Bunty believes pain is an issue that affects so many of us and our loved ones. A lot remains to be learned about when it comes to pain.

"It's an exciting time to be a pain physicians and it's an important time to be a pain physician."

[36:47] Choosing the Specialty Again and Some Final Words of Wisdom

If Bunty had to do it all over again, he would have chosen the same specialty. He's learning something everyday while being an educator. He says he's learning more from teaching than he is probably imparting. It's a humbling specialty but it's a very fulfilling career.

Finally, Bunty parts the show with a message to all medical students and residents out there to be very curious. Always be learning to learn. If you like a specialty that combines procedures, medications, and working with multiple specialties, then pain medicine is something to consider.

Links:

Specialty Stories Episode 17: What Is Pain Medicine? A Community Doc Shares His Story

MedEd Media

Sep 06, 2017
38: Discussing Pediatric Oncology with an Academic Doc
33:01

Session 38

Dr. Julie Krystal is an academic pediatric oncologist. Julie has been out of training now for two years. She discusses what she loves about her job, where she sees the specialty going and what you should do.

Please be sure to also check out all our other podcasts over at MedEd Media for more resources.

[01:00] Interest in Becoming a Pediatric Oncology

Julie always knew what she wanted to do. Back in high school, she wanted to be child life person where you get to do arts and crafts with kids in the hospital. So she was volunteering at Stanford Children's Hospital where she grew up in California. She was working with a lot of oncology patients. She then realized that the more she got to work with the doctors and see the fellows, they were actually doing a way cooler job than the child life people. That's when she decided it's what she wanted to do in high school and stuck with that. She felt strongly better all throughout her training, through college and all the way through her residency.

She did give other things a try since pediatric oncology as she describes is a tough path in many senses. So at some points, she tried to convince herself to like other things - better hours, better pay, etc. But nothing else was the right fit for her except for pediatric oncology which she felt was the one thing she really wanted to do.

What she likes about the subspecialty is you get to have a sort of primary care relationship over long periods of time. They remove the kids from their pediatrician while they're with them and while they're getting chemo or treatment. So the relationship goes over many years because these kids get to stay with them.

"You have that longitudinal sense that you get from primary care but you have much more interesting complex medical problems."

Julie describes it as somewhat the best of both worlds. It's something really interesting subspecialty-wise and that relationship that's so important. Whenever she tells people what she does, their first reaction is almost always negative. They think it's awful and sad. So she always tell them that it's not sad actually. The majority of children are cured from their cancer and they go on and have wonderful adult lives. It's her privilege to be with the family during the worst, most horrible thing that's happening to them and to see them through to the other side. So this part of it just really appeals to her where there is challenge and mostly a happy ending. And if it's bad, it's really bad and really sad. But most of the time, there is knowledge that you're able to get the family over something that's really hard. Then you get to see their child go on and grow up and do wonderful things. So for her, it's a wonderful role as a physician to get to do that.

[03:40] Traits that Lead to Becoming a Good Ped Onc Doc

Julie cites a few things to become a really good ped oncology doctor. First, is being a sunny and optimistic person. There are sad and depressing moments. The lifestyle is tough. It's academic and it involves long hours. There's no money in it. If you're doing grants and you're fighting to the nail against everyone else to get funding, things can get challenging. So you have to be willing to devote yourself. This job involves long days and long nights. So you have to go into it knowing that.

"You have to be accepting that this is your life and it's not a glamorous, fancy, sports car kind of gig."

[05:18] Types of Patients and Doing Clinical Trials

Julie mostly takes care of kids with brain tumors. In peds oncology, things can  be specialized these days. There's hematology and oncology. She's specialized to oncology and within oncology, there are doctors who do leukemia. Some doctors do bone tumors. While she mostly takes care of kids with brain tumors, like everyone else, they have to do a certain number of weeks of the year of in-patient service. When you're on it, you take care of admissions and all the new diagnoses that come in. Nevertheless, she keeps up to date with everything by doing that kind of work. She gets to see a little of everything. The vast majority of childhood cancer is leukemia. Those are the things that in the average week of service, one or two diagnosis of leukemia will come in or one brain tumor. But the vast majority of new diagnosis every week are leukemia. Other things common in the pediatric age group are the bone tumors. Brain tumors are the most common phallic malignancies and there are a lot of those. The majority of those have a good outcome.

Julie explains there's not a lot of jobs in academic peds oncology. There's more fellows graduating every year than they have open positions. Part of the reason has to do with funding since it's only academic institutions that have a lot of NIH funding. So it's very hard to find academic positions. Hence, people tend to shy away from brain tumors but Julie did otherwise. She found it to be interesting and it's a place where there's a real need.

"By doing something that other people are hesitant towards, I was able to get a job that I really love."

The other piece of work she does that's not directly clinical is working on early phase clinical trials. This is also something she loves and feel passionately about. There's a lot of new cancer therapies in adults and it's much harder to get those in the kids. So she works on getting early phase clinical trials up and running in her hospital. It's something she never envisioned doing but the opportunity kind of fell on her lap. She further says you don't really foresee all the stuff that are coming ahead of you but if you keep your mind open, really cool things will come your way.

[8:20] Why People Shy Away from Brain Tumors

Julie thinks people shy away from brain tumors because they're this own little thing. Leukemia and lymphoma are things everybody knows about. We all know what to do with it. But for brain tumors, they're much more of a niche.

"If one walks in the door and you don't know what to do, it can feel really scary because it's a whole different world."

Another reason she sees is that we've made huge progresses in lots of pediatric tumors. Especially in leukemia, the cure rate is over 90%, and in some cases, 95%. This is phenomenal. But they haven't had that huge leap for all types of brain tumors. There are certain types of brain tumors where the cure rate is still very low unfortunately. And she thinks people shy away from that because it's intimidating. It's hard to go through that professionally. But the way Julie looks at this is we still have room to make that progress. It's exciting to be able to keep working and trying and keep doing studies until we find the next thing that's going to make the biggest difference for this diagnosis. Moreover, she's aware of the challenges and working with families can get overwhelming. But there's room for so many great things to happen still.

[09:40] Taking Calls and Work-Life Balance

For Julie, she doesn't necessarily take calls. It takes three years for the fellowship and the first year of it is purely clinical. And after being a fellow, you'd be an attending and things are so much easier. So the call they take is when they're on service Monday through Friday. They're on during the day and they're also available at night. But the fellows take the first calls - from the ER, from the service, parents calling in, or from outside hospitals. And the fellows only contact the attending doctors in cases where they're looking for guidance or they're not sure what's going on. Some nights they take ten phone calls, some nights, none. So she does a week of that, eight weeks for a year. It's not a fully clinical position since she has research time. She finds this to be manageable as she gets to do other things like research and clinical trials she likes to do. Attendings don't do in-house call of any type. It's something when you're available at night time from phone. So you can still live your life. the fellows call in and ask you questions. So it's very doable.

Being a mom with two kids, she explains your really have to try hard to make time outside of the hospital. On academic days, things go early in the morning and late at night. So you have to be really conscientious about it. As for Julie, she plans her schedule carefully to make sure she gets to see her kids. Since her kids are so little and they go to bed very early, she just sets an alarm or make a stopping point. She will set a time when she'd leave the office regardless of what she's doing with her work. So she gets to spend time with her kids. They go to bed and she goes to work at night. It's very important to her to make sure she has that time with them.

When she's on service, those eight weeks a year, it can be very challenging. Some nights, she doesn't get to see them since she can't just leave. She thinks it's really something you have to be conscientious about. So she makes sure she plans out all of her days. So yes, you can do that but you have to be flexible and you have to plan around that and make it a priority.

"It's really something you have to be conscientious about... and you have to be willing to work at home."

[12:55] The Path to Residency and Fellowship

Julie explains that you do a general pediatric residency for three years. Most people during this training may only have a month of peds oncology exposure. So she encourages people to get more exposure. Because during peds residency, she was terrified about oncology because they had to deal with really sick cases and they're complicated.

"Get as much exposure as they can to see what it's actually like."

She says that just seeing those kids on the inpatient side doesn't give you a glimpse of what is actually like to do this job. Like she said, it's only a job she does eight weeks our of the year. That leaves all the rest of they year where she's doing other things - not being with those super sick kids admitted in the hospital. So she encourages residents to try to get more exposure and get exposure to the outpatient side, the research side. See what attendings actually do.

Moreover, once you do peds residency, you do another three years of fellowship, the first year being a purely clinical year. The second two years are research years, be it laboratory research or clinical research or MPH. Then you're finished. But if you want to torture yourself some more as Julie humorously says, there are sub-fellowships. So you can do an additional year of training. In things like brain tumors, you can do an additional year of training. There are brain tumor fellowships for an extra year. There are bone marrow transplant fellowships for an extra year. If you wanted to super sub-specialize and do additional trainings to get more exposure, it's something you can go on and do an extra year in that.

The fellowship is all combined. The three-year fellowship is one thing you match into. It's Pediatric Hematology/Oncology. You do train in both. But most people during their fellowship are gravitating towards one or the other. They gravitate towards hematology or oncology. Most very large academic centers are separated. In her division, people are either hematologists or oncologists or bone marrow transplanter. There are smaller programs where it's combined. So they only have one service and the attendings take care of everybody. Some people like this to get a little flavor of everything. But most large academic centers are very specialized into specific niches. But everybody at this point still has to do everything in the fellowship. As opposed to the adult side, you can do a hematology fellowship or an oncology fellowship. You don't do both. But in pediatrics, it's a combined fellowship and you have to train. And the boards cover everything so you have to train for both things.

Julie says matching for fellowship is not competitive. Again, this is something people try to shy away from. So most people who want a spot can find one. So it's not out of your reach if you don't have good board scores. There are a lot of fellowship spots in the country so there's plenty to go around.

[16:26] Bias Towards DOs and Subspecialty Opportunities

There are lots of DOs in the field. In fact, she didn't even know some of the people who were DOs. She thinks people are accepting of it and they're treated the same as an MD.

Other subspecialty options available include coagulation, hemophilia, bleeding disorders, and survivorship. Survivorship is relatively new. Thirty years ago, there were no long-term survivors of childhood cancer because they have all died. Now, these kids grow up and they're thirty years old or forty. They do have certain health problems or at risk for certain health problems due to the treatment they got. Survivorship is a whole new discipline that follows these patients through their adulthood. They're being monitored in terms of what kind of testing they should get or what they should do in terms of their lifestyle. Fertility issues are a big deal for survivors.

There are also programs for solid tumors and blood banking. Every hospital has a blood bank and the directors of the blood banks are all hematologists whether adult or pediatric. So you can work in blood banking.

"Blood banking is a more lifestyle friendly choice."

[18:06] Working with Pediatricians and Other Specialties

Julie says general pediatricians worry about missing something. They're worried they're going to miss a leukemia. She feels it could be hard being a general pediatrician. Kids come in and complain of headache. And how do you know who you should be sending for scanning and who shouldn't. When kids get diagnosed with brain tumors they always blame themselves. But Julie tells them it's okay. Most kids who have a headache do not have a brain tumor. The brain tumor is the zebra here. So she wants pediatricians to know to trust themselves and follow their workup and not to second guess what they're doing. Follow their normal steps and do the things that they're doing. Every kid doesn't need an MRI who has a headache. Similarly, when they see a kid and feel they need to get CBC and need to make a call to them, pedia oncologists are available. Pediatricians call their practice a lot and she really appreciates when they do that just to get general guidance."

"Pediatricians have a really hard job because they need to not miss these huge important things but also not overreact to everything."

What they should know, Julie adds, is that they're doing a great job. And not to second-guess themselves and regret they didn't do something sooner or later because they're probably doing it just right. Moreover, other specialties Julie works the closest with include surgery, ID, nephrology, pulmonology, GI, and others. They get to work with all other specialties because what they do affects every part of the body. Cancer and chemo affect every part of the body. So there's no service that they don't get to consulting. And because it's a unique population, their relationships with those subspecialists is really good since they work closely together. So they the opportunity to learn a lot from them and vice versa.

[21:11] Special Opportunities Outside of Peds Oncology

Julie explains how the industry is a big thing in terms of pharmaceutical companies. They are always looking for pediatricians to do drug development, clinical trials, etc. That is a very different lifestyle which a lot of people choose. She knows a lot of people who have gone that route. So if this is something you're interested in, it's a great career choice. There is a need for drugs. We need them to be studied in kids. Another would be clinical trials like the FDA. There's a whole group of peds oncology people who work at the FDA in terms of looking at new drugs.

Additionally, lab research is still a part of what they do. It's how they got to where they are with all of pediatric oncology treatment. And it's also how they're going to get as they go to the future. People not clinically oriented and just want to go into a lab and find out something cool, there's that opportunity as well.

Since Julie doesn't have a PhD, she really doesn't think it has hindered her ability to do the amount of research she wanted to do. She doesn't do bench research or research in the lab. But she thinks that if you want to do research in the lab, a PhD does give you an edge up for sure. That said, she knows people who've had successful lab careers and ran labs who don't have a PhD. But if you want to be competitive and if you're getting grants, Julie thinks having a PhD for lab work does make a big difference. Since most of the work she does are more early phase clinical trials and drug development, she doesn't feel it has made a big difference. She got an MPH when she was in Fellowship and she feels this gives her a little bit of an advantage. First, she knows a little more background about clinical trials. Secondly, she thinks people just take you a little bit more seriously. The more letters you have that you can say you're qualified for xyz even if it's bogus, it does get your foot in the door. It gets people to listen to you.

"If you're going to be having a lab career, the PhD is a very big boost."

[23:47] What She Wished She Knew & Most and Least Liked

What she wished she knew going into peds oncology is that it's so worth it. She has a job that she loves and gets to do it everyday. She is so grateful this is her job. During the many years of training and during fellowship, it's hard to see what your life is actually going to be like when it's over. If she could just go back, she'd tell herself this is so worth it. You're going to get to the end and you're going to have this awesome job. It's going to be the best thing ever. You can keep suffering for a little bit longer and then you're going to make it to the other side.

"So many jobs where there are so many long years of training, you can lose sight of what is actually at the end of it."

The thing she likes most about her specialty is the families and patients. She gets to go to work everyday and hang out with awesome kids fighting tough battles. But they don't care and they're just awesome about it. They're running around and playing. They're going to school. They fight so hard and they do incredible things. So the families and the kids are what makes her job so special. She gets to be with them. She gets to support them and help them in a way others don't get to do. So she feels privileged to be a part of that and a part of the family during that challenging time.

"Having a child with cancer changes the life of the child, of every person in the family. And I get to be a part of that."

Conversely, what she likes the least about her job is kids dying. It's hard. They know it's going to happen and they can't going to cure every child as much as they want to. It could be hard for her sometimes because she takes it personally. She finds it hard to accept that failure. One of her favorite mentors told her and that she's kept with her all the time is, "we're in charge of the process, but we're not in charge of the outcome." She says this to families every time she does a diagnosis talk. They can choose the steps they're going to follow and the path they're going to take. But ultimately, she can't choose the outcome. Otherwise, she could just make every child okay.

"I can't choose the outcome and I'm not in charge of that part. And it's hard to let go of that personal responsibility."

Julie adds that it's hard to see a family in much pain and to be a part of that. But they have a lot of support systems since this is part of it. They're going to be dealing with death. So it's something they have to be conscientious about and have to deal with. But she describes this as the worst part of her job. A particular kind of tumor is inoperable and all children will die from it within two years. And she says the very worst thing for her is when a new patient comes in with that diagnosis and she has to tell the family that. It's just devastating. This is another reason she's doing research because she hopes to get to the point where she doesn't have to say it anymore.

[27:54] Major Changes in the Future

Julie sees a lot coming in terms of training. They're getting hospitalists in a lot of places not only for nighttime care but also for daytime care. So she sees a lot of changes in the workforce. The hours tend to be intense and a lot of people want a better work-life balance. So people are trying to figure out how they can achieve that. There's going to be more and more shifts in the future and that will be changing things a lot. Technology-wise, she doesn't see any immediate changes coming but there are new drugs and treatments being developed that are incredible. They have the potential to shift the treatment paradigms and really change how children with cancer are treated. She believes they're moving closer and closer to being able to cure more and more children in a lot of ways. There is also so much new information with millions of journal articles coming out. This is one of the reasons things end up getting subspecialized so people can stay on top of new information and treatment.

[29:40] Julie's Message to Premeds, Medical Students, and Peds Residents

If she had to do this all over again, Julie says she still would have chosen the same specialty. Moreover, she encourages students who might be interested in this field that part of it is being open. This could be moving somewhere you don't want to move. Because it's super concentrated on both coasts.

"There are states in the country that literally don't have a pediatric oncologist. They have to send every patient out of the state."

Think of what a horrible experience that is for the family. Their child gets cancer and they have to move to get treatment. So you have to be willing to consider moving somewhere or doing something you originally weren't thinking of. She never thought of doing brain tumors. But by being open to that, she was able to find a great job.

She wishes to tell students that there are jobs and there is a need out there. But you can't be committed to working to New York or LA. You have to be a bit more flexible about where you want to go, what you want to do. But you can find the right spot for you.

The first steps students can take if this is something they're interested in is to find a mentor. Find a pediatric oncologist or somebody you can talk to. Get some guidance on what you should be doing. Most importantly, just get exposure. Do electives or sub-I's or whatever you can to go see different types of ped oncology and work out inpatient and outpatient research. Julie has had a lot of different mentors in the early phases of her career. She still gets a lot of mentorship as a young attending. So you have to establish this early on.

"Find somebody that you can talk to and let them help you sort the path out."

[32:13] Final Thoughts

Reach out to Julie if you have any questions. Do that through me and shoot me an email at ryan@medicalschoolhq.net. And I will connect you. Lastly, if there's a specialty you're looking for that I haven't covered yet, please find a physician for me to interview. Introduce me to him or her and I will get them on the show.

Links:

MedEd Media

ryan@medicalschoolhq.net

Aug 30, 2017
37: A Deep Dive into Dermatology Match Data and Surveys
21:28

Session 37

This week, we take a deep dive into the match data for dermatology. We cover the Match data from 2016 and 2017 to give you an idea of what you're up against. Dermatology is one of the hardest specialties to match into. Historically, it has been known as the ROAD specialties (Radiology, Orthopedics, Anesthesiology, and Dermatology).

"Dermatology is still one of the more competitive residencies to apply to as a medical student."

As we dive into this data, it gives you an idea of what you should be thinking about or doing when it comes to starting your journey. Hopefully, this will help you determine how much effort you put into getting the best possible board scores and everything else you need to get into dermatology.

Also, check out everything we have at MedEd Media Network including The Premed Years Podcast, OldPreMeds Podcast, and The MCAT Podcast.

[01:51] Match Summary

As always, all of this data come from the NRMP Main Residency Match Results and Data

  1. First off is Table 1 which shows the summary of the match. It starts with PGY-1 positions and Dermatology has 11 programs, 26 positions. Don't freak out since there are actually a lot more dermatology spots offered.

Dermatology has a prelim typically a medicine or transitional or surgery year that you do before you start your dermatology residency. As a medical student when you are applying to dermatology, you need to apply typically to a dermatology residency. This starts at PGY-2. Then you apply for a prelim year or an internship year which is your PGY-1 year at either a medicine, surgery or transitional program.

So you can't go look at those numbers on Table 1 alone. Instead, go down to the continuation of Table 1 which shows the PGY-2 positions. There you will will see they have 121 programs and 423 positions offered. Looking at this chart across the column, the total number of U.S. Seniors applying out of those 423 spots is 479. So there are more U.S. Seniors than there are spots available.

For this purpose, U.S. Seniors for the NRMP refer to students who are in an allopathic/MD medicine program and they're still in school. Now, out of those 479, 81.8% matched into Dermatology. That's a pretty good number and it's one of the higher numbers around.

"If you are a DO student or an international medical grad, your chances are already starting off not that great."

[05:00] U.S. Seniors, U.S. Grads, Osteopaths, and U.S. IMGs

Table 2 shows that out of 423 positions, 415 were filled on the main match. 346 of those 415 were U.S. Seniors, 48 were prior U.S. grads, which means prior MD graduates. These are those that possibly didn't match their first time around and then reapplied. Or maybe they didn't apply to a residency program the first time around because they weren't very competitive. They wanted to do some research. Maybe they really wanted to go to one specific program so they went to do some research in that program, reapplied, and got in.

There were 7 osteopathic students which makes up less than 2% of the 415 spots that were filled. It a very low number. Just to give you an idea, let's look at other specialties. Anesthesiology has 1,146 spots, 164 of which were osteopathic students. That's over 14% of Anesthesiology but less than 2% for Dermatology. It's possible there's still some bias tin the Dermatology world for DO's.

There were 3 International Medical Graduates or IMGs who are U.S. citizens that went to a foreign or international medical school and 11 were non U.S. Seniors or non U.S. citizens that went to an international medical school.

So it's high numbers for U.S. Seniors and good numbers for U.S. grads. Not good numbers for osteopathic students, and terrible numbers for U.S. International Medical Graduates. Lastly, it's pretty bad numbers for non-U.S. citizen international medical graduates.

"High numbers for U.S. Seniors and good numbers for U.S. grads. Not good numbers for osteopathic students."

[07:20] Growth Trends, Unmatched Applicants, and SOAP

Table 3 shows the growth trend of each specialty from 2013 to 2017. Dermatology has been growing and growing with 13.3% in 2013. In 2017, there was a 15.8% year over year growth. There were 399 spots in 2016 and 423 in 2017. There are more and more programs opening up for Dermatology which is good for you if you're interested in Dermatology.

"There are more and more programs opening up for Dermatology."

Figure 6 looks at unmatched U.S. Seniors and independent applicants ranking all the different specialties. Dermatology ranks up as the second highest for all of the programs with 33.8% total unmatched.

The majority of that are the independent applicants. They're outside of the U.S. Seniors and those were 47.3%. Almost half of the applicants were applying independently. Again, these are the IMG's and osteopathic students. I assume the U.S. grads are included here as well. The U.S. Seniors that went unmatched made up 13.8%. At a quick glance, it's the third highest behind Plastic Surgery and Orthopedic Surgery. So Dermatology is very, very competitive. Looking at Table 18 is the SOAP (Supplemental Offer and Acceptance Program) process, for PGY-2 positions, Dermatology had four positions available and all four were filled.

[09:48] Ranking, Steps 1 &2, Research, AOA

Chart 4 is one of the most telling charts when it comes to residency matching. When you match or apply to match, it depends on what programs you're applying to. A lot depends on how many program you are ranking. It's a big algorithm that matches you to programs.

"You submit a rank list. Schools submit a rank list. And the magic happens."

The median number of contiguous ranks is eight. This means that student that matched put Dermatology program eight times in a row. Those who did not match was only three. So you have a much lower chance of matching if you are much more selective when it comes to matching. The same goes if you're also being selective with the programs your'e applying to or you're interviewing at. Or you're not a competitive applicant and you didn't interview at a lot of program so could not select a lot of programs to actually match to. A lot of it comes down to how many programs you ranked. It's a numbers game. You apply to more medical schools, your chance goes up. You apply to more residency programs, your chances goes up. The same with fellowship programs.

Chart 5 dives into the mean number of different specialties ranked. Typically, if you want Dermatology, apply to Dermatology programs.

"If you have a Plan B, you're less likely to succeed in your plan A."

There's a lot of psychology research that shows having a plan B decreases the likelihood for your Plan A to succeed. But the data here shows that those who matched in Dermatology applied to a mean number of 2.2 different specialties and those that didn't match is 2.3. So the numbers are not very off. This could be skewed since in dermatology, you have to apply to a categorical or prelim year. I wonder if that data is being included in this. It doesn't mention anything in the graph data, but I wonder if that's the reason the numbers are so high at 2.2. It's much higher than everything else except for radiation oncology.

Looking at Table DM1, it gives us all the hard data behind Dermatology. The mean number of contiguous ranks is 8.9 versus 4.2. Mean number of Distinct Specialties was 2.2 versus 2.3. The mean USML Step 1 score was 249 for those that matched and 239 for those that didn't match. The mean Step 2 score is 257 to those that matched and 246 to those that didn't match. Sometimes, Step 2 score isn't really that useful. But the Step 1 score is huge here. The mean number of research experience is 4.7 for those that matched and 3.8 for those that did not match. Mean number of abstracts, presentations, and publications is 11.7. You need to get out there. You need to do your research.

"You need a very, very strong Step 1 score and a strong Step 2 score... you need to do your research."

AOA  (Alpha Omega Alpha) comprised 2.8% of those that matched. This means they were very successful in their medical school classes early on. Their pre-clinical is 52.8% of those that matched and only 25.8% for those who did not match.

Chart DM2 shows those that matched versus those that didn't with the number of contiguous ranks. You can clearly see that those that did not rank a lot of programs did not match. Then as soon as you get past that eight mark, it goes down. And after eight, only six people didn't match. So you have to rank a lot of programs.

"You have to be competitive enough to get interviews and to rank a lot of programs."

[15:40] Medscape Lifestyle and Medscape Physician Compensation Report

The Medscape Lifestyle Report 2017 talks about the lifestyle of a Dermatologist. As to which physicians are the most burnt out, Dermatology is near the bottom at 46%. (See Slide 2)The lowest is Psychiatry at 42%. As to how severe is the burnout, Dermatology is hanging at the top at around 4.3. Highest is 4.6 with Urology. (See Slide 3). Slide 18 shows which physicians are the happiest and Dermatology is number three on the list at 43% happy at work and 74% are happy at home.

The Medscape Compensation Report 2017 is the fun part. Highest salary is Orthopedics at $489K a year. Dermatology is number eight on the list at $386K. Below Orthopedics are Plastic Surgery, Cardiology, Urology, Otolaryngology, Radiology, Gastroenterology, and Dermatology. These are the top eight and all of these are procedure-based specialties. (See Slide 4)

"The way our healthcare system is set up, those who perform procedures and do surgeries are compensated with more money."

Even if what you're interested in is not within these eight, that's okay. You'd still make a good living as a physician. The lowest on this list is pediatrics at $202K. Dermatology pay according to this survey on Slide 5, only went up 1% (See Slide 5). Which physicians feel fairly compensated, Dermatology is the second highest at 65% (See Slide 18). Looking at slide 38, those who would choose medicine is up there at 80% and the highest is 83%. So Dermatologists are happy. They like being a doctor. They would choose it again. Who would choose the same specialty? Slide 39 shows it's Dermatology. They love their jobs. If you want to be a dermatologist, it might be good for you to check out Dermatology.

[19:25] Be an Intern

I'm looking for an intern. If this is something you're interested, email me at ryan@medicalschoolhq.net. I'm looking for one savvy for social media who can oversee my social media accounts and help me go out and find physicians to interview here on the podcast. It would be a great help to me and we can turn this into an extracurricular for you. We'll figure out a way to make it worth your time in helping this show succeed for every premed student, medical student, and even for residents out there looking for fellowships. In the subject line, kindly place Specialty Stories Intern. And I will get back to you as soon as you can.

Links:

MedEd Media Network

The Premed Years Podcast

OldPreMeds Podcast

The MCAT Podcast

NRMP Main Residency Match Results and Data

Charting the Outcomes 2016

Medscape Lifestyle Report 2017

Medscape Compensation Report 2017

Aug 23, 2017
36: What Does Academic Colorectal Surgery Look Like?
59:18

Session 36

Dr. Scott Steele is an academic Colorectal Surgeon and Chairman of the Colorectal Surgery Department at Cleveland Clinic. We discuss his love of the specialty. He has now been practicing outside of his fellowship for twelve years now. Dr. Steele also hosts his own podcast called Behind the Knife. Check it out as well as a host of all our other podcasts on the MedEd Media Network.

[01:17] His Interest in Colorectal Surgery

Scott knew he wanted to do surgery from the first time he got his clinical years and did some primary care. He also considered orthopedics since he likes sports. But colorectal surgery dawned on him when he met some mentors. Not being a sexy topic, he didn't really give it much time. But he found a mentor when he was in residency. Towards the end of his second year, going into his third year and on his fourth year, he began thinking about colorectal surgery. He hung around them and went to the meeting which he found an incredible experience. He thought they did both great in surgery and academics. They take care of patients that have diseases that he likes. They do some outpatient and inpatient surgeries, colonoscopies, and major oncological reconstructions. So it was something he was interested in.

He initially thought about doing heart surgery but he thought he wanted a little bit more of variety. He knew he didn't want to do orthopedics in medical school after he did one rotation at the University of Wisconsin. Although he likes orthopedics and how it's related with sports, it just didn't trigger him.

"I was more in the process of easily ruling things out."

So Scott did this process of ruling things out. Surgical oncology is okay but colorectal did great cancer operations as well. Surgical oncology tend to not do the wide breadth of people. They tend to serve old people, a lot of them are dying in a lot of cases. It was something he didn't want to do. Minimally invasive surgery was a burgeoning fellowship at that time and it was its own fellowship. But he thought colorectal also does minimally invasive surgery. In fact, now minimally invasive surgery is a standard component of any particular field. So it's not in and of itself. So he made the jump from heart surgery to colorectal surgery.

Scott was a general surgeon. He was in the military and he spent a year after his residency at Fort Hood, Texas where he practiced general surgery. So he basically did the vast bread and butter of general surgery. But growing up in a small town in northern Wisconsin that had amazing surgeons. And as a general surgeon, he didn't want to get pigeon-holed in being the hernia guy or the bowel obstruction guy or the lap chole person. He knew he wanted to do academics. He knew he wanted to do a subspecialty. So the more and more he went into colorectal surgery, the more he realized it fit his personality. It fit all the things he was looking for in a career.

"The more I went into colorectal surgery, the more I realized it fit my personality. It fit all the things I was looking for in a career."

[06:03] Traits that Lead to Becoming a Good Colorectal Surgeon

Scott says that it's more on how we are as people. But what he found with colorectal surgeons is that they don't take themselves so seriously in broad, sweeping strokes. They have a ton of fun. They are generally good people. But they also have a side where they're really busy clinical surgeons in the community and academic centers. And for those that did academics, it was great medicine. There was basic science research and others did hard core epidemiological research.

He adds that when you walk into a clinic and pick up a chart or log on the EMR and see what they're doing, patients have a special part of their body. They may not even tell their spouses of many years about what's going on with them. It tends to be something that's very intimate and very personal. It bleeds or itches. They feel something and that patient in many cases think they have cancer or they think something's wrong. If your arm itched or bled or you felt something, you'd look at it. But that part of the body is so hard to look at. So patients have an extreme amount of trust in you. Within five minutes of talking to them, you're asking them to pull down their pants and look at their back side. A lot of things can be in that person's mind. And in all of those aspects, you have to be able to go in and establish patient rapport right off the bat. Make them understand that despite their misconceptions, it's okay. It's very routine. And many people experience the same type of symptoms they're experiencing. So you need to keep it a little bit light. Let them know you take their symptoms seriously and that you're going to walk them through the process.

Keep in mind that in the United States alone, colorectal cancer is the second or third leading cause of cancer-related deaths every year. It's something we don't talk that much about. Scott says it's something they can intervene and interact with that given how serious the topic is, you don't yourself too seriously.

"Colorectal cancer is the second or third leading cause of cancer-related deaths every year."

[09:51] Types of Patients

As a colorectal surgeon, you see all age ranges and a mix of benign and malignant diseases. Scott is the lead editor of The ASCRS Textbook of Colon and Rectal Surgery and in the book, they talk about how they organize colorectal diseases. The organize it into six folds.

First, is endoscopy. It's a large percentage of what they do. They use scopes and they're able to do a lot of advanced procedures through it. Second, they see the plethora of anorectal disease such as hemorrhoids, fissures, fistulas, etc. It's the routine but stuff they do and a big part of the practice. Third subset is they see the malignancy - anal cancer, rectal cancer, colon cancer. Those are the major operations you can do minimally invasive procedures. You can use laparoscopy and open surgery. You can do robotics and all the different neat tools and tricks you do. Fourth, is they get to see a lot of the benign disease which includes a lot of the inflammatory diseases such as IBD, the Crohn's disease, ulcerative colitis, and diverticulitis. Fifth is you also get to see pelvic floor disorders. Those are the patients with obstructive defecations and those with rectal prolapse or fecal incontinence. And last is your miscellaneous type. But the first five types mentioned by Scott are the ones where when you talk about colorectal disease, you can break each of those down. You can see how you have all the plethora and combine that with scopes where you can do things endoscopically. They have one person in their department who is a very gifted and technical surgeon. He was able to take off early cancers through the colonoscopy and save people from having to go major surgery.

It's that wide breadth of patient variety, ages, outpatient, inpatient, scopes, major operations that is the unique part of colorectal surgery. Contrast that with things like surgical oncology or cardiac surgery and that's what drew Scott into the field.

“It's that wide breadth of patient variety, ages... scopes, major operations that is the unique part of colorectal surgery.”

[13:20] A Typical Week

For Scott, he spends his Mondays in the operating room. He has all-day clinic on Tuesdays. Wednesday is his admin day as the Chairman of the Department. He typically has a lot of meetings. Thursday is an operating day and Friday, he does scopes and some afternoon meetings. This is a pretty standard week for people where you have a mixture of clinics and other things.

The person who started Relay for Life, Gordy Klatt, was a colorectal surgeon. He died a couple of years ago. He was a community colorectal surgeon and one of the last independent providers. Scott covered for him for seven years. Scott was in the military and would take some vacation and cover for him. He had a much different practice. He saw clinic a half a day everyday. He would operate on most days as well. The admin days are part of many private practices but it wasn't part of his. He ran his own business with his wife being his business manager. He would have major operating days maybe three days a week. And he would do colonoscopy on a certain day of the week. He would also always come back to his clinic.

So there is a wide variety depending on where you're at and what is the practice you're in. If you have a big group practice or a multispecialty clinic such as the polyclinic in Seattle or if you're working at an academic medical center like the Cleveland Clinic. It has a very busy high volume center.

"Depending on what your niche is and what you'll be able to do really would determine your practice."

Somebody in his department that does pelvic floor may see a little bit more clinic than somebody who's an IBD specialist who may have a mixture of clinic and operating days. So this varies according to the individual unique practice that you want to set up.

[16:00] Operations and Calls

Scott says they treat colorectal disease. And as a part of that, the referral pattern you're in would determine a lot of how much medical management has already been done. Many pelvic floor disorders, for example, need medical therapy or workup. Fecal incontinence in many cases can be treated with bulking agents and some Imodium and some pelvic floor retraining. So they won't need an operation anymore. There's also a study that 50% of hemorrhoid consults are not hemorrhoids alone. Or there's something that never needs an operation. Diverticulitis can be treated with antibiotics. So you can see that a lot of these disease processes are treated with multispecialty type approach that medical management is a major part of it. So on a typical clinic, not accounting your post-ops or your follow-ups, anywhere between 20% or 30% depending on your individual practice may require surgery. But all of them have some semblance of needs for the colorectal surgeon to treat either surgically or medically.

"They look at you as an "expert" of the hindgut to treat whatever is going on so you do have to know your medicine."

With regard to calls, Scott says they vary more than anything else. It depends on who takes the call and how many people are there in the practice. It also depends if you're asked to do general surgery and colorectal or just colorectal surgery alone. It also depends if you have acute care surgery or you have fellows and residents. Scott thinks that they're one of the largest colorectal departments, if not, the largest in the United States and maybe in the world.  They have well over 20 colorectal surgeons. So for them, call is busy. But they can be extremely busy when you're on call because it's a major referral center. At their clinic, they get patients all over from the northeast Ohio to Kentucky, West Virginia, and all over the world. So a lot of the diseases that can happen that affect the colon in such a busy hospital. They have fellows and residents. It's a very busy fellowship and a very busy residency. Scott says they are up all night long. It's a busy call but they're not crushed with calls. He has been on call a lot more in other places that he has worked.

Additionally, you have to determine that as a subspecialist, especially a subspecialist branching out from general surgery. This could include bariatrics or minimally invasive surgeon, surgical oncologists, colorectal surgery. In each of these, you're oftentimes asked to take general surgery call. When he was in the military, his call was colorectal surgery and also general surgery call. That mixes in your bowel obstructions, cholecystitis, appendectomies, hernias, etc. That can drastically change your call in terms of the number and the types of patients you see. Some people want to do that. Scott did general surgery call for seventeen years. But he doesn't do it anymore and he doesn't do trauma anymore. He's fine with that. But other people are looking for jobs as a part of their colorectal practice that they can still do a little bit of general surgery.

Unless you're going to a major medical center where it's a colorectal call only, you may be asked to do some general surgery calls. And that has its pluses and minuses. Some of their east side hospitals take a bit of general surgery call. That's part of the institution you're working at. People primarily at the outer institutions away from the main campus take general surgery calls. But that's part of the hospital they're a part of. They also have other jobs in the hospital. You're working with people and you get to know the fellow doctors you're working with. You help out. You cover for them and vice versa. So that's a unique aspect of that. Scott took general surgery call because he liked it. At times it's rough. But he can say that especially earlier in your career and especially if you're going to a community based setting, don't be surprised that you're going to be taking some general surgery call.

"If you're going to a community based setting, don't be surprised that you're going to be taking some general surgery call."

[22:45] Work-Life Balance

Scott explains that time is the most precious commodity that you have. That's why you need to prioritize. Really determine what do you want to do in life and what do you want to be. What are your goals? Regardless of your specialty, you have to prioritize and figure out what type of practice you have. What type of priorities do you have and where do you go?

Earlier in his career, he knew he wanted to do academics. So he had a very hard time saying no. Anybody would ask him to write a chapter and he would do it. Or they'd ask him to review an article or travel or teach a course or cover a call, he'd do it. Being in the military, he started being deployed. And then he got deployed for a number of times. The next thing he knew, he has one daughter, grew up and realized he's missing a lot of her life. You're going to be busy. If you want to do academics, there's never enough time for academics. There's no such thing as protected time. And even for those who have "protected" time, everything else impinges on it. So you have to really set aside time to decide what you're going to do. Scott has had friends who started on academic career and did a bunch of stuff. Then they felt they didn't have the passion for it. So they stepped back from it or did it selectively. And that's great because it works for them.

Scott likes academics a lot and says that unfortunately, you have to find time. He reviews for a number of journals and serves as an editor for several textbooks. He has traveled the world and has met wonderful people. He has operated in places he never thought he would operate on. He would have never thought he'd see some of those places and had the unique experiences.

"Academic surgery has been a very fulfilling and wonderful career. "

But Scott knew he wanted to be the guy who wants to be involved in the journal and the textbooks. He wanted to be involved in teaching fellows and residents. So when he sits down with fellows, he asks them who they want to be. Training is funny especially in medical school and residency. You constantly have people come up to you and say how you could chose this profession and that. You feel this angst that you can't talk bad about. Or you can't say what you really want to do. Especially when you're training in academic institutions, you feel this push to say that you don't want to be a community based surgeon but that's what you want to do. Scott believes over half of their specialty is made up of community colorectal surgeons. That's the socio-economics we have. That's the demographics and the geopolitical aspect we have. It's a big land mass. Many general surgeons cover a lot of things. Colorectal people may find themselves clustered or be in an independent town working on their own.

When Scott went into his first week of surgical residency, he knew he wanted to be a program director. As he progressed along his residency, he knew he wanted to do academics. And he knew he wanted to be the chairman one day. He feels like he's the luckiest person in the world to be the chairman of colorectal surgery at the clinic. He finds it a really great job at a wonderful institution with extremely talented people in and our of his department. He has many other friends at other institutions that are lifelong friends outside of medicine. But he knew those are all he wanted to do. He knew he wanted to do the complex cases. And one of his best friends don't want to do it. He wants to be the guy that just does the bread and butter thing and take care of patients. He just wants to be a very busy person and get home at five so he can teach his kids softball.

Now, Scott has the opportunity to do much more of this. But it's a matter of how you want to prioritize. His advice to people is to be true to yourself. There's going to be people telling you do this and that. They're going to fade in and out of your life as time goes on depending on those relationships. But you have to be happy.

"The worst you can make is find yourself in a career that you never wanted to be in the first place."

