Dr. Perlman is a Pediatric Neuromuscular Neurologist- what is this specialty, and what was his journey to his current career?Links:Full Episode Blog PostMeded MediaBlueprint MCAT

<p>Dr. Perlman is a Pediatric Neuromuscular Neurologist- what is this specialty, and what was his journey to his current career?</p><h2>Links:</h2><p><a href="https://medicalschoolhq.net/ss-229-the-path-to-pediatric-neuromuscular-neurology/" rel="noopener noreferrer nofollow" target="_blank">Full Episode Blog Post</a></p><p><a href="https://medicalschoolhq.net/meded-media/" rel="noopener noreferrer nofollow" target="_blank">Meded Media</a></p><p><a href="https://blueprintprep.com/mcat" rel="noopener noreferrer nofollow" target="_blank">Blueprint MCAT</a></p>

229: The Path to Pediatric Neuromuscular Neurology

Dr. Hlaing is a Critical Care Cardiothoracic Anesthesiologist. Let's chat about their path to this anesthesia subspecialty.Links:Full Episode Blog PostMeded MediaBlueprint MCAT

<p>Dr. Hlaing is a Critical Care Cardiothoracic Anesthesiologist. Let's chat about their path to this anesthesia subspecialty.</p><h2>Links:</h2><p><a href="https://medicalschoolhq.net/ss-228-the-heart-of-cardiothoracic-anesthesiology/" rel="noopener noreferrer nofollow" target="_blank">Full Episode Blog Post</a></p><p><a href="https://medicalschoolhq.net/meded-media/" rel="noopener noreferrer nofollow" target="_blank">Meded Media</a></p><p><a href="https://blueprintprep.com/mcat" rel="noopener noreferrer nofollow" target="_blank">Blueprint MCAT</a></p>

228: The Heart of Cardiothoracic Anesthesiology

Dr. Grody specializes in Medical Genetics &amp; Molecular Diagnostics. Let's talk about their journey and the lessons learned over their 33 years of practice.Links:Full Episode Blog PostAmerican College of Medical GeneticsNational Society of Genetic CounselorsAmerican Medical Association (AMA)Journal: Gene Editing — A Cure for Transthyretin Amyloidosis?Meded MediaBlueprint MCAT

<p>Dr. Grody specializes in Medical Genetics &amp; Molecular Diagnostics. Let's talk about their journey and the lessons learned over their 33 years of practice.</p><h2>Links:</h2><p><a href="https://medicalschoolhq.net/ss-227-its-in-the-genes-medical-genetics-diagnostics/" rel="noopener noreferrer nofollow" target="_blank">Full Episode Blog Post</a></p><p><a href="https://www.acmg.net/" rel="noopener noreferrer nofollow" target="_blank">American College of Medical Genetics</a></p><p><a href="https://www.nsgc.org/" rel="noopener noreferrer nofollow" target="_blank">National Society of Genetic Counselors</a></p><p><a href="https://www.ama-assn.org/" rel="noopener noreferrer nofollow" target="_blank">American Medical Association (AMA)</a></p><p><a href="https://www.nejm.org/doi/full/10.1056/NEJMe2110557" rel="noopener noreferrer nofollow" target="_blank">Journal: Gene Editing — A Cure for Transthyretin Amyloidosis?</a></p><p><a href="https://medicalschoolhq.net/meded-media/" rel="noopener noreferrer nofollow" target="_blank">Meded Media</a></p><p><a href="https://blueprintprep.com/mcat" rel="noopener noreferrer nofollow" target="_blank">Blueprint MCAT</a></p>

227: It's In The Genes: Medical Genetics & Diagnostics

Today we chat with Dr. Derek about his journey to specializing in Nephrology and Hypertension.Links:Full Episode Blog PostAmerican Society of NephrologyMeded MediaBlueprint MCAT