[27:42] Mentorship and the Path to Residency and Fellowship

As a colorectal, you start out in the communities. This is the reason you see a lot of the major colorectal training programs are community-based clinics (Asher Clinic, Mayo Clinic, Lahey Clinic. University of Minnesota, where Scott trained, was one of the few universities that had a major training program. A lot of the university centers felt general surgeons could do it all and they didn't have the need for a colorectal surgeon. As medicine has changed as well as life in general, they have found there is a call for subspecialists. The call for having subspecialists, not always in every place, is a need. So the subspecialization in many cases has got a positive and negative effect on it.

For example, you have people that think they're going to learn everything they want to learn in their fellowship. So they can just coast through their residency. But Scott disagrees with this. Their goal in fellowship is to refine and retrain people, not to teach them from the basics. The subspecialization has become a bit more prominent, And as colorectal surgery has really taken off and now found a niche, not only in the community but also in major academic centers, now they can go everywhere. Scott is proud to say that for the last several years, they've been one of the most highly competitive and sought after matches. That's when you consider the programs, slots available to the number of applicants that apply.

"For the last several years, they've been one of the most highly competitive and sought after matches."

Scott says when you look at some of these kids that come through and you see their CV's, you'd be surprised to see what they've done. You will hear many colorectal surgeons that if they had to apply now, they won't know if they'd get a spot. The point is that the field is now becoming more competitive. Scott's advice to those who want to get any fellowship, including colorectal surgery, it's important to plan ahead. It's important that you now have some research and have good board scores. It's important to have good mentors in life. Moreover, Scott says the best part about medicine is we never stop learning. Technology continues to evolve. Disease processes and what we know about them continue to evolve.

"Link up with a mentor. Find out what they do. And you get a lot out of a mentor-mentee relationship."

Depending on the general surgery you have, it usually involves five years of clinical time plus or minus research. Most programs are one clinical year. A few would be research year of colorectal and then a clinical year after that. Then post-training is one or two years. In many cases, they have a clinical associate year. It's like a super-fellow where after finishing your fellowship year, you spend another dedicated one-year training or six months doing reoperative surgery for example. But only a few selected institutions have that.

[32:53] Bias Against DOs

Scott notices that any bias has changed over time. He doesn't know if the MD versus DO is as prominent as it used to be. He recalls during training that there were programs that won't accept a DO student even no matter how great they were. He was in the military for a long time and they had both MD and DO residents. Some of the best kids he has trained were osteopathic students. He also had a roommate in Iraq. He is a DO ER doctor and toxicologist and he describes him as the one of the brightest physicians he has ever met. Ultimately, you have them in both sides of the fence.

Scott went to Madigan Army Medical Center and he's proud to be in the military and trained in the military. But comparing it to training at Cleveland Clinic, he knew he had to distinguish himself. He had to be much better. So what he tells DO residents is that they have to be real. There still may be a stigma associated with going to an osteopathic school for medical training. And because of that, you may not get the interview or they may look at you as someone who should blow their socks off. So your scores have to be that much better. Your publication should be that much better. That doesn't mean you're not better than the person next to you. But take that stigmatism out of it will blow their socks off. Scott adds that if in a program somebody comes to you and has an automatic bias against you, then maybe that's not the program you want to train in anyway. Surgical residency is a fun time and it's a lot of growth.

"Put yourself in a good position where you almost force them to take a solid look at you and put everything else aside."

[37:45] Subspecialty Opportunities and Working with Primary Care and Other Specialities

At Cleveland Clinic, they have teams. It's not all they do but they have a focus of things. They have a cancer team, an IBD team, and a pelvic floor team. They have a team of hard core basic science researchers who also still maintain a clinical practice. They run labs. Scott says you can make yourself and find your niche and do that. You can both that in an academic medicine as well as in the community. That's the unique aspect about medicine and about surgery, specifically, colorectal surgery. Another unique aspect of being a colorectal surgeon is you can transition into teaching or mentoring type program. You can also transition into primarily endoscopy only. Or you can do just outpatient surgery and focus on anorectal type of disease. You can also do mentoring and teaching medical students. Scott says that's the cool thing about colorectal surgery because there's such a wide range of patients and such a wide range of disease processes that you can take care of. It really fits at all stages of your surgical career.

"That's the cool thing about colorectal surgery...it really fits at all stages of your surgical career."

Scott explains that you become a doctor when you know more about walking in other people's shoes. You see what they do and get a feel for their care path or how they treat patients. It just allows them to be better care providers. This is especially true for primary care providers being the frontline care providers. The more they know about subspecialists, it saves the patient a lot of grief when they come and see them with rectal bleeding but they've never been treated with fiber. Or they have hemorrhoids but they've never been truly treated with a medical therapy. Patients come to him and they automatically think they need surgery. So Scott's advice to primary care providers is to take a look if their institutions have those and learn about them via algorithmic textbook. You're never too old to take a look at just a textbook and look at rectal bleeding. You could have been trying something else all along that could either help the symptom or conversely rule it out. So you can then move on to the next step of therapy. You mostly see this in the anorectal type of processes and disease states in colorectal surgery. Hemorrhoids are the classic ones. the anatomy can be confusing to people. Nobody is expecting you to be a subspecialist or to treat complex disease. But you need to understand the very basics about certain health problems.

Other specialties Scott works the closest with include medical oncology and radiation oncology. They also work with pathology and radiology as part of the multidisciplinary team report. They also work with urogynecologists on pelvic floor disorders. They also work with general surgeons specializing in abdominal wall reconstruction. Other specialties they work with are urology, plastic surgery, neurosurgery, gynecology, and gastrologist.

"We're all in this fight together to take care of patients. We all want our patients to have good outcomes."

Scott's advice to students is for them to understand and appreciate what doctors do and the disease processes they treat and the tremendous amount of hard work they do. As you get older, these are the patients that refer patients to you. So have that good referral relationship because patients are your lifeline. So you realize they're not your enemies but your colleagues who have gone through a lot of training as well.

[47:25] What He Wished He Knew About Colorectal Surgery

Scott explains that at the end of the day, it comes down to patients. It's about understanding the degree of what a patient is going through. The medical journey is extremely fulfilling. You can do anything you want to from being a busy clinical colorectal surgeon to being a hard core academician. And colorectal surgery, like a lot of other things, provides you that.

What's neat too is you get to mature as a physician. But if you've ever been sick or you've known somebody close to you as sick, sometimes you lose that perspective where you're in a job on a day-to-day basis. You forget that the person sitting next to you has so many things going on.

"Keep in mind that that's a person there and not a case number or a sticky."

Scott says it's easy to lose sight of this but keep all under perspective and it makes your job even much more fulfilling. What he likes most about being a colorectal surgeon is being able to operate. He loves the ability to do something. He tells his students there's no more intimate relationship you'll ever have than having the trust of somebody allowing you to cut into their bodies and operate on them. Somebody's entrusting to you that they're going to sleep. You're cutting into them. You're taking out the cancer. You can't get more intimate than that. You'll be inside somebody else's body. So it's an incredible amount of trust they have that you will hopefully take care of them. Understand that you're human and you're fallible. There are complications that can come up.

On the flip side, what Scott likes the least about being a colorectal surgeon is the amount of time you have in medicine in charting. He likes seeing patients but the amount of time physicians have to do this is becoming less and less. Combine that with charting and EMR. Then you lose sight of the fact that you had a great interaction with the patient. This can somehow get diminished or lost in the shuffle. Scott finally says that time is probably the most precious commodity that we have in all things. It's something everybody needs to take a better look at. Realize what you want to do. How do you want to spend it in the most effective and efficient manner that you can?

[52:45] Major Changes in Colorectal Surgery

Scott explains that technology always changes and always drives. People have a curious mind and they will continue to drive. They see a problem. They think about a problem and try to find something to fix it. Some of those things revolutionize medicine and others fall by the wayside. Right now, the hottest thing is pushing the limits of endoscopic therapies for different types of diseases and minimally invasive surgery. As we go more towards natural orifice surgery, they try to decrease that.

Finally, when asked whether he still would have have chosen colorectal surgery if he had to do it again, his answer was an absolute yes. All he can say is that it's a wonderful career. It's extremely rewarding. And he looks forward to doing it for a long time to come. His advice to premeds or medical students getting started on this journey is to find a mentor. Find somebody that can sit down and tell you the ropes and guide you a bit. You can read a textbook or listen to a podcast such as this or his podcast Behind the Knife. The information is out there and you have to have fundamental basic knowledge. But there's nothing that beats relationships and has that ability to have somebody guide you through that process. Have great board scores. Do research in the field you want to go into. And you have to be competitive. You have to have the baseline minimum.

"Find a mentor. Find somebody that can sit down and tell you the ropes and guide you a bit."

But the more fulfilling part of life is having and building those relationships and finding out what makes people tick and what makes the specialty so great. That's where the mentor-mentee relationship comes into play. Meet other people and truly get to know them.

[58:15] Final Thoughts

If you're interested in colorectal surgery, follow Dr. Steele's advice. Find a mentor. Find a colorectal surgeon out there that's doing what you want to do. And start connecting with those people. Don't forget to check out Dr. Steele's podcast, Behind the Knife.

Links:

MedEd Media

The ASCRS Textbook of Colon and Rectal Surgery R

elay for Life

Cleveland Clinic

Madigan Army Medical Center

Dr. Scott Steele's podcast Behind the Knife

Aug 16, 2017
35: Private Practice Pediatric Ophthalmology
22:43

Session 35

Dr. Chris Fecarotta is a Pediatric Ophthalmologist. He has been in private practice for five years now. He shares with us his reasons for choosing the specialty and what you should think about if this is a field you’re considering.

I would love for you to recommend The Premed Years Podcast to your premed friends along with our other podcasts on the MedEd Media Network.

[01:30] Interest in Pediatric Ophthalmology

Chris admits he didn't know he wanted to be a pediatric ophthalmologist until late in the game. He figured it out at the beginning of his fourth year. Knowing he always wanted to do kids, he went into medical school thinking he would be a pediatrician of some sort. But he didn't know exactly what.

Then he discovered as he went along that he wanted surgery more. He had a friend who had some family members who were in ophthalmology. He talked to them about it and though it was an interesting field. So he decided to put the two together and thought about doing pediatric ophthalmology. He shadowed a pediatric ophthalmologist and went into residency thinking it was what he would do and stuck with it.

"The eye is a very fascinating organ. It's a lot more complex than people think."

Chris says he likes the very small surgery. He likes the patient environment considering he's not a huge fan of doing in-patient work. So pediatric ophthalmology fit all those things very well. He also likes how it can afford a reasonable lifestyle. There are not that many emergencies in it and you can really make a big difference in children's quality of life by improving their vision. These are the things that really appealed to Chris.

[03:16] Traits That Lead to Being a Good Pediatric Ophthalmologist

Chris stresses how important it is to enjoy working with children. It's a very challenging field as he describes it. It's not the easiest thing to convince them that it's okay to examine their eyes. So you have to be able to work well with children. You have to be very patient and have a very good rapport. He also adds the importance of being detail-oriented, especially for ophthalmology since they deal with a very small organ.

Chris says there are people who have the natural ability to do surgery especially small surgery. But he doesn't think it's not something it can't be learned. It's not something you need superhuman dexterity for. Some with normal dexterity can do it with dedication and practice.

"I don't think this is not something that can be learned. I think it's very possible to learn it."

Chris explains there are varying levels of natural ability just like with anything else. There are people that find they're just not really cut out to do surgery. But that's rare. Most people can learn it and do just fine.

[05:35] Types of Patients and Typical Day

Chris treats mostly children with strabismus (cross-eyed) or amblyopia (lazy eye). These are the bread and butter of pediatric ophthalmology as well as nasolacrimal duct obstruction. He sees all age ranges and premature babies who have retinopathy of prematurity all the way up to young children with strabismus and amblyopia. He also sees teenagers continuing their eye care. He also treats adult strabismus. So he treats all ages, mostly children.

"Pediatric ophthalmologists also generally treat adults with strabismus from a variety of causes as well."

As a private practice doc, Chris gets to the office between 8:00 am and 8:30 am. He sees patients through the day. He doesn't typically take a full lunch although he tries to sneak food in-between patients. Then he's generally done between 4:00 pm and 5:00 pm. He takes call but it's generally not very demanding. There are eye emergencies but there is not that many of them. Usually, most things can be triaged and then seen the next day.

An example of eye emergency where he as to go in is an injury where the eye is ruptured globe. It's an emergency if the eye is cut and the contents of the eye are exposed. It usually needs to be surgically repaired that night. Another eye emergency is a retrobulbar hemorrhage from an orbit fracture or trauma to the eye. If there's bleeding behind the eye in the orbit, it can cause a compartment syndrome that can compress the optic nerve. So it needs to be decompressed. Angle-closure glaucoma is another one but this does not happen in children. So it's not a pediatrics problem but this is one of the other few emergencies in the ophthalmology field. Other than these emergencies, most things can be pushed off until the next day.

[08:18] Private Practice and Work-Life Balance

What caused Chris to move from academics to private practice was his friend offering him the job along with his wife. It was more of a personal decision for him than anything against academics. He mentions both private practice and academics have upsides and downsides.

Only 10-15% of his patients are brought in from the outpatient setting to the operating room. Most of his patients are not surgical in pediatric ophthalmology. In general or adult ophthalmology, there is a higher percentage of surgical patients. Most of the adults are there for cataract surgery. Pretty much everybody, if they live long enough, gets a cataract and needs surgery.

"The volume of surgery for pediatric ophthalmology is less than general ophthalmology."

In terms of work-life balance, Chris thinks it's one of the most ideal fields for that. If you like surgery and you like children and you want a reasonable life, Chris thinks it's a great choice. There is also a big need for them. There's not that many pediatric ophthalmology so it's easy to find a job, not to mention that it's very rewarding.

[10:12] Path to Residency and Fellowship

The path to ophthalmology residency includes an intern year. Most people do a transitional year but you can also do a medicine year. Some programs will let you do a pediatric year if you want to specifically do pediatrics. Then you would have to do ophthalmology residency consisting of three years. Then a year after that, you can do a fellowship in pediatric ophthalmology of strabismus. So it's five years after medical school graduation. It's not as long as other surgical fields.

Chris says ophthalmology is competitive to match in out of medical school but pediatrics is easy to get a fellowship in.

"It's not a very popular fellowship so there's open spots usually. Most people can get a spot if they want."

There are a couple of reasons Chris thinks the fellowship is not as popular. First, he doesn't think most ophthalmologists go into the field looking to deal with children. He thinks he's an exception but most are not that thrilled about seeing children. They didn't go into it for that reason.

Children are much more difficult to examine than adults so it's challenging. And he thinks a lot of people are intimidated by it or don't want to deal with the hassle of examining the child. Another possible reason is that it pays less than general ophthalmology for a variety of reasons. One, is there's less surgery. Just because the field is less surgical, a lot of children are on medicaid. So the reimbursement for pediatric ophthalmology is not as strong as for general ophthalmology. So Chris things these things discourage people from choosing it. But if you like children and it's what you want to do then it's a great field to choose. He would still encourage anyone to do it if they like kids.

Like all the competitive fields, the most important thing to be competitive for ophthalmology is to do well in your classes and your USMLEs. Chris thinks it's your letters of recommendation that can get you in the door to an interview. Then have a good interview where you're likable and people can see working with you for three years. Chris believes that research helps but doesn't think it really makes or breaks anybody.

"You get your foot in the door by your academics and your letters of recommendation. Then your interview is really what seals the deal."

With regard to sub-I's, Chris thinks it's not a bad idea to make yourself known by doing a sub-I. But you have to make a good impression otherwise you've pretty much killed your chances of going there. So you better make an A+ impression or else you'll actually probably hurt yourself.

[14:30] Bias Towards DOs, Subspecialty Opportunities, and Working with Other Specialties

Chris thinks it's challenging for a DO to get an ophthalmology residency but it's not impossible. There are DOs in ophthalmology. There are specific DO ophthalmology residencies so it's definitely possible. And once you're in ophthalmology, getting a pediatrics fellowship is not hard at all as what Chris has mentioned. The hard part is if you were a DO and got into ophthalmology residency. After that, you can do pediatrics if you want without a problem.

Once you're a pediatric ophthalmologist, there are other opportunities to further subspecialize. Although most people don't do it, you can do a second fellowship. But if you want to be very academic and you want to be the world's expert on pediatric glaucoma, you could do a second fellowship in glaucoma. You could do neuro ophthalmology and do pediatric neuro ophthalmology. There are only four or five of them in the country. And this can help you in terms of finding jobs and being an academic.

"You can subspecialize within pediatric ophthalmology but the vast majority don't."

Other specialties they work the closest with include pediatric ENT, pediatric rheumatology, and pediatrics. The general pediatricians are usually the referral source for a lot of patients.

To make their job easier and provide more care for the patient, pediatricians being able to provide history always helps. He also thinks most pediatricians know they need to do that. So he doesn't really have much problem with that. He doesn't think most non-ophthalmologists are comfortable with the eye. So he would encourage them to refer to pediatric ophthalmology if they're concerned about anything. Better be safe than sorry. They would be happy to see any patient any time. So they should send patients to them if they feel uncomfortable and let them help.

Moreover, Chris recommends to primary care doctors to have the book The Wills Eye Manual in their office. It's the most common manual of ophthalmology out there. Most eye providers have it in their office. They can look up the different diagnosis, treatment, follow up, differential diagnosis, etc. They can use this book as a reference for anything they want to look up about eyes.

When it comes to special opportunities outside of the office, Chris says that if you're going to be an academic pediatric ophthalmologist, there's always good pathways to be a chairman. There's also lots of research you can do.

[18:59] What He Wished He Knew and His Most and Least Liked Things about the Field

Chris was initially discouraged from pediatric ophthalmology by other ophthalmologists who said that the pay wasn't very good. While it may be true they make less than general ophthalmologists, he doesn't think it's a reason not to the the field. He feels they get paid pretty reasonable. So he would probably go back in time and tell himself not to worry about that.

"If you like kids, I think you should go ahead and do it and not worry about the money because the amount you get paid is reasonable."

What Chris likes the most about being a pediatric ophthalmologist is being able to play with the kids everyday. It's a lot of fun. He thinks they're adorable. There's everyday that they say something that would make him smile or laugh. For him, it makes the whole day worth it. On the flip side, what he likes the least is the small 5-10% of children who are very difficult to deal with. He had to pry their eye open to get him to do an eye exam.

[20:00] Major Changes Coming to the Field and Chris' Final Advice for Premeds

Chris mentions some interesting things on the horizon for ophthalmology. recent research has been focused on treating amblyopia with a certain type of iPad game. It encourages stereopsis in using both eyes together to treat amblyopia. This is an exciting development in their field that he's waiting to see the results from.

Retinopathy of prematurity is a disease they commonly encounter and there are some new treatment options in the last five years. They're waiting for really good results from it. So there's a lot coming around the corner.  It's a very rapidly moving and progressing field.

"Ophthalmology is a very exciting field for technology and innovations. There's always new stuff going on."

Lastly, if Chris had to do it again, he would have chosen the same field in a heartbeat. He thinks it's a really great field. His advice to premed students out there is to not jump into making a decision. Take time. Do rotations and explore as much as you can before making a decision. Once it's made, you can't really change it. It's difficult.

[21:45] Last Thoughts

If you are thinking about pediatric ophthalmology or any pediatric subspecialty for surgery, this gives you an idea of what is out there for you. If you have any recommendations for specialties we haven't covered yet or you know somebody you'd like to hear on this podcast, shoot me an email at ryan@medicalschoolhq.net.

Links:

The Wills Eye Manual by Adam T. Gerstenblith

The Premed Years Podcast

Specialty Stories

www.medicalschoolhq.net/group

ryan@medicalschoolhq.net

Aug 09, 2017
34: Community Based Interventional Gastroenterologist
32:09

Session 34

Dr. Sushil Duddempudi is a community-based Gastroenterologist who specializes in interventional endoscopy. He has been in practice for ten years now and specifically as an interventional endoscopist for the last seven or eight years. He used to be in academic hybrid private practice. Check out what he thinks about the field and what you should be doing if you're interested in this field.

Also check out all our other podcasts on MedEd Media Network.

[01:45] An Interest in GI and Interventional Endoscopy

Dr. Sushil Duddempudi knew early on that he was going to be in a procedure-based field. It's a running joke in the field that GI people aren't smart enough to do anything else so they use procedures as much as they can. Then leave the complex stuff to the nephrologists, neurologists, and everybody else.

Sushil started residency leaning towards cardiology until realizing he hated EKGs. So he gravitated towards the GI field. He says it's not uncommon for students somewhere during their intern year where they're interested in one area. Once he started the GI fellowship, he knew he was into doing procedures. He found interventional endoscopy as a good fit for him because it lets him do procedures most of the time. But he still has this continuity with his patients which he loves. So about two-thirds to three-quarters of his time is spent doing procedures. Then maybe a quarter to a third is spent in the office seeing patients.

"GI is a pretty cut and dry field compared to some of the other fields."

Sushil describes they usually have a definitive diagnosis early on after seeing a patient and he likes the finality of it. GI borders that surgical mindset and a lot of GI's have mindset.They see a problem and they want to take care of it. Also with GI, there is finality. If the patient has rectal bleeding and you had a colonoscopy then you'd have an answer 99% of the time. When patients have abdominal pain unless it's functional, most of the time, they come up with an answer.

Moreover, Sushil likes the opportunity to do procedures. Other specialties he did consider include ENT or Neurology which would have probably worked for him as well or one of the subspecialties that are procedure-based. Ultimately, he ended up in GI.

[04:40] Traits that Lead to Being a Good Interventional Endoscopist

Sushil describes how many of those starting GI fellowship often say they want to do interventional endoscopy. Then over their first year or two, they'll select out.

"You have to enjoy doing procedures."

Some fellows he has worked with and trained over the years come in with a certain special knack. Some people just have good eye-hand coordination better than others. 90% of it can be taught and trained. But the people they look up to in the field are born with a little bit of it. This is what Sushil differentiates them from the rest. They are the guys doing the hard core cutting edge stuff. So it's a bit of something you bring within you into the fellowship and then 90% of it is just practice.

[06:15] Patient Types and Typical Day

If you're an academic interventionalist, you can tailor your practice to focus on that. This could mean 75% of your practice doing procedures. Community-based interventionalist flip it all the way around. In gastroenterology, the bread and butter is still colonoscopy.

If you're a community-based interventional endoscopist, you could be doing around 25-75% general and then the remainder is advanced interventional endoscopy. Then as you get older and you've done all the cutting edge stuff and you want to settle in a little bit, you can then focus on general gastroenterology. Then you can do the interventional stuff maybe 25% of the time.

For general GI, the younger groups tend to come in with more functional disorders and abdominal pains. As they get older into their 50's, they start to do a lot of colonoscopy screenings. Also in the 50's and 60's, they start to see a lot of GI cancers.

"Interventional endoscopy is very focused on GI cancer. That's where a lot of the techniques are being used."

For general gastroenterologists, most of them will do roughly about a half day in the morning. They start at around 7 or 8 to about 12 or 1pm doing endoscopy. Generally, you are in an outpatient surgery center. Then the afternoons would be spent in the clinic.

Sushil says that more and more gastroenterologists are coming out of the hospitals and staying in their office in surgery centers. Moreover, a new breed of GI hospitalists are starting to happen where you're focusing on inpatient training. This happens less in the big cities. But generally it's a mix of outpatient procedures an outpatient office visits which is 90% of what gastroenterologists do. While the other 10% would be composed of inpatient.

If you're an interventional endoscopist, you'll me a little more focused on the in patients because that's where a lot of the work comes in. This involves cases like bile duct construction, GI tract tumors, etc. Although they see this in the office, a lot of work comes in the emergency room. In Sushil's practice, the way they do it in the group is that most time is spent in the hospital early on. Then after two years, you will transition out to the outpatient side. So the new guys coming in cover all the hospital work. Then the partners are just focused on the outpatient work.

"Like many practices, it transitions over time based on your interests, time constraints, the type of practice you have."

[10:56] Work-Life Balance

Sushil didn't actually feel he had any work-life balance. But he would say that in general, interventional endoscopists are in the hospital the latest.

"It's definitely a field that you're committing extended hours compared to general GI guys."

This is because more of your work comes in in the inpatient setting which is always unpredictable. Your day could be extended. And the procedures you do tend to be a little longer . They are a bit less predictable than a colonoscopy or endoscopy which you can do in fifteen-minute blocks. Interventional endoscopy procedures are a bit harder to put into certain blocks.

[12:30] The Path to Residency and Fellowship

For interventional GI, sometimes called advanced endoscopy, you do your three-year medicine residency. Then you do three years of general GI fellowship.

And then there is another year of sub-fellowship. This has actually has crept up in the last five to ten years. Currently, there is only one ACG-accredited post GI fellowship that is liver transplant. And there are are five non accredited which include interventional endoscopy, clinical hepatology, motility, inflammatory bowel disease. Interventional endoscopy is the most popular. Just a year or two ago, interventional endoscopy actually went into a formal match process. Previously, you just apply to all the programs in the country and you get interviewed, you get offers and pick one. Now, it's a formal match process. It's also expected that in the next couple of years, it will be a fully accredited ACGME fellowship just like interventional cardiology.

If you didn't do the special training, you wouldn't be able to do certain procedures in GI. Currently, a lot of the older generation gastroenterologists still do ERCPs. Most of the younger people don't because they did numbers of them on their training of all GI fellows. So once it comes to full fellowship and board certification, it's expected that new trainees, if they don't do the actual training, won't be allowed to be allowed to do ERCP, EUS, and stents, and other interventional procedures.

Interventional GI fellowships are pretty competitive as Sushil describes it. GI and cardiology balance it back and forth when it comes to post-medicine fellowships.

"GI, number-wise, is the most competitive fellowship."

When Sushil applied eight years ago, there were only about 30 program in the country. Now, it's close up to 75 with about 35,400 GI fellows graduating a year. So he reckons only 25% apply for the advanced interventional training.

Although he wouldn't describe it as ultra-competitive but the majority of fellows he had trained that wanted to get it got in. Some may have to wait a year. But most fellows interested, eager, and did the right electives and the right types of research, got in. Sushil says you have to be focused and you need to take the right steps. Then there's a pretty good chance you're able to get into a spot.

[16:37] What Makes a Competitive Applicant

Sushil cites some qualities of a competitive applicant. He adds most interventional endoscopy directors look for people that have that extra knack (eye-hand coordination). Some of the hard skills are hard to train in one year. You need fellows that already have some experience.

Moreover, you are gauged through letters from your program director and the number of procedures done during your general GI training. He adds it's important to consider who you want to hang out with for the whole year.

"Unlike other fellowships, interventional fellowship is a one-fellow-a-year at any program."

So it's basically just you and you're generally working with one to three core interventional endoscopy faculty. So you're spending a lot of time with just a couple of people. Compared to general GI training, you're rotating around different hospitals and different services. So you work with a number of faculty. This is different from interventional endoscopy training since you're only focused with one person or two. So who do you want to hang out with for a year? Lastly, be nice to them on your interviews.

[18:30] Bias Against DOs and Working with Primary Care and Other Specialties

Sushil had the opportunity to train alongside DO's throughout his career. There have been some who were awesome while there have been some who weren't so good. This is also true for MDs and just with any other specialty out there.

But in terms of inherent institutional bias against DO's from the program directors, he doesn't think there is any. They don't look at it one way or another if a resident DO has gotten into general GI fellowship or interventional endoscopy. He adds that once you got to that level, you're met a lot of floors already. So he really doesn't think it's as relevant. Looking at interventional endoscopy fellows across the country, Sushil estimates that at least a third of them or maybe more are foreign grads.

In terms of working with primary care physicians, Sushil explains how fellows complain all the time about nonsense or bogus consults. But because he thinks his career has been mostly private or quasi-private settings, his view has changed.

"If a primary care or hospitalist called me, what I know and what they know are two different things."

While he may see it as a simple question and answer and it's going to take him two seconds, they may see it as something more complicated. If you'd ask Sushil the protocols or the GNC7 or up to 9 in primary care, he would have a tough time treating hypertension diabetes. That's because he hasn't done it so long. Hence, he looks at it as something they don't do very often. They have a question. They need some help.

So if a primary care physician has a question, the best thing to do is just call your local GI guy. Mostly, GI guys are laid back and not too uptight. His referral networks all have his number so they can always reach out to him whenever needed. As a specialist especially in GI (maybe more so in other fields), Sushil explains they're here to provide a service for them. They're here to do procedures and solve problems primary care physicians don't have the tools to solve. So when they call, help them out.

Other specialties he works with the most are general GIs and surgeons for interventional endoscopy. They work a lot with specialty surgeons like biliary and colorectal as well as interventional radiologists. Things they can't take care of generally go to surgery.

"That's where interventional GI has found its niche. It's at the interface between medicine and surgery."

They don't cut on the surface or on the skin but they do almost all of their cutting inside. Sushil describes it as the next evolution from open surgery to laparoscopic to robotic. Now there's a new thing called NOTES (Natural Orifice Trans Endoscopic Surgery). They're doing surgical procedures through natural orifices. As a result, there is less incision time, and less recovery time. They're still trying to figure out where the interface is going to be. Whether it's surgeons doing these procedures or interventional GI guys or a radicalization of medicine surgery that are going to end up being guys that do these types of procedures.

[23:57] The Most and Least Liked About His Specialty

What Sushil knows now that he wished he knew back then is that anybody on their feet a lot for doing procedures have got to have very comfortable shoes. He wished he had bought a quality pair of shoes right after training. He went from one brand to another until just back to regular sneakers.

What he likes the most about being an interventional endoscopist are procedures. He loves doing it. He loves the definitive nature of it. He likes that a patient comes in with a certain specific issue. And he's able to solve that issue most of the time. He likes to be able to give them definitive answer.

What he likes the least is being oftentimes the first person to inform someone that they have cancer since they deal with a lot of GI oncology. Sushil explains it's very rare that an oncologist has to give someone a cancer diagnosis. Usually by the time they're going to an oncologist, diagnosis has been made. Unfortunately, they get a lot of referrals for lumps and bumps on a CT scan and they're the first one to have to break the news to the patient that they have cancer. No matter how many times he has done it, he feels terrible every time. Colon cancers are pretty terrible but a lot of stuff they do in interventional endoscopy is pancreatic, liver, and gallbladder cancers which are generally not so treatable.

[27:00] New Changes in the Field of Interventional Endoscopy

Sushil sees the field as having this continuous evolution. If you went in for a colonoscopy for whatever the reason and they found a four-centimeter polyp, they'd stop the procedure. They'd work the patient up. They'd give them a referral to go to see a colorectal surgeon. About ten to fifteen years ago, that changed. Gastroenterologists started doing advanced training, becoming interventional endoscopists. They started doing removing those polyps out themselves. It's relatively rare that a non-cancerous polyp in the colon is sent for surgical resection. It's relatively rare nowadays for a procedure called a PTC to be done. This was a procedure done routinely after cholecystectomy. The procedures they're starting to do now are coaching more and more on the surgical fields. Patients often went for surgery before for a lot of GI polyps and tumors, etc. A lot of that is now done more being minimally invasive that's being done by laparoscopic surgeons. But even more minimally invasive than that is where a GI guy comes in.

"We're continually moving into this more and more non-invasive type procedures."

A their technology is getting smaller and smaller, they're able to go into areas that thy were never able to go in before.

Lastly, if he had to do it all over again, he still would have chosen the same thing. He enjoys GI and interventional endoscopy. He finds that it has the right blend of procedures but a little bit of continuity on the clinic side. He finds it as a good fit for him and what he enjoys. He doesn't think there's only one field a physician could go into but multiple fields. He thinks that people who enjoy the cerebral aspect of certain fields have a couple of different fields that would work for them. The same goes for those people that enjoy procedures. But all in all, Sushil has not complaints about the field he went into.

[29:40] Final Words of Wisdom

To those interested in going down this path, Sushil says it is never too early to start prepping your CV to get into GI. Consider that it's harder to get into GI given the numbers that is interventional endoscopy. When you start as an intern, go by the GI lab. Let the faculty know you're interested. Get involved. Get involved in research projects. They're not going to let an intern do that much. But there's always a need for someone to collect data, to collate data, to run statistics, to write papers. Get involved early on so that by the time you're second or third year role is around, you're seen as a junior fellow. You're part of the GI team. You're a resident but you're always hanging around the GI lab at any free time you have.

"It is never too early to start prepping your CV to get into GI."

Then when you move on to interventional endoscopy, the same thing. Go hang out with the interventional guys. Work on the papers with them. Come up with research proposals. Work on research projects, new ideas, new techniques. Be a junior interventional fellow.

Links:

MedEd Media Network

Aug 02, 2017
33: An Academic Pediatric Neurologist - Headache Doc
38:58

Session 33

A lot medical students go through the process end up at a time where they have to submit their rank list and they have no clue what they want to do. And this is a lot of unneeded stress. In this podcast, I talk to a specialist that you can't get hold of so you can understand what is out there for you.

Today's guest is Dr. Lauren Strauss, an academic Pediatric Neurologist who specializes in headaches. She is a DO at a large academic medical center for an allopathic residency program. She is currently the Residency Program Director at Wake Forest Baptist Medical Center for Pediatric Neurology. Listen to her thoughts on the field and what you should be looking into. Also check out our other podcasts at MedEd Media.

[01:50] Interest in Pediatric Neurology

Lauren has an interesting background having started in engineering. She did her major at UPenn in bio-engineering. She has always loved science and math. Her grandfather being an engineer and not having any doctors in the family, Lauren decided to do engineering. She thought bio-engineering would be offering her a big variety. What she found she loved the most was being able to do projects that brought them over to the hospital and allowed them to interact with clinicians.

When she decided to do her senior engineering project, she ended up in the Neurology lab where they did research related to vertigo. At that time, she didn't know she wanted Neurology but she knew she liked other things outside of engineering.

After graduating in engineering, she decided to take a year off while looking into medicine as an option. She worked at a pediatric practice for her pediatrician. She worked there for a summer which later turned into a whole year. Then she realized she wanted to go to medical school to be a pediatrician.

It was during their pediatric subspecialty month that she could rotate through a lot of different specialties and neurology was one of them. It still didn't hit her at that point that it was what she was going to. When she picked a full month in a pediatric specialty, some subspecialties she signed up for were already filled except for pediatric neurology. She did the rotation anyway.

"It was the perfect opportunity mixed with meeting the right people at the right time."

Then she decided to apply to Pediatric Neurology. Lauren describes it as a hard decision to do.  Nowadays, most programs are categorical where you do your pediatrics and neuro in the same location. But at that time, there were still some where you could train at two separate places. Hence, it was a difficult process. When she talked to her medical school at New York College of Osteopathic Medicine, they never had anyone else who had done Pediatric Neurology.

She is very happy she did take the plunge though. Where she ended up doing her training was pediatrics at a larger children's hospital at Long Island Jewish Medical Center. Then she did her child neuro training at Boston Children's Hospital.

She then found out that a lot of people will pick an interest within Neurology and academics and go on and subspecialize with fellowship. She initially considered epilepsy since majority of the practice in pediatric neurology is developmental delay epilepsy and headache. Since she had an engineering background, she felt it was best for her to go into epilepsy. The reading of EEG's relies on physics. She soon discovered her love for patient interaction and taking a history from a patient and solving a puzzle. But she didn't love reading an EEG as much and sitting by herself.

[06:18] Becoming a Pediatric Headache Specialist

Lauren says a lot of people don't know you can subspecialize in headache. As a new emerging specialty, Headache Medicine is part of a UCNS (United Council for Neurologic Subspecialties) fellowship. A lot of people going into the field are adult headache specialists being the paved route. It's much easier from the adult side.

"Headache is a new emerging specialty."

Lauren notices that headaches in kids can be as young as age two but majority of them are in the pre-teen or teenager years. She loves the challenge of convincing the patient to give her that history. She also loves the overlap with some of the social dynamics and healthy living. She loves how to coach them back towards a better life. She also likes the fact that a lot of headache patients tend to get better if you have the right tools in place. She finds this very satisfying.

So when she looked into Headache Medicine, she explored her other options including a pediatric pain fellowship as well as an adult pain fellowship. She likes procedures but realized she didn't like it to the extent that majority of her practice was going to be procedures. So she ultimately settled in doing a headache fellowship. She ended up doing an adult headache fellowship at the Brigham and Women's Hospital, one of the first headache centers established in the country. Their adult headache fellows were very interested that she was doing her child neurology training locally. So they got interested in collaborating with and training a future pediatric headache specialist.

Lauren is actually one of the pioneers of the said field. She knew that when she graduated fellowship, she wanted to have all of the necessary tools. If she left the programs in Boston, then she would want to be at a center where there is no other pediatric headache specialist. She is currently at Wake Forest being one of the few fellowship-trained pediatric headache specialists in a several-state-region.

Moreover, she is heavily involved, not only in patient interaction, but also in education and community efforts. She is streamlining protocols for the emergency room and educational materials for patients. It's very common but there is also a lot of need in headache since not everyone has gone onto this subspecialty level.

[09:07] Traits that Make a Good Pediatric Headache Specialist

Lauren illustrates that anyone interested in going to pediatrics has to be a little bit more patient and creative.

"You have to be able to adapt to new situations."

When you're examining children or taking a history from a child or family, you have to be willing to go out of order. The child might not let you examine at the beginning of the visit until the end of the visit. So you have to be able to charm people. You have to use your communication skills to warm up the child or the parents to what you're trying to ask and what the plan is going to be. In headache, those skills are taken into the extremes. The patients and their families are dealing with a situation where their child is very much in pain. They don't initially know other families are dealing with the same condition. So it can be very isolating and very anxiety-producing. It can be a huge struggle.

Moreover, a lot of these patients can be very disabled by their condition. They can look like other children but they're dealing with special issues. They could miss school and have many other challenges. As a specialist, they have to be able to coach them and be firm at times on helping them get back. Hence, communication is very helpful.

Lauren adds that you want to be a little bit of a problem-solver. You may want to ask a few more questions to make sure it's migraine and not something else. You have to be able to understand the exam and how that fits into the history.

[11:15] Patient Types and Procedures

In general neurology, they see all ages up to eighteen in pediatric neurology. In the outpatient setting, they will usually do evaluation for young children who are delayed in walking or talking. They try to understand if it's something they're going to catch up on. Or is it something related to a genetic condition or a metabolic condition? You need to assess if you need to do another workup. How do you help them get the right services they need so they can catch up on their milestones.

Additionally, they see first time seizure patients or refractory seizure patients. They try to see how they can help diagnose the right epilepsy condition. They have a lot of patients that get better. They can make a diagnosis of a seizure disorder that they know by the time they're teenager, it may go away or in a few years. So they have to make not only a diagnosis but also be able know whether it fits into an epilepsy syndrome. This way you can help the family understand what the true prognosis is.

So epilepsy is a big bulk as well as headache. Since her passion is headache, most of her outpatient practice over time has become headache. Headache patients come in various types. You can see someone with their first headache that may be had some interesting features to it. They can have a visual aura. Children, just like adults, can have very interesting aura symptoms for their migraines. They can see a cracked glass, speckled colors, sparkles, shooting stars and a whole gamut of things. And this can be very scary for the first time it happens.

Part of Lauren's expertise is sorting out how consistent it is with migraine or if there's any workup needed. She also sees patients with repeated headaches or those that never go away everyday. Some of the typical medicines they would use over the counter won't seem to stop it. So it's also part of her practice to sort out which medicines they can use to help the patient. Or if there are certain things in your lifestyle that contribute to this such as overuse of caffeine found in local soda or sweet tea.

"People don't even realize that they have a young child who's exposed to a lot of caffeine."

They also focus on avoiding skipped meals, hydration, exercise, and addressing other concerns like bullying or other things going on at a school setting. Moreover, Lauren is also trained in procedures to help manage pain. They can do  a nerve block. The patient takes a numbing medicine and the specialist injects on the scalp to numb it and give it temporary or long-lasting pain relief. They also do Botox which is a muscle paralyzer which you can use in managing chronic migraine. You inject in 31 places on the scalp and the neck. It affects the nerves locally to prevent them from spreading neuropeptides and inflammatory markers to perpetuate pain. Lauren explains there are a lot of interesting ways to treat headache including coaching and procedure. This keeps her practice very interesting.

[15:10] Choosing Academics versus Private Practice

Lauren initially thought really long and hard about what she wanted her career to look like. She thought private practice was very attractive because you have more control over your schedule. You might see consistent types of patient population You might have more consistent hours. The reason she ultimately chose academics is she wanted a job where it could grow with her as her interests change.

As a young faculty, she knows she loves education but she doesn't really know if that's her path. If she went into private practice, she thinks she would have missed a lot of things - being with the residents and medical students and seeing the collaboration and the discussing of interesting patients. Since she has been at Wake Forest, she started up a Headache Case Conference. They host it once a month where they get together and talk about their most fascinating headache patients. Because of this, they can get back up on patients they need more guidance on as well as be able to hear from other providers. She loves this kind of collaboration and learning all the time.

Lauren is glad she chose academics. She has gotten so passionate about education that she is now the Residency Director for their Pediatric Neurology Program. She now helps design curriculum and make sure block schedules look nice. She looks into ways to improve the education for their residents at all stages.

"I love education. I can't imagine, now in this role, going back into private practice."

Another thing she likes about academics is that it allows you to be part of both the inpatient and outpatient sides of it. She loves being in clinic and it's the majority of what she does in headache managements. But she also loves being occasionally on inpatient service. You see so many different things there that by the time you see them on clinic, they've already been stabilized and they no longer have ongoing concerns. Academic allows you to be varied and depending on where you get hired, you can have all different types of job descriptions.

[18:00] Work/Life Balance

Lauren stresses this is something very important to look at when choosing a field not only for women, but for anyone when choosing their career. You never know what your home life is going to look like when you're making these big decisions.

"Having flexibility or knowing what kind of support you have from your family is helpful."

Lauren knew she was going to likely possibly leave the area where her family lived. She would be in an area without initial extended support and friends. She wanted to be in a place where she didn't have to work nights and weekends all the time. Lauren loves the balance in pediatric neurology. She generally works Mondays through Fridays and works one weekend every six weeks. She's not in-house for those calls and works from 9-11 doing patient rounds and then she goes home. She also answers pages from home on the weekends she's on.

For Lauren, it's manageable because it ends up being an 8-5 job with lunch breaks. Then she can also squeeze the meetings. But in general, her practice is very manageable for having a family.

[19:35] Residency Path and Fellowship Training

Lauren explains that a lot of programs have moved towards combining your match into being able to apply once into both pediatrics and child neurology at the same hospital. At Wake Forest, you come for a two-day interview. You will be interviewed by the pediatrics group and then by the child neurology group. But when they make a decision and you get your match result, it's at one program. Lauren did her training at two separate places. It does have its benefits like being able to know all these different hospital systems. But she reckons it's nice to spend all five years (two in pediatrics and three in child neurology) in one place. It allows you to build connections much easier and you spend less time worrying about computer systems. Then you can focus more time on learning as you transition from pediatrics to child neurology.

What's different in their field is you spend two years purely in pediatrics. Then when you transition over to child neurology, you will spend a bulk of that first year in adult neurology training. You're treated just like another adult neurology resident. Lauren describes this as a hard transition to go from general pediatrics to dealing with adult patients who may have internal medicine problems. Some of those conditions may have overlaps in pediatrics in ways.

Moreover, programs approach problems differently. At their program, their pediatric neurology residents don't do in-house call on the adult neuro side.

"You have to be careful when you choose programs that it's a match for your personality and what you're hoping to go into for your career."

How competitive Pediatric Neurology is depends on where you want to practice. Some of the top five programs tend to be larger programs but they're biggest hits in the major cities. So several of those programs can be very competitive if you had your heart set on one of those programs. But in general, pediatric neurology every year will have a few spots that are unmatched across the country. Relative to some other specialty fields, Pediatric Neurology is less competitive. Compared to adult neurology, it's also less competitive.

The fellowship training is a one-year program. There are programs that offer a two-year program depending on what your research interests are. But usually, it's a one-year clinical fellowship. Then you may add on a second year if you have plans to complete a certain type of research project by the end.

[22:50] DOs, Primary Care, and Other Specialties

As a DO, Lauren was very worried in some of the programs she was interviewed at being it could be something that was mentioned or asked about. At the program she settled at Boston Children's Hospital, she was worried about it being a Harvard-based program. She was afraid being an osteopath would be seen negatively. But it was a positive to them as their prior residents and chief residents have also been DO's.

You would be sometimes be worried that it's going to be a problem in a program. But there are programs that you're unexpectedly amazed that they see that as a strength. She interviewed at a place in New York and she was asked why she didn't go to a real medical school. She thought it was a joke until she realized it was actually happening in real-time.

"Your job is to seek out opportunities and use your skill set and your background to keep seeking out additional opportunities."

Everyone will have things in their CV that they're very proud about or other people are going to question. If someone says something negative, Lauren says you just have to rise above and say you're proud of where you come from. Explain to them why they should be excited about what you've done in the past. Other than that on interview though, she has never experienced any negativity towards being a DO. She finds this as a huge strength in her clinical practice because she practices an OMM (Osteopathic Manipulative Medicine) or OMT (Osteopathic Manipulative Treatment). She tends to use it on the head and neck in some of her headache patients. And they really appreciate the hands-on approach. Lauren admits she's blessed and happy she chose the training she did. It has opened some doors that would have been opened for someone else.

"You have to kill everything with possibility and realize to make decisions which are best for you."

Working with primary care, Lauren says it's helpful that as you're going through training, seek out as many opportunities that might be out of your comfort zone. She recommends gaining as much information as you can during rotations. You never know when that knowledge is going to come back into play and be helpful for that one particular patient. She thinks that if you decide to  only do pediatrics, you may have opportunities where you're able to interact with a neurology patient during training. Lauren recommends taking the opportunity to do neurology month or take things you may not always deal with. You never know when you have that one patient in your practice and you feel very uncomfortable with. Moreover, Lauren says it would be helpful to say why you're worried and what you've already discussed to the patient. Other specialties she works the closest with include general pediatrics, neurosurgery, and neuroradiology.

[28:33] What She Wished She Knew And What She Likes Best and Least

Going into pediatric neurology and headache, what she wished she knew that she knows now is that they have a great work-life balance but their pay is less compared to other pediatric subspecialties or adult colleagues. Nevertheless, she is very happy with her work-life balance and her salary but she just didn't realize this was something in play. She thought that if you treated the same complicated type of cases that you'd be compensated the same. Lauren points out how resources account for this. You're very lucky in academics if you're at a children's hospital that is layered with different administrative support and fund raises.

Lauren's favorite thing is when patients get better. She loves it when a patient comes back and they're doing really well. You can't cure everyone but she says it's very rewarding when you hear that someone's life was upside-down and now they're back on course. On the flip side, what she likes the least is the frustration of trying to help your patients but they can't see a path out. They're not willing to improve their lifestyle like cut caffeine or sleep better.

If she had to do it all over again, Lauren says couldn't imagine what else that other career would be or what else would she be so excited about. She simply loves her job.There are times that anyone and any job can feel that have a frustrating day or interaction with someone. But in the end, she finds what she does as really fascinating and the opportunities are very rewarding. She says you don't get to have that kind of rewarding and intense job as much. But she would choose the same specialty all over again.

"I get to do something really cool everyday and I get to be a part of someone else's life."

[34:30] Lauren's Final Words of Wisdom

No matter field you're looking at, Lauren says it's always about reaching out to areas you're thinking about and finding out what opportunities are available. It could be spending time with someone in clinics or in the operating room. It could be spending time on the inpatient side or in a research project.

"Don't be afraid to reach out to people especially when you're in a training environment."

Especially in academics, Lauren says everyone is excited when they have someone reaching out to them. When you see someone young and enthusiastic and looking at what you're doing, it can be contagious. So it's very important to be involved in that process and don't be afraid to reach out. Introduce yourself or maybe attach your resume so they can also understand your background. Be honest to say you don't know if neurology is for you. Then ask if you could schedule a time to be able to spend time with them in the clinic just to see how you're going to love that experience.

[36:30] Breaking the DO/MD Stigma

It seems that the DO and MD stigma is going away. Lauren is a DO at a large academic medical center for an allopathic residency program. Hopefully, you understand that being a DO is not holding you back. If you're listening to this as a DO student, there are some self-limiting beliefs that you don't actually need.

If you are in the Wake Forest area and that triad of medical hospitals and universities looking at pediatric neurology, go reach out. See if there's an opportunity to shadow her or somebody else in the program in that department.

[37:31] Compare and Contrast

Two weeks ago, we did adult headache medicine and this week we did pediatric headache medicine. Now you're seeing some differences if you're thinking about headache and you're thinking about adults versus kids. Listen to these two episodes. Compare and contrast.

If you have a specialist you would like for me to talk to, shoot me an email at ryan@medicalschoolhq.net.

Links:

UCNS (United Council for Neurologic Subspecialties)

Wake Forest Baptist Medical Center

adult headache fellowship at the Brigham and Women's Hospital Specialty Stories Episode 31: What Does a Headache Specialist’s Job Look Like?

Brigham and Women's Hospital

Jul 26, 2017
32: A Community Plastic Surgeon Gives Us a Look at His Job
53:30

Session 32

Dr. Russell Babbitt is a Plastic Surgeon in private practice for the last seven years. He took the time to share with us his thoughts on what he likes and what he doesn't like about it and what you, as a premed or medical student, should start doing now to become a better applicant for Plastic Surgery.

[01:18] His Love of Plastics

Around that time when the show ER was popular, Russell started medical school thinking he wanted to do Emergency Medicine but realized it wasn't for him. Instead, he liked doing surgical rotation along with his plastic surgery rotation which he describes as gelling very well. He also started college as an art major so the visual-spatial aspects really appealed to him once he got into plastics because it wasn't just a cookbook, do-this-do-that case but it involves applying spatial problems to different situations which appealed to him. The second he got onto his plastic rotation, he knew it was where he needed to be.

Russell went to UMass for medical school and during their third year surgery rotations, they had a three-month block spent on general surgery and the other half was subdivided into other subspecialties. Many of them ended up rotating through plastics. Other specialties he did consider include general surgery and vascular surgery. He likes the disease processes in general and being able to intervene into a lot of different illnesses and have the ability to take care of sick people across the board. Ultimately, he was meaning to be a well-rounded surgeon and the fact that plastics builds on that was nice.

[04:30] Traits Leading to Becoming a Good Plastic Surgeon

Russell cites meticulousness as the primary trait of becoming a good plastic surgeon as well as being a good visual-spatial thinker. Being a good communicator is also very important since. You need to be willing to sit down with the patient and explain the disease process, the problems, the solutions, how you're going to get there, oftentimes, there are many ways to get there and there's many different things that can happen.

Russell further explains that the doctors who don't communicate tend to have more difficulties regardless of what the outcomes are and this is especially true in plastics. Beyond that, you also have to be a good technician and be able to develop a plan, know what you're going to do, and see the technical problem you're going to solve and actually execute it.

Also, you must be able to see the long term outcome, not just the proper three-dimensional result but it has to look good three to four months and years down the road. Blood supply also has to be intact at the end of the day. One of his mentors once told him that when he's out in private practice, one of the things he has to do is while doing a skin graft, you have to make sure every mitochondria survives.

"You have to just be really meticulous in every single thing that you do and that people are watching and the patients are watching. That's one of the things people look for in a plastic surgeon."

Russell adds that another innate trait in a plastic surgeon is being anal. In terms of having an arts background, although not necessary when you become a plastic surgeon, a lot of people that go into medicine in general tend to be very agile-thinkers so Russell thinks a lot of it can be taught. But he personally thinks it helps a lot in terms of little shortcuts that allows him to know what to do before he even thinks about it. This may also help in certain other areas where it would have been hard to to teach it.

[09:00] Types of Patients and Typical Day

Russell sees a mix of 50% cosmetic and 50% reconstructive patients. To his surprise, he's doing a lot of breast reconstruction. They have a very busy breast reconstructive program where he's the director at a local hospital. This was something he didn't expect to be doing a lot but he ended up doing it anyway.

The reason for breast reconstruction is almost always breast cancer in various stages or it may be due to genetic predisposition where the patient has a high risk of developing breast cancer in the future or maybe that the patient has an active diagnosis of breast cancer or very late stage precancerous lesions which would require mastectomy and therefore they would then need Russell to reconstruct the breast. He describes it as a very intense process and oftentimes, he is the one the patient sees the most of throughout the process. They see them after surgery and on a weekly basis to fill tissue expander that expands the breast's skin envelop after radiation and mastectomy. Nevertheless, Russell sees this as a nice aspect of what they do.

Another thing they commonly do is reconstruction after skin cancer resections with dermatologists which can sometimes be very large defects. On the cosmetic side of things, they do a bit of facial cosmetics like face lifts, rhinoplasty, ear correction, fillers, Botox, facial rejuvenation, liposuction, tummy tucks, and a lot of breast surgeries.

"15% of what he does involves taking care of complex cosmetic breast patients which is a fairly challenging field."

Russell finds himself in the operating room at least two full days a week and even up to three full days a week. He works between 40 and 60 hours a week. During his office-only days, he gets in around 9 am and finishes around 6-7pm. His OR days start at 730am and finishes between 4 and 5pm. He does his larger cases first thing in the morning and then the local type cases like mole removals or lesion removals or skin cancer reconstruction in the afternoons.

Russell has an amazing physician assistant who has been with him for about two years now that sees a lot of his postoperative patients in the office. They are very much on the same page and because of the high demands, they've gotten so busier across the board. Nevertheless, they try to balance things out to avoid burnout and try to make it sustainable.

[15:00] Private Practice Goals for Work-Life Balance

Russell would like to have his weekends off so he covers himself 24/7, 365 days except when he's on vacation. Other than that, he's available for patient issues that only he can answer unless his PA is available to answer it. He doesn't do office hours on a weekend and reserves it for family time and he tries to be home every night to help with the kids to bed and stuff. Pretty much, he's going all out throughout the week and works as hard as he can to get as many patients. Most importantly, he makes sure they're taking enough time with each patient.

One reason he shies away from being employed is he doesn't want to be in a position where he's being told how many people he has to see a day. He's okay with this perspective.

"I don't want there to be other metrics that I need to have to use. Other than that, the patients are happy. We're taking good care of them and that my bills are paid."

Basically, this is how he likes to do it right now compared to his colleagues where it's not how they're living so he feel extremely fortunate for it.

[17:30] Patients that Go to the Operating Room

Russell estimates their conversion rate in the high 80%. These people come to his office because they want to see him and they're not doctor-shopping as much. They've waited a decent amount of time to see them so they're there to see him and are typically there to have surgery. Also, nobody goes to the operating room without seeing him in the office first with the exception of local anesthesia procedure where they get to meet him that day, he talks to them, and they'd have to wait for the procedure. But if somebody gets general anesthesia, they may see his PA first and then get a second appointment with him to have another formal sit-down discussion if they're going to go forward. He doesn't do internet-based consultations since it's not how he wants to do things in terms of how he wants to care for patients.

Russell says there are patients coming in who are insecure about something and they come to see you for one thing.

"Just because one thing that bothers. it doesn't mean there are other things that may be addressable as well. It is a strict policy in our office to not mention those other things or to try to market other things."

In other offices, patients would come in for tummy tuck and then the surgeon there would ask you to consider getting a neck lift or breast done, or whatever. They basically walk in to talk about getting fillers in their lips and they walk out with $30,000 worth of clothes and a whole new complex because they didn't realize all those other things need to be addressed.

"As a plastic surgeon or cosmetic surgeon, you have a lot of power to make somebody feel better about themselves or feel worse about themselves."

Doing it ethically and conscientiously, Russell sends a lot of people in the office telling them they don't need surgery and don't listen to anybody that tells you that you do. He emphasizes that this is the right thing to do because at the end of the day, they're still physicians that took an oath to do the right thing for people and he feels it's job to make sure that if people need to do surgery, it has to be done safely and in the right circumstances. He needs to do it well and do it safely. He needs to do it under the right circumstances for the right patients.

Russell admits he is bothered by a lot of plastic surgeons out there that are making a lot of decisions for financial reasons impacting other people's lives negatively and they're doing a surgery for that reason which makes them all look bad collectively, reason plastic surgeons and cosmetic surgeons have a bad name sometimes.

[22:05] Taking Calls

Russell is in a position where he doesn't cover much call at the surrounding hospitals. In metropolitan areas, most hospitals require call as a stipulation of privileges for credentials. He doesn't have to do that, which means being allowed to use their operating rooms. The majority of what he does would be at a freestanding ambulatory surgery center which is a facility not attached to or affiliated with a hospital but he still has to do everything that is like a major operation they do at a hospital. He also has a lower threshold for doing certain things in the hospital than some doctors do because it's cheaper to do things in an ambulatory center than it is to do at a hospital. He actually anticipated to take calls when he took the position he took but when he got there, he was told it wasn't necessarily expected. But he does stay on as a courtesy like if he's available for something thing where if he can go, he will. So he's like "always on, but always not on." This seems to work well and they like the fact he's available if he's available. Nevertheless, Russell describes having a symbiotic relationships with the ER, where he is available in the middle of the night if they need to call him and if they need to send a patient to his office later on for a suture removal.

[24:35] Residency and Fellowship Training

There are two typical approaches. One is to finish medical school and go into general surgery, neurosurgery, orthopedics, or ENT and then match after that into a plastic surgery fellowship. The other approach is matching into a categorical plastic surgery program, which is a dedicated program for plastic surgery. Neurology is the other pathway they can do it from.

In Russell's case, he did his general surgery program at UMass and transitioned into the plastic surgery program so it was more of a traditional approach and a bit hybrid because he was able to transition out after his third year general surgery being the only type of residency you can do it from.

With the traditional fellowship pathway, you don't have to finish general surgery but you have to finish all the other types of residencies before you go into a plastics fellowship. Russell was already at UMass for his general surgery training, did two years in the plastic surgery laboratory, and worked on various projects with them so he was a known commodity. Additionally, Russell says you have to be very competitive with the rest of the applying population. All in all, it was a seven-year pathway. Categorical might be six and then general surgery can end up being nine consisting of five years general surgery, two years of research, and two or three years of plastics although he thinks all plastic fellowships are now three years mandatory. Many will also do an additional year of hand fellowship because it's so competitive. The year he applied, there were only 92 plastic surgery fellowship spots in the country excluding the categorical spots but just post general surgery positions.

Plastic surgery is among the subspecialties in surgery that are the most competitive. Dermatology might be the only one most competitive in terms of everything else but in terms of the categorical spots, plastic surgery, Russell believes, may be the most competitive now.

[28:30] How to Be a Competitive Applicant

Russell illustrates that to be competitive, you have to set yourself apart by showing interest in plastics early on. The good sub-I's  pretty much have an inside track to the spot because it's a month-long interview. Some international students even spend extra time doing research and this makes a huge difference. You're much more like to want to match somebody that you know and you know is good.

Additionally, you want to show them that your hands are good and that you're conscientious and good with patients and the staff. Know that the staff can have a remarkable amount of power.

"The chairman's secretary is going to have more say in the ultimate decisions of who gets into the program than potentially sometimes the junior faculty."

You need to be nice to those people when you call or you're trying to coordinate something with the program since they have the ear of the program directors and the higher up's. Russell adds that we tend to focus a lot on research, volunteer work and stuff, but all that is part of the baseline. You have to be good at all those other intangible things on top of those.  These are the awesome people that can make your like a lot easier.

Additionally, Russell recommends doing international volunteer work if you have the resources because it's very helpful as well as research in plastic surgery being at the forefront of tissue engineering so there are always labs looking for residents and medical students to do stuff.  There's a lot of data mining right now which can be a little dry but you can eventually find your way into something more interesting and surgical. And remember, this boring data stuff that nobody else wants to do it, could be your foot in the door.

[32:40] DO's, Subspecialties, and Working with Primary Care and Other Specialists

Russell thought general surgery was the way he would go, finishing it for five years and then decide later on if he wanted to do plastics then continue on. The  more he was doing rotations for general surgery and plastic surgery as part of it, the more he knew it was where he wanted to go. Then it went solidified by the time he went to the plastics lab and he finished his second year of residency.

Whether there were negative biases towards DO in the field, Russell would describe it as rapidly diminishing if there was any. One of the strongest sub-I's they had in the program who ultimately did not match into their program, ended up as a major ambassador to this side of things.  Nevertheless, he sees it's diminishing.

“Whatever factors may have led that person to that pathway had nothing to do with that person's academic strengths.”

So he thinks it never should be a factor in the first place. What he also notices among DO's is they had to work twice to prove these MD's wrong and to dispel whatever biases they have towards DO's and it's unfortunate they have to do this but this tends to be the case.

Moreover, Russell says there's a million of opportunities to subspecialize once you're a plastic surgeon including pediatric craniofacial,  general burns specialist, microsurgery. If somebody becomes affiliated with a children's hospital, they tend to stay very isolated in their pediatric craniofacial. But most people who do microsurgery fellowship for a year will still have to do a lot of general plastics in addition to microsurgery.  There's also hand surgery that overlaps a lot with orthopedic surgeons.  After most plastic surgery residencies and fellowships, you are pretty much qualified to do hand surgery but Russell happens to do none. But you specialize all the way up to the shoulders as a plastic surgeon. And of course, there's cosmetic surgery where a lot of people prefer to do strictly cosmetic, which they actually call aesthetic plastic surgery.

In terms of working with primary care providers sending patients to him, what Russell wishes them to know is about general health maintenance stuff. Before most plastic surgical operations, smoking cessation (and all nicotine products) is huge more so than probably any other type of surgery because we rely so heavily on blood supply.

Nevertheless, Russell says they tend to be treated well by most primary care providers and other specialties. In fact, he feels like they're "rheumatologists" of surgery that if they don't know where to send the patients they'd be sent to plastic surgeons.

"I would probably approach it another way. I would go into a room of primary care doctors and say, how can I better serve you guys?"

Plastic surgeons work the closest with general surgeons, surgical oncologists, and dermatologists.  In terms of opportunities outside clinical medicine, a plastic surgeon can do collaboration and consulting on research and product development. On the corporate side of things, you may collaborate with those products you really believe in a lot.

[43:25] What He Wished He Knew and The Things He Likes Most and Least

What he wished he knew before getting into plastic surgery, he wished he would have started saving earlier. He also gives a piece of advice to students thinking about going into medicine since people can be so quick to tell you to run away and to not get into this but it's a good life.

What Russell likes the most being a plastic surgeon is being able to help patients in mostly happy stuff and not a lot of giving depressing and bad news.

"What I like the most is I'm getting to use a unique set of skills to help make people whole again and it's extremely rewarding."

Russell feels extremely very lucky to be able to do what he gets to do. Although there are patients that when you think about them can give you a lump in the throat but he has more of a handful of patients that make it all worthwhile. On the flip side, what he likes the least is the idea of people exploiting patients and securities for personal gain and with zero concern for the patient's well-being.

At this point, there are a lot of 'cosmetic surgeons' that are not even in the core surgical specialties or plastic surgeons that are calling themselves board-certified cosmetic surgeons.

"They're doing these massive operations in their offices and taking advantage of patients who don't know that there is no such thing as a "board-certified" cosmetic surgeon."

There's no training program for that. That's not recognized by the American Board of Medical Specialties. They're taking advantage of patients. Number one, it's giving any physician who does aesthetic operations a bad name. Number two, it's exploiting people's insecurities and subjecting them to extreme danger. Russell exclaims that this is really very frustrating. He explains that when you see something in the news about a patient dying on the table, it is almost never a board-certified plastic surgeon. It's someone who's typically not qualified and who doesn't know what they're doing, and just trying to hand money, hand over fists, taking advantage of patients.

Russell says this is very upsetting because it's going on in a deep level and they're usually a very good salesman and not shy about posting things on social media and would make claims as board-certified plastic surgeons when they shouldn't be because the Code of Ethics prevents them from making certain claims. But people with less ethics are taking advantage of patients.

[48:55] The Future of Plastic Surgery

At this point, they are using patient's own fat to reconstruct their breasts as well as other areas of the body. There also things like tissue engineering and cellular engineering that ebb and flow. So much of what they do is based on their skill set so a lot of the technology only tends to be complementary and not just a huge quantum leap kind of things. Many of the surgical advances come from the developing countries. All you really sometimes need is a good microscope and some good hands to do some pretty incredible surgical procedures and lose institutional ethic rules. Nevertheless, he sees the field more of a cognitive innovation versus technical.

[50:20] Final Words of Wisdom

If he had to do it all over again, he would definitely have chosen plastic surgery. He wouldn't think of doing it any other way. As his final pieces of advice, he recommends students to ask people who seem to like what they're doing, why they're doing what they're doing, seek out opportunities whenever you can, and do what you can to set yourself apart from your peers because that's the only way to get ahead but not in a cutthroat sense. But be a good person.

Lastly, Russell gives the same advice he got from his mentor which is to go where you're needed. Get experience, get good. And then the word spreads and that's how you get busy. Do not give up and do not listen to the discouragement. The people discouraging may have met roadblocks you won't even be subjected to. The things that stop them are not necessarily that things that can stop you. They may try to beat you down repeatedly. Just ignore it and believe in yourself.

Links:

MedEd Media Network

Jul 19, 2017
31: What Does a Headache Specialist's Job Look Like?
29:29

Session 31

Dr. Kristen Sahler is a community-based Neurologist who specializes in headache medicine. She has been practicing for four years outside of her fellowship and she shares with us what drew her to it and her advice if you're interested in it.

[01:28] Her Path to Headache Medicine

Kristen knew she was going to be a neurologist when she was fourteen years old having been motivated by having a family member with Tourette's syndrome so very early on, she was learning about it and about the brain and got fascinated by all of it. She then hyper-focused on that pathway and never gave up on it.

As for getting into headache medicine, it wasn't on her radar until her third or fourth year of medical school on her neurology rotation where she was sent to see a headache consult. She became fascinated by the patient's story and thought her interesting visual aura was cool and learned about migraine. By the end of medical school, Kristen has already carved out that headache was the field for her which was confirmed as she went through residency every step of the way.

What she likes about the field is how interesting it is having all these strange phenomenon and visual disturbances. But essentially, she has always been interested in the central nervous system and in neurotransmitter systems which hearkens back to his brother with Tourette's syndrome. With migraine, it's predominantly common with the serotonergic system which she's interested in.

"I like that there were so many treatment options and that we could really turn the course of someone's life around."

Additionally, she was interested in Parkinson's disease being a neurotransmitter-based disease but she didn't feel as much excitement seeing the inevitable decline of patients experiencing it since you can't change the course of their disease. Whereas a lot of the other primary headache disorders have disorders that can change people's lives taking them from being completely disabled an in pain everyday to nearly pain-free.

[04:37] Traits that Lead to Being a Good Headache Specialist

Kristen cites patience as the one skill she uses the most day-to-day considering how headache patients don't give the greatest history. You don't always know how to describe they're feeling so you need to guide them through it to get the information out of them that you need.

Another trait is liking the detective work because there are so many things that can cause a headache and not each one is a migraine or whatnot so you need to be able to fuss out what the underlying causes are.

Lastly, you need to okay with psychiatry because there's a lot of overlap between headache disorders and psychiatric disorders. In particular, migraine is comorbid with anxiety, depression, and bipolar so she sees a lot of people with psychiatric co-morbidities which she's not managing but she needs to be able to be patient with them ad help them cope through these things.

"If you're somebody who does not like to deal with psychiatry, it's probably not a good field for you."

Alternatively, if you're really interested in psychiatry, you could choose to manage both issues. In neurology, they study a good amount of psychiatry so you could choose to be a headache specialist and also manage their anxiety or depression and just choose to do both. Kristen though doesn't like to manage the psychiatric issues because she feels she's not up-to-date on the management side of it but she's comfortable seeing patients with those diseases.

Kristen says she never thought of any other specialty pulling her from her path to neurology. Although she was interested in some fields but she never once thought they were the right field for her. She thought psychiatry was interesting but when she looked to the day-to day of what a psychiatrist does, she knew it wasn't for her. She thought internal medicine is the best field because for her the most impressive people went into internal medicine. She practically thought of them as rock stars but she knew still that it wasn't the field for her. She wanted to be that person who was going to dig her hole really dip and narrow and just do headache but do it really, really well.

[08:03] A Typical Day in the Life of a Headache Specialist

Kristen is doing outpatient for majority of the day. She takes some calls at a local community hospital but not very often. She's usually in the office for seven hours seeing office patients, new consults, or follow-up visits for patients she's already seen. She predominantly does headache so she is a 75% headache specialist and the other 25% is being a general neurologist dealing with a variety of issues including dementia, epilepsy, Parkinson's multiple sclerosis. The reason being is that she's in a multi-specialty group so her referral days is a group of primary doctors, OB/GYN's, pediatricians who want to have somebody with general neurology skills. She also likes to have a little bit of general neurology since some days, she feels like she's seen so many really complicated headache patients back-to-back which can be emotionally and cognitively exhausting so having someone coming in with, say, a carpal tunnel syndrome is nice break for her.

If you're in a headache specialty center as a headache specialist and you're only doing headache and you're not going to be doing any general neurology at all. But her typical day is just seeing patients in the office, managing callbacks, medications, and emails that may come in. Patients may call in complaining about a bad migraine so she spends about an hour everyday speaking with them on the phone and helping them through it.

[09:55] Types of Procedures

She does procedures for patients too. This is another trait she wants to point out if you want to be a good headache specialist is that you should like procedures. Kristen does simple procedures such as nerve blocks, trigger point injections (focused on muscles, neck, head, and shoulders) as well as another type of nerve block called the sphenopalatine ganglion block which is a catheter that goes up through the nose to block the nerve cluster behind the sinuses and she also does Botox for chronic migraines They're all relatively simple procedures which you can do in the office. They are quick and easy and they relieve pain very effectively and they're pretty lucrative, relatively speaking for the amount of time it takes to do them.

"It's a nice supplement to the day-to day of being a headache doctor since you're not just sitting and talking all the time because sometimes you're doing things with your hands."

Not to mention, these are very low-risk procedures and the complication rates are pretty much next to nothing. They're very low-stressed procedures but they can help the patients a lot. Another procedure she does are lumbar punctures but if you don't want to do them, you're going to need to refer them out to get them done somewhere else.

[11:38] Taking Calls and Work/Life Balance

Kristen works at a stroke center and they don't have any other support. They have a neuro hospitalist who's in the hospital from 9-5 Mon-Fri so she's never torn away to the hospital and she can just focus on her office these times. But every once every two weeks, she will have a shift from 5pm - 9am where she's on call for any hospital issues. Generally, they get an acute stroke code around every other day so it all comes down to luck. For example, she got a stroke code at midnight and had to get out of bed, go to the hospital to see the patient, give them TPA, admit to ICU, and go back to bed.

That is unfortunately the reality of taking call at a stroke hospital but most headache doctors don't do the stroke call coverage. Again, this is because Kristen still does a bit of neurology so she's involved in a general neurology coverage group that she's doing these calls.

"Most headache specialty centers don't have the kind of call that would require you to go in after hours."

Kristen says she has a fantastic work/life balance which is partly her own choosing because she had chosen to only schedule patients 32 hours a week. She split her days up, some days longer while others shorter but she only schedules patients for 32 hours a week, doing an extra hour a day doing phone calls and messages which adds up to about 36 hours a week of clinical work which she thinks is a perfect number for her considering she has two young kids so she still has to take care of family and she wants to have the time to do this with them and not rush the time. With headache, you have that freedom over your schedule. If you're at a surgical center, you can just set your office hours and decide what works for you.

[14:25] Residency Training and Competitiveness

The road to residency training includes doing an intern preliminary year although Kristen thinks you can't do a transitional year for neurology. it has to be a preliminary year then do a neurology residency for three years and then one year in headache fellowship.

"There's more and more headache fellowship positions every year. It's really an expanding field."

Kristen did her fellowship at St. Luke's Roosevelt in New York City. After finishing your headache fellowship, you have to take the board certification for headache medicine. If you didn't take the boards, you could still call yourself a headache specialist, just without that additional board certification. Also, you have to do the neurology board certification after your neurology residency.

Kristen thinks Headache Fellowship was competitive when she applied for it only because there were fewer headache fellowship spots. But now, the number of spots available in the last four or five years has nearly double so it has become less competitive now than before. Because it's becoming a popular field and people are knowing more about it, more schools are now starting their headache fellowships. She adds that if you want to be a headache specialist, you will be able to get into that position and find that role.

Additionally, Kristen says a lot of neurologists get really turned off by headaches since they feel like patients are demanding and crazy although she feels otherwise seeing that her patients are in a lot of pain, are suffering, and they have some anxiety and depression who are the patients that need the most help. So she never got turned off by it. Alternatively, the majority of neurologists pursue neuromuscular. Kristen says that more often than not, you're going to end up being the only person in your class of neurology residency that wants to do headache.

"The diagnosis for primary headaches disorders are made by clinical criteria, no blood tests, no nerve tests, no MRI, nothing. So you need to be confident in your ability to look at a pattern and identify that as being a certain diagnosis."

[17:50] How to be Competitive for Headache Fellowship

Kristen recommends getting involved in either headache research or in the Move Against Migraine Campaign by the American Migraine Foundation which is a political campaign and also a social awareness campaign.

"13% of the country has migraine. !8% are women and 6% are men."

The campaign seeks to educate people on how common it is and how debilitating it is and help getting more research money to go to migraines so they can get more treatments for people. Kristen is involved in helping spread the word for such campaign. And if you just start offering your help, this would be very impressive to anybody in the headache world.

[19:13] DO's, Subspecialty, Primary Care, and Other Specialties

Kristen doesn't see any negative bias towards DO and nobody couldn't even tell who was a DO in their residency because nobody cared. Moreover, Kristen explains there are no further subspecialty within headache. But she has colleagues that focus more on one type of headache which is easier to do for migraine. There are some headache specialists known as the "migraine guru" as well as those known for being the go-to specialist if you need in-patient management. So you can essentially carve out a niche for yourself.

In terms of working with primary care providers, she would want them or anyone referring any patients to her to not give them any opioids or any Butalbital medications. A lot of patients come to headache specialists who have been managed by primary care for a period of time and they're given Butalbital-caffeine combination medicine, for example, just to help them get to the neurologist and help their pain until they see a neurologist. Unfortunately, those types of medications worsen migraines and a lot of headaches. Not to mention, that they can develop dependency on them.

Kristen recommends that if you're worried the patient has to wait a certain amount of time and you worry about their pain, don't give them a pain pill. She prefers for them to call her and talk to her to ask to get them in sooner rather than have to see them in three to four weeks and have to not only manage their headaches but help them detoxify from such medications since headache specialists don't use those kinds of medicines in headache. Nevertheless, Kristen welcomes any type of headache issue primary care providers would send in her way. Aside from primary care, other specialties she works the closest with include internal medicine, OB/GYN, pediatricians, psychologists, and psychiatrists for co-morbidities.

[23:25] What She Wished She Knew About Headache Medicine

Kristen would have wanted to learn early on how to cope with failure. As a headache specialist, she is often the third neurologist they've seen or the third headache specialist they've seen and they've already tried everything in her toolbox but you can't cure all people. This was hard for her when she first started.

"When you're a young physician of any kind, you put your heart and soul into every day and you really invest yourself in it and if someone doesn't get better and you feel like you failed, that's tough."

It took Kristen a little bit of time to process that and learn how to not take it as a personal failure but to learn how to conceptualize it and move past it although this might be one of the skills that you just have to learn as you go.

[24:35] Most and Least Liked Things About Headache Medicine

Kristen likes the ability to help to people and seeing that huge impact they can have in someone's life, helping them get back to work, get them functioning, and be a better mother or spouse, and basically get them back to their lives and feel good about their themselves.

What she likes the least is the failure part since you're going to see the toughest cases so you're not going to always have those wins. She really dislikes the stroke call she takes but again, for most headache specialists, it's not going to be part of the deal. She also would have hated the different psychiatric co-morbidities if she was asked four years ago, but she has now adapted to it and understands it so much better now alongside her skill sets that have already expanded.

[26:15] The Future of Headache Medicine

Kristen mentions a new and exciting class of drugs coming into the market soon called the CGRP antagonists which are monoclonal antibodies targeting the one of the main neuropeptides that transmits migraine pain signals which is probably going to hit the market in 2018 to early 2019. This is the first preventative medication for migraine specifically targeted just for migraine which she sees as a very exciting new treatment and revolutionary in terms of migraine management. She thinks this is going to spur a lot of new research since they will definitely expand off of this and look at other pain neuropeptides and develop other monoclonal antibodies to them.

"The field is going to grow bigger and we will have more tools in our toolbox to be able to treat migraines."

[27:15] Last Words of Wisdom

If she had to do it all over again, she would have chosen the same being a very big fan of headache medicine. She thinks it's one of the most interesting parts of neurology and one of the most rewarding parts. On the flip side, it could also be one of the most difficult parts but she likes the combination.

Finally, Kristen's advice to those interested in this field is to make sure you're interested in the information. Make sure you like reading about the central nervous system or neurotransmitters and that you don't hate psychiatry and that you can find the passion in the information since you're going to need to really delve nitty-gritty into these systems and if you hate all that stuff then that's telling you something. So make sure you like what you're reading or the process of learning about the brain and just go from there.

Links:

MedEd Media Network

Move Against Migraine Campaign by the American Migraine Foundation

Jul 12, 2017
30: A Deep Dive Into Ophthalmology Residency Match Data
19:30

Session 30

This week, we're doing a deep dive into the 2017 Ophthalmology Match Summary Report which is actually outside the NRMP match.

The match is the program you apply to while in your medical school to determine where you're going to do your residency. The people that made the algorithm actually won a Nobel Prize for it and it's used in a lot of different things now other than the match. However, not every specialty participates in the main ERAS match which stands for Electronic Residency Application Service put on by the NRMP (National Resident Matching Program). Most specialties are part of the main match so when you hear "The Match," this is what most people are talking about.

Today, we're covering Ophthalmology, the rare exception that does not participate in the normal match but it's done by the SFMatch system. While normal medical student match for their specialties in march, students applying for Ophthalmology match in January.

[03:30] Spots Offered, Filled, and Left

Looking at Page 2 of the Ophthalmology Match Summary Report 2017, they have data going all the way back to 2008 so it's nice to see a ten-year data for matching. In 2008, there were 454 spots offered and 468 in 2017. It hasn't been growing a ton and what's interesting is the number of spots left open after the match which is 1 in 2008 and 6 in 2017. Ophthalmology is typically one of those residency matches that are very competitive and the fact here are 6 left.

"Keep that in mind when you are applying for other residency programs that the match data the NRMP gives out shows that those that don't match are typically not ranking enough programs."

As for Ophthalmology, there are 6 spots left probably because students weren't applying broadly enough. Everybody wants to be in New York or California and nobody things about the "flyover" states in the middle of the country. If you are flexible, this is a big opportunity for you to look at those other options as well.

[05:35] Means for Matched and Unmatched

The matched mean for 2017 was 243, which is a very high number, and the unmatched mean is 227.

Once you're in medical school, you know that the MCAT and GPA are important but usually, a strong application can help overcome some deficiencies in some areas.

But this is one of the unfortunate things with the match is that when it comes to matching.

"Your Step 1 score or COMLEX Level 1 score for DO's is basically it. It's a huge part of your application and it's what opens the doors for you for these competitive residencies."

[06:50] Allopathic and Osteopathic Students

Still found on Page 2 of the data, the U.S. Allopathic Seniors made up 80% of those that matched in Ophthalmology. U.S. Allopathic Graduates were 7%. So 87% of all the physicians that matched were from U.S. MD schools. 4% were from osteopathic schools.

"For you DO's out there, it's a slimmer chance but there is the opportunity."