<p>Today we chat with Dr. Derek about his journey to specializing in Nephrology and Hypertension.</p><h2>Links:</h2><p><a href="https://medicalschoolhq.net/ss-226-the-road-to-a-renal-hypertension-specialist/" rel="noopener noreferrer nofollow" target="_blank">Full Episode Blog Post</a></p><p><a href="https://www.asn-online.org/" rel="noopener noreferrer nofollow" target="_blank">American Society of Nephrology</a></p><p><a href="https://medicalschoolhq.net/meded-media/" rel="noopener noreferrer nofollow" target="_blank">Meded Media</a></p><p><a href="https://blueprintprep.com/mcat" rel="noopener noreferrer nofollow" target="_blank">Blueprint MCAT</a></p>

226: The Road to a Renal Hypertension Specialist

Dr. Ramsey-Goldman has been a Rheumatologist since 1986, and today, she spills everything on her journey and specialty. Tune in for her wisdom!Links:Full Episode Blog PostMeded MediaBlueprint MCATAmerican College of Rheumatology

<p>Dr. Ramsey-Goldman has been a Rheumatologist since 1986, and today, she spills everything on her journey and specialty. Tune in for her wisdom!</p><h2>Links:</h2><p><a href="https://medicalschoolhq.net/ss-225-route-to-rheumatology/" rel="noopener noreferrer nofollow" target="_blank">Full Episode Blog Post</a></p><p><a href="https://medicalschoolhq.net/meded-media/" rel="noopener noreferrer nofollow" target="_blank">Meded Media</a></p><p><a href="https://blueprintprep.com/mcat" rel="noopener noreferrer nofollow" target="_blank">Blueprint MCAT</a></p><p><a href="https://www.rheumatology.org/" rel="noopener noreferrer nofollow" target="_blank">American College of Rheumatology</a></p>

225: Route to Rheumatology

Today we talk to an abdominal transplant surgeon who's been practicing for 18 years in an Academic setting. Let's talk about their journey.Links:Full Episode Blog PostMeded MediaBlueprint MCATAmerican Society of Transplant Surgeons

<p>Today we talk to an abdominal transplant surgeon who's been practicing for 18 years in an Academic setting. Let's talk about their journey.</p><h2>Links:</h2><p><a href="https://medicalschoolhq.net/ss-223-thoughts-on-transplant-surgery/" rel="noopener noreferrer nofollow" target="_blank">Full Episode Blog Post</a></p><p><a href="https://medicalschoolhq.net/meded-media/" rel="noopener noreferrer nofollow" target="_blank">Meded Media</a></p><p><a href="https://blueprintprep.com/mcat" rel="noopener noreferrer nofollow" target="_blank">Blueprint MCAT</a></p><p><a href="https://asts.org/" rel="noopener noreferrer nofollow" target="_blank">American Society of Transplant Surgeons</a></p>

223: Thoughts on Transplant Surgery

Dr. Cao is a physician who specializes in the pathology of the GI and Liver. Let's chat about his journey and the type of person this specialty is a fit for.Links:Full Episode Blog PostMeded MediaBlueprint MCAT

<p>Dr. Cao is a physician who specializes in the pathology of the GI and Liver. Let's chat about his journey and the type of person this specialty is a fit for.</p><h2>Links:</h2><p><a href="https://medicalschoolhq.net/ss-222-the-path-to-gi-and-liver-pathology/" rel="noopener noreferrer nofollow" target="_blank">Full Episode Blog Post</a></p><p><a href="https://medicalschoolhq.net/meded-media/" rel="noopener noreferrer nofollow" target="_blank">Meded Media</a></p><p><a href="https://blueprintprep.com/mcat" rel="noopener noreferrer nofollow" target="_blank">Blueprint MCAT</a></p>

222: The Path To GI and Liver Pathology

Dr. Sterling has been an academic Gastroenterology and Transplant Hepatology physician for 26 years. Let's talk about his journey.Links:Full Episode Blog PostMeded MediaBlueprint MCATThe American Society of TransplantationAmerican Association for the Study of Liver Diseases