You can't just base on this data to say that you're not going to a DO school because that's not always the case. This doesn't mean you shouldn't go to an osteopathic school. It just means it's going to be harder for you to go into ophthalmology if you go to a DO school. There could be a number of reasons why it's harder. Probably it's because you don't have exposure to academic medical center where most of these ophthalmology residencies may be. So you're not getting the exposure MD students are going to get. Or it could be because you need to travel around a bit for your clinical rotations so it's harder to build relationships with program directors and get that experience and research. So if you're in a DO school, don't give up on being an ophthalmologist. Just think through what else you may need to do.

[09:10] U.S. Allopathic and Osteopathic Seniors and Graduates

Looking at Page 3 of the data, 26% of U.S. Osteopathic Seniors matched. It's interesting to note that while 34 registered for the match, only 19 participated in the match and 5 of those matched. Comparing that to 89% of U.S Allopathic Seniors that matched, it's a big difference.

For U.S Osteopathic Graduates who are DO students that took some time off probably to do some research or maybe they didn't match in the prior year, nobody matched while for US Allopathic Graduates, 19 matched which makes up 44%. These are those who graduated from an MD school and went off to do the research to strengthen their application.

36% of International Graduates matched which is a higher number than osteopathic students. Again, this does not mean that you should go to a Caribbean school because your chances are higher just because you based it on these numbers. Interestingly in 2016, U.S. Osteopathic Seniors made up 41% match rate versus 23% for International Applicants.

[11:25] Choosing Your School

This is the key reason why I don't recommend, if you're premed, looking at match data to choose where you go to medical school because it varies from year to year, student to student, class to class. It has nothing to do with the school. It could be affiliated with the top ophthalmology residency and you get great exposure and it's going to increase your chances of getting into an ophthalmology residency but it's you that goes out to form that relationship with the residency program and form that network with the other residents, program directors, and the attending physicians.It's you that goes out to get those letters of recommendation. It has nothing to do with the school. It's you that does well on your boards and goes out and networks and builds those relationships to match in a competitive program.

"Don't look at the school match list to determine where you should go to school."

[12:40] Average Number of Applications

Page 4 shows the Average Number of Applications per Matched Individual which is 70 in 2016 and 72 in 2017. Applying to medical schools, most people are freaking out over 20. This is 70. It's not as bad as medical school where you're writing secondaries for every school.

"If all these 70 schools want interviews with you, that's a lot of travel, a lot of money."

Compared to USMLE NRMP data where the matched versus unmatched usually has a big divide, for Ophthalmology match in 2016, those that went unmatched applied to 73 programs, which is just 3 programs more than those that matched. In 2017, there were 72 average number of applications per matched individual versus 67 for those that did not match.

[14:20] USMLE Step 1 Scores

The USMLE Step 1 Scores Information is shown on page 7 of the data. From an average USMLE Step 1 score of 232 for those that matched in 2008, it went up by 11 points to 243 in January 2017. For those unmatched, the average USMLE Step 1 score was 212 in 2008 and 227 in 2017, which went up by 15 points. When you see numbers like this, it means it's getting more and more competitive. It was even higher in 2016 with 244 that matched and 229 for unmatched.

“If you're thinking about Ophthalmology, research is important as well as getting those connections, getting those relationships, and Step 1 scores are obviously huge.”

[16:00] Medscape Lifestyle and Physician Compensation Reports

Based on the 2017 Medscape Physician Compensation Report, Ophthalmology is a little bit higher at $345K for average annual physician compensation. Orthopedics is at the top at $489K. Around Ophthalmology is General Surgery at 352K and Emergency Medicine at $339K.

Ophthalmology had a 12% increase in their compensation from last year. For the percentage of physicians that feel fairly compensated, Ophthalmology is at 53%.

Whether they would choose medicine again, Ophthalmology is on the higher end at 79% and whether they would choose the same specialty again, Ophthalmology is there near the top at 93% so they seem to like their job.

Moving on to the Medscape Lifestyle Report 2017, Ophthalmology is near the bottom of burnout at 43% while Psychiatry is the lowest at 42%. As how severe is burnout, it's still near the bottom at 4 on a scale of 1-7. As to which physicians are the happiest, ophthalmologists are the second happiest at 74% outside of work and 42% at work.

[18:20] Final Thoughts

Ophthalmology residency is outside of the normal match (ERES/NRMP) which is through SFMatch. They match earlier in January instead of March for the NRMP. Check out the SFMatch.org for more information including some links and FAQs. They have lots of good information to help you get ahead so come match time, you're not surprised with information at the last minute.

Links:

SFMatch.org

2017 Ophthalmology Match Summary Report

2017 Medscape Lifestyle Report

2017 Medscape Physician Compensation Report

NRMP

Jul 05, 2017
29: What is OB/GYN? A Community Doc Shares Her Thoughts
46:42

Session 29

Dr. Renée Darko is a community-based OB/GYN. In our podcast, she talked about her path to OB, what you should be thinking about during med school, and some tips as you're going through the process of deciding whether OB/GYN is right for you. If you haven't yet, please listen to Episode 127, I dove into the residency match data for OB/GYN.

[01:30] Community Setting Practice

Renée practices in a community setting. Although at one point, she considered an academic setting while she was in residency but shortly before she graduated from residency, she started realizing that she needed to explore a little bit more of the setting she wanted to be in so she began doing Locum Tenens in terms of practice rather than joining a group or an academic center. During the time she was doing Locum right after she graduated from residency, she also did a Health Policy Fellowship to give her a little bit of time to think of what she wanted to be and what she wanted to do. Renée graduated from her residency in 2010 so she has been practicing for seven years now.

[02:44] An Interest in Pediatrics to OB/GYN

Renée did not want to be an OB/GYN when she first entered medical school. In fact, she says it was the last thing she ever wanted to do. She actually wanted to be a pediatrician. The she did her pediatric rotation in her third year of medical school and she hated it, not because of the kids or the parents, but she just didn't enjoy the medicine of pediatrics and realized it wasn't for her.

During the last rotation of her third year was OB/GYN and knowing it was the last rotation and knowing she wasn't going to like it, she thought she didn't know what to do. But upon her first week of OB, she absolutely loved it. She loves the versatility of it as well as going to the OR, doing the deliveries, and doing the procedures in the office. She then realized considering an OB/GYN more seriously.

Renée's experience in pediatrics was somewhat a repetitive cycle which she didn't like. She didn't enjoy it because she didn't think she was very good at it mainly because it didn't interest her. Whereas she found OB to be a lot more versatile even as a generalist. They were doing things that could be potentially considered as subspecialties like surgery. She basically likes the fact that she can work with her hands and do a bit more to keep herself busy.

Before she started her path to OB/GYN, Renée had not considered a procedure-based practice. She never really thought about the procedures being a major part of what she would be doing as a physician. She thought that if she liked a particular population, being a new mom and that she loves kids, then that's the population she wants to work with. She realized she needed more than just the population. She needed something that was going to motivate her, keep her busy, and something that she was going to enjoy. So to her, the practice of OB/GYN was just of more interest to her. This is another example of keeping an open mind going into medical school.

[07:15] Traits that Lead to Becoming a Great OB/GYN

One trait that leads to becoming a great OB/GYN is being a good listener and allowing the patients to feel comfortable with you. When Renée was in residency, one of the things her attending used to say to her is that you're not your patient's social worker. Part of the reason she was being told that is because she would go in doing more than just prescription or procedure. She would actually sit down and listen to patients as they tell her their lives and all things that affect people outside of just looking at their differential diagnosis. Hence, Renée recommends thinking about the things affecting your patient's health. She adds this is a very intimate type of specialty so you need to go in thinking that and realizing that the patient is going to tell you intimate details and for you not to shy away from listening to those details otherwise you might miss things.

[09:22] Keeping an Open Mind

Renée was so dead-locked on being a pediatrician that she didn't let herself open to looking at other specialties. Apparently, she was so hooked to pediatrics until their peds rotation when she realized she didn't like it. Again, it was only till the end of his third year that she did an OB rotation so she felt she missed a lot of other opportunities and that she should have considered other specialties. That said, Renée loves OB/GYN and she says she wouldn't trade it for the world.

[10:25] Types of Patients and Typical Day

As an OB/GYN, you deal with patients on the OB (obstetrics) side composed of pregnant patients and the Gynecology side consisting of non-pregnant patients ranging from teens to the elderly. Aside from pregnant patients, she also sees patients trying to conceive, those with fertility issues, menstruation issues as well as women going through menopause. Basically, she sees a wide variety of patients and this is what makes her job more interesting instead of just one diagnosis she sees constantly throughout the day.

Renée's typical day would be going into the office at around 8:45 and sees about 10-12 patients in the morning and around the same thing in the afternoon. The first patient may be a pregnant patient and if it's her first visit, she has to assess all of her risk factors - her age, previous pregnancies and/or complications, genetic disorders (including the father), medical conditions. The she does an exam on her to make sure she's doing okay and measure the size of her uterus. If she's far enough along, Renée can listen to the baby's heartbeat. Then they make a plan as to how the pregnancy is going to go, things to expect, follow-up appointment, and what to expect for next time. Every patient may be a different diagnosis and coming for a different problem. The next patient may be an elderly woman having the hot flushes. So her patients vary everyday in terms of the number and versatility of patients she sees.

[13:58] Taking Calls

For Renée, she doesn't take a lot of calls although previously, she had to take calls three to four times a week which can get pretty hectic. Basically, the number of calls you take as an OB/GYN depends on how many people you have in your call rotation. Calls vary as well in that there are different models of OB. One of the more popular ones is the Laborist model where you're in the hospital and that's all you do so you typically won't see patients in the office. Renée didn't practice this in the past.

However, if you see patients in the office and take calls at night, you can either take call from home if you live close enough. You can take call in the hospital where you have to stay in the hospital overnight or you can take call from home and do something called second call, the most recent kind of call she has taken, which Renée describes as when someone else is taking the primary call.

For example, the family practice doctors who practice OB (common in a rural setting) are the first line of call so they take care most of the pregnant patients that come in. But if they ran into a problem such as a complication or the patient is more high risk than they anticipated or if the patient needs a C-section, she will then be called and she will come in from home into the hospital.

[16:40] Work-Life Balance

Renée says she has work-life balance right now but she has significantly changed how she practiced. She is currently doing independent contracting so she gets to choose when to work and when not to work which is not a typical model most OB's would follow. But she describes her previous model as difficult and cumbersome to balance your home and work life, bringing work at home a lot of times or staying at work late to finish things. In fact, sometimes when appointment ends is when work has only begun such as notes to catch up on, accumulating messages in her inbox, and looking at lab results coming in which she ordered days before for her previous patients. Renée typically goes home at around 7:30-8:00 pm. She still has to put dinner and decompress then go to sleep and do it all over again when she's not on call.

[19:50] Path to Residency

OB/GYN residency takes four years. Typically in your first year of residency, you're doing mostly general OB and GYN rotations. For Renée's residency, she did OB rotations in different hospitals as well as a GYM rotation along with GYN ER where she saw patients in the emergency room as an OB/GYN resident. In your second year, you're going more into the subspecialties such as MFM (Maternal Fetal Medicine) or high risk obstetrics dealing with not just pregnant patients but also those with high risk issues, Gynecologic Oncology dealing with women's health type of cancers, and Urogynecology which entails a lot of surgical experience. In your third year, you're expected to take on a little bit more of responsibility. By your third year residency, you're considered a senior resident and you may have a team that you're actually leading. Your team may be made up of a second year and a first year resident and you're leading that team.

Throughout your residency, you're also doing "night float" which means taking night call maybe from 6 pm one night to 6-7 am in the morning. You're doing this for four to five days out of the week. Again in your third year, you're taking a little more responsibility with your OB rotations so maybe you're making more decisions and the same thing with gynecology in the OR doing a more advanced type of procedures. Whereas in your first year, you may have been doing minor procedures like tubal ligations or LEEP. In your third year, you might be doing a little bit more of hysterectomy (removal of the uterus). Then your fourth year is even more responsibility. You're leading a team and doing night float but you're doing OB, GYN, and potentially maternal fetal medicine. All these are broken up into rotations so you're not going to be doing these all at once but you're doing it four to six weeks at a time. Renée describes it as a pretty busy residency but you get so much out of it.

[23:45] Matching Into OB/GYN and Choosing a Program

Renée says matching into OB/GYN can be competitive and she recalls her year to be a pretty competitive year. She adds the importance of going into doing audition rotations like your sub-internships pretty early in your fourth year and seeing where you want to be so you're not blindly picking where you want to go. It's a surgical specialty so you want to be sure that wherever you go, you're going to be in a place that does enough surgery. Delivering babies is fine but if you have a program that is so obstetrics-heavy and not enough gynecology, especially surgeries, Renée suggests reconsidering going into that program. At the end of the day, you have to really know how to work your hands to do surgery. You will learn how to deliver a baby wherever you go but doing hysterectomy, particularly vaginal hysterectomies and other types of gynecological procedures, you're going to really want to get good training in that. So when inquiring about the program or doing a Sub-I or interviewing, be sure to ask about it and get a sense of what your training is going to look like, particularly your surgical training.

[26:30] Bias towards DO's

Renée is a DO and applying to residencies, she actually never experienced any bias. She did the MD match and chose to opt out of the DO match because at that time, there weren't enough programs in the region she wanted to be. She is from New York so she wanted to come back to the New York/New Jersey area and there weren't enough DO programs at that time that she was interested in. Anyway, she didn't experience any type of bias. In fact, their program chair specifically told her she wanted Renée to be in the program.

[28:20] Subspecialty Opportunities

You can just do OB although Renée recommends that if you're just coming out, you probably want to do OB/GYN. You can also just do GYN. Other subspecialties are Maternal Fetal Medicine (high risk obstetrics dealing with pregnant patients with high risk issues) which consists of a three-year fellowship, Urogynecology (an additional three years and very surgical-heavy), Gynecological oncology (dealing with cancers, another surgery-heavy specialty which is also an additional three years), and Pediatric Gynecology which is one year. There is also the Reproductive Endocrinology and Infertility, which Renée was originally interested in and where you deal with infertility patients and other endocrinology disorders which is another three-year fellowship.

[31:00] Working with Primary Care

Renée explains that depending on what organization you talk to, OB can be considered primary care. But she doesn't think it's primary care in the sense of how they look at it. I personally think it's primary care for women's health but there's still a primary care physician for a woman's overall care. Nevertheless, she wants primary care physicians to understand that they are the first line for women's health so it's important they have a relationship with primary care physicians with regard to women and women's health.

Renée sees some women going to their family practice doctor and they've seen them for years but they haven't had a pap smear or breast exam in years. She adds family med doctors are pretty good at doing mammograms but the breast exam is still recommended. As an OB/GYN, Renée stresses that the clinical exam is still extremely valuable in evaluating patients. These are the kinds of things she wants for the primary care physicians to keep in the back of their minds to always ask their women patients if they've seen their OB/GYN or if they've already had their pap smear. This is even important with teenagers because Renée says there are a lot of instances where they could have treated or prevented issues but they've missed the boat on that.

[34:30] The Laborist Model

What she wished she knew about OB/GYN which she didn't know going into it is how flexible it actually can be. The Laborist, also called the OB Hospitalist Model, is currently getting popular. As a laborist, you're primarily in the hospital rather than being in the office and having to take calls and having to do everything in one day. Now that she knows that, Renée is actually taking more advantage of it and seeing it as her saving grace being a new mom and so it's really important for her to spend time with her baby. She gets that flexibility of being able to work in the hospital alone and set her schedule in the hospital where she gets all the work done in the hospital so she doesn't have to bring her work home and be able to spend more time with her son.

[36:35] Most and Least Liked Thing

What she likes most about being an OB/GYN is talking with patients. She is very candid with her patients so they would feel comfortable talking with her especially about sensitive topics where they may feel ashamed of so they're trying to hide it such as domestic abuse or sexual abuse or postpartum depression. Sometimes, they're not comfortable telling a perfect stranger but Renée sees it as a privilege for someone to be able to say that to her. So it's all about the trust her patients put into her that she's carrying for them.

On the flip side, what she likes the least about being an OB/GYN is when it gets too busy where she feels like she doesn't have the time she needs to either talk with her patients or have the time she needs with her family. Another thing she doesn't like is having bad outcomes especially on the obstetrical side when you're dealing with either miscarriages or stillborn which is heartbreaking. These are the things Renée says you never get used to such as bad diagnosis of, say, cervical cancer.

[40:10] Changes in the Field

Renée explains there is always something coming down the pipe. In particular, she sees genetics to become really big where there are a lot of genetic technologies coming down the pipe for OB. Most recently, cell-free DNA has come out which can give a lot of information about a fetus during pregnancy, something we didn't have in the past. Policy-wise, Renée sees the fight with women's health so it's interesting to see what policies are going to be emerging with regards to women's health in the next few years.

[42:30] Final Words of Wisdom

Renée gives her last pieces of advice to medical students looking at OB/GYN as a future career. First, don't underestimate it and don't not consider it. Don't tunnel-vision your way. She was lucky that when she did OB, she liked it. If you like using your hands and you like using your brain, OB/GYN is something where you can help a lot of women. You may never see a male patient again which Renée humorously sees as a blessing but they do circumcisions as OB. Nevertheless, you're going to help a lot of people. One of the things Renée and her husband learned during their medical mission about women's health is that women are typically the gatekeepers to their family's health which is very important. When you take care of a woman, there's a very good chance you're taking care of their entire family. If they prioritize their own health, they will do the same for their children, their husbands, their mothers, their sisters. They are the people who tend to keep the family healthy. Renée says it's very important to consider that when you're considering OB/GYN, you're not only helping that person sitting in front of you but you will also be helping potentially their entire family which is a beautiful thing.

Links:

Send Ryan an email at ryan@medicalschoolhq.net

Locum Tenens

Specialty Stories Podcast Session 127: A Deep Dive into OB/GYN Residency Match Data

Jun 28, 2017
28: What is Trauma Surgery? Dr. Darko Shares His Story
48:08

Session 28

Dr. Nii Darko is a community-based Trauma Surgeon. He's also an Osteopathic physician. Listen to his journey and what you should be thinking about. Dr. Darko has also been on The Premed Years podcast back in Session 196 and he is the host of the podcast called Docs Outside the Box.

[01:05] An Early Interest in Trauma Surgery

Practicing for almost five years now, Dr. Darko knew he wanted to be in two points of his life. As a seventeen-year-old, Nii had the opportunity to shadow a trauma surgeon in Newark, New Jersey, with his first exposure to trauma case was a person who got shot where they evaluated the patient and seeing a whole chorus of nurses and different medical staff helping the person. The trauma surgeon he was shadowing was at one corner of the room conducting the stuff, which to him seemed like an orchestra or rather a concerted type of chaos. The patient was taken into the operating room and when the doctor came out, he talked with the family. The doctor comes out of this operating room as a big superhero and saves the day. From then, he got hooked.

Fast-forward to residency around ten to twelve years later, Nii noticed that general surgeons were doing everything including trauma and found himself moving towards operating on the unknown which to him was the fun part about trauma. You don't know exactly what's injured so you have to use all of these different detective-type qualities to figure out exactly what's going on. So Nii felt trauma surgery was the best mix for him in terms of taking care of patients who need things like appendix or the gall bladder and at the same time use his superman qualities in high-adrenaline and highly stressful situations.

[04:40] Traits that Lead to a Good Trauma Surgeon

Nii cites patience as a very big trait considering that oftentimes, with trauma, you don't know what's going on  and a lot of things are going on at the same time. Another important quality is leadership. You need to understand that it's a very highly stressful situation. You have the ability to take a step back, be patient and at the same time, have the qualities where you direct people respectfully. Nii stresses the fact that no man is an island, particularly in medicine and although you'll be making decisions on your own, you are leading a team and if you can lead them effectively, it's always going to end up, for the most part, with good results for the patients.

Nii initially wanted to be obstetrician being greatly inspired by Bill Cosby of the Cosby Show who played the part of an obstetrician who was a positive African-American doctor figure. In fact in medical school, Nii was the first year representative for the OB/GYN club and he quickly realized afterwards that it wasn't for him. Orthopedic surgery was also in the running for a very short period of time for him but everything fell by the wayside when he did a rural general surgery rotation in the middle of Kansas and then knew from then on that general surgery was for him.

[06:58] A Typical Day and Types of Patients

Nii gets into the hospital by seven in the morning and a sign out period occurs where they talk about all the patients on the list, anything major that occurred the night before and then they talk about the plan for the next 12-24 hours. From 8 am to 7 pm, Nii handles different duties whether it be patient evaluation at the trauma bay or someone on the general floor. By 7pm, they do the sign out process again and whoever is on at night handles any situation that needs to occur at night and then do it all over again.

Nii typically treats patients from all walks of life, children and elderly patients as well patients in their late teens and 20's. As a trauma surgeon, majority of patients he sees are patients in their teens to mid-late 20's and 30's, which he describes as the "invincible years" where people think they're invincible so they do more of the reckless stuff. Additionally, he sees a huge boom of geriatric patients consisting of the baby boomer generation who as they get older are more prone to falls and different types of mechanisms, making them the second largest patient population he deals with.

70% of his job consists of true trauma cases such as car accident, gunshot wounds, stab wounds, and critical care while 30% goes to general surgery. Only about 10-15% of his patients that come through the trauma bay get taken to the operating room for various operations such as removing a spleen or fixing a liver laceration or a washout of an exposed bone. A very small percentage of patients get taken to the operating room which is a significant shift from trauma surgery that our generation knows from most TV shows in the 70's and 80's. Because of how advanced technology now is, those days are way behind us. Now, you can study someone and take a look in their, say abdomen or chest, and have more information before you take them to the operating room.

[12:08] Calls, Work-Life Balance, and Burnout

In terms of taking calls, Nii works in a two-week-on-two-week-off type model which is basically a shift work where he and another surgeon alternate call for two weeks and he gets another two weeks off. No administrative work, no hospital work, no patients. So Nii works hard in Central Pennsylvania for two weeks and then he's able to get home for a week to see family. This makes it attractive for people who really care about being able to travel or being able to do things with their families that they may not be able to do in a regular type of job. But that said, Nii describes his two weeks on as tough. You can do it but it's not for everybody. However, Nii finds those two weeks off as very valuable.

When his patients come back during the two weeks he's off, they have this agreement among all surgeon where it's no longer his patient but their patient. Hence, other doctors take care of him or treat him during his time off. Nii sees this as the wave of the future. It may not be necessarily two week in a row and two weeks off but more and more specialties are taking on this type of work model with varying number of days on and off and where they're working as a team. Considering the amount of work or the amount of patients one person has to see and to be able to have the lifestyle with the new generations coming up, millennials and GenX, he sees lifestyle as coming into center stage and as a result, this type of schedule is becoming a lot more attractive.

Nevertheless, Nii still feels he has enough time for family since he's working very hard for two weeks and prior to this year, he was in a situation where he spent 24 hours in the hospital and another 24 hours afterward is for backup in case he's needed to come in. he ends up convincing the OR to give you time to operate early in the day which doesn't happen much due to elective cases filling in. So you may be spending an additional five to six hours in the hospital. Again, Nii stresses how tough those two weeks are and oftentimes, you may still not be able to see loved ones during that time, but during the two weeks off, you may still catch up. But it's not for everyone. Nii has still missed a lot of important life events and he honestly says there are times he's questioning if this is all worth it but in order to be human, you have to have that type of thought process at one point. Nii is not complaining but this is real talk. This is bringing to light something people have not talked about before and it may have been manifested in bad behaviors in the operating room. So it's important to have this type of discussions now.

[17:35] Residency, Fellowship, and Competitiveness

Nii did five years of general surgery residency which includes training in a whole bunch of various areas of surgery such as general surgery, surgical oncology, ENT, neurosurgery, a little bit of orthopedic surgery, but less focused on general surgery. Afterwards, he was allowed to practice general surgery and decided to do a one-year fellowship where he did additional training at University of Florida's Ryder Trauma Center. He got as much experience in trauma as he could as well as critical care experience. After his training, he became board-eligible to practice trauma surgery and critical care surgery as well as general surgery.

Nii describes trauma surgery as not a very competitive residency for a host of reasons. For one, a lot of people are little bit nervous about the hours you work with trauma. Second, it's very stressful. Third, a lot of programs offer trauma so it's not as competitive as in the realms of vascular surgery or any other type of subspecialty such as laparoscopic surgery or bariatric surgery. For the most part, people may think of trauma surgery as not being too competitive but it's very hard to get into the top trauma centers like the University of Miami, Grey Memorial Hospital, USC in California, or Shock Trauma in Maryland, these hospitals.

[19:55] How to Be a Competitive Applicant

From a medical student's perspective, Nii cites the the key things for becoming a very competitive applicant to general surgery. First, set the groundwork by being an excellently trained general surgeon. Show your interest in general surgery whether it be going to conferences or shadowing a general surgeon. You're going to be doing a general surgery rotation so you may want to do an additional rotation as a third or fourth year doing a sub-internship in general surgery or trauma surgery. Get excellent letter of recommendation and do well on your board exams.

Once you become a general surgery resident, make sure to have an open mind. Make sure you're giving every rotation that you're doing enough attention and being as open as possible to basically learn as much possible. Be open to the idea that maybe you thought you wanted to do trauma surgery but you're actually really interested in surgical oncology or what have you. At this point, which usually happens during your second or third year, start getting yourself involved in research or doing some additional trauma surgery rotations if you like or get yourself involved in co-authoring a chapter in a textbook if you're at a large institution that does that. As for Nii, University of Miami has opportunities for not only medical students but also for general surgery residents to attach themselves to one or two general surgeons who are making probably a 25-30-chapter textbooks. There are plenty of opportunities to get yourself ready but focus on getting into a general surgery residency and as a resident, start putting your hands in different ways to show your commitment to trauma surgery.

[22:40] Tips for Choosing Your Program

Nii says he wouldn't have done anything differently with how he chose his program. The way he did it as a fourth year surgery resident at Grey Memorial Hospital where there was a lot of trauma done, there were multiple trauma surgeons who train at various places and they've come to work at that hospital. What he did was querying all of those surgeons, going to various people and asking them about their program and why they think it would be good for him to train there. Aside from getting advice from them, he went online and looked up more about those different programs and even calling up the program directors where some of them accommodated him.

Nii wants people to understand that medicine is an extremely small world but as you start to get into more sub-specialties like trauma surgery, it's a very, very small world. For instance, their chairperson knew the trauma director at Miami and they ended up getting introduced in that way so he got to talk to him and told him about the program. So he applied and ended up working for him.

Additionally, when you apply you get the opportunity to interview at these places if given the interview, which is an opportunity for you to showcase how well you speak and think or how you are in person, outside, separate from a piece of paper. Also take it as an opportunity to interview them. Ask them in how well they train their residents or fellows and in doing well on their board exams, how much experience do they get operating in x or y, how much time do they get off.

[25:00] His Hustle to Allopathic Residency as a DO

Nii is a DO but he went to an allopathic residency program for general surgery. Based on the NRMP Match Data for 2017 for Surgery programs, out of 1,276 positions filled, only 64 were filled by osteopathic students.

When asked about how it was for an osteopath to get into an allopathic residency, Nii explains how much he hustled which means grabbing an opportunity and not waiting for someone to give you an opportunity. He knew he wanted to do general surgery and was open to doing a general surgery residency at an osteopathic program. He went through the rounds of interview at all these different DO programs and at the same time he decided to interview at all different places. He got a phone call from three or four general osteopathic surgery programs that they have matched outside of the match, which was part of their culture. They at times will just agree to take in a certain person before the match.

So Nii had no other places available to him to get into a DO general surgery residency. But since he got to interview also at allopathic programs, he still had that chance within that allopathic realm. He ended up doing a last-minute sub-internship at Morehouse School of Medicine in the Medical Intensive Care Unit (MICU). When he got there, he made it very clear that he was doing the MICU rotation because he tried to get into the SICU (Surgical Intensive Care Unit) rotation but it wasn't available. He actually got lucky he had a very good pulmonology critical care physician and he honestly told him that he enjoyed intensive care unit but at the same time he was really interested in being a surgeon but he took the opportunity since it was the only thing available to him. Then every now and then he would request to round with the trauma surgeons and then he eventually maneuvered that into seeing what they do in the trauma. He basically got his foot on the door and hustle his way into making sure they know him.

As a result, he got accepted into their program. It wasn't until his second year that he had the opportunity to talk to the chairperson who accepted him because they saw his ability considering they have never ever taken an osteopathic medical student before. By the time he graduated from the program, he was the best resident that has ever come through that program. Nii's advice is to make sure that if any osteopathic medical students are ever interested in their program, you have to take them more seriously. Think that we're all going through the same trials and tribulations and stress. Nii thought they may think that because he's a DO, he's different but he went above and beyond and he crushed it. Back then, they didn't treat him any differently or did anything to make him feel that way, but it was the thoughts he had at that time. His advice to medical osteopathic students out there is if you want to get it then go get it. And if you have to get into a general surgery in the allopathic world, then go and be as aggressive as possible and take the opportunities that may be presented to you. Kick the door open and don't wait for someone to give you an opportunity otherwise you're going to be on the outside looking in.

[31:40] Subspecialties, Other Specialists, and Special Opportunities

As a trauma surgeon, your subspecialty is called Trauma Critical Care. You can go and get some additional education like other specialties can like take additional courses in ultrasound. This is very useful if you're trying to figure out if someone is bleeding in their abdomen or has blood anywhere else. Using it is cheap, quick, and it doesn't require moving the patient to a CT scan where their pressure can drop or end up dying of a collapsed lung. You can get additional training in mostly anything. It won't get you additional certification but Nii explains it's always good to have that additional training in your back pocket because you never know when you're going to use it. Moreover, if you want to get any type of additional training that would get you certified in something else, you may have to do an additional fellowship aside from trauma surgery such as laparoscopic surgery or plastic surgery.

In trauma, Nii always works with an orthopedic surgeon for broken bones, neurosurgeons for head and spinal cord injuries, plastic surgeons and oral and maxillofacial surgeons for broken bones in the face or missing teeth, broken nose and broken sockets. Other specialties they work a lot with include cardiothoracic surgeons.

Other special opportunities outside of clinical medicine for trauma surgeons can be EMS. For example, if EMS is called to a scene and a patient is found down, if there's enough training, and EMT may bring that patient to the ER and allow the ER to work that patient up. But if the patient has a bunch of bruises on the head or anything on the rest of the body that may suggest they've fallen, if a trauma surgeon did the education and ER comes together, they may be able to educate EMS as to what to do first.

You can also create your own type of experience. You can do a podcast like Nii where he interviews ordinary doctors do extraordinary things. And as with any other specialty, the world is your oyster. Nii further says that as a doctor, whatever you do, you just have so many opportunities to do anything you want. There are so many ways that you can branch off and go into.

[36:38] What He Wished He Knew Going Into Trauma Surgery

Nii trained in Atlanta, Georgia and from his experience, he found trauma surgery as a burden in their hospital since majority of trauma patients at their facility were indigent populations. Other services are expensive  so if a patient with polytrauma comes through and they don't have insurance, it could be a huge expense for the hospital since a lot of that care has to oftentimes be written off. This normally occurs in areas where you have patients who don't have a lot of insurance or indigent populations.

When Nii ended up becoming a trauma surgeon and going into areas where people have car insurance or people have other health insurances to pay for this, he didn't know that trauma surgeon could be as lucrative for a hospital as well as for the providers. And at the hospital he's currently at, trauma surgery is not a burden and instead is the biggest money maker for the hospital just because there are so many tenets of care.

He wished he had known this before because he used to often get physicians who tried to turn him away from trauma surgery whereas in his current situation, trauma surgery is not seen as a burden and the administration can't get enough of trauma surgeons and want more of them.

[39:00] Most and Least Liked Things About Trauma Surgery

The thing Nii likes the most about trauma surgery is being the jack of all trades. He enjoys stressful situations and being trained in all different areas knowing you've got to stay calm. You get to orchestrate a lot of people and run a team and you're seeing someone literally from the door as they come in and all the way to when they're discharged and you're in charge of all facets of the care. He finds this very fascinating reason that the went to trauma surgery in the first place.

On the flip side, the thing he liked the least is also the stress that comes with it that there's a lot to handle. In other specialties, you get to triage it to another person but you don't have this option in trauma surgery. There is constant stress which can eventually wear you down considering that Nii is still in his late 30's and he already feels the stress of that so he knows he can't continue like this into his 50's since it's not sustainable. But Nii loves this too so it's like an addiction.

[40:45] Major Changes in Trauma Surgery

Nii explains that trauma in the 80's and 90's was known to be not as operative as other specialties. There were even times when a lot of trauma surgeons lost the operative skills they've acquired during residency so a lot of trauma surgeons were not very good at operating. But a new field has come up called Emergency General Surgery or Acute Care Surgery, which Nii describes as a different thought process. For instance, if a trauma surgeon has to be in-house, he handles all the general surgery emergencies that occur in a hospital. This helps the general surgeons who have very busy elective services in the morning so they won't have to come in during the middle of the night to take out an appendix when at 7am they had a whipple surgery, which is one of the most intricate surgeries you can do in the abdomen that takes roughly about five to seven hours. So the general surgeon is no longer tired because he doesn't have to come in the middle of the night while the trauma surgeon can still get his hands dirty.

Technology-wise, it continues to push things further and further. The obvious things would be technology getting smaller and smaller that you can transport patients with, which Nii considers as a small thing compared to the combination of trauma surgery and general surgery.

[44:00] Would He Be Doing It All Over Again?

If he had to do it all over again, Nii actually doesn't know if he would do it all over again. His thought process has changed a lot from medical school and residency, from a gunner mentality to now more of enjoying what he does and at the same time, he is no longer defined by being a physician. There is more to Nii Darko than just being a doctor. And if he had thought process in medical school, he may not have decided to go into general surgery and he may have decided to do something else where he'd be really be able to take care of patients not only in the way he would want to take care of them but also at the same time have a lifestyle where he can get away and that when he's off, he is off. No work no matter where he goes. Sure he does work two weeks on and two weeks off, but this may not be the same in another facility. As opposed to Emergency Medicine, you work a certain amount of shifts a month and you're guaranteed some time off. So if he had to do it all over again, he may have chosen something different.

[45:40] Final Words of Wisdom

Nii's advice to premed and medical students and residents looking at trauma surgery is to relax and take a big deep breath. If you want to be a trauma surgeon, there are plenty of places and spots available for you to get into trauma surgery. From a premed standpoint, focus on getting into medical school and being the best student you can be. At the same time, take opportunities to shadow a general surgeon and contrast that with shadowing a trauma surgeon so you can see the differences in how they practice. From a medical student's perspective, this is the time for you to really do as well as you can with your boards and with your rotations. At the same time, start laying the foundation for your commitment to general surgery if this is where you're interested in. Finally, as a resident, keep an open mind and give all of your rotations an equal share of your attention. At the same time, if you know for a fact that it's what you really want to do, go and get it. Don't let anybody keep an opportunity from you and know that trauma surgery is extremely rewarding. Although very stressful,  Nii enjoys it everyday and at the same time you deal with people at their most vulnerable states and being able to take care of someone every step of the way, not many other specialties say they can do that so he is very grateful and humbled he has the opportunity to do this.

Links:

Docs Outside the Box Podcast

The Premed Years Podcast Session 196 (interview with Dr. Nii Darko)

NRMP Match Data for 2017

University of Florida's Ryder Trauma Center

Jun 21, 2017
27: A Deep Dive Into OB/GYN Residency Match Data
30:54

Session 27

This week I'm breaking down and reviewing the match data for OB/GYN. There are a handful of surgical specialties thought to be a good mix of medicine and surgery specialties. OB/GYNE is one of them along with ophthalmology, urology, and ENT. If OB/GYN interests you, take a listen to this episode to see what you need to do!

[02:30] Match Summary

Table 1 of the NRMP Main Match Data 2017 shows the summary of the match and OB/GYN is listed separately from everything else having its own category. There are 241 OB/GYN programs. Compared to other specialties, Surgery has 267 programs, Internal Medicine has 467 programs, Emergency Medicine has 191 programs.

While OB/GYN has 241 programs, there only 1, 288 spots available compared to Emergency Medicine with 191 programs but there are 2,047 spots. That's almost 800 more spots even if there are 50 less programs. Hence, there are less spots per program in OB/GYN.

Out of those 1,288 spots, there were 1,202 U.S. Senior applicants. This means there are less of them applying than there are spots available which is a good thing. (For our conversation, U.S. Seniors based on this data specifically talks about allopathic medical students. The NRMP is the match for allopathic medical schools.)

There are a total of 1,753 students applying. Aside from U.S. Seniors, there could be physicians in another country applying for OB/GYN residency here in the U.S. They could be Caribbean grads, DO students, etc. Only 81.4% of the U.S. Seniors matched so out of 1,202 U.S. Senior applicants, only 1,049 matched and 153 did not match. There could be a number of reasons students are not matching for residency. Maybe they weren't competitive enough or they interviewed poorly. Or maybe they didn't apply to enough residencies or performed poorly on their audition rotations.

[05:45] SOAP and PGY-1

For OB/GYN total, 100% of spots were filled. If for some reason you're trying to Scramble, which is now called SOAP, for OB/GYN in 2017, there were no spots available.

There are only 19 PGY-1 OB/GYN spots, Typically, for OB/GYN spots, you have medicine, surgery, or a transitional year which is a mix of medicine and surgery. It's pretty interesting that OB/GYN has a prelim year. This is for the students that need to SOAP and the students that didn't match maybe they were able to get a PGY-1 spot. However, there is no discussion about OB/GYN having any PGY-2 positions. I'm wondering what happens to these students once they finish their PGY-1 spot.

So there were 19 programs and 23 positions offered, which seems to be just an extra spot for interns, and then 8 programs went unfilled. 142 U.S. Seniors applied and 202 total applicants and only 6 U.S. Seniors matched. As to why this is the case, they probably applied to both categorical OB/GYN spot and the prelim spot so you get a lot more applicants to the PGY-1 spot that hopefully matched in the categorical and didn't need to go onto the prelim year. If that's the case, they wouldn't have matched in terms of how the algorithm works because they are two different programs.

[09:00] Specific Applicants and Trends

Table 2 shows who matched in the specialty. For OB/GYN, there are 1,288 spots for the categorical programs and all spots were filled. 1,049 were filled by U.S. Seniors so 81.4% of all spots went to U.S. Seniors who are those still in school. 11 of those spots went to U.S. graduates who are students that went to an allopathic or MD school who aren't in school anymore that possibly reapplied or took a year off to do some research. There are 123 osteopathic/DO students matched into an allopathic OB/GYN categorical spot.

Outside of the U.S. allopathic and osteopathic students, 64 U.S. IMGs matched into an allopathic OB/GYN categorical spot and 41 non-U.S. citizen IMGs matched. So 105 graduates from a non-U.S. medical school matched.

Table 3 shows the growth of programs year over year (2013-2017). For OB/GYN, it's been growing around 4.5-4.7% every year and this is a good pace.

Table 8 shows the percentage of applicants filled by U.S. Seniors from 2013-2017. 81.4% of those that matched were U.S. Seniors in 2017, 77.5% in 2016, 79.8% in 2015, 76.5% in 2014, and 76.2% in 2013.

Table 9 shows how popular OB/GYN is compared to all of the other specialties. 4.7% of all applicants who matched, matched into OB/GYN. To give you an idea of what that looks like, 7.4% matched into Emergency Medicine, 4.1% into Anesthesiology, 5.4% into Psychiatry categorical.

Table 10 looks specifically at U.S. Seniors who matched by specialty. 6% of all U.S. Seniors matched into OB/GYN. This is a good number. Table 11 shows osteopathic students who matched into OB/GYN.  4.2% of all osteopathic medical students matched into OB/GYN.

Table 12 shows foreign-trained physicians (international medical graduates) and only 1.6% of IMGs matched into OB/GYN. This makes sense since more of the subspecialties are harder to match into as an international medical graduate. Now compare this to 46% of all IMG's matching into Internal Medicine.

Just to give you a comparison here for students who matched into Internal Medicine, Osteopathic students make up 23.5% (Table 11) and 25.6% for all applicants (Table 9) and 18.6% were U.S. Seniors. 25.6% of all applicants is kind of held up by the International Medical Graduates leaning into Internal Medicine.

[14:36] Applicant Choices by Specialty, Matched and Unmatched

Table 13 shows the applicant choices by specialty. For OB/GYN with 1,288 total positions available and all of them matched. 968 of U.S. Seniors that matched only ranked OB/GYN programs. 198 U.S. Seniors ranked OB/GYN as their first specialty and they had a different specialty after that. 36 students U.S. Seniors had a different specialty before OB/GYN. This is common but I personally can't understand ranking more than one career. This is your residency training. This is your specialty. While yes, it is possible to change careers at some point, don't you only want to do it once? I wonder how it feels like to open up your envelop seeing you matched into the specialty you didn't rank first. My advice is try to narrow it down to one program because the data shows that when you rank more than one program, it starts to work against you. There's probably some psychology working in there but it's interesting information.

Table 14 shows the ones that actually matched who ranked their specialty as their only choice. For OB/GYN, there are 890 that matched out of the 968 that applied as their only choice.

Figure 6 shows the percentages of unmatched U.S. Seniors and independent applicants who ranked their specialty as their only choice. OB/GYN is near the bottom for total unmatched percentage at 15.4%. This is pretty good since we covered Physical Medicine and Rehabilitation before and their unmatched rate is 27.5%. Family Medicine is 25.3%.

The majority of those unmatched applicants are the independent applicants. Unmatched U.S. Seniors is very small at 8.1% for OB/GYN (Pls. refer to Table 14). Compared to other specialties, this percentage is on the higher end of U.S. Seniors unmatched. Anesthesiology is only 0.9% of U.S. Seniors, Internal Medicine is 0.5%, PM&R is 7.1%. So even though the total unmatched rate is 27.5% for PM&R and OB/GYN is 15.4%, the U.S. Seniors unmatched is still pretty high at 8.1%.

Table 18 covers SOAP information for 2016-2017 and as mentioned earlier, the 1,288 spots available for OB/GYN went completely filled. When you look at this, Table 1 shows you all of those that matched pre-SOAP and if there are no programs available based on table 1 then obviously, no programs are available for the SOAP. With the OB/GYN prelim year (PGY-1), there were 8 programs, 9 spots available and 8 of those spots went filled.

[20:27] Charting the Outcomes 2016

Looking at Chart 5 of Charting the Outcomes 2016, the students that did not match were equal to or more than the number of different specialties ranked. Those that did not match rank more specialties in their match list than those that did match. So you're focusing your efforts on too many different places instead of honing in on one and putting all your cards on the table for one specialty. Based on the data, it shows that those who spread out too thinly and applied to more programs didn't match whereas those who applied to fewer programs actually matched. Hence, focus your energy on one specialty.

First, note that there is an overlap with a lot of different specialties. For example, diagnostic radiology can be very similar to interventional radiology.

Chart 8 shows the mean number of research experiences from U.S. Allopathic Seniors and OB/GYN is higher for those that matched at 3.2, a decent number right in the middle of the pack. Orthopedic surgery is at 4 and Otolaryngology (ENT) is at 5.1. Those that did not match for OB/GYN had 2.8 so not a lot fewer.

Chart 12 shows the percentage of U.S. Seniors who are members of the AOA (Alpha Omega Alpha), the honor society for medical students. For OB/GYN, 15% matched while 2% of those that did not match were AOA.

[23:25] Contiguous Ranks, Step 1 & 2 Scores, Top 40 Schools

Moving down to the OB/GYN specific information Table OB-1 (Page 123), the mean number for contiguous ranks that matched was 12.5. If you've listened to any of these deep dives before, you will know that this is one of the key indicators of who's going to match and who's not. You are more likely to match when you rank more programs. Those did not match had 6.7 mean number of contiguous ranks. So those who matched almost doubled than those who did not match.

For those that matched, the mean Step 1 score of those that matched was 229 versus 214 for those that did not match. Mean Step 2 score was 244 for those that matched while 230 for those that did not.

The tenth on the list indicates the percentage who graduated from one of the 40 U.S. medical schools with the highest NIH funding. I get a lot of students asking if it matters where to go to medical school and the I always tell them it doesn't matter unless you have aspirations of being a top academic person at Harvard or Stanford and then think about going to some of those more elite schools. But for OB/GYN, specifically, 31.2% of those that matched came from one of those 40 schools. This goes to say that most of the students are coming from somewhere else. You don't have to go to an elite school to match into OB/GYN. On the other hand, 29.8% of those that did not match went to one of the top 40 U.S. medical schools based on NIH funding. To me, this doesn't tell anything about the quality of schools, it just means the school does a lot of research and it's good at writing grants for money.

[26:25] Medscape Lifestyle and Compensation Reports 2017

Looking at the Medscape Lifestyle Report, it tells us that OB/GYNs are pretty burned out, being the second highest on the list at 56% next to Emergency Medicine at 59%. Slide 3 shows the severity of burnout and OB/GYN is near the top at 4.3 in a scale of 1 to 7 (where 1 equals "It does not interfere with my life" and 7 equals "It is so severe that I am thinking of leaving medicine altogether.") When you look at all of the specialties listed here, none of them dropped below 3.9 so it seems everybody is on the way out. This is one of the questions for premeds out there, why do you want to enter this? You have to be ready to answer that question on your interviews. Slide 18 shows which physicians are the happiest, OB/GYN is right in the middle at 69% happy outside of work and 32% happy at work.

Moving on to the Medscape Compensation Report 2017, OB/GYN is near the middle but lower than half at $286K as the average annual physician compensation. Orthopedics is first at $489K and Pediatrics at the very bottom at $202K. Slide 18 shows which physicians feel fairly compensated and OB/GYn is near the bottom at 48%. Whether they would choose medicine again, OB/GYN is second from the bottom at 72%, just above Neurology at 71% while Rheumatology is on top at 83% followed by Psychiatry at 82%. Whether they would choose the same specialty again, OB/GYN is pretty near the bottom at 76%. It looks like not a lot of OB/GYNs are happy with their chosen specialty.

[29:30] Final Thoughts

With a lot of OB/GYN not very happy with their career, more so, not choosing the same specialty again. But information is power. Knowledge is power. So take this information and use it to your advantage. A lot of people go into specialties not knowing enough about the specialty or what their life is going to be like and this why we have this podcast. Take this information and use it so you can best make an informed decision.

Links:

NRMP Main Residency Match Results and Data

Charting the Outcomes 2016

Medscape Lifestyle Report

Medscape Compensation Report

MedEd Media Network

Jun 14, 2017
26: How to Think About Choosing a Residency & Specialty
22:01

Session 26

There are many things to think about when you are deciding your future career. In this episode, we discuss how you should start that process.

The goal of this podcast is to speak to specialists from every field, both community and academic. But I want to rewind a little bit and talk about the whole process of just thinking about these specialties and the questions you should be asking yourself, and what you should be thinking about as you're going on this journey so that as you listen to these interviews, you will have a better sense of what you're thinking about and your goals in career and life in general.

[02:10] Keep an Open Mind

A large percentage of premeds that go into medical school know what they want to do. But keep in mind that most medical students change their minds. They may get in a specific field after exposure and research but as they get more involved in the field through rotations and doing a lot more clinical work as a medical student, they realize it's not for them. So realize that your preference can change. Don't hold onto your convictions of wanting to be a certain specialty. Let go a little bit of that and keep an open mind as you are going through this process.

[03:38] Academic/Community, Urban/Rural Settings

Understand that with that, what you see as a medical student is typically urban, academic medicine. For DO students, that's not always the case because most DO schools are not associated with large academic medical centers. You have to go around to different hospitals. Some are academic while others are more community-based or more on the suburbs or more rural, wherever the hospitals are that you rotate at based on the schools you go to.

Understand that what you see day in and day out as you're a first year, second, third, or fourth year student doing your rotations and doing your preceptorships and your pre-clinical years, the medicine you're likely seeing is not how the majority of medicine is practiced. So when you're out shadowing a cardiologist in a large urban, academic medical center, the life of that cardiologist could be 180 degrees different than a community-based cardiologist or a rural-based community cardiologist.

As you're setting up rotations for your sub-internships and getting more involved in some of these electives (cardiology is not the best because it's a fellowship you do after medicine), try to mix up academic and community settings to give yourself an idea of what you want for yourself. Do you see yourself as an academic person? Do you want to be around residents and medical students? Or do you just want to work as a physician and practice? Do you enjoy teaching? Do you enjoy doing research? Research is usually big in the academic world. You can do plenty of research in the community too but in the academic world, research is more mandatory. Or do you want to have a hybrid setup? We talked to Dr. Topf back in Episode 16. His is more of a community-based nephrologist but is also involved in academics and running a fellowship program for nephrology. So you can have a little bit of the best of both worlds.

Start thinking about those settings. Start thinking about where you want to go to residency. Have those ideas in mind regardless of the specialty.

[07:00] Introvert or Extrovert

Think about what kind of person are you? Are you an introvert or an extrovert? I, myself, am an introvert by nature. When I go out and interact with people and when I used to interact with patients all day before medical school and during medical school, when I was interacting with clients all day while I was a personal trainor, I would be completely drained at the end of the day. Working with people drains me. Even being at conferences drains me. If I would have taken that into account and it was significant enough that at the end of the day, I was completely wrecked and couldn't do anything, maybe I would think about a specialty that is a little bit patient-focused. If that's the type of person you are, think about it.

There's also that opportunity to fake it till you make it. I put on a big smile on my face during work and at conferences and just deal with it then at the end of the day, I get tired and would need lots of alone time. I need to be by myself to recharge my batteries.

Or you may be the type of person that recharges being around other people. If you're a people-person, look into those fields that are more people-heavy like psychiatry or some of the general primary care specialties.

For the introverts, when you try to get away from people, possible specialties include radiology or pathology. We did an interview with Dr. Judy Melinek back in episode 24. She is a forensic pathologist and she interacts with the deceased's family members whom she calls patients. So she's still interacting with people as a forensic pathologist.

[09:30] Stressful Situations

Think about what kind of stressful situations do you like to be in? Are you ready for anything at any notice and life and limb and death in your hands? Maybe the emergency department is right for you. I personally liked the emergency department but not the sort of intensity. I wouldn't want to work in that sort of stress. I originally wanted to be an orthopedic surgeon. Complications happen in the operating room and you need to be able to handle that. But you're already in a controlled environment. Hopefully, you're thinking through these situations as you're going through it. You're always thinking three steps ahead. In the emergency department, anything can come in at any time so you always need to be prepared and really be able to handle that.

[10:38] Length of Training and Variety

A couple silly questions I don't think are valuable in asking is what time frame do you have or how long do you want to train? Neurosurgery is seven years versus pediatrics which is three years. But if you really want to be a neurosurgeon and think it's too long so you're just you're just going to settle for pediatrics, you're making a huge mistake. Don't settle on something or don't avoid something just because the training is going to be longer than you hope for. It may seem a long time at the beginning of your career, but it's actually not a lot when you look back at it. So don't use this as your criteria for deciding what specialties you're looking at.

Another question you should ask yourself is do you need a lot of variety? Maybe the emergency room is good for you. I interviewed an emergency medicine physician back in episode 02 and he said majority of the day is spent dealing with a lot of the same stuff over and over again. All the other stuff is just a small percentage of what you see. Everything you do as a physician will get monotonous so you need to really love the monotony. Don't go into emergency medicine because you want to treat gunshot wounds all day long because that's not what your career is going to be like. You have to like all of the other stuff.

[12:50] Blood and Guts

How much you can handle blood and guts and how squeamish are you is a silly question. As we've heard from Dr. Melinek, again back in Episode 24, as a forensic pathologist, she deals with a lot of nastiness. With crime scenes and accident scenes and everything else, you're dealing with squished heads and blown up bodies. She said you just get used to it and get desensitized to it. It's something that happens all the time with your training. Right now as a premed or medical student, don't think that you don't like blood and guts because as you progress through your training, you will become more and more accustomed to blood and guts. Maybe you're different, but use that criteria right now and put that aside.

[13:55] I Am Not Good with My Hands!

Surgical skills can be taught so don't worry about that. If you feel you don't have that much manual dexterity, a lot of that stuff can be taught. Don't write off surgery just because you don't have the manual dexterity. Practice and get better. There's still lots of time.

[14:35] Medicine or Surgery

These are the general things to think about as you're starting this search and as you're hearing these episodes. When you're starting down this path and you're getting into the weeds and thinking what you're interested in, there's this huge divide. You have medicine and surgery. Medicine is going to be pediatrics, neurology, radiology, and internal medicine docs and a lot of those subspecialties. You're going to deal with a lot of the bread and butter.

To get started, go to the AAMC Careers in Medicine website to check out a huge list of medical specialties and what is available for you. This is where you start looking as far as what's out there.

On the other hand, F.A.C.S. (Fellow of the American College of Surgeons) recognizes fourteen surgical specialties. But surgery is surgery. Do you like the O.R. or not? Again, do not think about it as whether you like blood and guts or you get queasy around it because this is stuff you will get used to every time. Don't worry about it from that perspective. Personality-wise, the O.R. is a little bit different. The environment is different as well as the pace. Do you like that sort of environment? You don't know until you get in there.

There are four specialties typically named that are a great mix of medicine and surgery. We had this in last week's episode with urology (Episode 25). Urology, ophthalmology, EENT, and OB/GYNE are considered a really good mixed specialties that have medicine and surgery. So if you find yourself stuck in the middle of wanting to be in the O.R. but wanting to do a lot of medicine as well, take a look at those.

Do you like procedures? Dermatology is huge with procedures.  I've talked with Dr. Chris Sahler back in Episode 13 about Physical Medicine & Rehabilitation and how there's a lot of procedures in that specialty. Are you interested in working with your hands and doing that sort of thing but don't really want to be in the operating room?

There's a great ScutMonkey Comics by the blog site The Underwear Drawer that presents The 12 Medical Specialty Stereotypes, which I think are pretty spot on and funny. Take a look at it too as well as a couple of fun algorithm charts out there or a flow chart of how to choose your medical specialty.

[18:37] Final Words

Things you don't want to look at when it comes to choosing a career is income. It should be last on your list as far as what you're hoping to do in the future. Don't look at potential income as you won't be happy. You may get lucky but more than likely, you won't be happy if you're in it for the money which is the wrong reason.

Don't think, either, that just because you're choosing a certain specialty in an academic setting, you're stuck there for the rest of your life. Once you have your specialty, you can go move to a community hospital.

So these are the things I want you to think about just to get you in that mindset of what you should be thinking about when you're listening to these physicians talk about their specialties. I ask these doctors what traits do they think are good for this particular specialty, and when you listen to those, they are very much always the same. Nephrologists seemed to be the odd men out with one specific thing that you have have to love attention to detail. But everybody else says you have to work hard and you have to want to help people, be a lifelong learner, and all those generic things.

If you have something else that you want to add to this list to help choose a specialty, shoot me an email at ryan@medicalschoolhq.net.

Links:

Specialty Stories Podcast Session 16: A Private Practice Nephrologist Who Also is in Academics

Specialty Stories Podcast Session 24: What is Forensic Pathology? Dr. Melinek Shares Her Story

Specialty Stories Podcast Session 2: What is Emergency Medicine? A Community EM Doc's Story

Specialty Stories Podcast Session 25: An Academic Urologist Shares His Thoughts on the Field

Specialty Stories Podcast Session 13: What is Physiatry? (Physical Medicine & Rehabilitation)

AAMC Careers in Medicine

Fellow of the American College of Surgeons

MedEd Media Network

The MCAT Podcast

The Premed Years Podcast

The OldPreMeds Podcast

ScutMonkey Comics

ryan@medicalschoolhq.net

Jun 07, 2017
25: An Academic Urologist Shares His Thoughts on the Field
35:18

Session 25

Academic Urology is a mix of medicine and surgery. Listen to Dr. Peter Steinberg discuss what drew him to the specialty, whether you and your personality would suit in this field, and what you can do to be a competitive applicant given that urology is one of the more competitive fields out there.

[00:50] Academic Practice

Dr. Steinberg chose academic practice over a typical community practice for two reason. First, he wants to have a more sub-specialized focus in his practice available in most community practices. Second, he enjoys working in training residents. He has been practicing for seven years now.

Peter started residency training in general surgery, which at that time most programs would require you to two years of general surgery prior to four years of urology. So he decided during his intern year to do urology, which was his second rotation as an intern and it was he deemed would fit him and his personality rather than general surgery. It took a while to get into a urology program but he kept doing general surgery and did the two required years before switching.

[02:05] A Better Fit to His Personality

Dr. Steinberg cites a few things that make him fit to be in Urology. First, the types of problems you encounter in urology involve a greater variety of issues compared to other fields like general surgery (at least as a resident where they often encountered issues that are extremely serious, extremely acute, and very challenging.) Urology, on the other hand, has a very broad spectrum of different things they dealt with ranging from simple issues to very serious and life-threatening and everything in between, something Dr. Steinberg was looking for.

Secondly, he noticed the personalities of the residents and the attending physicians matched his personality a lot better than a lot of the surgeons in terms of having a healthy work-life balance, good sense of humor, being jovial and collegial. And this speaks to the issues they're dealing with which are a little bit less stressful. He add that because of the nature of some of the problems, you have to deal with them with a little sense of humor with issues relating to people's sex lives and genitals.

As to getting a sense of what community general surgery was, Dr. Steinberg actually did a community general surgery rotation towards the end of his second year as a trainee, where he spent three to four months at a community hospital. They dealt with issues like hernia, gall bladder issues, and some serious issues occasionally. But  he saw a different pace as opposed to an academic center.

Dr. Steinberg stresses that the Venn diagram of overlap between training and practice can be very small depending on what you're interested in doing. He reminds med students and residents that in whatever job or field you're in, you can get it.It may not be exactly what you want, but whatever you want to construct in the medical field, someone somewhere will let you practice it. So seeing the community general practice was eye-opening for Peter where they seemed much less stressed and doing quick procedures with not a lot of complexity.

[05:49] Traits Leading to a Good Urologist

Dr. Steinberg describes Urology as a mix of medicine and surgery like EENT (Eye, Ears, Nose, & Throat) and that you need to have a couple of different aspects to your personality. You need some of that surgeon mentality of seeing problems that can be fixed and dealing with them rapidly and decisively. You also need a little bit of that family practice doctor type mentality where you're going to be dealing with people longitudinally where you have to get used to having rapport with people, building some trust, and dealing with them over time.

For instance, Dr. Steinberg does a lot of kidney stone work and a lot of nephrology where he deals with people with tinkering medications and their diet where he has to deal with them over the years. He also deals with them who have acute and surgical issues. You can have a multi-year relationship with someone where you go from doing some basic things to operating on them and dealing with them over time or they get another urologic problem over time.

Dr. Steinberg says you need to have a little bit of the longitudinal kind of primary care doctor personality and interest in dealing with the medical side of things but also some of the traits that go with being a surgeon in terms of being decisive and knowing when to and when not to operate on people.

Other traits he thinks would make a good urologist is having a good sense of humor that helps with everything in life, being loose, and being used to hearing things like sex lives and how they go to the bathroom. You need to have some degree of not taking things too seriously otherwise you'll have a hard time dealing with just how people describe their chief complaints and histories.

[08:40] Types of Cases, Typical Day, and Calls

Dr. Steinberg describes his mix of cases and patients with about two-thirds of his practice consisting of kidney stones, falling into general urology. The third is straight up general urology, encompassing issues like those having trouble urinating, blood in the urine, urinary tract infections, prostate issues, and other urinary complaints. He also deals with pain or complaints related to the penis and the testicle such as trouble with the foreskin, pain in the genitals, pain and swelling of the testicles, etc. This is the big bulk of general urology.

A typical week for a general urologist is somewhere between two and four days in the office and then one and two OR days. As with Dr. Steinberg, he will have a day consisting of office in the morning, a two to three-hour procedure in the afternoon, or in the office all day seeing a mix off new and returning patients and doing some office-based procedures such as stethoscopy or endoscopic checks of the bladder, vasectomies, biopsies of the prostate under ultrasounds. Some days he will be in the OR all day doing 30-60-minute outpatient kidney stone procedures and other endoscopic procedures, where he will do five or six of those in a day.

He sees around 1,500 patients a year and he does around 150-200 operations. He is a referral provider for other people sending in complex things. So it's a small percentage of the people he sees end up getting operated by him.

In terms of taking calls, Dr. Steinberg describes urology calls not to be horrendous. Most of the issues can be dealt with by emergency room physicians or some basic techniques known to other types of providers. In the group he's in, there are five of them taking calls so they are on call basically one week night and they have a larger group of people that take calls over the weekends so they're on call one weekend a quarter, a little less on the weekend than an average person but it really depends on the group size. Peter thinks most times, urologists are on call. If they do get called, they can have things the can deal with over the phone or things they need to be dealt with urgently or straightforward, as opposed to calls in other fields where calls deal with a lot of operations and doing a lot of stuff in the middle of the night. Basically, calls are very heavily phone, triage-based.

[14:37] Work-Life Balance

Dr. Steinberg says he has a good work-life balance. First, he takes all his vacations. Secondly, he enjoys going to medical meetings and he has found a good way to attend a variety of different meetings each year, about three to four of them which allow him to get away from work. Their national meeting is usually around May and regional meeting in the Fall. the subspecialty meeting is close to the end of year. He likes to ski so he also finds a ski meeting he goes to in the winter. So on top of going on vacation, he also gets away from work to go to meetings which he finds relaxing.

During his free time, he does things he enjoys such as skiing, sailing, and surfing. And living in Boston, he works around a lot.

[15:50] Residency Training Path and Competitiveness in Matching

Urology residencies have increasingly gone into five-year programs, which now include one year of general surgery internship and then four dedicated years of urology. More urology training goes to fellowship now because a lot of times, they're not getting all the skills they want in a particular subspecialty during their undergraduate training.

In terms of matching, Dr. Steinberg describes Urology as a very competitive field to get into. There are a couple of things unique about it. One, it has its own separate match and not part of the conventional match. It's one of the early match programs such as ophthalmology and plastic surgery and it's run by the American Urological Association. It's highly sought after now because of the work-life balance a lot of people find within the field. A typical urology applicant nowadays has a strong resume in terms of academic achievement in college and the basic science part of medical school. They have good marks on rotations like surgery and medicine and often get very good board scores, which is often the screening tool that programs use to pick out who they're going to interview. A lot of people have research experience or some other type of unique clinical experience such as doing an underserved clinic or traveling to the third world to bolster their resume.

Additionally, something very critical in matching into urology is doing away rotations at programs you're highly interested in matching in and performing well there. Most of these are pretty standard in terms of competitive programs having students come from other medical schools and you function as a sub-I on the service. Generally speaking, you're graded on a couple of things such as your performance day-to-day. Most programs make you give a big sum-up talk at the end of your rotation, a big area you're graded upon. Dr. Steinberg thinks most programs pretty heavily weigh people's performance on those types of away rotations as far as their rank list goes. Lastly, letters of recommendation go a very long way in this field because it's a small field. There are only so many training programs.

[20:03] Bias Towards Osteopathic Physicians

This was a big debate about a decade ago, having concern at the higher levels of organized urology about things like extending board-certification to osteopaths. But his has mellowed and there's been much more embracing of osteopaths within the field. There are some osteopath-specific programs out there such as Michigan State. Peter is not seeing any huge bias towards it but he thinks most osteopaths still currently congregate towards a couple of the more osteopath-specific training programs. This may improve in the future but for the time being, a lot of osteopaths going into the field end up in the more osteopath-oriented residency programs. Although Peter doesn't have osteopathic physicians as colleagues at their academic center, he thinks this is somewhat regionalized. He went to medical school in Philadelphia and PCOM (Philadelphia College of Osteopathic Medicine) was around so they were used to having osteopathic colleagues on rotations and as residents and faculty because there were so many PCOM graduates in Philly. He remembers the best anesthesia resident he ever worked with was a PCOM grad. So Dr. Steinberg thinks it's still somewhat regionalized given the fact that osteopathic schools tend to be regionalized. So a urology training in Philadelphia or Michigan is still that way to some extent.

[22:25] Message to Primary Care Physicians

Dr. Steinberg has actually been waiting for this to be asked for three years now. He sees three things that are routinely issues and backed up by the data people have acquired. He sees tremendous reluctance on the part of house officers and even attending physicians in practice to not do a genitourinary exam, a pelvic exam, or a rectal exam. They teach this to the second year medical students at Harvard where they do a half-day session on these skills. He finds it remarkable how often they get consulted and there's no documented genitourinary exam in the chart. The same goes with outpatient referrals.

He emphasizes that you have to learn how to do those exams as they're not that complicated. In fact, any urologist would be happy to show you how to do these things if you don't know how.

Secondly, Dr. Steinberg says that people need some basic skills in medical school and residency to put a Foley catheter in. You're not always going to have a urologist close by where you're going to be. It's not that complicated. There are times when you need a urologist to help you do it and there are certain things to look for there but it's a very important basic skill for everyone to learn.

Diagnostically, he thinks it's almost embarrassing how he feels like people have lost sight of how to do some basic work ups of common problems we see such as hematuria, kidney stones, working up an elevated PSA, a urinary tract infection, and just the basic things. If you're confused about the basic work up, especially when it comes to imaging for certain problems, the American Urological Association and other associations have tremendous guidelines on how to deal with basic problems. Dr. Steinberg recommends seeking the guidelines from some of these subspecialty areas to get some basic information on evaluation of hematuria, kidney stones, etc. So just know some basic things about what imaging tests you need, doing a good exam, and being able to put a Foley catheter in would go a long way and this would put you at the cream of the crop of internists in terms of dealing with these things.

[25:10] Working with Other Specialties and Subspecialty Opportunities

Dr. Steinberg is a bit unique in a way that he does a lot of complex kidney stone work so he deals with interventional radiologists and this is true for a lot of radiologists doing a bigger practice. Interventional radiology and radiology in general is going to be one area where you work very closely together.

Other specialties a urologist might work with include Pathology (if you do a lot of prostate biopsies, prostate cancer, bladder cancer, kidney and testes issues), medical oncology, gynecologic oncology, gynecology, obstetrics, colorectal surgery, nephrology, and pelvic surgery.

Moreover, fellowship opportunities are rampant within Urology including oncology, endourology, minimally invasive surgery and robotics, pediatrics (a separate board-certification now), female urology and incontinence, voiding dysfunction in men, reconstructive urology (urethral stricture disease), sexual dysfunction, andrology, male infertility and doing vasectomy reversal. Obviously, there is a variety of areas of subspecialization you can pursue.

In addition, if you go into practice and your group is big enough, usually people will tend to subspecialize to some extent. Even with urology, just residency training, there is tremendous ability to carve out your niche in the team like you could be the incontinence person in the group or the kidney stone, etc.

Dr. Steinberg explains that gender re-assignment is extremely subspecialized and that most of the male to female full reassignment is done by plastic surgeons. Some urologists will do male to female surgery because it's less technically demanding and does not require microvascular or microsurgical skill but that tends to be pretty heavily done by plastic surgeons. There are a few urologists involved in that and if you did want to get into that as a urologist, there is tremendous opportunity out there to be involved with that. Peter thinks it's a very under-served area without a lot of people with good skills. He adds that If you did reconstructive fellowship, you will immediately have a two-year wait list for operative patients if you went out into practice.

[29:05] Special Opportunities

Dr. Steinberg says there are ample opportunities to do things that are not direct patient care such as research in an academic setting or in any industry. There are tons of innovation within urology especially devices like for kidney stone, robotic surgery, incontinence surgery and pharmacologic work on things like the bladder, prostate, and in oncology.

There are tremendous opportunities in hospital administration and a lot of leadership opportunities within urology. You can do legislative work and advocacy. They have a political action committee called UROPAC. There's a congressman in Florida who's a urologist.

You can also do consulting to work with investment firms to figure out would certain areas be good investments. You can be a typical healthcare consultant. You can also do medical legal work as an expert witness.

[30:30] Most and Least Liked about the Job and Major Changes in the Future

What he likes most about his job is taking people who are feeling really unwell and getting them back to normal health. The least think he likes about being a physician in general is a lot of metrics in bureaucracy is making daily patient care more challenging. The focus of large healthcare organizations is getting slightly off-track from patient care and physician empowerment. Although Peter thinks the pendulum is going to swing the other way a little bit on this but it's his biggest gripe.

Dr. Steinberg thinks we've been in a drought for the last five to ten years and he thinks we're due for something. He's not sure where it's going to be but he thinks Urology is definitely due. Another big thing is the change in how care is delivered within the specialty in terms of people becoming employed by hospitals, larger groups forming, fewer small, private practices, and the consolidation of physicians together.

If he had to do it all over again, Dr. Steinberg would still have chosen Urology as the field suits him very well and he thinks it's an excellent choice for people with his personality and interests.

[33:50] Final Words of Wisdom

Dr. Steinberg leaves us with an advice that if this something you want to do, you will find a way to get into it. If you've got some deficiencies in your application in some ways, it's very easy to make up for problems with low board scores or some bad rotations. You can make up with it very easily with a strong research program, picking a program where you want to go and becoming a known entity there through research and away rotations. Don't be discouraged. With some embellishment of your CV, by being affable, and by being a good team player, it can be achieved if that's what you really want to do.

Links:

MedEd Media Network

UROPAC

American Urological Association

May 31, 2017
24: What is Forensic Pathology? Dr. Melinek Shares Her Story
47:15

Session 24

Today's guest is Dr. Judy Melinek, a New York Times bestselling author and a Forensic Pathologist based in California. She documented her journey through her fellowship training in her book, Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner.

One important thing to note is that Pathology isn't actually a required rotation in medical school, one reason that it's not commonly under the radar of most medical students. Listen to our discussion about the field of Forensic Pathology and how you can explore if this is something you're interested in.

[01:20] Working as a Forensic Pathologist

Dr. Melinek does some academic work. She is currently affiliated with UC Davis as a Research Associate. Forensic Science students from their Master's and undergraduate programs shadow her but she isn't presently on staff at any academic institution.

Most forensic pathology jobs tend to be for government agencies, either a coroner/medical examiner's office. Any academic affiliation usually tends to be in the clinical instructor's status teaching residents and medical students.

Dr. Melinek did her fellowship in Forensic Pathology from 2001 to 2002 and then she did another fellowship in Neuropathology from 2002 to 2003. In 2001, she started working as a Forensic Pathologist because even during fellowship, she got paid doing autopsies being part of the coroner/medical examiner's office, specifically working for the New York City Medical Examiner.

[02:49] The Road to Forensic Pathology

Dr. Melinek only figured out she wanted to become a forensic pathologist until later since she wasn't exposed to it as a specialty in medical school. She stresses this is something we need to further discuss and explore because it's a real failing in our medical education that pathology is relegated to second year academic discourse but there is no required pathology rotation in medical school like there is for internal medicine or general surgery. It's only something people have to discover on their own.

Dr. Melinek got exposed to Pathology in second year medical school just like all medical students and then they offered this post-sophomore fellowship in pathology, which is an extra year you take in medical school between second and third year and work in the pathology department. You're just like a resident and you get paid but you're not just a resident or MD yet. But it's an opportunity for them to expose people to pathology in a more hands-on level.

She basically did this post-sophomore fellowship in Pathology having wanted to take a gap year between college and med school. But she got in off the waiting list and she was afraid she would lose her spot if she decided to defer. So she found this as an opportunity to take a break but still be doing medicine and working at the same hospital she was training at. Dr. Melinek describes it as a great experience having been exposed to multiple different rotations in pathology including the blood bank, autopsy, and surgical pathology. Also during that time, she was allowed to do research and she actually decided to do research with the liver transplant team. That's when she fell in love with surgery and decided she wanted to be a surgeon. But everybody in Pathology convinced her to be a pathologist.

Upon finishing medical school, Dr. Melinek matched in Surgery and went to a General Surgery residency and lasted for only six months until she collapsed from exhaustion and decided she wanted to be a Pathologist realizing it was a better fit for her personally and professionally. Because of her impressive work, the pathology department at the UCLA Medical School had saved her a spot outside the match so when she quit surgery, they gave her a spot to start in July. Dr. Melinek claims it was the best decision she ever made.

[05:40] Post-Sophomore Pathology Fellowship and Demand

This type of fellowship is sponsored through ACGME and the American Board of Pathology. The organizations that accredit pathology residency programs allow a year of pathology while you're still in medical school and it accounts towards your residency. This existed when Dr. Melinek was still in medical school. (Upon checking on the internet, some institutions that offer this program today include UCLA, Stanford, Duke, and West Virginia University. Check with the institution you’re interested in getting into if they offer such program.)

Of the six post-sophomore fellows they had during her time, three ended up in Pathology. Dr. Melinek says this program helps people who are interested in the field to pre-select and also it cements their interest. It's an easy way to get people interested in it.

She adds that Pathology is easy to recruit for once you're exposed to it. It's such a wonderful field. It's so intellectually stimulating. People are really nice. It has pretty decent work hours and not as physically or emotionally grueling as some of the other specialties can be, especially surgery. Dr. Melinek thinks it's easy to recruit but the problem is it's not a required rotation in medical school so it's not in the radar of a lot of students. It's not something they think about.

As a result, there are only about 700 or so board-certified forensic pathologists practicing in the United States, which is half of what they need for the demand. She sees job openings that are open for months and even years because there is just not enough forensic pathologists to fill. Dr. Melinek therefore highly recommends the field for medical students to consider in terms of job security and opportunities.

[07:51] Surgery versus Forensic Pathology

Dr. Melinek got drawn to surgery because of it's hands-on nature and you get to fix things, as a practical person that she is. However, she wasn't attracted to the field's lifestyle and found it to be too exhausting. She was on call every other night and she had to watch her attending physicians cycle through multiple marriages and being there late at night for long hours, sacrificing their family times and their own mental health in exchange for the career, which she thought as unnecessary. She believes it's a financial burden and a cultural problem in the field and that you really don't need to train surgeons this way as there are more reasonable programs in general surgery.

What Dr. Melinek likes about pathology is the reasonable hours. She basically was drawn to it primarily because of that exposure she had in medical school though at that time she didn't have the passion for it that she had for surgery. She felt disconnected from patients and that she wasn't being a real doctor. People do criticize that which of course Dr. Melinek thinks is such a crap. Anyway, she felt disconnected from patient care and from the action and excitement that surgery had until she did her forensic pathology rotation at the New York City Medical Examiner's Office.

[09:22] The Work of a Forensic Pathologist

When she was a resident in Pathology, they did rotations in different fields and she went to the New York ME's office for a one-month rotation. There she fell in love with the field, being able to go to crime scenes, testify in court, and interact with police officers and with family members of those who had died. She finally got that variety and excitement she was missing.

Dr. Melinek wants people to understand that this is the pathology work. You're not just in a lab doing autopsies and looking at microscopic slides all day. You do a lot of field work, going out to scenes as well as a lot of work interacting with a lot of families on the phone. You testify in court at least once a month on average for her. You also interact with lawyers as you try to explain the science to them. Basically, you're built in as an academic and a teacher even though you're not officially in an academic environment. Dr. Melinek finds herself educating family members about the disease process that killed their loved ones over the phone. She finds herself teaching juries about science so that they can make a good decision about guilt or innocence about civil liability. She considers herself a teacher, just not in formal academic setting.

[10:55] Traits of a Good Forensic Pathologist

You have to be curious and to be the kind of person who digs more into something when it doesn't make sense or it sets off your BS meter. A lot of medical specialties are not going to have all the answers and you have to take the best pass forward given the limitations of your time and financial resources. But in forensics, you have time. They have an expression in forensics that is kind of tongue in cheek, "They're still be dead tomorrow." On the plus side, it means you can work on a case the next day and not have to rush it. The other aspect of that is you can put this off 24 hours and think about it. You can look up another article or contact your colleagues and wait. There's no rush in those cases for you to come up with conclusion. What's more important is for it to be rigorous, accurate, and defensible.

[12:12] A Day in the Life of a Forensic Pathologist

Dr. Melinek currently works three days a week at the Alameda County Sheriff/Coroner's Office and sometimes fill in on Mondays or Tuesdays if other people are sick or on vacation.

Her typical day at work is waking up at 6:00 to 6:30 am and gets a text from her boss informing her of the number of cases she has. She gets her kids off to school and then driver to the office which is a 40-minute commute for her. She gets in at around 8:40 am. She reviews the cases and paperwork generated by death investigators from the office who are deputy coroners and they're the ones who went out to the scene and collected the dead body. They have a clinical summary about what happened to the deceased, whether they were ill or drug abusing, or when they were last seen alive, when and how they were found, the condition of the body. All of these are in the report. They review the reports and then split it up among themselves. In her current office, there is one chief forensic pathologist and four assistants who stagger their schedule so there's usually two or three of them on a given time. From 9am to noon, they go in the morgue doing the autopsies. A typical autopsy takes about an hour or an hour and a half at the most if it's a homicide case. Some cases can take multiple days where she would do two hours one day and two or three hours another day or splitting them up over several days. But majority of the cases can be done in an hour to an hour and a half.

In the afternoon, she does paperwork, field phone calls, talk to lawyers, and also does her consult work. In addition to working for the coroner's office, she is also an independent forensic consultant so she can get hired usually by attorneys and sometimes family members to do a second autopsy or give an opinion in a case of wrongful death, whether civil or criminal cases. She looks at paperwork and reports and gives them her opinion. Sometimes, she gets called to testify for court.

[15:00] Percentage of Cases

For the bodies that she's doing an autopsy for, their causes of death are a mix. About 10-20% of her cases are homicides, which is disproportionate compared to what you see on television. The remaining 80% is a mixture of natural deaths, people who are elderly or young people with natural disease but haven't seen a doctor. They either died at home or en route to the hospital or in the street and they don't know why they died. Then when she does the autopsy, she finds natural diseases, heart disease being the most common as well as lung disease from smoking and complications of obesity on the natural death spectrum. Another equal percentage of cases comprise accidents which are predominantly motor vehicle fatalities and overdoses. They can make it to the hospital and survive for a period of time but they'll still come to their office because any case that is sudden, unnatural, or violent gets evaluated by the medical examiner. A smaller percentage would be suicides. Dr. Melinek reckons it's 20% homicides, 80% split up between natural, accidents, and suicide.

[16:35] Call Schedule and Crime Scenes

In her current position as a contract pathologist, she doesn't take calls. The only person on call is the chief forensic pathologist and she estimates that he gets called out to scenes maybe once or twice a month at the most. In the previous job she held at the San Francisco Medical Examiner's Office, there were four of them who would split up calls. So they'd be on call for one week at a time, which means you just get called out at night to crime scenes and she gets called out about once a month. It would be unusual for her to called out twice in the same week, and it's usually once a week.

Most people may think that when you're being called out in a crime scene, they'd imagine CSI, Bones, or Dr. House. In reality, Dr. Melinek says it depends on the case. When she was In San Francisco, they get called out just for homicide, which are clear cut cases or those where they suspected a homicide. If she went out to a scene, it would have already been cordoned off by the police with a lot of police activity and the medical examiner would be the one would come in underneath the line. First, you have to sign in so they have a log of who comes in and out of the scene. You have to have your personal protective gear, gloves, booties, depending on the condition of the scene. The first thing they do when they get there is get basic information from the police officers at the scene about what happened, how was the body found, were shots fired, what did people hear or see, what are witnesses telling you. Then they go over to the body. They don't move it until after it's been photographed. A lot of time on the scene is typically spent waiting for the crime scene unit photographers to do their work and document everything with photography and video. And only then can they move the body, take a look, and assess the injuries so they can give the homicide detectives at the scene an idea of what they're seeing on the body and some leads about things they can question witnesses about.

When asked about how she gets used to seeing these crime scenes, Dr. Melinek explains that all of medicine is a desensitization process. She remembers the first time she came in and got introduced to a cadaver on her first year of medical school and she freaked out. She knew she would be dissecting a cadaver because that was part of medical school and she's always been fascinated in human anatomy and how the body works. She says there's always a gross out factor but you still find yourself getting drawn to it. You actually get desensitized over the course of medical school, the first time you see a delivery or an autopsy or you do surgery and you see somebody's chest wide open with a heart beating. It's shocking yet you're trained sufficiently to do your  job and follow the lead of the people with you in terms of learning how to cope with the stresses of the job.