<p>Dr. Sterling has been an academic Gastroenterology and Transplant Hepatology physician for 26 years. Let's talk about his journey.</p><h2>Links:</h2><p><a href="https://medicalschoolhq.net/ss-221-teaching-and-practicing-hepatology/" rel="noopener noreferrer nofollow" target="_blank">Full Episode Blog Post</a></p><p><a href="https://medicalschoolhq.net/meded-media/" rel="noopener noreferrer nofollow" target="_blank">Meded Media</a></p><p><a href="https://blueprintprep.com/mcat" rel="noopener noreferrer nofollow" target="_blank">Blueprint MCAT</a></p><p><a href="https://www.myast.org/" rel="noopener noreferrer nofollow" target="_blank">The American Society of Transplantation</a></p><p><a href="https://www.aasld.org/" rel="noopener noreferrer nofollow" target="_blank">American Association for the Study of Liver Diseases</a></p>

221: Teaching and Practicing Hepatology

Today we chat with a community sports medicine physician about his journey from med school to residency and beyond. Tune in now!Links:Full Episode Blog PostAmerican Orthopaedic Society for Sports MedicineMeded MediaBlueprint MCAT

<p>Today we chat with a community sports medicine physician about his journey from med school to residency and beyond. Tune in now!</p><h2>Links:</h2><p><a href="https://medicalschoolhq.net/ss-220-a-sports-medicine-story/" rel="noopener noreferrer nofollow" target="_blank">Full Episode Blog Post</a></p><p><a href="http://www.sportsmed.org" rel="noopener noreferrer nofollow" target="_blank">American Orthopaedic Society for Sports Medicine</a></p><p><a href="https://medicalschoolhq.net/meded-media/" rel="noopener noreferrer nofollow" target="_blank">Meded Media</a></p><p><a href="https://blueprintprep.com/mcat" rel="noopener noreferrer nofollow" target="_blank">Blueprint MCAT</a></p>

220: A Sports Medicine Story

Today we chat with Kenisha Campbell, MD about her experience working in Adolescent medicine.Links:Full Episode Blog PostMeded MediaMelanin Hues PodcastThe Society of Adolescent Health and MedicineBlueprint MCAT

<p>Today we chat with Kenisha Campbell, MD about her experience working in Adolescent medicine.</p><h2>Links:</h2><p><a href="https://medicalschoolhq.net/ss-219-adolescent-medicine-connecting-with-teens/" rel="noopener noreferrer nofollow" target="_blank">Full Episode Blog Post</a></p><p><a href="https://medicalschoolhq.net/meded-media/" rel="noopener noreferrer nofollow" target="_blank">Meded Media</a></p><p><a href="https://www.melaninhuespodcast.com" rel="noopener noreferrer nofollow" target="_blank">Melanin Hues Podcast</a></p><p><a href="https://www.adolescenthealth.org/Home.aspx" rel="noopener noreferrer nofollow" target="_blank">The Society of Adolescent Health and Medicine</a></p><p><a href="https://blueprintprep.com/mcat" rel="noopener noreferrer nofollow" target="_blank">Blueprint MCAT</a></p>

219: Adolescent Medicine: Connecting with Teens

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

I’m a non-trad admitted DO from NJ. I start med school in my home state in a couple of months. Listening to these podcasts has been informative and helpful in allowing me to see the different fields that medicine has to offer. I have enjoyed listening to different stories of the day to day life of physicians and it has made me to reflect deeper on what kind of physician I might want to be.

Amazing stories

As a non-trad trying to make decisions that will not only affect my life but the lives of my husband and children forever, this podcast has been so valuable as I weigh the pros and cons of each specialty! I love getting the insight and perspective into different specialties from physicians who are actually living and working in that lifestyle. Thank you for hosting!!