Dr. Melinek finds that forensic pathology is actually less stressful than taking care of living patients for which she has done both. When taking care of patients, there are demands of the patients and families which can be unreasonable. They're in pain and suffering. They're not happy. So she found it more stressful given that and it was harder for her to separate from that and forget about it once she gets home than it is for her dealing with the horrible things she sees on the daily basis because she knows they're no longer suffering and out of their misery. She deals with this by thinking it's her job to make sense of this chaos and give some closure to the family and answers to the legal system that can help repair the mess that a few seconds of impulsivity created.

[21:05] Postgraduate Training for Subspecs

After finishing medical school, the minimum is three years of anatomic pathology residency and one year of forensic pathology fellowships. That's a total of four years of postgraduate training before you can go and work at a medical examiner/coroner's office.

Dr. Melinek did surgery first and then when she went to pathology, she didn't know she wanted to do forensic so she did both four years of anatomic and clinical pathology. Anatomic and clinical pathology combined make you more marketable for working in a hospital setting. Clinical pathology involves laboratory medicine so it involves managing the laboratories at the hospital, the blood bank, the hematology lab, the toxicology lab, the microbiology lab. It involves learning how the test work, the assays work, and how to supervise and manage the equipment and the technologists who work there.

So instead of the minimum three, Dr. Melinek did four years of residency and then two years of fellowship, one in forensic pathology and the other one is forensic neuropathology, which was a program that her fellowship placed at the New York City Office.

A typical neuropathology involves working in a hospital setting where you're diagnosing tumors and doing surgical pathology. It's a two-year program where one year is spent examining brains and doing surgical pathology while the other year is spent doing research in order to be board-certified. Instead, Dr. Melinek just did one year of examining brains in a forensic setting. It's both brains and spinal cord taken out of the autopsy in cases where the death is sudden or violent, sometimes they have gunshot wounds, sometimes history of seizure disorder, sometimes without any history and the pathologist out of prudence, saves the brain and spinal cord for a more thorough analysis by a neuropathologist. They would slice the brain and spinal cords and then look them under the microscope to make a diagnosis of things like Alzheimer's disease or chronic traumatic encephalopathy (CTE) which is injury caused by repeated concussions.

[23:41] Competitiveness and Testing the Waters

Dr. Melinek says it's not competitive to become a forensic pathologist, in fact, it's easier compared to other specialties and subspecialties. She adds that a lot of pathology programs don't fill. This is actually surprising to her because it's a great, fun job, especially now that she's hitting middle age and a lot of her friends and colleagues that have gone into other specialties are hitting burnout but she's not tired at all. She actually has colleagues in their early 80's and are still practicing because they love what they do. Everyday is something new. Everyday is challenging.

If this is something you're interested in or you just want to test the waters, Dr. Melinek recommends that you do well in your histology and pathology coursework in first and second year of medical school. Then start talking to your teachers, most of them are in the pathology department at your hospital. Find out about doing rotations with them and see if you can shadow them. Go down to the surgical pathology division and find out when they have their rounds or when they have their teaching cases. Sometimes they have resident conferences where they sit around the microscope and they look at slides. They always have extra room for medical students. She further says there really are not enough medical students who are interested in this field so they get so excited when someone shows up. You can just set up the microscope, listen in and look at the pretty pictures. If you get dizzy looking at the microscope, just look away when they're moving the slide and look back when they got it fixed. Lastly, start reading about the subject. She recommends doing rotation in your third and fourth year. It's going to have to be an elective. And if your medical school is affiliated with a coroner/medical examiner's office, she recommends taking an elective at least one week there to see what they do. Even if you don't end up going into forensic pathology, say you're interested in internal medicine or surgery, you will still benefit from it because it will give you a perspective that nobody else has and it will help you understand how to prevent death in your patients.

[26:47] Osteopaths, Subspecialty Opportunities, and Interaction with Other Specialties

Dr. Melinek explains there are plenty of opportunities for osteopathic students in forensic pathology. Having a DO is not an impediment in getting either a residency or fellowship in general pathology or forensic pathology. She has several DO friends who have gone through the program. The only frustrating thing for them sometimes is keeping abreast of the osteopathic manipulation requirements necessary for licensure and continued certification, which can be annoying since it's not something they use everyday but they just take the courses and do it.

Other subspec opportunities after forensic pathology include neuropathology, anthropology, pediatric pathology, and cardiac pathology.

Dr. Melinek doesn't work directly with other specialties but she interacts with them through medical records like when she gets charts from people who have died and she calls the primary care doctor of the deceased to get more information. More of them are psychiatrists such as issues pertaining to substance abuse and suicidality and cohort population. She also interacts with geriatricians especially when they don't write death certificates properly and she'd have to educate them about how to properly code or write a death certificate that would be accepted by the Department of Public Health. She also interacts with other pathologists and consults with them on their cases and getting additional information about things like unusual tumors or those less common in their cohort. She sometimes get unusual disease process she doesn't see frequently enough to be able to diagnose right way that's why she sees the importance of being affiliated with or have relationships with hospital pathologists to help guide you.

Her advice to those getting into geriatrics to schedule an elective rotation during medical school in the pathology department or at the medical examiner/coroner's officer to give them a better appreciation of who it is doing the job and why they do it and how they're trained. It would also teach them to write proper death certificates so they don't run into trouble as they mature as practitioners.

[30:45] Other Special Opportunities Outside Practice

Dr. Melinek considers doing extra witness consult work as the most lucrative and rewarding where you get hired by either family members to do a second autopsy when they don't trust the first autopsy or if the coroner/medical examiner has declined to do the autopsy saying it's not within their jurisdiction but the family members will sometimes want an autopsy anyway so you can do private autopsies in that setting.

As for legal cases, Dr. Melinek finds that her consult work is a lot more challenging than her work for the coroner/medical examiner with regards to the complexity of the cases. If something's going to court, it's because of a dispute, which is something people don't agree with. It can be challenging to review all the materials and come to some sort of consensus or opinion that can bring the sides together which she finds very rewarding.

[31:45] What She Wished She Knew Before Starting Forensic Pathology

She wished she had known how political it could be. Although it wouldn't have changed her opinion since she still would have chosen the same path, she thinks she would have been a little bit more prepared for it emotionally and mentally for some of the challenges that the field has, especially for issues that officer-involved shootings or in-custody deaths, high-profile cases such as when a celebrity dies. She finds it stressful to be the one that everybody is search answers for and having the pressure of the family and media and supervisors are trying to get you to come up with an answer quickly. And as she reiterates, forensic is best done over time meticulously and slowly so you can come up with a thorough answer that's defensible. Granted there are some circumstances like in surgery when someone is bleeding out where you have to work quickly, but in majority of cases in medicine, you do have some time. And if anybody is trying to rush you or do a stat on something that doesn't need that level of urgency, you should immediately put the brakes on and slow down because that's when you're going to screw up. Dr. Melinek insists this is an important lesson to pass on to anyone that it's important to take your time and do a thorough job otherwise you're going to miss something if you're stressed and under outside pressure.

[33:40] Media Training

Dr. Melinek says most of the training comes on the job itself. Having a good fellowship program and having good mentors who are willing to teach you about it especially if you go to a good urban area as opposed to a suburban area, you will get exposure as there will be high profile cases and stuff in the press. You have to learn from your colleagues and the staff you work with on how to manage it. She adds it's worthwhile later in your training once you've already become a forensic pathologist to take some time to do media training and learn how to work with media professionals to answer questions in an interview setting. Give sound bites to the press and interact with them so you're able to get your message across. Media training is something you're not going to get in medical school. You're not going to get it on the job and it's something you essentially have to seek out and pay for yourself. She did it a few years ago when the her book, Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner came out, which she co-authored with her husband, T.J. Mitchell. It's a book about her forensic training. She had to learn how to interview and how to talk to the press and the training she did for the book publicity has reaped rewards as a forensic pathologist as well because it has taught her how to interact with the press in high-profile cases.

[35:20] The Most and Least Liked Things about Forensic Pathology

What Dr. Melinek likes the most is the excitement and unpredictability of it and the fact that she is here to serve anyone. When she walks into the morgue every morning and gets the list of cases, it could be someone wealthy or poor, a really famous person or someone unknown. She compares it to a box of chocolates, you never know what you're going to get. Death is like that as well as life, you don't know what you're getting in the morning and you just have to learn how to roll with the punches and deal with it the best way you can. She adds how rewarding it is to be able to help family members. She loves having patient contact in terms of relating with the family members of the deceased who are her patients too, helping them with grieving, closure, and understanding the process.

What she likes the least is true with any job and it's dealing with nasty people. Sometimes you have to interact with people under stress or micromanaging supervisors. Working at a sheriff/coroner's office, some of her immediate supervisors are not physicians so they don't understand medicine. She finds it frustrating sometimes to explain to them what she does and why it's important in terms of getting the financial or time support she needs.

[37:53] Changes in Forensic Pathology Over the Years

Dr. Melinek has seen changes in her career in the past fifteen years such as the advent of CT scans with 3D imaging coming into the forefront which is becoming more common not only in the hospital setting but also in the medical examiner's setting. Genetic testing has also advanced tremendously so now they have access to genetic tests for sudden cardiac death genes, things that can predispose someone to channelopathies or risk factors for sudden cardiac death that they can communicate to families. There now changes in histopathology in terms of the quality of slides they're getting, the scanning capacity, digital forensics, being able to share information.

The basic techniques are the same since you're still have to cut a dead body and you're still going to need your scalpel and scissors. There is virtual autopsy where people use CT scans or MRI to diagnose certain diseases but ultimately, autopsy is the gold standard and you can't use a virtual autopsy to diagnose an infectious disease and you still need to take a sample from the body and grow it in a laboratory. Or you still need the microscopic sections of the heart to diagnose cardiac defect. Radiology is good to a certain degree but autopsy is the gold standard and still relied upon on most court settings.

Lastly, if Dr. Melinek had to do it all over again, she would still have chosen the same specialty. In fact, she would have skipped surgery and went straight into this field. She also wishes to leave a message to medical students. In medical school, she got the impression that once you choose your specialty, that's it. And if you fail out of your residency or hate it, you're stuck and you're not going to be able to find another residency. It's going to be difficult for you to switch. About 1/3 of doctors switch their specialties at some point in their career, whether during residency or after it and then they do a separate residency. Some do it halfway through a career even in their 50's. Dr. Melinek wants students to be aware that switching is possible. You're not a loser if you hate your residency or you're miserable. There are other options. Sometimes places will take you outside of the match, other times you can go through the match again and you will find a position that fits. Sometimes it's also not the career but the job. It may be the right career for you, which is the right specialty but you just happen to be in a bad residency program or a bad job environment with a bad supervisor and sometimes switching jobs is the solutions. But there are options out there so don't feel like you're not going to be able to find a position in medicine because you're not happy where you are currently.

[41:15] Working Stiff

Dr. Melinek explains the impetus for writing her book, Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner. While she was in medical school, she had a professor who encouraged them to keep a journal to document their transition from lay people to medical people, how they learned the terminology and how they became doctors. When she decided to do forensic pathology and was starting the fellowship, she thought how inaccurate all of these televisions shows are and nobody knows about the forensic process she's going to be going through in the next year so she decided to start writing her journal. Everyday, in her one-hour commute to work and another hour going back, she had two hours a day for writing, using a handheld device where she kept a journal. At the end of her fellowships for two years, she had a baby and restructure the journal by cases. She had to take it out of chronological order to get a case-based narrative. She was working so she had to hand it to her husband, T.J.Mitchell who was an English major at college and had been working as a writer for other people.

The couple basically sat on it for about ten years. It was the tenth year anniversary of 9/11 that changed things for them and it was no longer personal history but what she had experienced was history since Dr. Melinek was one of the thirty forensic pathologists in New York City at that time of the World Trade Center attack. She was the rookie in the team, arriving in July and had two months to training before that attack happened. This then became a big part of her diary as well and tackling those chapters were the most difficult for her.

She didn't want to write a book specifically about 9/11 but something that would encourage students and experts in different fields to understand what it is they do and what the training process is like. Now, the couple are transitioning to a detective fiction novel they're working on.

If you're curious, there some shows working with consultants. In fact, Dr. Melinek has consulted on some shows in the past such as ER. The problem is they have to do change certain scenes in order to move the plot along. They do have consultants but they don't always listen to them.

[45:30] Final Words of Wisdom

If you're interested in pursuing this field, Dr. Melinek recommends you check out her website www.PathologyExpert.com and linked to that is her blog.

Specifically check out Dr. Melinek’s  blog post about the steps to becoming a forensic pathologist, addressed to students at different levels of their training, what to do if you're in high school, college, medical school, or in residency, as well as a paragraph each about the next steps and what you should look for.

Links:

Dr. Melinek’s  blog post about the steps to becoming a forensic pathologist

Dr. Melinek’s website: www.PathologyExpert.com

Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner

Post-Sophomore Pathology Fellowship Programs:

UCLA School of Medicine

WVU School of Medicine

Stanford University School of Medicine

Duke University School of Medicine

A Not Entirely Benign Procedure by Perri Klass

May 24, 2017
23: A Deep Dive Into PM&R Residency Match Data
22:40

Session 23

Our episode with Dr. Chris Sahler was one of our most popular episodes. I decided to bring you the PM&R residency match data since many of you seem interested!

[02:33] NRMP Main Match Data for 2017 - PGY-1 & PGY-2 Positions

Table 1 shows the match summary for all the different specialties and Physical Medicine & Rehabilitation only has 32 programs under PGY-1 positions. This is also one of those specialties where you can match into a PGY-2 spot and you have to separately apply for your internship. This table shows there are 62 programs for PGY-2 positions and that gives you a total of 94 programs. Just be careful when looking at data since some specialties may have they PGY-1 built-in while some do not.

Looking at PGY-1 spots, there are 119 positions. This is a relatively smaller program with almost 3 and 3/4 per program. And out of those spots, only one program went unfilled. There are 294 U.S. Seniors applying out of 595 in total who applied. (Remember for the purposes of this podcast when talking about match data, U.S. Seniors refer to U.S. allopathic students so these are students who are still in medical school going through the normal timeline so they're not taking any gap years after medical school.) This implies that more than half them applying for these spots are U.S. Seniors. Interestingly, only 74 U.S. Seniors matched for Physical Medicine & Rehabilitation out of 118 that matched.

Only 62.2% of the students that matched were U.S. Seniors. Comparing this to other specialties, 78.2% of those that matched in Emergency Medicine were U.S. Seniors, Neurosurgery at 83.9%, Neurology at 50.6%, and OB-GYNE at 81.4%. There is a very wide spectrum of what percentages of students matching are U.S. Seniors.

For PGY-2 Positions, students also need to rank and match into a PGY-1 spot, whether it's a surgery year, a transitional year, or an internal medicine year. So these are three different prelim years you can choose from. Out of those 62 programs, there were 294 spots available so it's almost 4 and 3/4 per program. This is a little bit bigger compared to PGY-1 position programs. And out of those 294 programs, none of them went unfilled. Out of 633 total applicants, 306 were U.S. Seniors and only 61.16% of those that matched were U.S. Seniors.

[07:28] Matches by Specialty and Applicant Type

Table 2 of the 2017 NRMP Main Match Data shows us where the other people are coming from. For PGY-1 positions, 33 were osteopathic students out of 118 physicians that matched in PM&R. This is 27.97%

Compared to other specialties. Emergency Medicine had 283 matches for osteopathic students (a pretty big number for non-primary care) out of 2,041 total students. That's 13.9%. So PM&R is 14% higher than that which is very interesting.

Looking at this data, you can't say osteopaths are at a disadvantage because less osteopaths are matching into some of these surgical positions. But if a student goes to an osteopathic medical school because they believe in their philosophy and manipulation, then going into surgery maybe doesn't make sense and so is going into pathology. So you can't just look at the numbers. You have to look at what's the reasoning behind the numbers.

It's easy to hypothesize that osteopathic medicine fits very well with PM&R, which is basically, non-surgical orthopedics. You're dealing with people who have aches and pains and joint issues as well as other things and osteopathic medicine works with that. So these PM&R programs seem to be very open to osteopathic students. In fact, Dr. Sahler talked about this in Episode 13 that PM&Rs are very open to osteopathic physicians.

For PGY-2 spots, all 294 positions went filled. 181 were U.S. Allopathic Seniors, 5 were U.S. Grads (these are students outside of the normal timeline), and 83 were osteopathic students, which means 28.2% of osteopathic students actually matched. So if you're an osteopath and are interested in this stuff, you have a good shot to get a spot here. Moving on, 17 were U.S. International medical graduates, 8 were non-U.S. citizen international medical grads.

[11:40] Positions Offered, U.S. Seniors, All Applicants, Osteopaths (2013-2017)

Table 3 tells us how the the number of spots is growing and looking at PM&R, it's growing slowly over the last four year at 0.4% every year for PGY-1 while for PGY-2, it's been growing much faster at 11% in 2017 from 10.9% in 2016. If you're interested in it, it's obviously a growing field for you.

Table 8 shows the percentages filled by U.S. Seniors versus all applicants from 2013-2017. It basically shows us a trend of what programs are doing, whether they prefer U.S. Seniors or U.S. Graduates or other students. Looking at PM&R for PGY-1, 62.2% in 2017 were U.S. Seniors, 61.16% in 2016, 60.7% in 2015, 56.3% in 2014, and 59.8% in 2013. So it has gone up pretty steadily over the last couple of years with more preference towards U.S. Seniors. For PGY-2, 61.6% U.S. Seniors matched, 52.8% in 2016, 45% in 2015, 53.7% in 2014, and 51.7% in 2013. There was a huge dip in 2015 which is really interesting.

Table 9 shows all applicants that matched by specialty. 0.4% of all students matched for PGY-1 spots matched into PM&R. Compared to other specialties, Surgery is 4.6%, Internal Medicine is 25.6%, Family Medicine is 11.6%, Anesthesiology is 4.1%.

Table 11 shows us osteopathic students matching into PGY-1 spots with 1.1% of all osteopathic medical students are matching into PM&R. Comparing that with the previous table of 0.4% by percentage, more osteopathics actually match into PM&R than allopathic students. This is very interesting yet it still goes with the fact that it does fit with osteopathic medicine.

[15:12] Unmatched and SOAP

Figure 6 of the 2017 NRMP Main Match Data shows the Percentages of Unmatched U.S. Seniors and Independent Applicants Who Ranked Each Specialty as Their Only Choice. PM&R is near the top of the list for total unmatched students at 27.5%. Internal Medicine (Prelim) is the highest followed by Dermatology, Psychiatry, and then PM&R. Majority of these students are independent applicants which means they are not U.S. Allopathic Seniors. You have osteopathic students, U.S grads who are already out of school and international medical graduates making up this number. This is a little scary since PM&R is higher on the list. Remember there was only one unfilled position so it's highly sought after for a specialty.

Table 18 is all about the SOAP (Supplemental Offer and Acceptance Program). Again, there was only one unfilled spot in all of PM&R. So for the SOAP, there was also only one spot available and as expected, it was filled through the SOAP.

[16:48] Charting the Outcomes 2016

Based on Charting the Outcomes 2016, Table PM-1 (Page 168 of 211) shows the number of contiguous ranks, Step scores, research, work experience, AOA, etc., to give you a picture of what these students look like for those who matched and did not match.

For U.S. allopathic Seniors, the mean number of contiguous ranks that matched are 14.2 programs while those that did not match were only 5.6. I can't stress enough the need for you to rank enough programs in order to match.

When you submit your rank list, you actually don't have to apply to only one specific residency program. You can apply to General Surgery and Orthopedic Surgery programs. For Physical Medicine & Rehabilitation, the mean number of distinct specialties ranked is 1.6 for those that matched and those that did not match were 2.2. Those ranking more programs are not going to be able to verbalize and communicate to these programs why they specifically want to go into PM&R because maybe they're out there ranking other programs.

Back on the data, the mean Step 1 score is 226, mean Step 2 score is 238. These are not terribly high Step scores. Those that did not match are 210 and 221 for Steps 1 and 2 respectively.

They have data for osteopathic students as well. Looking at Level 1 score for those that took the COMLEX, they have a 551 for those that matched and 492 for those that did not match, 563 for Level 2 that matched and 491 for Level 2 that did not match.

Charting the Outcomes 2016 Table PM-1 also looks at work experiences and volunteer experiences. AOA members comprised 6.2% of those that matched while 0% for those that were unmatched. (AOA in the allopathic world is for Allopathic medical students)

[21:10] Medscape Physician Lifestyle and Compensation Reports

Normally, I would also check on the Medscape Physician Lifestyle and Compensation Reports but PM&R is not included in the data probably because it's a smaller field so they didn't have enough respondents for it. So we do not have enough feedback to have the data here.

Links:

Specialty Stories Episode 13: What is Physiatry? (Physical Medicine & Rehabilitation)

MedEd Media Network

2017 NRMP Main Match Data

Supplemental Offer and Acceptance Program (SOAP)

2016 Charting the Outcomes - NRMP Medscape Lifestyle Report 2017

Medscape Physician Compensation Report 2017

AOA

May 17, 2017
22: What is Aerospace Medicine? Dr. Gray is Interviewed
46:37

Session 22

Aerospace Medicine is a subspecialty of Preventive Medicine and very unique usually to the military, though there are civilians equivalents.

If you are a premed student and you're getting ready to prepare for your medical school interviews, check out The Premed Playbook: Guide to the Medical School Interview. Its paperback version will be released on June 06, 2017. Preorder the book at Barnes and Noble now and you will get about $100-worth of free gift including a 1-month access to our brand-new mock interview platform (only currently available to those who preorder) and a 13-video course on the medical school interview. Text PREORDER to 44222 to get notified with instructions on how to get on this.

Back to today's episode, I will be interviewed by Ian Drummond, a fourth year medical student and the host of The Undifferentiated Medical Student podcast. Ian interviewed me back in Episode 24 of his podcast about aerospace medicine and I'm playing a part of his interview with me specifically relating to aerospace medicine.

[03:29] What is Aerospace Medicine?

AAMC's Careers in Medicine didn't actually have a description of aerospace medicine although it was listed under Preventive Medicine. Ian, however, will refer to this description provided by the Aerospace Medical Association and we will take it from there.

"Aerospace medicine concerns the determination and maintenance of the health, safety, and performance of persons involved in air and space travel. Aerospace Medicine, as a broad field of endeavor, offers dynamic challenges and opportunities for physicians, nurses, physiologists, bioenvironmental engineers, industrial hygienists, environmental health practitioners, human factors specialists, psychologists, physician assistants, and other professionals. Those in the field are dedicated to enhancing health, promoting safety, and improving performance of individuals who work or travel in unusual environments. The environments of space and aviation provide significant challenges, such as microgravity, radiation exposure, G-forces, emergency ejection injuries, and hypoxic conditions, for those embarking in their exploration. Areas of interest range from space and atmospheric flight to undersea activities. The environments studied cover a wide spectrum extending from the microenvironments of space to the increased pressures of undersea activities. Increased knowledge of these unique environments of “Spaceship Earth” helps aerospace medicine professionals ensure participants are physically prepared, physiologically safe, and perform at the highest levels."

[05:28] Building Trust and Relationships with Patients

I agree with all of it as a great representation from the organization. One of the biggest things missing which is unique to aerospace medicine is the relationships with patients. In fact, it is a huge factor in aerospace medicine which I think deserves its own call out there.

I will speak specifically to the Air Force although it's pretty similar for the army and navy which also have civilian flight surgeons. There are AME's (Aviation Medical Examiner) out in the real world that do physical exams for pilots. There is a civilian equivalent, just a little bit different for the military.

For the military, specifically for pilots, they usually go and see the flight surgeon for a few things. One is the mandatory annual physical examination (crossing their fingers that nothing is found). Second, if something is really wrong and they need help.

Typically, a pilot doesn't want to go and see the flight surgeon outside of those two things because every visit to the flight surgeon is an opportunity to lose their wings, which means they would no longer be able to fly. Because a flight surgeon has that control to make sure pilots and other people interacting with aircraft are safe operating the aircraft, it's their job to make sure that if they have any medical condition, we have to determine if they should continue flying or not.

As a flight surgeon, I was a rated flyer where I got to wear a flight suit and had wings. I was required to fly four hours a month to be part of the air crew to build that rapport and build that trust. I went for an MRI one day because I was having some symptoms and I got diagnosed with MS so eventually I was no longer allowed to go up in an airplane for the Air Force. Because of that fine line between being allowed to fly and have your career or you're not allowed to fly out anymore, it's such an important relationship to have that trust and rapport. It's one of the best parts about being a flight surgeon. There could be cases they're lying and hiding things from us, like a cat and mouse game, because they want to fly. They love their jobs and they love the camaraderie that comes with it and everything else so it's a large part of who they are.

Personally, I thought it was a stupid rule that I got grounded. MS is one of those weird things for aerospace medicine. The Israeli Air Force lets their pilots with MS fly. Ours is less progressive so they worry more about the cognitive decline since 75% of MS patients have some sort of cognitive deficit and that's what worries them. I did argue for a while but I lost.

[11:32] Flying the Plane

There are a couple of caveats here. In the navy, flight surgeons go through some of the pilot training courses. The army may do it like the air force where you go through a little bit of ground pilot school. For instance, they get to ride in a small Cessna plane and fly to see what it's like. The whole point of the flight surgeon is to make sure that pilot and other people can do their job so you have to understand what they're going through. Then you get to see how much there is to do.

I have my private pilot license. I have always been fascinated with airplanes so when I had the opportunity to get my private pilot license, I jumped on that.

As a flight surgeon where I had to fly four hours a month, it meant being part of the aircrew. So the majority of aircraft that I was in were bigger airplanes so I would just hang out in the back or in the cockpit but not actually controlling anything. Sometimes I would talk on the radio and help them with the radio stuff. The one time I got to fly something was in the backseat of an F-16 because the controls are right there.

When you have wings, it means you're in some way affiliated with the airplane. So it's not just the pilots, but also, load masters, navigators, flight surgeons, etc. having wings is just a designation that you're like a "real" Air Force and you're part of the plane considering there are other jobs in the air force that have nothing to do with planes (ex. bus driver, cook, etc.)

[16:08] Civilian Physician vs. Air Force Physician

When you're, say a Primary Care physician, there is almost never this thought about what job a patient does or can they continue to do it. It's usually the patient that asks for some time off because they don't want to work. But as a flight surgeon, that's always the first question at the top of my mind. I have to know what your job is and whether or not you can continue to do it. So if you're a pilot and you come in with a knee pain and I know that if an engine goes out and you need to push full rudder to keep the plane straight and land it, you're probable not going to be able to do that with how bad your knee is. So you can be grounded for a week or two to make sure your knees are better and then come back and see me to reevaluate.

*There is no such term as a "flight surgery" but it's an old name that's been held out for a long time. The actual practice is aerospace medicine and there are aerospace medicine residencies but you are a "flight surgeon" as an aerospace medicine specialist. There is flying but there is no surgery and there's definitely no surgery while flying. 

[18:44] A Typical Weekly Routine and Patient Types

A typical week for a flight surgeon is an ambulatory setting where you're seeing patients depending on what based your stationed at as an active duty flight surgeon. In some bases, you see dependents (the family members of the active duty member) while in others, you see retirees. So the types of patients you're seeing vary but you're seeing normal clinical stuff.

You're seeing a lot of occupational health visits. When a pilot comes in for their annual flight physical exam, it's an occupational physical where you check their vision, hearing, and other things making sure their healthy. But a lot of them are occupational-based which means making sure they meet the qualifications for continued flying. If seeing dependents and retirees, flight surgeons are basically a family practice physician so family members are treated for normal aches, pains, and colds, etc.

Depending on where you're at, 50% is seeing patients and another 50% is hanging out with air crew and building rapport, doing "shop visits." As a flight surgeon, you're an occupational health physician so if your base has airplanes and you're visiting the flying squadron to make sure things look good there and the facilities are clean. You go to the maintenance squadron and make sure people working on the airplanes are keeping a clean environment and not working with lead-based paint and bring it into their offices and where they eat. You're simply making sure the base stays healthy. So you're basically outside of the clinic a lot of times and interacting with the rest of the base population which keeps things varied and you get a lot of diversity.

When you go to site visits, it's like carrying a clipboard with a checklist like making sure they keep separate wipes for their masks or have separate sinks for different things. So a lot of the things are structured that way while some of it is just using your intuition and question-asking skills. Usually, you go out with a team consisting of public health or bio environmental engineering while you're focused on the health side So it's a very collaborative team-based approach.

[23:16] Flight Surgeon as a General Practitioner

50% of the time, a flight surgeon is basically a practitioner except of the military. Also, a large majority of flight surgeons are general practitioners which means they're only internship-trained. This is the way the Air Force gets flight surgeons wherein a lot of them are fresh out of their internship. There are also a lot of flight surgeons with residency training, like OB/GYN, Orthopedics, Family Medicine, or Internal Medicine. You can actually have any specialty and be a flight surgeon if you choose to. And if you have specialty training and become a flight surgeon, you have to go through all the aerospace medicine training before becoming a flight surgeon because it's unique and different.

Aerospace medicine is a subspecialty available to everyone in the military. They usually need flight surgeons so there are several physicians that jump ship from their specialty and subspecialty and come over to the aerospace medicine world.

[24:50] Patient Outcomes

Typical outcomes would be just like a family practice doctor where you're seeing people with their aches and pains, sniffles, and flu so you're treating an acute thing for a week or two and grounding them for a week or two and then they come and see you and things are better.

Although there are also some unique things that could happen like somebody losing their vision or has a random new diagnosis. There are a lot of bad things that can happen to cause somebody to lose their wings. As a flight surgeon, you also take care of firefighters, which is another big occupational health job.

The outcomes are usually normal healthy people but when you get those random diagnosis, it's a life-changer.

[26:23] Most Exciting and Most Mundane about Aerospace Medicine

The most exciting is being able to go out and be part of the aircrew and fly around the world or fly an F-16 or do all sorts of missions, experiencing what the rest of the base is doing. Conversely, the most mundane part is dealing with normal aches and pains like dealing with blood pressure management or diabetes management, basically the boring normal doctor stuff.

[27:10] Wish I've Known About the Specialty

When I got the call to say I was going to be a flight surgeon, I didn't know what it was. When I was in it and now that I'm out of it, I don't think there's really anything that I had wished I had known about other than I wish I would have known about it.

Consider doing aerospace medicine especially those who are on an HPSP scholarship. It's an amazing job and there are so many things you can do. Even if you're interested in a specialty, go be a flight surgeon for a couple of years and then go live the rest of your life. The stories I can tell now, having been a flight surgeon, are going to stay with me forever.

[28:40] What is HPSP Scholarship?

HPSP refers to Health Professions Scholarship Program that offers about 150 scholarships a year where you get into medical school and you apply for the scholarship. Once you get accepted, they pay for medical school and then you owe them a year for a year of scholarship, where you can do a 3-year or 4-year scholarship.

[29:28] Combat, Non-Combat, and AME's

Because it's more of a military-based career, I will divide this into a non-combat and combat.

As a non-combat flight surgeon, depending on where you're stationed, you can be stationed anywhere throughout the world. You can be stationed at a place without planes. But majority of your job is to make sure that the population of that base is healthy. It's always an ambulatory setting. There would be no need for an in-patient hospital-based flight surgeon.

When you're deployed in a combat setting, you can run different parts of the medical evacuation triage tents and stations along the way. When somebody gets injured in combat, they're evaluated and triaged to see if they need to be evacuated out to a bigger hospital or if they can just be treated where they are. As flight surgeon doing that evaluation and determining what kind of aircraft they need to fly on, meaning is this an injury that is going to get worse at altitude or do they need at low altitude, do they need to be in a helicopter and stay low or stay in an unpressurized aircraft at a low altitude. So you're basically doing a lot of cool triage in trying to figure out what's best for the patient based on aircraft, altitude, and other things.

An AME is an Aviation Medical Examiner, a designation where you get certified through the FAA. As an AME, you're usually a family practice doctor or an internal medicine doctor or somebody interested in aviation. It's a cool job because it's usually a cash-based business. You can see Class 1, 2, and 3 pilots which need a certain number of physical exams depending on the class. You have to go through FAA training which is free. The population of AME's has significantly decreased over time so it's now getting more difficult for pilots to find an AME and get their physical exams. An AME is very similar to a flight surgeon where there are strict guidelines that determine whether or not you're able to fly and bases your evaluation on those guidelines and makes recommendations based on that. FAA training is not the same as an aerospace medicine residency. It's a week to two-week long course that the FAA puts on.

You can be a flight surgeon at NASA. I've been down to the space center in Houston and visited the world's largest swimming pool where the astronauts do all their training for weightlessness. And as a flight surgeon in the air force, I did see people that wanted to be astronauts and I would do their initial physical exams before they would go down to Houston to get their full physical.

[36:15] Pilot Physician

Moreover, you could be a Pilot-Physician of which the Air Force gives 20 spots. A student I'm working with is in the Air Force right now and wants to go back to medical school but she's also a pilot, not in the Air Force but she is a private pilot with 600 hours and she flew with the academy on their stunt team.

They typical path for a pilot physician is you're a pilot and if for some reason you get interested in medicine and you go to medical school and you still want to be in the military, you become a pilot physician. So you're a physician first but you have the pilot training and usually, you're doing a lot more higher level things than just seeing patients in a clinic but you're looking at a lot of the regulations being written, research into new technologies, etc. Since there are only 20 slots in the Air Force, it's a highly sought-after position and because there are not enough pilots are going on to be physicians, they're looking for physicians that may be interested in going into pilot training through the air force to be pilot physicians. I did look into this but I didn't pass the age requirement. I was too old to start since 29 is the oldest to start the training and I was already 30 or 31.

The Air Force is taking any physician but you obviously have to go through their aerospace medicine training at some point. The unique thing a pilot physician offers is the research and more of having the deep knowledge base and foundation of having both careers under your belt and being able to make those regulations and see things from both sides.

[39:56] The Biggest Challenge and the Future of Aerospace Medicine

One of the biggest challenges of aerospace medicine is that a lot of people don't understand us so there is much pressure for us to start doing more and seeing different types of patients. Apparently, there is a lot of misunderstanding from the greater Air Force of what our job is.

What the future holds for aerospace medicine in 10-20 years would be that as we go to more and more autonomous aircraft, where we have drones, majority now are remotely piloted. They are not unmanned aircraft, they're manned, just in a different location. Because of that, interest in aerospace medicine will go down. Part of the lure is being able to go fly and so why would you be doing it if there is no plane to fly. There could also be unique psychological challenges that come into play for drone pilots. We're going to fighter planes (F-22 and F-35) that are only single-seat planes, which means the flight surgeon can't go up there and the less experience they get. There will be the heavier aircraft like the C-5 and C-17 and re-fuelers.

[44:35] Final Words

Aerospace medicine is an awesome and great job! Although pretty much specific to the military, there are civilian residencies for aerospace medicine. For this podcast, I'm not going to dive into all medical specialties in the military for two reasons. First, the practice of Pediatrics in the military is not very different than pediatrics in the civilian world and really, there aren't that many military premeds out there to warrant individual episodes. I'm a huge advocate for doing the military to pay for medical school and to serve but I don't think I'm going to dive into it here on the Specialty Stories.

Links:

The Undifferentiated Medical Student

The Undifferentiated Medical Student Episode 24: Aerospace Medicine with Dr. Ryan Gray

Careers in Medicine

Aerospace Medical Association

HPSP

FAA AME training

Pilot-Physician

May 10, 2017
21: Looking at the Match Data for General Surgery
25:49

Session 21

General Surgery is gaining in popularity, which shows in its competitiveness for residency. You need to be on the top of your game to match. And similar to Internal Medicine, it is the gateway to a lot of subspecialties.

As we're presenting the data here, remember that this is not just for those looking to be general surgeons their whole life but those who are looking into other subspecialties which we will be featuring here on the podcast in the future such as Surgical Oncology, Colorectal Surgery, Surgical Critical Care, Minimally Invasive Surgery, etc. There are certainly a lot of things you can go on and do after your general surgery residency.

The 2017 NRMP Main Match Data is now available since the match happens in March of every year.

[01:45] Total Number of Programs and Applicants

For General Surgery, there are a lot of physicians available with 267 programs around. There are 236 Psychiatry residencies and 204 Pediatric residencies so that gives you an idea that there are more general surgeons than pediatrics. There are 241 OB/GYN residencies so there are a lot of surgical residencies.

General Surgery has two categorical residency programs. A categorical program is one where you apply to the program from medical school and that's where you're going to do your five years of General Surgery residency. Then there are prelim surgery positions and there are more prelim surgery positions than there are categorical.

Somebody doing a surgical prelim can do it because they're going into a surgical subspecialty straight out of medical school and they're required to do their PGY-1 year separate from their categorical residency.  In this episode, I will only tackle the full five-year categorical surgery programs consisting with 267 programs for categorical surgery.

Out of 267 programs, there are 1,281 spots. There are almost 5 spots at each program. Interestingly, there are not a ton of U.S. Seniors applying for these categorical programs. And out of these spots, there were only 1,383 that applied and 2,388 total applicants. For the purposes of this data, U.S. Seniors equals Seniors at an allopathic (MD) medical school. Hence, this does not include graduates of an MD medical school. These are only students who are still in school. Those who took some time off to do some research or didn't match the first time are not included in the U.S. Seniors data. There were 3 unfilled programs which means a lot of of people are matching with 99.6% of the spots filled.

I want to briefly mention that if you don't match in a categorical spot, it's typically pretty easy to do a Supplemental Offer and Acceptance Program (SOAP), which used to be called Scramble. There are only 61.7% of those spots were filled. So it's very easy to do a SOAP into a program if you don't match in a surgical program.

But assuming your stats are decent and you're a good person, you're probably going to match because it's not overly competitive for U.S. Seniors which is interesting.

[06:55] Types of Applicants

Table 2 of the 2017 NRMP Match Data breaks down the types of applicants for each specialty. For categorical surgery, there were 1,281 positions and there were 1,276 were filled. So there were 5 empty spots and 3 programs that went unfilled.

Out of the 1,276 filled positions, 1,005 were U.S. Seniors while 74 were U.S. Grads (students that either didn't match the first time or didn't apply because they were doing research or something else. Total number of U.S. Seniors (allopathic MD students) was 1,079 out of the 1,276 positions. The rest of it was filled by 64 osteopathic students and 62 U.S. International medical graduates.

Something that is highly debated in the premed world is whether to go to a U.S. DO school or an international MD school, specifically Caribbean schools. If General Surgery is something you're interested in, there were 64 students that matched from U.S. osteopathic schools and 62 from international medical schools.

Moving along, there were 71 Non-U.S. International medical graduates that matched into General Surgery. For me, this is a peculiar number and is not something I would have thought to see. It just goes to show that there is still a high demand for General Surgery spots so they're taking as many possible and the most qualified and a lot of those happen to be non-U.S. citizen international medical graduates.

[09:47] Trends in Positions Offered and U.S Seniors (2013-2017)

Table 3 of the 2017 NRMP Match Data illustrates the total number of physicians offered from 2013 to 2017.

This is the fourth time I've looked at the Match Data and the numbers always seem to very consistent. Surgery is no different at 4.4 to 4.5 every year, going at a a good, steady pace and hopefully it continues that way.

Table 7 shows the number of U.S. Seniors being accepted compared to all applicants over the course of the last five years. As the number of seats in each program has increased all the way up to 1,281 for 2017, the U.S. Seniors are increasing as well. This is a good thing in that more U.S. allopathic students are going into General Surgery to fill this increasing need for spots. It's not necessarily a good thing for DO students or U.S. International medical grads because the demand is rising among U.S. Seniors as there are more spots.

Table 8 shows the actual percentage of U.S. Seniors for each of the programs. There were 80.8% of U.S. Seniors in 2013 and it dropped down to 76.5% in 2014, back up to 80% in 2015, back down to 76.4% in 2016, and then up again at 78.5% in 2017. This suggests that maybe the demand is not as high also looking at the data in table 7.

Table 9 shows the percentage of applicants that matched into a given field compared to the rest as a whole. 4.6% of all applicants that matched in all fields matched into Surgery (categorical). So it's up there. Internal Medicine is huge at 25.6%, Family Medicine at 11.6%, Emergency Medicine at 7.4%. This gives you an idea of where Surgery lies. Interestingly, Psychiatry (categorical) is at 5.4% which is more than Surgery and Pediatrics at 9.7%.

[13:25] Osteopathic Students, Unmatched U.S. Seniors, Independent Applicants, and SOAP

Table 11 looks specifically at Osteopathic students who have matched into PGY-1 spots as a whole. This is similar to the last table but this one looks specifically at osteopathic students. As expected, General Surgery has a lot less total number of osteopathic students percentage-wise. Looking at all specialties adding up to 100%, Surgery only made up 2.2% of all osteopathic students that matched into an allopathic General Surgery (categorical) program.

Students may think it's harder to go to an MD General Surgery residency as a DO student and if this is what they want to do, then they should probably only apply to MD programs. My different perspective on this is that if osteopathic schools are doing a good job at recruiting students that meet this "osteopathic" philosophy and are looking at recruiting and attracting more students that are interested in Primary Care, then there should obviously be a lot less that are matching into a surgical program.

Figure 6 of the 2017 NRMP Match Data shows the percentages of Unmatched U.S. Seniors and Independent Applicants (outside of the U.S. Seniors which, for these purposes, are considered U.S. allopathic students who are still in school). General Surgery had one of the higher unmatched rate at 20.7%, which is 9th on the list. Majority of those are unmatched, independent applicants (non allopathic students, non MD Seniors). The unmatched U.S. Seniors was only 9.6%. This is still high compared to a lot of the other specialties. It seems it's getting more and more competitive and this is a trend that I've heard from speaking to others that General Surgery is becoming more and more competitive as there are more options available for these subspecialties and fellowships afterwards.

Table 18 breaks down the SOAP process and looking into Surgery (categorical), there were 3 programs that needed to fill 5 spots and all 3 programs filled those 5 spots through the SOAP process.

Looking at the National Matching Service Data for 2016 for the different program types, there were 49 programs for General Surgery for osteopathic students and 155 positions. 149 positions were filled and 6 went unfilled.

The data given is not as robust at the NRMP so I'm uncertain if there were a lot more applicants than these 155 spots and a lot went unmatched or if there weren't just that many applicants.

[17:43] 2016 Charting the Outcomes - NRMP

Based on the 2016 Charting the Outcomes for the NRMP, Chart 3 shows the match rates and there was an 83% match rate for U.S. Allopathic Seniors for General Surgery. Looking at other specialties, Dermatology at 77%, Neurosurgery at 76%, Orthopedics at 75%, Plastic Surgery at 77%, and Vascular Surgery at 71%. So General Surgery is right there with all of the other surgery subspecialties.

Chart 4 shows the Median Number of Contiguous Ranks of U.S. Allopathic Seniors. For students that matched and those who didn't, the chart shows you how many programs they ranked on their rank list when they submitted. Those that matched ranked 13 as a median number while those that did not match ranked 5. If you are picky about where you go or if you didn't get an opportunity to apply or to interview at a lot of spots, then you have a lot less chance of matching.

Chart 12 shows the percentage of U.S. Allopathic Seniors who are members of AOA (the Honor Society for medical students showing good academic success in medical school). For those that matched only 17% of the U.S. allopathic Seniors were AOA whereas 52% for Plastic Surgery and 53% for Dermatology. So General Surgery is in the lower end for a surgical specialty.

Looking at the Summary Statistics (Table GS-1) for General Surgery, those that matched have a decent Step-1 Score at 235 and those that did not match at 218, which shows a big difference in Step scores. This is one of those things where you need to be very realistic with your chances of matching. If you don't match, why? Could it be that because your Step score is not high enough? The mean Step 2 score is 247 for those that matched and 231 for those that did not.

[21:20] Burnout, Happiness, and Compensation

The Medscape Lifestyle Report 2017 and Medscape Physician Compensation Report 2017 are two separate reports that Medscape releases every year.

For the Lifestyle Report, more than 14,000 physicians over 30 specialties have responded in the survey. The numbers are not necessarily the best data-wise because it's a survey so just take this with a grain of salt.

Who is the most burned out? General Surgery is lower on the list at 49% which is more than halfway down the list. This is good. But looking at how severe is the burnout, surgery is higher up on the list at 4.3 from a scale of 0-4.5.

Which physicians are happiest at work and outside of work? General Surgery is higher up on the list with 35% happiness at work and 69% happiness outside of work. So it's on the higher end of the scale.

Moving on to the Medscape Physician Compensation Report 2017, General Surgery is higher up on the list with an average annual salary of $352,000. Above it is Anesthesiology and below it is Ophthalmology. So it's a decent living as a general surgeon. Although if you think about the lifestyle and everything else, it's harder. So you're compensated for that harder lifestyle.

Looking at the rate of increase year over year,General Surgery had a 9% increase which is pretty decent. The number of physicians who feel fairly compensated for General Surgery is lower at only 48%.

Whether a specialist would choose medicine again, General Surgery is right in the middle at 77%. While only 82% said they would choose the same specialty, which is a little in the lower half of all the specialties there.

[24:50] Final Thoughts

If you're not sure what you're interested in yet, go through these numbers. It's eye-opening to see what is going on in the world when it comes to matching and physicians that are happy and making money and those that aren't.

Links:

MedEd Media Network

2016 Match Data NRMP

Supplemental Offer and Acceptance Program (SOAP)

National Matching Service Data for 2016

Charting the Outcomes - NRMP Medscape Lifestyle Report 2017

Medscape Physician Compensation Report 2017

AOA

May 03, 2017
20: An Academic Neurosurgeon Discusses What His Job is Like
53:07

Session 20

Dr. Stephen Grupke is an attending Neurosurgeon at the University of Kentucky. In our episode today, he discusses the residency path to neurosurgery, what makes you a competitive applicant, his typical day, the types of patients and cases he serves, what he likes best and least about his subspecialty, and more.

Stephen and I went to New York Medical College together. Currently, he is a neurosurgeon in an academic facility and a new faculty being an assistant professor at the University of Kentucky.

[01:30] Choosing the Specialty

Stephen knew he wanted to be a neurosurgeon when he was in graduate school. Being a chem major in undergrad, he was working in a lab in grad school. A neurosurgery resident at New York Medical College did a research under his belt and took Stephen under his wing doing experiments and showing him different amazing stuff and he was just taken by it right there. That was actually the first time he saw what it's like to be a neurosurgeon and it was something he would love to do. That was what sold him to be a doctor.

[04:33] Traits that Lead to Being a Good Neurosurgeon

Stamina is a major key in being a good neurosurgeon since taking out a brain tumor can take hours and hours and that can be very physically and mentally taxing. You can have long clinic with a lot of people and a lot of varied problems so you have to think every one of them through, giving genuine, concerted effort to every single person considering they have very different pathology. Emotionally, the level of acuity in what they see is profound, having several highs and lows in one day. You could see pretty horrible things like abused children coming in with brain traumas and people being diagnosed with brain tumors. Then you have to relay this information to the family. On the same note, you can bring somebody from the brink of death in the operation and give somebody function back with a simple spine surgery that enables them to live without pain. In short, there is a lot of emotional highs and lows and to just deal with that day in and day out is kind of tough. You just have to focus on the highs in between and move on to the next thing and do the best you can for every person that comes to your door.

The longest case Stephen has been in was a brain tumor case as a resident that went fourteen hours. Although they've also had spine operations that ended up being broken up in a couple of days such as a long, complex scoliosis case in multiple levels.

Besides Neurosurgery, other specialties that crept into his mind was Neurology, being cerebral and focused on the central nervous system and everything that entails. He likes having to think of esoteric pathology you need to figure out. Internal medicine is another specialty of interest for Stephen, as it shares a lot of things with Neurosurgery in terms of the complexity and diversity of the cases you see. There's a lot of detective work involved and you get to see a lot of different specialties.

One of the things that led Stephen to Neurosurgery is knowing a lot of varied information in a lot of different specialties such as Endocrinology for pituitary tumors or traumatic brain injury cases. You have to be adept at critical care management as well as fluid and electrolyte maintenance. There is so much intermingling of other sub-specialties since the brain is ultimately involved in every other system of the body.

[10:10] Types of Patients and Typical Day for an Academic Neurosurgeon

As a neurosurgeon, Stephen sees all sorts of pathology. In his practice, he tries to focus on cerebral and vascular neurosurgery like cases of aneurysm, arteriovenous malformations, etc. But when you're on call, you have to be willing to take whatever is thrown at you and treat everybody from premature babies all the way up to the very elderly, people from all different socioeconomic classes and all kinds of pathology from taking out a tumor in the peripheral nerve and spine surgeries to open surgeries and endovascular surgery. Because of its variety, it keeps things interesting.

Stephen's typical day would be getting into the office at 6 in the morning to give him a breathing room to go over some of the labs and images of the patients from the day before. He spends one day of clinic a week from 8am to 5pm, which consists of seeing new patients and operative followups. A couple of days in a week would be spent in the operating room treating patients. Another couple of days in a week would be spent in the endovascular suite doing things like diagnostic cerebral angiograms or treat aneurysm cases or angioplasty and stenting to treat coronary stenosis or treat arteriovenous malformations with glue embolization.

As a resident, Stephen has done several hundred cases as part of an enriched curriculum that focuses essentially on endovascular treatment of cerebrovascular disease. Now, he's doing another year under the tutelage of a group of physicians at the University of Kentucky who also serve as his mentors so he can get a certification in cerebrovascular intervention. So Stephen does this for two days a week.

Some specialties like interventional radiology and neurology are also doing these fellowships to become adept at this intervention. Stephen doesn't really see any turf war going on in his institution especially that one of his mentors is an interventional radiologist and is grooming him to be a partner in his practice. In general, however, he is seeing a little bit of turf war across industries that are trying to get in on it. Moreover, there is a move for interventional surgery to standardize fellowships to make sure that everybody that comes out from these other specialties that they're giving an essentially comparable product.

[15:15] Taking Calls and Procedures

As far as interventional call, Stephen takes one-third of the call which they do a week at a time. This is much less rigorous than primary neurosurgery calls. Things they would have to come in for would be endovascular treatment for aneurism or stroke. Thrombectomy for stroke has taken off since February 2015 when several studies released showed its efficacious intervention. As a result, it has opened the door for a lot of people that may not have been candidates in the past to have a mechanical thrombectomy. For that, they end up getting called in the middle of night. Being a comprehensive stroke center, they've always got somebody on call to do that. Generally, they don't get any call every single night by any stretch but primary neurosurgery calls would be every 6 or 7 nights which is totally manageable and doable.

Considering he spends one day a week for clinic, only a small percentage of those patients are being brought to the operating room. Some people are keyed up to come in that have been sent to him from pain clinics and anesthesiologists to have interventional pain procedures done. These are people that have already been worked up and already know they're getting a surgery. But for ten people he sees for back pain, a common thing that primary care doctors send to them, one-tenth of them or less is something worth going to the operating room given that conservative management has been done first (ex. physical therapy, eat, rest, ice). In general, 20% of the people end up getting into surgery and the rest involves counseling in terms of pathology and management. For most cases, he tries to be conservative with.

[18:56] Work-Life Balance

Stephen doesn't think any neurosurgeon does since neurosurgeons have this workaholic stereotype he sees as true to some extent. He has a nasty habit of bringing work home with him. He has three small children and he's happy he gets to spend a lot of time with them. He his fortunate to have a program that emphasizes a good home-work balance since their chairman wants to make sure they are happy at work and a big part of that is making sure you have a good balance in life. Nevertheless, there are many nights spent on signing notes, reading upcoming cases, or writing papers at home. Still, he makes it a point to take time out of his day to do as much family time as he can.

[20:52] Academic vs. Community Setting

One of the biggest benefits Stephen sees being in an academic center is being surrounded by a great group of residents. He gets to play a part in teaching them and helping them to become the next generation of neurosurgeons and being able to walk them through the same steps his predecessors did for him so it's his way of paying back.

Additionally, it puts him in the forefront of what's going on academically in neurosurgery which is a wide open field. There is so much that's not known about the brain and there's so much research going on and it's really exciting to be on the forefront of that and seeing that happen in real time. They get to a lot of these interventions before the community even gets to them being involved in the big multi-institutional research projects. They get to see a lot of unusual pathology being sent to them since only a big university that have resources and experts such as theirs that can deal with that.

[23:00] Neurosurgery Residency and Matching

The ACGME requires a certain number of these different categories of procedures under your belt while being a resident and you have to do so much time in the ICU and such.

For Stephen, he graduated from medical school and spent the year doing an internship that is part general surgery subspecialty and part neurosurgery and neurology. (Today, they're now more focused on neurosurgery and neurointensive care.) Then Stephen had to go through six years of neurosurgery residency. As a junior resident, he did a lot more of the carrying the call pager, dealing with the ER, seeing new consults, helping staff clinics, and helping taking care of the patients on the floor and in-patients. As he went on, he spent more time in the operating room and spent more time doing academic stuff. He spent more time on the lab and molded his curriculum in a way he could enrich himself in certain subspecialties once he met his prereqs. As he got on towards the fifth to seventh year, he took on more of the administrative roles, working with scheduling of junior residents and juggling taking care of the operating rooms, being the chief on call, and helping junior residents on the floor and be the resource for the younger ones. Typically, it was a total of seven years of residency training for neurosurgery.

Neurosurgery is basically competitive when it comes to matching and Stephen imagines it getting more and more competitive having met some really smart, capable, qualified folks over the last couple of years that unfortunately ended up in the scramble. It's relatively competitive since there are not that many spots and there's a lot of very smart, capable, and qualified applicants. Stephen thinks that despite the specialty being a very tough and rigorous lifestyle and residency, there are a lot of people that are up to meet that and take that as a challenge and want to face it head on.

[28:00] What Makes a Competitive Applicant for Neurosurgery

As somebody who has been a chief resident and as an attending who has been in the committee that goes over all of the applicants, Stephen sees that everybody that gets on his table has great boards scores and good grades but that's not what seals it for you but being able to show in the interview that you're a reasonable person. There are smart people that are capable of making a hostile work environment so you want a good esprit de corps and you want everybody to get along that makes life nice and that's what their resident group has.

Having said that, their match system is difficult in that they interview applicants for a day, similar to speed dating. Stephen says one of the best ways to see if you would fit is to go to place you're interested in and do a sub-internship there whether a month of medical school or just a week. Go back for a second look after you've done your interview to spend some time with them. Any residency program can really put on a good face for a day so it's important to be able to see how everybody is on a day-to-day basis. What makes a good applicant for Stephen is them being able to trust that they're going to get along with you.

[30:58] DOs, Subspecialties, Primary Care, and Other Specialties

Unfortunately, Stephen doesn't know a lot of DO neurosurgeons probably because he has not just been out of the academic world for a long time and he went to an allopathic school as well as throughout residency. Although he knows there are some designated DO neurosurgery programs, but he doesn't know enough about them to comment on this.

After seven years of residency training, subspecialties available include Pediatric Neurosurgery or Cerebrovascular Neurosurgery. Today, physicians can get CAST or Certificate of Advanced Surgical Training where they do an enriched program, meeting a certain amount of criteria, and do several cases to qualify for this. Then you get a certification that you've done something above and beyond, whether that be for spine, epilepsy, peripheral nerve, and a lot other subspecialties for neurosurgery that you can focus on.

To be able to do this, Stephen suggests being in an academic center where you have other folks that can cover the rest of the subspecialties. such as functional neurosurgery like deep brain stimulation. While you want to subspecialize in something else, they have a good complement of attendings in their group.

Stephen has a good relationship with primary care physicians in their area, them knowing that neurosurgeons are there to help. The important thing is for them to know that neurosurgeons are always available to help them with things, even the non-surgical stuff, such as back pain and neck pain which are sometimes better dealt with physical therapy or a physiatrist. It can be hard to make heads and tails of which one is surgical or which is not, and they're more than happy to go over that with a patient and let them understand what's going on. This makes people feel they're being carefully looked at or things are fully being explained to them.

Other specialties neurosurgeons work the closest with include Oncology (for tumors in spinal cord and brain or peripheral nerves), Physical Medicine and Rehabilitation (for brain pathology due to stroke), Hospitalists, Vascular Surgeons, Carotid Artery Pathology, Trauma Surgery, Endocrinolgoy (for Cushing's disease and pituitary tumors) Neurologists are their closest colleagues, sharing management on stroke patients and epilepsy. They end up being closely involved with a lot of different departments.

[38:40] Special Opportunities Outside of Clinical Medicine

You can take part in academics and research in the lab. You can take things from the bench off to the bedside since you have access to the patient base. Some neurosurgeons also end up doing stuff in the administrative side of things. Otherwise, many of them are clinically and academically busy between teaching, writing, and doing their clinical duties. Other than those, you can do pretty much anything according to Stephen.

[40:12] The Best and Least Liked Part

Stephen explains he would reassure himself that he'd still love what he's doing even after all the grind. A lot of times, things could get tough and it wears on you physically and mentally. But literally being able to take care of people in their darkest hour and be there and be involved in the most important part of a lot of people's lives is hugely fulfilling. The same goes academic-wise, it is very fulfilling in that you can do detective work while you get to teach the next generation of smart and eager neurosurgeons. He gets tired but he never felt that feeling of dragging yourself off to work and just to work for the paycheck. Stephen finds his professions as very fulfilling.

When asked what he likes the least about being a neurosurgeon, Stephen says there could be bad days like having a streak of patients you're not able to help or you think you did a case by the book and did everything right but the patient gets a bad outcome so there's that feeling of hopelessness. You present that case in M&M and you still study and that if you had the chance to do it again, you'd probably have done it the same way but if it still turns out poorly, you think about it and it keeps you up at night.

[43:46] What is M&M?

M&M stands for Morbidity and Mortality. It is a conference where you and your colleagues are in a room and every time a patient has a problem or die or has a complication of some sort, their case is presented and is picked academically by other colleagues. This is done systematically to try to prevent errors in the future and see where in the care and management of the patient did something break down or how could have it done prevented and whether a change in protocol is needed in the future. Then you come up with a solution. It's stressful and it's rough on you if it's your case being presented. but it's important to make sure everybody is treated appropriately in the future, for accountability, and for teaching the residents.

[45:30] The Future of Neurosurgery

There is so much more that is not known about the brain or the central nervous system that leaves a lot opened and some exciting new things are going on such as neuromodulation  or deep brain stimulation for all sorts of different pathologies right now. It's commonplace for Parkinson's disease and tremors but there is a lot of potential utility for it in the future. There are also implantable devices help detect seizures and extinguish them before they become a problem.

Stephen sees a lot of interesting technology on the horizon as well as new utility for old technology such as stimulators for spasticity and stroke and stem cells implanted for stroke, Parkinson's disease, and neurodegenerative diseases in general. This is another way they're going to be involved with their neurology colleagues as they come up with ways to potentially intervene and help patients that were once thought to just have progressive neurodegenerative disorders that have promising interventions such as treatments for traumatic brain and traumatic spine injury and neural computer interface for moving appendages. With a little fine-tuning, he doesn't see it being too off before it becomes something that you're able to use an artificial limb and perform complicated maneuvers. It's close to being a thing so we're in really exciting times.

[48:00] Final Words of Wisdom

If he had to do it all over again, Stephen would still have chosen the same residency as he had a great time making friends for a lifetime and had great teachers. The field of neurosurgery itself is still what he keeps by his bedside as something to read on. Even in lay media, it's what he picks up and what he's drawn to. So he definitely still has a fire for it and it's been great so far.

If this is something you're considering but quite unsure, Stephen recommends to look in yourself and make sure it's something you want to do. And if it is, then you should do it. It's rewarding and interesting. There maybe some tendency for folks in the early medical school community to want to be a neurosurgeon but not necessarily do neurosurgery and that's a wrong attitude to have. TV may glamorize the specialty probably inappropriately more so than other surgical subspecialties which require just as much scholastic aptitude and manual dexterity. So look inside yourself and make sure this is what you want to do.

Plan it out and keep a balance in your life. Go out and get some fresh air. Do some recreational activities you like. Spend time with your family. These are all important things to maintain even if you may be tired. It may take a little more effort than it did before when you're able to sleep in but once you embark on this path, try to keep a balance. Lastly, Stephen wishes every body good luck and that you've chosen a great field no matter what subspecialty of medicine you go into. Congratulations for getting this far!

[51:28] My Last Thoughts

Neurosurgery is one of those more rigorous paths to becoming an attending and still as an attending. But as Stephen has said, there are still a lot of demands and it's still very competitive to get into. If you're interested in neurosurgery, go reach out and find some programs and find some mentors.

If you know somebody that would be a great guest for this podcast, let me know and shoot me an email at ryan@medicalschoolhq.net.

Links:

Specialty Stories podcast session 03 interview with neurologist Dr. Allison Gray

MedEd Media Network

University of Kentucky

New York Medical College

ACGME

Apr 26, 2017
19: Orthopedic Surgery Match Data Deep Dive
25:53

Session 19

Today, I'm going to do a deep dive into some match data for Orthopedic Surgery, which is one of the more competitive specialties out there. Let's look at the data to see if this holds true and find out who you can set yourself up for success early on if this is something you’re interested in.

In general, Orthopedic Surgery is a surgical specialty. It's a five-year residency with a lot of subspecialties after that. I had Dr. Muppavurapu to talk about being a hand surgeon back in Episode 05 and he talked about the many other things you can do like joints, spine, hand, and so much more. Today we're going to talk generically about ortho residency matching as a medical student.

[02:55] Number of Programs, Spots, U.S. Seniors

NRMP is the MD application. (If you're reading this way in the future, words like ACGME and AOA won't really mean much because the MD and DO residency programs will have merged assuming all goes well as planned out for 2020.)

Looking at Table 1 for the NRMP Results and Data 2016 Main Residency Match, there are 163 programs in the country for orthopedic surgery. Just to give you an idea of the number of programs for other specialties, Anesthesiology had 119 PGY-1 spots and 77 PGY-2 spots, a total of 196 compared to 163 for Orthopedic Surgery. Neurosurgery had 105 programs, Emergency Medicine had 174 programs. This somehow gives you an idea of how many programs are out there for Orthopedic Surgery.

Another important number to look at here is the number of spots available. Orthopedic Surgery had 163 programs with 717 different spots available so that's average of 4.398 spot per program. Comparing to other programs, Emergency Medicine had only 11 more programs but more than double the number of spots offered.

Out of the 63 programs for Orthopedic Surgery, none of the programs went unfilled. Many residency programs here had 100% fill rate so it's not unusual but again, an important thing to keep in mind.

As you think about your specialty, how competitive is it for you to match into? How spots are going to be available? If you don't match for some reason, can you do the Supplemental Offer and Acceptance Program (SOAP)? Can you find an open program? For something competitive like Orthopedics, you probably won't be able to find one and it's going to be much, much harder for programs that typically go completely filled.

There were 717 available spots while there were 1,058 total applicants. 874 of those were U.S. Seniors. Note that the number of U.S. Seniors applying are even more than the spots offered. Out of the number of students that matched, 650 were U.S. Seniors. That means U.S. Seniors make up 90.6% of students that matched into orthopedic residency. U.S. Seniors here are allopathic U.S. Seniors (students at MD Programs).

Ortho do not have any programs that match directly into PGY-2 positions. They are all categorical spots where you apply for ortho, you do your internship right there in that one program for five years.

[07:25] Allopathic and Osteopathic Students

There is always this DO versus MD "competitiveness" going on in the premed world. Here is where there is some bias among residencies. Orthopedic Surgery has been known historically as one of the biggest residency programs out there that has some negative bias towards DOs.

NRMP Match Data Table 2 shows matches by specialty in applicant type and looking at Orthopedic Surgery with 717 positions, 717 filled, 650 were U.S. Allopathic Seniors, 49 were U.S. Grads (this refers to those who either took some time off and didn't apply during the normal time you're supposed to apply to residencies or maybe didn't match the first time, went and got some research opportunities and ended up matching after graduating), and only 4 of the 717 were osteopathic students. That is just about half of 1%.

Compared to other specialties, Anesthesiology seemed very favorable to DO's with osteopathic students comprising 14.4% of all that matched. While in Emergency Medicine, 11.8% of those that matched in the filled spots were osteopathic students. Apparently, Orthopedic Surgery stuck with the the tried and true position of not being very "DO friendly."

Remember that osteopathic schools and students can apply to osteopathic residencies and you can also apply to the MD residencies which accounts for the number of osteopathic numbers on the NRMP (allopathic) data. But in the osteopathic world, there are orthopedic surgery residencies. Therefore, don't think that just because you only got into an osteopathic school that your chances of getting into an orthopedic surgery residency are going to be slim to none.

Based on the AOA Match Data for 2016, there are 40 Orthopedic Surgery programs in the osteopathic world, with 121 positions, 118 were filled, 3 went unfilled. In the MD world, it's highly unusual to have unfilled orthopedic spots.

[11:06] Growth, Positions Filled, U.S. Seniors and All Applicants

NRMP Match Data Table 3 shows the growth of each of the specialties over the period of five years (2012-2016). Orthopedic Surgery is among those growing at a good pace around 2.5% each year. With 682 spots in 2012, it has grown to 717 in 2016 which suggests a pretty steady growth. This is good for you especially if you're thinking about Orthopedics since it means there are more and more spots offered.

The data in Table 7 confirms how Orthopedic Surgery is usually a specialty that doesn't go unfilled. There were no available spots in 2016, 2015 and 2012, only 2 spots in 2014, only 1 spot in 2013.

Looking at Table 8, it shows the Positions Offered and Percent Filled by U.S. Seniors and All Applicants (again, U.S. Seniors being MD Seniors that have graduated from an MD school).

In 2012, 94% of those offered a position consist of U.S. Seniors. This percentage dipped to 91.9% in 2013 and went back up to 93.4% in 2014, and 94.3% in 2015, and then dropped down further to 90.7% in 2016. This tells us that there are a lot of students who are non-U.S. Seniors filling these spots. They could be international medical graduates or U.S. grads that were not Seniors who are people that have taken some time off.

[14:15] PGY-1 for All Applicants and Osteopathic Students and Unmatched Students

Table 9 shows the percentage of applicants that have matched to a PGY-1 spot in each specialty compared to the whole. Anesthesiology is at 4%, Emergency Medicine with 7.1%, Family Medicine 11.5%. Orthopedics is 2.7% which is pretty small compared to some of the bigger ones like Family Medicine, Internal Medicine, and Pediatrics. Even Psychiatry is pretty big at 5.1%.

For the Osteopathic students looking at the NRMP Match Data Table 11 shows the percentage of students that are osteopathic graduates that matched into Orthopedics with only 0.2% of all osteopathics students that matched did match into Ortho that means only 0.05% osteopaths matched into a spot. And comparing this to the bigger programs, Anesthesiology at 6.4%, Emergency Medicine at 9.3%, and Family Medicine at 15.9%. Again, it is very hard for an osteopathic student into a MD orthopedic surgery residency.

NRMP Match Data Figure 6 shows the percentages of unmatched U.S. Seniors and independent applicants who ranked Ortho and other specialties. 25.1% of all those that applied to Orthopedic Surgery went unmatched, 20.8% were U.S. Seniors, 56.6% were unmatched independent applicants (the DOs and international medical grads). As a non-US allopathic medical school grad, it's very hard to match into an allopathic orthopedic surgery residency.

[17:05] Charting the Outcomes for U.S. Allopathic Seniors

Looking at the data found in NRMP Charting the Outcomes 2016, Table 1 breaks down the number of applicants per position for Orthopedic Surgery. With 717 positions offered and 1,034 applicants, there were 1.4 applicants per position. Outside of four other specialties, Orthopedic Surgery is the most competitive. Dermatology is last at 1.4, General Surgery at 1.49, Psychiatry at 1.54, and Vascular Surgery at 1.91. This goes to show how Orthopedic Surgery is a highly competitive residency.

Chart 4 shows the Median Number of Contiguous Ranks of U.S. Allopathic Seniors. This is the ranking of how many programs they've ranked, they've matched and didn't match. And this is always one of the biggest question marks if you don't match into a residency, which is: Did you apply to enough spots? The answer is usually no. This is very similar to medical school application where if you didn't get it, you'd have to ask yourself if you applied to enough schools to increase your odds.

For Orthopedic Surgery, the median number of contiguous ranks was 12. Those that did not match was only 6. So if you only ranked half of those that matched, then you'd have a much better shot at not getting in.

[19:15] USMLE Step 1 Scores, Research Experiences, and AOA

If you're a medical student getting ready to study for the Boards or if you're in your first year and just preparing, we are launching a Step 1 Level 1 Board Review Podcast called Board Rounds in the next couple of weeks so stay tuned for that! Subscribe to it now.

Charting the Outcomes 2016 also shows the USMLE Step 1 scores for U.S. Allopathic Seniors. For Orthopedic Surgery, it's at the top spot with some of the other more competitive specialties with those that matched averaging at 248-250 and those that did not match were right there on 240. Therefore, you need to do well on Step 1 to match into Ortho.

One of the misconceptions about Orthopods is them being dumb jocks but that's not true of course. You need to get really great board scores to get into Ortho and research experience doesn't lack either. Based on Chart 8, the mean number of research experiences is 4 for those that matched and 8 for those that did not match. So if you're interested in Orthopedics, do some research as it seems important based on this data.

Chart 12 shows the percentage of U.S. Allopathic Seniors who are part of AOA (Alpha Omega Alpha), the honor medical society that highlights the students who do well the first couple years of medical school. For Orthopedic Surgery, 34% of those that matched are AOA students while 12% for those that did not match. The takeaway here is to start off medical school doing really very well so you can try to get AOA.

[21:47] Medscape Lifestyle Report 2017

The Medscape Lifestyle Report 2017 presents data on burnout, bias, race, etc. Orthopedic Surgery is in the bottom half of the burnout chart at 49%. Yes, this is still a lot but this is the bottom half of the chart. The biggest takeaway is that a lot of physicians are burned out and Orthopedics is one of the least, which is good.

How severe is the burnout? Orthopedic Surgery is in the lower half of the chart.

Which physicians are the happiest? Orthopods make up the top half with 37% saying they're happy at work and 71% saying they're happy outside of work. This is another pretty good data compared to the rest.

[23:00] Medscape Physician Compensation Report 2017

Looking at the recently updated Medscape Physician Compensation Report 2017, Orthopedics is at the top of the list for most compensated physicians with an average annual compensation of $489,000. If you're interested in Orthopedics then you will probably make a very good income which is well-deserved. And this is up 10% from last year.

Only 48% of Orthopods feel fairly compensated and this is strange considering they're the highest paid of all the specialties. 79% of Orthopods say they'd choose Medicine again, and unsurprisingly, 95% of Orthopods say that they'd choose Orthopedics again. In general, Orthopods are pretty happy with their career choice.

[24:29] My Final Thoughts

I hope this helped you get some clarity with Orthopedics Surgery if this is something you're interested in. I hope you're also pretty early on in your journey because as I've mentioned, research is necessary and you need to do well on Step 1 as well as try to get AOA. Therefore, you need to start setting yourself up for success as soon as you can.

Links:

NRMP Results and Data 2016 - Main Residency Match

AOA Match Data for 2016

NRMP Charting the Outcomes 2016

Medscape Lifestyle Report 2017

Medscape Physician Compensation Report 2017

Board Rounds Podcast

SS 05: What Does the Life of an Orthopedic Hand Surgeon Look Like?

NRMP

ACGME

AOA

Supplemental Offer and Acceptance Program (SOAP)

AOA (Alpha Omega Alpha)

Apr 19, 2017
18: A Look at Private-Practice Child and Adolescent Psychiatry
33:00

Session 18

If you're a medical student, we are about to launch a new podcast called Board Rounds Podcast, where we focus on the USMLE and COMLEX Step 1 and Level 1. Check us out at MedEdMedia.com. It's going to be a co-branded podcast with MedQuest so stay tuned!

Today's guest is Dr. Jacqueline Hubbard, a private-practice Child and Adolescent Psychiatrist. Hear her thoughts on the specialty, what you can do to get involved, and see if this is something you might take interest in.

[01:55] Choosing Her Specialty

Jacqueline knew she wanted to go to medical school when she was a sophomore in college. Then in medical school, she narrowed down her choices. Having interest in both Pediatrics and Psychiatry, she ended up picking psychiatry and decided on the Child and Adolescent Fellowship.

When she was on Pediatrics, she felt like she was being rushed as she wanted to talk more to the patients instead of just doing the physical exam. She wanted to always have more time to sit down and get to know the patients on a deeper level.

Just like in Pediatrics, there is a lot of parent involvement in her specialty, education is one. She talks a lot about parenting skills, behavior modification, and positive reinforcement.

[03:22] Traits of a Good Child and Adolescent Psychiatrist

Some of the traits that lead to being a good child and adolescent psychiatrist include being a good listener, empathetic, caring about the patient and looking at the patient as a whole, patient, inquisitive, and making sure you're looking at the big picture and ruling all the other things that may not just be your specialty like vitamin deficiencies or thyroid, etc.

[04:05] Private-Practice And Patient Types

After graduating, Jacqueline took a job working at a community mental health center where she ran an in-patient unit while doing some outpatient work. They had a residency program there and knowing she wanted to teach residents and medical students, she felt rushed working at the outpatient and thought she could provide better care if she worked for a private-practice model. Consequently, she took a job doing a group private-practice and ended up leaving it because she wanted to just do it on her own and made it exactly the way she wanted or if she were the patient, it's how she would want to go in and see someone.

As a Child and Adolescent Psychiatrist, Jacqueline treats patients with ADHD, depression, anxiety, OCD, autism spectrum disorders as well as those with bipolars, oppositional defiant kids, and for substance-use. She also sees some adults for binge eating disorder.

She is actually more particular about who she takes. She sees a lot of severe anxiety, OCD, depression in adults as well as some childhood issues. Kids with autism end up being adults with autism so she finds that Child and Adolescent Psychiatrists are good providers for those types of issues since they're used to treating them.

Jacqueline is double-board certified, with a board certification in General Psychiatry and another board certification in Child and Adolescent Psychiatry. She tries to focus her practice mostly on Child and Adolescent Psychiatry because of the huge demand considering that there is not that many Child and Adolescent Psychiatrists. She further explains that there are not many fellowship spots and a lot of medical students are not exposed to it as often as they could. Where she trained at University of South Florida, they only had two spots.

A general psychiatrist can technically see child and adolescent patients, basically depending on their comfort level. However, a lot of times during the general psychiatry training, they only had a month of child psychiatry and half a day in outpatient per week so you only got limited exposure to treating kids especially when you pick up autism,, for example, which is something that is picked up most of the time in the pediatric populations so you don't really get the training and experience treating those kinds of patients as well as those with ADHD.

[08:38] A Typical Day

Jacqueline would describe her typical day as everyday being different, something she likes about her job. Because it is private practice, she can typically decide when the day starts. If she chooses to, she can see patients early and fit somebody at 7 am since she likes to come in early instead or working late. So she would start anywhere from seven to nine or ten, depending on the day and gets done by five.

For kid evaluation, she would see them for 90 minutes while for adults, she would typically give herself 75 minutes. She would also do half-hour follow ups and one-hour therapy for some patients on a more regular basis.

Having a lot of variety, she basically doesn't know what she's going to get for that day especially when she's seeing new patients, making it more interesting and fun for her.

[09:43] Follow-Up, New Patient Consults, & Therapy

For a new patient, a full clinical interview is done. If it's a child, she would sit down and talk with the family. If the parents want to talk alone and not in front of the child, she will talk with the parents and find out their concerns.

For all kids, she would try to meet with the child alone only if they're willing to or if the parents allow her to. They will then all sit down and talk together, the parents, the patient, and herself, and then come up with a treatment plan which she has written down while talking with them so they can walk away and not try to remember things. This is the typical procedure whether she's recommending a specific type of therapy or exposure and response prevention, or lab work or order, medications and supplements, or other referrals for other things like an occupational therapy or speech language referral, or neuro-psych testing. She would also try to get them to sign a release for their primary care provider. She feels that part of her job is working with an interdisciplinary team consisting of their primary care provider and any specialist. So they cover all of this and she books them for a follow-up.

For follow-up appointments, they will go over the treatment plan again and see what's been done in between appointments, if they've established with a therapist, an occupational therapist or speech therapist. They will talk about their medications and make sure they're not having side effects and find out what's been going on in between the appointments, how school is going, how family life is going. She will also refill their medications.

For therapy, Jacqueline is trained in cognitive behavior therapy, which is a therapy approved for anxiety and depression. She is also trained in exposure and response prevention, an excellent therapy for OCD and social anxiety. It involves doing exposures for kids and adults, where they are put in an anxiety-causing situation starting at the bottom of the hierarchy. This lasts for about an hour. Sometimes, they will use work books tailored for young kids for example. She basically sees therapy patients on a more regular basis, for one hour weekly or every other week. She loves getting to know the patients at a different level as well as the families as you're able to see them more often.

She also has patients that will see an outside therapist like a counselor or social worker, at which she will have the patients sign a release so they can work all together and they'll see her more for medications and managing the treatment team while they see the therapist for therapy.

[14:20] On-Call, Out-of-Network Provider, and Work-Life Balance

Jacqueline explains that the extent upon which they do calls depends on the state you're in or if you take insurance. As for her, she does not directly accept insurance but she's an out-of-network psychiatrist, which means patients can see her and they pay out of pocket to see them and they can request reimbursement from their insurance. Insurances require that you have some type of call system in place. Her policy as an out-of-network psychiatry states that if in case of emergency, they can call 911 or go to an ER. With her  practice, she does have a secure portal where patients can send in a secure email which they can do anytime so she gets messages which she encourages. She also gets calls after hours that go to voicemail, but if it's an urgent voicemail, they can press the number four and she'd be alerted that's it's an urgent voice message. However, during their first appointment, Jacqueline actually explains to her patients that she doesn't have an on-call service or emergency service after hours.

Being an out-of-network provider is common in her area, both geographically and specialty-wise, because it's easier to run the practice that way and they won't have to hire any staff so the overhead expense is a lot lower. Not having any office staff, Jacqueline basically does everything from the patient's first phone call to taking their payment.

Being her own boss, Jacqueline can say she has definitely a good work-life balance as she enjoys the flexibility of it, blocking her schedule whenever she chooses for her personal or family life.

[17:10] Residency, Fellowship. and Matching

After medical school, the General Psychiatry residency program takes four years and the Child and Adolescent Fellowship Program is an additional two years. However, most programs allow you to enter into the two-year fellowship after three years of the General Psychiatry residency, cutting out a year. Overall, it's a total of five years after medical school.

Fourth year is residency is usually a lot of electives so you're doing different rotations and you basically have gotten everything required during the first three years. Moreover, they know you're going to be doing inpatient and outpatient work and consultation work in doing the fellowship.

In terms of the competitiveness of residency matching, it varies year to year and according to where you're going. However, it's not as competitive as when you're doing plastic surgery or dermatology. However, Jacqueline found matching for fellowship to be very competitive with only two spots available and there were four of them in their class of eight that wanted to go to their fellowship program and they only applied to their program so obviously only half of them got it.

In order to stand out for Fellowship, get to know the Child Faculty if you're considering going into Child and Adolescent Psychiatry Fellowship. During her second year, they had electives and they applied during third year so her Child and Adolescent rotation was by the end of second year for which she wasn't sure of because they haven't had any exposure to it. So she scheduled her electives earlier in the year for Child and Adolescent Psychiatry to get to know the Child and Adolescent faculty in order to make sure and confirm that she really wanted to do it.

If you show an interest in it, it's important to get to know the faculty so that you can get great recommendation letters from the faculty. Jacqueline also encourages joining AACAP (American Academy of Child and Adolescent Psychiatrists), a national organization that accepts medical students for free. They hold a yearly conference where medical students can attend and residents can also participate in at discounted rates.

[21:06] MDs and DOs

Jacqueline did not see any bias towards DO's. In fact, the other Fellow she graduated with was a DO. She also thinks a lot of DO's gravitate towards Psychiatry probably because of their training where they take a holistic approach to taking cases.

[21:53] Other Subspecialty Opportunities

As a Child and Adolescent Psychiatrist, you can pursue more fellowships such as Forensic Fellowship and focus on the juvenile justice system or an Addiction Fellowship where you add an additional year. You may also choose a diagnosis that you really enjoy treating and just focus your practice on that. There are autism private-practice psychiatrists where they treat mainly autism.

[23:00] Primary Care and Other Specialties

Jacqueline believes it is important for everyone to work together. She tries to make it easy for pediatricians or IM's for them to work together. She would coordinate with them with regards to the diagnosis along with the lab work. A lot of times, primary care doctors order lab work before the psychiatrists do so if they're referring to a specific psychiatrist and the patient agrees in the office, Jacqueline thinks it would be great to have them sign a release through a little form sent over indicating the patient referral and lab work. If they're concerned about depression, it's important for them to be thinking of psychiatric diagnosis and screen for safety concerns, and if there is any, it's definitely good to have a referral relationship with the psychiatrist they trust where they can call them and run cases by them.

Specialties she works the closest with are therapists, GI doctor for stomach pains, Neurologists for headaches, but mostly primary care from a medical standpoint as well Endocrinologists and OB/GYNEs.

What she wished she knew before going into her current specialty is to have more exposure to the different areas one could practice. If she had done so, she would have explored the justice system and community mental health. She thinks it's important to be aware that where you do your training can be different elsewhere as well as to seek out mentors outside of where you train.

[27:15] Most and Least Liked Things & The Future of Child Psychiatry

Jacqueline thinks it's a great privilege to work with families and getting to know the patients and working with families and how rewarding and exciting it is to see patients get better. When you treat kids, you really get to see kids make a lot of strides and you can make a huge difference in the trajectory of their lives in general.

What she likes the least about her job is the administrative side of things compounded by the fact that she is in private practice.

In terms of the future of her specialty, it's important to stay on top of what's happening in their field with all the cool things coming out like telepsychiatry where you get to see patients remotely.

[29:22] Special Opportunities Outside of Medicine

There are opportunities to get involved with the education system especially in educating parents, as well as do talks in the community for mental health issues in general like the importance of sleep. You may also work with the school systems to educate, not only parents, but also, teachers and guidance counselors on mental health issues and advocacy issues children face.

[30:18] Final Words of Wisdom

Jacqueline says that if she had to do it all over again, she would have definitely chosen the same specialty. Lastly, Jacqueline encourages students interested in this specialty to look into it and to reach out to a Child and Adolescent Psychiatrist and learn more about it because there is a demand for this specialty so you will always have a job, not to mention the huge difference you can make in the lives of kids and young adults. Learn more about it to make sure you want to do it!

Links:

MedEdMedia Network

MedQuest

Board Rounds Podcast

AACAP (American Academy of Child and Adolescent Psychiatrists)

Apr 12, 2017
17: What is Pain Medicine? A Community Doc Shares His Story
42:38

Session 17

Dr. Fred Weiss is a Radiologist by training who did a Fellowship in Pain Medicine. However, he's going to share with us today what he likes least about the specialty, part of the reason he's not currently practicing Pain Medicine.

Let's jump right in and learn about Pain Medicine!

[01:38] Residency and Fellowship

Fred is currently an emergency radiologist at Geisinger Health System in Danville although he previously practiced as a Pain Medicine physician in Florida. Finishing his last fellowship in 2014, he's been practicing as an attending for about two years now. He actually did two fellowships, one was a half and half fellowship in Neuroradiology and Musculoskeletal Radiology, and the second was in Pain Medicine in University of Pennsylvania.

Prior to medical school, Fred was a physical therapist and he really enjoyed the musculoskeletal system and the nervous system, finding those were the easiest for him to understand, digest, and put into practice. During rotations, Fred enjoyed all the subspecialties affiliated with pain but didn't actually see himself as a surgeon although he liked interventional radiology-type procedures. So it was a matter of choosing a base specialty for going into Pain, doing neuro and musculoskeletal procedures the most.

[03:45] Traits of a Good Pain Doctor

Fred underscores patience as a major key to becoming a good Pain Medicine physician, along with compassion since you mostly see patients with chronic pain as a Pain doctor. Although right now, Fred admits that the best trait to have is patience with a political system and medical system we're currently in with all the complications going on with opioids where a lot of physicians feel like they have targets on their back. More so, pain physicians feel that the most because they're prescribing opioids considering the country is going through a national opioid epidemic right now.

[05:05] The National Opioid Epidemic

During interviews for attending jobs, Fred sees a lot of diversity in the way people practice pain medicine. There are those that practice only interventional procedures such as injections, epidurals, facet injections, Neuro Blocks, spinal cord assimilators, etc. On the opposite end of the spectrum, there are those that only prescribe pain medications and when you only do this type, there are only a few classes of medications being prescribed including opioids. And there are those people doing things in moderate amounts of injections and pain medications.

There's a lot of heterogeneity in the way people practice and there are people who abuse these medications and seek them while there are those who really need it and those who don't. Fred finds how difficult it is not just on a day-to-day basis, but also, on a patient-to-patient basis to figure out who's a good candidate for certain medications and for certain procedures, and who would respond to what.

[06:46] Ways to Get into Pain Medicine

In the physical therapy world, Fred's specialty was manual therapy as he enjoyed putting his hands on someone to make them feel better either for mobilization or for therapy purposes, similar to osteopathic medicine. It drew him toward that especially that he found success in those sort of techniques so he wanted to carry it over to the Pain Medicine field. To some extent, he was fairly successful in getting patients off pain medications by simply using manual therapy techniques and other modalities. Fred is not an osteopathic physician. He actually applied to nine osteopathic medical schools and got rejected from all of them. Instead, he got accepted to an allopathic school.

When he was in medical school, there were a limited number of specialties eligible for Pain Medicine Fellowship such as Anesthesiology, Physical Medicine, Neurology, and Psychiatry where he has done rotations in all of those. When he did his rotation in Radiology and met an interventional radiologist who did a bit of pain management procedures, he decided to go into Radiology, then do Interventional Radiology, and do the pain part of it. But when he went into Radiology while doing interventional rotations, he found that the only part of it that he enjoyed were the pain procedures. So he wanted to do a Fellowship in Pain Medicine.

Along the way, he met his mentor who is a neuroradiologist and a neuro interventional radiologist at UC San Diego, who was actually the first radiologist to become board-certified in Pain Medicine. What he actually did was apply for fellowship in UC San Diego where he was already part of the faculty, completed the fellowship, and was able to be boarded under the American Board of Psychiatry and Neurology. The institution then sponsored him for the exam to get certified. A few years later, another physician did the same thing but he was sponsored by the American Board of Physical Medicine and Rehab.

However, there was a lot of political change happening in the field of pain management around the time he applied. The Anesthesiology board was simultaneously closing and opening options and required physicians to have their primary boards sponsoring the examination. Consequently, Fred appealed to the American Board of Radiology (ABR) and had multiple organizations rally around this and lobby for pain medicine to become an official subspecialty of Radiology since many of the procedures were even invented by radiologists. So he wrote an 80-page application for the ABR and then to be submitted to the American Board of Medical Specialties (ABMS) and were successful in getting Pain Medicine to become an official subspecialty for Radiology. Other boards that applied included the American Board of Emergency Medicine and the American Board of Family Medicine. As a result, pain medicine is now an official subspecialty of those skills as well.

[12:12] Types of Patients

Pain Medicine physicians treat patients across the board from the developmental spectrum treating patients, children and adults alike. When he was in Florida, Fred was treating mostly 80-year-old females with back pain and neck pain as the most common issues.

The youngest patient he has treated was a eight-year-old for a chronic pain, biomechanical issue due to pes planus (flat feet) where he gave her a few exercises (incorporated with martial arts exercises being a black belt himself) and prescribed no medications. She was pain free after a month.

[14:40] A Typical Day: Clinics and Procedures

Fred's typical day depends on whether it's a clinic day or procedure day. If mixed, he would see about 15-20 patients between 8am -12pm. Then do a 10-minute follow-up on someone he did facet injections previously. Other patient are those with chronic regional pain syndrome where he would do regional blocks or ultrasound-guided like stellate ganglion block. He also treats chronic ankle pain where he injects joins with ultrasound guidance. Fred describes his typical day as similar to sports medicine clinic day.

On his procedure, he would usually have epidurals, facet injections, nerve blocks that are image-guided under fluoroscopy. His nurses would then bring patients in from the waiting room to have them prepped and ready to go and doing procedure after procedure. Fred also adds how patients would cry and give you a hug after they've treated you and they're pain-free which is very rewarding for him.

Fred performs procedures on 60%-70% of his patients since a lot of patients will respond to physical therapy. Being a physical therapist, he has a general idea of who responds well to it or who may need a little push like an injection to give them temporary relief in order to be able to tolerate more physical therapy. While there are also patients who flat-out refuse to go through physical therapy which he finds pretty challenging. He further explains that injections are only temporary for the vast majority of patients and what helps long-term is physical therapy and rehabilitation. This is reflected in the newest guidelines where physical therapy and exercise modalities are the first line of defense rather than prescribing opioids or doing injections.

Fred remembers one of his deans who taught in primary care class that there is no evidence for physical therapy prescribed for back pains and now it's come to a complete 180 degrees which he thinks as much more appropriate.

[19:05] The Role of Injections

With a lot of theories on how injections work, Fred points out that reducing inflammation is one of them. He also adds being a radiologist poses an advantage who are able to figure out what types of patients can respond really well to steroids coming from a perspective of decreasing inflammation. However, most of the time, physicians don't see much inflammation going on but there is remodeling or irritation of bone-on-bone arthritis and those patients respond to a combination of local anesthetics and steroid since the steroid will allow the local anesthetic to last longer, where the duration of which varies from patient to patient.

One of the challenges they have in pain medicine is really figuring out who is going to respond the best and the most to the procedures that we do for the best bang for their buck. Fred can actually figure things out based on what he can see on the MRI.

[21:23] Taking Calls and Work-Life Balance

For outpatient pain, you don't take any calls. In the practice he was in, he would take calls Mon-Fri/8-5 and no call on weekends. If patients had issues, they were instructed to call the emergency room or the primary care doctor and follow up during daytime hours with their office if the issue is really urgent.

As pain doctor, your work-life balance basically depends on your practice setting. If you're just opening a private practice, you will be developing your practice so you have to put your heart, soul, gut, and time so you probably won't have any vacation. But on a typical steady state, you get to have your 3-4 weeks of vacation per year, work Mon-Fri, 8-5, and no call on weekends.

[23:10] Different Pain Fellowships and Matching

Fred explains that the process for fellowships is unifying more and more every year where it's the same umbrella and category of fellowships, largely housed in Anesthesiology academic programs throughout the country, with only six or seven are currently in Physical Medicine and only one or two in the Neurology department. Everyone is applying for those fellowships and depending on the department, there is some bias as to whether it's calculated or not in terms of taking a certain number of anesthesiology or PM&R residents for their program. For instance, for anesthesiology, you can apply to any program and that's fine but if you're in PM&R, only a certain of spots are allotted for some fellowships.

Moreover, Fred describes matching as very competitive in that back in 2015, 65% of those who applied ended up matching which means 35% did not match, quite a large percentage of people.

[25:18] How to be a Competitive Applicant

If you're in Anesthesiology, Pain Medicine is already built into your program where you will be doing a couple months of it irregardless. In order to be a competitive applicant, you have to go in rotations, work hard, show some interest, and a get as much hands-on as you can. Ask for it. Sometimes you even have to beg for the fellows to give up their procedures or work directly with the attending to do some procedures. Other ways to be competitive is to get involved in research and doing a presentation for society meetings to show some initiative and to show the attending physicians that you're willing to put a little extra work in it as there is really not that much work to put in.

If you're a PM&R resident, seek out pain doctors who are fellowship-trained for this process. Get to know them and get their tips. Get their connections. A lot of times, it's not necessarily what you know but who you know. So really network as much as you can. Fred gives the same advice to the Anesthesiology resident to put an extra effort to do a little bit of research and get to know the people in your department and work with them.

[27:05] Pain Medicine Subspecialities and Boards

As part of the training, you basically do some hospice palliative care training so you can work in that type of setting. So you can also do a subspecialty in Cancer Pain, which is a lot of opioid management but nothing to worry about patients getting chronically addicted because they really won't live that long so it's really just for palliative care. The procedures tend to be more complicated with cancer pain patients. Additionally, opioids don't have a complete effect for relieving their pain so they have to get intrathecal opioid pain pumps, another type of procedure which is very effective in cancer pain.

Just like any board exam prep, you're going to have to study and work hard. But because only a few people talk about pain medicine boards in general, there's this fear about them. For those in pain fellowships right now, Fred suggests that it's almost identical to the process of taking the in-training exam. So if you did well on the in-training exam, you're going to do well on the boards. There are books available online (some for free) that you can download and do those questions. There are also question banks online that you can practice on but they are fairly expensive and Fred thinks they're only marginally useful. Overall, you can do this easily with just a free book.

[30:08] Primary Care and Other Specialties

What Fred wants to communicate to, not just primary care physicians, but also to all fields referring to pain medicine, that pain medicine does not equal opioids. Pain medicine equals a comprehensive management for pain that's both behavioral, procedural, medical, and rehab. Fred often encountered patients who'd say they've been referred to him by their primary care doctor because it's illegal for them to prescribe it. The truth is that it's never illegal for a primary care doctor to prescribe opioids but the bottom line is that opioid care is not good pain care. It requires procedures and rehab and other types of medications that are much better for pain.

Therefore, if you're going to refer to Pain Medicine, Fred believes that patients need to have a clear expectation of what to think and what they're going to receive on the first day and it's certainly not going to be a controlled substance.

Other specialties Pain Medicine works the closest with include Neurology, Neurosurgery (for nerve blocks), Orthopedics (for chronic knee pain), and Primary Care referrals.

[32:30] Special Opportunities Outside of Clinical Medicine

As in any field, you can do medico legal consulting as well as present for various pharmaceutical companies but there could be a lot of ethical issues involved so you want to make sure you're not only pushing the drug but that it also works for your patients. Several pain doctors also open their own surgical centers.

[33:33] The Emotional Aspect of Pain Medicine

Going in from radiology which is really cognitively challenging throughout the day, Fred finds pain medicine as less cognitively challenging because you have already practiced patterns for step-by-step management so the cognitive aspect is not there as much as the emotional aspect. It is very emotionally challenging throughout the day. 20% of Fred's patients do really well, while some do neutral, a chunk of them just don't get better. What Fred wished he would have known before entering this field is how emotionally taxing the practice can be throughout the day as you will be seeing a lot of patients crying and feeling hopeless. And on top of the chronic pain, patients also have financial issues and even on top of that is the absence of physical therapy practices that took Medicaid. In fact, a lot of the procedures he offered that he thought would be best for patients were not covered since the organization he worked for did not believe in free care so he was not allowed to provide those procedures.

In the end, his patients were stuck taking medications they didn't want to take because that was the only option they had, some stuck with opioid medications because that was the only class of medications that their insurance company or Medicaid would cover.

Sadly, a fairly large part of our country has been addicted to prescription opioid medications. This is one of the reasons Fred went back to the practice of Radiology because he didn't believe in this process that is self-feeding and defeating at the same time, making the problem worse than better.

On the other hand, what Fred likes the most about Pain Medicine is seeing his patients get better especially when he's able to bring the two skill sets of Radiology and Pain Medicine together. Patient get better with the right diagnosis and the right directed targeted treatment.

If he had to do it over again, Fred would still have chosen Pain Medicine despite all the political issues being that it's a fantastic and rewarding field because it challenges you on every level.

[38:44] The Future of Pain Medicine

What Fred sees on the horizon is more technology dedicated to things like spinal cord stimulation, a device implanted subcutaneously that create electronic bursts to block pain signals. These types of technologies would come forward in the algorithm of treating patients earlier with higher end procedural intervention rather than doing medications, steroids, and local anesthetics on a frequent basis.

Stem cell therapy is another thing that he sees having a lot of potential. As more research comes out, there's going to be niche indications for certain types of stem cells to be injected into various nerves, joints, and tendons that will stimulate healing.

[40:25] Final Words of Wisdom

If you really want to do this despite the political climate, go for it. At the end of the day, you're going to be extremely well-rewarded for the work that you do. The patients are going to love you and get tons of Christmas cards and hugs. It's a very rewarding field but it takes a lot from you cognitively, emotionally, and physically but at the end of the day, it's well worth it.

Links:

ryan@medicalschoolhq.net

Geisinger Health System

Apr 05, 2017
16: A Private-Practice Nephrologist Who Also is in Academics
39:23

Session 16

This week's guest is Dr. Joel Topf, a private practice and academic Nephrologist who loves teaching and the small details. Back in Episode 06 of the Specialty Stories Podcast, we first covered Nephrology where I talked with Dr. Jean Robey, a private-practice Nephrologist.

As you get to listen to both episodes, you will hear some differences in both of those settings. My goal for this podcast is to not just give you insights into what a certain specialty does, but also, for you to see the differences between an academic specialty and a community specialty, or a private-practice physician and be able to compare those different settings.

As you go through your medical training, most of the exposure you get is the academic side of medicine and that is not the majority of medicine practiced. Hence, I wanted to give you insights into all of the different aspects of it and be able to compare a private-practice Nephrologist (back in Episode 06) and this episode which is more of an academic Nephrologist.

[03:00] Choosing Nephrology

Having finished his fellowship in 2003, Dr. Topf is in a hybrid setting where he works for private practice but hired by the hospital to run their fellowship program. He teaches medical students (second to fourth years and the residency program), although it's not a pure academic role since he doesn't do a lot of research.

Coming out of medical school, Dr. Topf wanted to do a specialty that allowed him to subspecialize so he chose Med-Peds. It was on the third year of his four-year residency that he decided to do a fellowship and specialize in Nephrology. What led him to this decision is finding how interesting medicine gets and as you study it more, it gets even more interesting. Then before you know it, you can't escape. Dr. Topf was so delighted with Nephrology. However, he was also working on another project, writing a textbook on fluids and electrolytes. So while he was learning a lot of Nephrology, he was also learning a lot of Renal Physiology and fell in love with it.

By the time he was choosing his specialty, he felt like Nephrology had picked him more than he picked the specialty and there was nothing else he would ever consider doing. Had he had a more open mind, Critical Care would have been something he considered but he's happy with Nephrology since a lot of the very interesting cases that he likes in Nephrology are shared with Critical Care.

[05:35] Traits of a Good Nephrologist

Dr. Topf says that the most important trait that leads to being a good nephrologist is being detail-oriented and fastidious since it involves a lot of numbers and balls to keep in the air when you take care of these patients who have a number of problems especially when it comes to dialysis or transplant cases.

Most other primary care doctors and specialists want to take their hands off and leave it all up to the Nephrologist to take care of that so you end up being a generalist for a wide span of patients. So even though much time is spent focused on Nephrology, at least in training, Dr. Topf emphasized that you still need to keep your Internal Medicine skills sharp (reason that he re-certified in Internal Medicine).

[06:40] A Typical Day Being a Nephrologist

Dr. Topf would usually start his day at an outpatient dialysis clinic or two. They see all of their hemodialysis patients once a week and they have around 50 hemodialysis patients. So he goes to a couple of dialysis units in the morning and see a few of his first shift dialysis patients. Next stop is the hospital to see patients through the rest of the morning then have clinic patients in the afternoon. Sometimes in the middle of the day, he would also see dialysis patients on the second shift and at the end of the day, he often stops at the dialysis unit to see patients on a third shift.

Hemodialysis patients need to get dialysis three days a week so people are either on a Mon-Wed-Fri schedule or Tues-Thurs-Sat schedule. Each dialysis typically runs about four hours starting somewhere between 5-6 am and the first shift will go from 5-9 am or 6-10 am. Then at 10-11 am, the second shift will go on and then at 2-3 pm, the third shift will go on. Dr. Topf has patients at multiple units on all those different shifts so he has to find a way to see them once a week.

[8:20] Types of Patients and Other Procedures

In the U.S., 45% of people that are on dialysis get there via diabetes while about 30% get there from hypertension. Essentially, somewhere between two-thirds and three-quarters will be diabetes and hypertension. The rest is everything else that causes kidney disease such as glomerulonephritis, severe kidney injury that never recovers, polycystic kidney disease, cancer, myeloma, etc.

Dr. Topf doesn't do procedures that Interventional Nephrologists normally perform. Although during his Fellowship, he did a lot of kidney biopsies and put in a lot of temporary dialysis access. He also has partners that are more interventional who still do kidney biopsies and others put in peritoneal dialysis catheters and hemolysis catheters, but it's not something Dr. Topf likes doing.

[10:10] The Academic Aspect of Being a Nephrologist

Dr. Topf gives standard lectures every month where he gives a morning report to the residents at their hospital who are in the internal medicine program as well as lectures to their five Nephrology Fellows. He participates in the Fellowship in terms of interviewing and selecting the next year's fellows as well as in evaluating the current fellows.

Additionally, he runs one of his outpatient clinics as a fellow clinic so he staffs that fellow in a clinic. He also has a standard role of teaching third year medical students three lecture series as a new group of internal medicine third year students rotate through the hospital for basic nephrology concepts.

Another one of his responsibilities in the Fellowship Program is helping coordinate the Fellow Research Projects so these get into fruition.

[11:53] Seeing the Two Sides of Nephrology

What attracted Dr. Topf to the job was the opportunity to teach as this is something that he really wanted to do. He just didn't want to be locked into the bureaucracy of a traditional academic program with lots of pressure to publish and get grants. So he found this hybrid model that fits the kind of practice that he wanted to do. Basically, it was his practice that became the driving force to bring both of these things to the hospital.

[13:00] Work-Life Balance

Dr. Topf describes his Nephrology practice as enjoyable. It's more of a traditional physician model where he doesn't have set hours and has a call generally once a month with certain exceptions such as when a partner gets sick or death in a family so he would have to get calls twice or thrice a month, which happens rarely.

But nephrology in general is more of a traditional internist model. It's not a hospitalist nor an E.R, doc so you're not punching in or out. Dr. Topf describes himself as a business owner so he works harder because he owns it and the work he puts in is delivered back to him in monetary rewards.

When he gets a call, he covers all the patients in the hospital so he typically sees somewhere between 20 and 30 patients in the hospital each day that he is on call, which would be a full day.

[14:55] The Path to Residency and Fellowship

If you want to be a pediatric nephrologist, you need to do three years of internal medicine and then you need to get a Nephrology Fellowship, which is traditionally three years long (Commonly today, there are two years now.) In the old model, it consists of one year clinical and two years of research. For most fellowships now, it's two years of clinical experience with some clinical research in the second year.

During his adult fellowship, he spent a lot of time doing Pediatric Nephrology where he did special rotations at the children's hospital and got a lot of experience. What he found out from that experience is that it really is a different specialty. There is a crossover but there isn't all that much because the diseases they see are quite a bit different.

If he lived in an area that didn't have a pediatric nephrologist, he would absolutely see children but he lives in Detroit where there is a children's hospital two to four miles away from his hospital so it would be absurd for parents to take their kid to see an adult nephrologist when there is a pediatric nephrologist right next door. He did think about doing it early on in their training but as he began to appreciate what being a specialist really meant, it made less and less sense for him. If you want to be a generalist, don't sub-specialize. If you want to be a specialist well then you need to be a specialist where you need to focus on just the patients that you're going to be taking care of.

Why he chose adult nephrology over pediatric nephrology is primarily because of the way higher demand for an adult nephrologist. He has heard stories of people finishing pediatric nephrology fellowships and not being able to find a job or they're not able to use that training having to spend for years waiting for a position to open up so in meantime would have to do general pediatric work so they don't get to use their training.

[18:30] Competitiveness of Nephrology Fellowship and the Hospitalist Boom

A nephrology fellowship is not competitive, in fact, Dr. Topf reckons it's close to two nephrology spots for every one applicant. So it's absolutely a buyer's market. Therefore, the residents are in great positions where they will definitely get offered interviews everywhere and they will be able to put a very aggressive rank list since there would still be a match system. Very few people who want to be a nephrologist are unable to become a nephrologist.

What they want to see in nephrology fellowship applicants is somebody who has a strong desire to be a nephrologist rather than just someone who sees it as a fallback. They're looking for someone who really loves the specialty and wants to be a nephrologist and not just what's available to them.

This is demonstrated through a research experience in nephrology or letters of recommendation from fellow Nephrologists they know or have done rotations in their institution or they've contacted them early on and shown interest to it. All these could put any applicant way higher on the rank list.

Six years ago, they had 200 applicants for their two to three spots a year but the number has waned this year to just 22. The demand thereby fell off to 90% in six years. Dr. Topf’s theory is that this could be caused by the hospitalist boom, a huge new specialty that emerged from nowhere that they have to staff up every resident plus they pay excellent salaries, offer shift work, and they start getting paid the next day their residency ends. Whereas in a nephrology fellowship, you have two more years of postgraduate training to go through and then you get a job where you're going to work more than 40 hours  a week. Compared to a cardiologist or a G.I. doctor that gets a much higher salary than as a hospitalist but at the end of a nephrology rainbow, the salary may just be modestly better or the same as with a hospitalist.

[22:30] Subspecialty Opportunities

Subspecialties available include Transplant Certified, which happens one year after fellowship, and Interventional Nephrology, which is less regulated. Some fellowships do that, others have two or three-month courses run by dialysis access companies that give them all the training needed for those procedures (no board certification for that). Others do Hypertension subspecialties, which is just a test given by the American Society of Hypertension. You can do fellowship and get formal training for it but a lot of people just take the test and gain that certification.

[23:45] Primary Care and Other Specialties

Dr. Topf thinks primary care physicians are doing a good job with it but they should be more aggressive with hypertension and less aggressive with glycemic control since he sees a lot of patients suffering from over-emphasis on trying to get the A1c all the way down causing a lot of hypoglycemic spells. But these are style issues more than knowledge gaps.

Among other specialties he works closest with include critical care, E.R. cardiology and endocrinology. They also get consults for the same diseases oftentimes such as hypercalcemia.

[26:10] Special Opportunities Outside of Clinical Medicine

A huge opportunity outside of clinical medicine is a Dialysis Medical Director. There are thousands of dialysis units around the country that cannot operate without a medical director.

Medical directors need to be board-certified in Nephrology. Dr. Topf adds that this is a different type of medicine than you've ever practiced before since you will be providing population health and be looking at all the infections that happened in, say, 80 patients there that month and try to find patterns causing these infections.

They also have to go over the water treatment system considering the massive amount of water used in dialysis, meaning 5,760 liters per shift and you run three shifts per day so that is close to 20,000 liters of water being treated in a dialysis unit everyday. Keeping all that equipment up-to-date and functioning is a continual exercise and you have experts that help you with it but the medical director is at the top of all those experts to make sure they're doing a good job and doing all the reports on water quality, infections, and meeting targets in hemoglobin, albumin, and phosphorus. You will also be working with a Nutritionist or a social worker.

Apparently, there are a lot of different benchmarks of a dialysis quality and as a medical director, you're responsible for those.

[29:30] The Best and Least Good Thing

Dr. Topf finds being a nephrologist to be a rewarding career for him. His advice to a brand new nephrologist is that your first few years coming out of Fellowship are still a major learning moment. You are nowhere near the top of the mountain so there's still a lot of learning you need to do so be humble.

What he loves best about being a nephrologist is the teaching side of it. He also loves having that longitudinal experience with his patients where he is able to see and take care of patients through all the different phases of their kidney disease.

On the flip side, what he likes least about being a nephrologist is those four dialysis visits a month for each dialysis patient which he considers as an overkill. He thinks he didn't need to do this that much since you could do all the medically important stuff in just two visits but this is a requirement(which is also a reimbursement-driven thing) that ends up being unnecessarily burdensome for him .

[32:15] The Future of Nephrology

The advancements in technology and techniques taking over much of the diseases have significantly reduced the numbers of procedures needed in treating diseases related to, for example, cardiology.

Nephrology is highly dependent on dialysis so if a new technology comes on, whether it would eliminate dialysis or dramatically reduce its need would be a major earthquake for the specialty.

Nanotechnology creating smaller filters to create a transplantable artificial kidney is something he doesn't see being viable for a long time. It sounds cool but it doesn't really address the biggest problem with current dialysis which is access, the mere process of getting the blood in and out of the body safely. Unfortunately, this technology doesn't address that.

[35:30] Final Words of Wisdom

If he had to choose Nephrology again, he would still have chosen it in a second. Lastly, Dr. Topf wants students to know that if they find the kidney to be interesting but intimidating because of how difficult it is, then it's not that difficult. You will be able to learn the kidney from its very fundamentals when you go to fellowship and you will be building a model of it in your brain. Once you have that model, everything makes sense and it all falls into place. That is difficult to understand how much simpler everything will be when that happens. Once you get it, you get it and it's not very hard. If you're interested in it, pursue it because it's not that hard.

[36:40] Bias Among DOs and Caribbean Graduates

Dr. Topf said that they have a DO on the board in their practice and will likely be the next CEO. Their assistant program director is also a DO. So there no bias, not even close to having a bias. They also have a Caribbean graduate who is an excellent doctor as a partner.

Links:

Get connected with Dr. Joel Topf on Twitter @kidney_boy.

Shoot me an email at ryan@medicalschoolhq.net

MedEd Media Network

Specialty Stories Podcast Episode 06: A Private-Practice Nephrologist Talks About Her Job

American Society of Hypertension

Mar 29, 2017
15: Interventional Radiology: A Community Doc Shares His Story
54:05

Session 15

This week, I speak with Dr. Fayyaz Barodawala, a community-based Interventional Radiologist from Atlanta, Georgia, about his career decisions, what an IR physician does on a daily basis, the struggles and triumphs that come along with his practice and specialties opportunities outside IR and other interesting topics like exclusive hospital contracts and artificial intelligence replacing diagnostics.

[01:15] Choosing Interventional Radiology

Practicing medicine since 2005, Fayyaz knew he wanted to be an Interventional Radiologist on one particular day during his third day of medical school. He initially found interest in plastic surgery, vascular surgery, and orthopedics.

He had exposure to medicine growing up with his parents both physicians but it was on his third year, surgical rotation that he remembered being chewed out after having observed a surgical procedure passively for so long. During that same day, he went to see a family friend how happened to be called in for a pulmonary arteriogram and surprised at how quick the procedure was. At that point, he was considering orthopedics or radiology with the full intention of going into interventional, if he did the latter. What he likes about the field is the fact that you get to do different and relatively short procedures that make a difference and people happy.

[04:10] Traits of a Great Interventional Radiologist

Fayyaz says the things that make great interventional radiologists are knowledge of imaging and problem-solving. A lot of what he has to do is a lot of problem-solving. There may be defined pathways to do certain things but If they don't go as planned, then you have to improvise a lot. You have to be able to figure out how to accomplish your goal using the tools you have.

A running joke during his fellowship was that IR was the last name on the chart so when everybody thinks a procedure is too high-risk for them, they'd call IRs to take care of it. IRs do so much work like put filters in, arterial work, oncologic work, spine work, etc. So they have their hands on a whole bunch of different places but problem-solving and thinking outside the box are good traits to have for Radiology. And of course, you need to know your Anatomy.

[06:22] Types of Patients

Interventional radiologists treat younger, healthier patients that they might see for as simple as venous access like a PICC or younger women who have heavy menstrual bleeding due to fibroids. They do uterine artery embolization. They treat veins for cosmetic and medical reasons like a vein ablation and sclerotherapy.

They also treat older patients with spinal fractures for vertebroplasty or kyphoplasty. They treat a lot of oncologic patients which branches off into its whole own sub or super-specialty, even treating hepatic tumors such radio embolization, chemo embolization, or radiofrequency or microwave ablation or cryoablation.

Hence, the see a full spectrum of patients who are younger and healthier to older and very, very sick.

[07:32] A Typical Day for an Interventional Radiologist

His current practice is less hard core and interventional than he would have liked. Bread and butter for them would be paracentesis, thoracentesis, chest port placement for chemo, various biopsies, vertebral kyphoplasty for spinal fractures. In his latest practice, he had gotten into a lot of pain management procedures such as epidural steroid injections, lumbar puncture, and myelogram. In between, he reads diagnostic imaging.

Interventional radiologists do a wide variety of cases. Today, Fayyaz did paracentesis, thoracentesis, fluoroscopy, breast biopsies, and red PET scans. Other days, he could be doing a lot more like nephrostomies, biliary drainage, kyphoplasties. They're also currently ramping up their oncologic work at the new group he's in, doing ablations and radio embolizations that are starting to pick up now.

Even if you're a little ADD, you can find stuff that's good because it's not monotonous. On the flip side, they do very heavy-duty cases like TIPS which do not occur as often but these cases could be longer.

In their group of 4 IR doctors, they're on call every fourth so once per quarter for a weekend and random days here and there depending on the hospital setup. Fayyaz further says that if there's enough for two or three people to do full time interventional, the more interventional you want to do, the more call you have to take because in their practice, it's not full-time interventional all the time.

[12:21] Work-Life Balance and Managing Expectations

As reimbursements have fallen, IR does not generate as much income for the practice. Fayyaz thinks it's about managing expectations. You're better being a diagnostic radiologist if you simply want to go in there, punch a clock, and get out. There are also non-traditional options like the outpatient vascular access centers where they do dialysis interventions which are pretty regular hours. Then your work-life balance can be great.

Fayyaz would describe his work-life balance as pretty good, starting work at 8 am and usually done by 4:30-4:45 pm. Diagnostic calls can be brutal but interventional calls are not as bad. Again, it's about managing expectations.

If you prefer cool cases, then you might get called in the middle of the night for a G.I. bleed for instance. But if you're doing bread and butter cases, work-life balance is fine.

[14:25] The Residency Path

Back in the mid-90's, there was a time when internship was not required so you go right into Radiology. That changed in around 1995 when they've changed the mandate.

The traditional pathway is a year of internship (surgery. medicine, pathology, transitional, pediatrics) then you do four years of Diagnostic Radiology and then one year Interventional Fellowship  It's a six-year thing.

The direct pathway is for the Diagnostic and Interventional Radiology-enhanced clinical track. However, this is going away in favor of a pure IR residency right now as they shift into a new paradigm that's evolving more quickly. As more and more programs go towards that, you will match into Interventional Radiology directly from medical school, which includes more clinical time, cut down the diagnostic time a bit and increase the interventional time. (The first set of programs was just approved last year. so they're just starting.) This is great if you want to do something interventional but Fayyaz is not sure how this is going to work for the private practices so he has some reservations.

He further explained that a lot of these plans are placed by academics which is a really different setup than private practice. It's tough for a private practice doctor that doesn't have a ton of interventional because they're not going to be as versatile. Hence, in huge practice, it's great but in a not-huge practice, that remains to be seen.

The new model is to set up your own practice just as a surgeon or cardiologist would, see patients clinically and then bring them to a hospital. But that's probably they're going to end up. In order to compete, you can't have the old model just sitting there waiting for procedures to come to you. You have to market, you have to evaluate patients and do consults which not some of the older guys are used to.

[18:14] Matching for Interventional Radiology

Competition for interventional radiology goes in phases. As a job, the competition has tightened as more interest is starting to happen in interventional due to the difficulty of outsourcing it. People also enjoy doing procedures so it has been incredibly competitive in the last couple of years, to the point that people are not matching for Interventional Fellowships.

To be competitive for matching, you have to be a hard worker and have a mentality of saying yes almost all the time. And if you say yes all the time and then you say no, then people respect your opinion. Be willing to get your butt kicked for a while so you will be ready to handle everything that comes at you.

Other things that can make you competitive are being innovative, being able to do problem-solving, knowing the imaging, being clinical, willing to constantly learn new things, and understanding that there are things you don't know so just be able to take in what you can and learn as you go afterwards.

Fayyaz doesn't necessarily believe that scores tell everything. It's one tool for weeding but it shouldn't be the only tool.

Fayyaz went to a program where research was not a priority but if you're looking at research-heavy programs, it depends on what your goal is. If your goal is academic research and publish, then look for a program that can cultivate and nurture that. If you want to be a work horse, then you want something that gives you more clinical training. During his residency, there were very few Fellows so they had to do a ton as a resident.

It's nice to have a highly resident-centric program when you're a resident and a very fellow-heavy program when you're a fellow. Nevertheless, research is important in helping the interventionalist. A lot of procedures are pioneered by radiologists but as they get more commonplace and more routinely and more lucrative, other specialties start snipping away at it so you're going to be experiencing turf battles. For instance, a lot of people might be fighting for a cerebral angiogram which can be done by interventional radiologist or a vascular surgeon, a neurologist, and neurosurgeons.

[24:47] Bias Against DOs

Fayyaz worked in New York hospital that had a deep Radiology residency DO program and would be joking to them about how MDs couldn't go into the DO programs and DOs could go into the MD program. On a serious note, he doesn't really see any distinct bias but it's there for some other people.

[26:50] Special Opportunities for Sub-Specialties

Some interventionalists would like to do peripheral arterial but that’s contentious because different specialties have gotten involved and everybody wants to do it thinking it's cool and reimbursements can be very high. Some people work with vascular surgeons and even joined vascular practices.

But the big thing right now is Interventional Oncology and that's where everybody wants to get into. It involves stuff like radio embolization, chemotherapies, and various regimens. Other people do Neuro Interventional which typically requires a Neuro Radiology Fellowship and then Neuro IR Some also get involved in Stroke Intervention. There is some overlap between Neuro Intervention and IR next. You can also do Pediatric Interventional Fellowship.

[28:48] Working with Primary Care and Other Specialties

Speaking of clinical IR and not waiting for people to refer to you, Fayyaz meant not waiting for  a vascular surgeon or cardiologist or somebody else to refer to you. Peripheral vascular disease, for example, are marketed successfully by primary care physicians to family practice, internal medicine, pediatrists. He's not sure if they really understand exactly what  IRs do which has been a problem for them because they're not aware of the services they offer.  IRs hundreds of chest ports and they could probably do even better than surgeons sometimes as backed by evidence. They could do it faster and cheaper. So  IRs do more than just that, they do biopsies, spine interventions, peripheral arterial, biliary stuff and those people thought as surgical procedures. They also do fibroid embolization, venous disease, and gastrostomy in so all these things can be done. What feels frustrating is they sometimes feel just as a back up and they're only sought for because no one else is available to do it. It would be nice to have a great relationship between the primary physician and the IR. Check what  IRs are doing because you might be surprised what the interventionalist can do for you.

Other specialties Interventional Radiologists work the closest with include Oncology, Orthopedics, Hospital/Critical Care. Fayyaz says the best way would be an alliance between vascular surgery and radiology and interventional competing against cardiology.

[33:05] Diagnostic Radiologists Replaced with A.I.

Interestingly, Fayyaz mentioned that there have been thoughts of merging Diagnostic Radiology and Pathology into one specialty. The argument is that given it's a lot of pattern recognition on the diagnostic side, those should be handled by computers and the physician would be instead be involved in the management.

I personally believe that within 20 years, radiologists are going to be replaced with AI for diagnostic purposes. Fayyaz agrees it may come and could be scary. But there is a lot of grey zone for now. If computers could just highlight findings of questionable significance and let somebody go through it then that would be helpful in making their job faster and better.

[37:00] Other Special Opportunities Outside of IR

Radiologists have a lot of unique opportunities since they interact with a lot of specialties.  They can be very strong in administration. Fayyaz adds that  IRs are somewhat anchors for the group in the hospital because they're providing a lot of coverage that can't be easily outsourced. Again, it's important to not wait for things to come to you but to be out there somewhat marketing yourself, being available, getting your face shown so people know who you are a