Very Informative

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 <a href="http://MededMedia.com" rel="nofollow" target="_blank">MededMedia.com</a>

Specialty Stories

Dr. Kohler is an interventional pain &amp; regenerative medicine specialist. Today he shares his experiences on the frontier of a rapidly advancing field.

<p>Dr. Kohler is an interventional pain &amp; regenerative medicine specialist. Today he shares his experiences on the frontier of a rapidly advancing field.</p>

131: A New Frontier in Pain Management: Regenerative Medicine

Session 118 Where will you see the most variety of patients? Internal Medicine, of course! Dr. Hilary Ryder gives us a peek into subspecialties and the IM lifestyle. Hilary is the Internal Medicine program director at Dartmouth-Hitchcock Medical Center. She shares her internal medicine residency experience, how to pick a program, and how to stand out in your applications and rotations. If you haven’t yet, please do check out our other resources on Meded Media. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:13] Interest in Internal Medicine Hilary was initially unable to make a decision about what specialty she wanted to go into. Into her fourth year, she thought she wanted to be a dermatologist. What drew her to it was the lifestyle having no nights and weekends. It felt like a lifestyle specialty that she could get into. During her third year clerkship in medicine, she really loved what she was seeing but she wasn't sure if she could handle the 30-hour shifts they were doing. Eventually, she did a medicine sub-internship in hospital medicine that didn't have any overnight shifts. She ended up falling in love with her team and with how diverse the cases she was managing. She started to take on more ownership of patients. She found it so rewarding that she found the 30-hour shifts to be all worth it. The'res this idea of spending of 6-12 weeks on Internal Medicine doing some hospital medicine work, ambulatory care work, etc. Then you're going to figure out this is what you're going to do. And so a lot of people choose IM since they haven't really made their decision. But then when you're in your residency, you're stuck making another decision because there are so many different ways to be an internist. You have the breadth of opportunities all over again within internal medicine. [Related episode:  What is Private Practice Internal Medicine-Pediatrics?] [05:45] Types of Patients Hilary explains that the types of cases an internist might manage basically depend on your geographic location. She's from New England and a lot of their primary care doctors are internists. If you travel more to the midwestern states, you're going to find that most of the primary care doctors are family medicine doctors. So you go into internal medicine planning to subspecialize. You can do an internal medicine residency and go into Sports Medicine, Allergy, Interventional Gastroenterology, Interventional Cardiology, Geriatrics, or Critical Care. If you go into Anesthesia or Psychiatry, you're going to do just a couple of months of medicine. If you're going into Neurology or Radiology, you're going to do a year of internal medicine. If you want to be an Endocrinologist, you're going to do a three-year IM residency. And then spend some more time in a fellowship subspecializing even more in terms of the types of patients you're going to take care of. Many of the mentors you're going to see in your second year are internists. In your preclinical years, a lot of the physiology and the pathophysiology are going to be taught by internists. In Nephrology, you're going to learn your acid-base. And you're going to learn your electrolyte disturbances from internist. They completed their three years of internal medicine and they went on to a Nephrology fellowship. [Related episode:  5 Traits Patients Want Their Doctors to Have] [09:30] Typical Day Their internal medicine residents rotate through a variety of different specialties within internal medicine. A third-year clerkship student rotates through a variety of different departments. In their program, they have residents in the intensive care unit for a month. They have residents on the interventional cardiology service. They have those taking care of bone marrow transplant patients. They have residents in clinic and residents doing home visits. In general, students know what the inpatient experience is, the interims of pre-rounding, then the rounding with the residents and seeing patients. What they may not see are some of the other work residents are doing. Their residents do homecare visits with geriatric populations on their mandatory geriatrics rotation in the second year.  They have dedicated rotations on medical education to try and make their residents better teachers. Because they're an academic program, they want residents to be able to teach medical students. So they spend some time on medical education. In medicine, they work in teams. So residents are going to have to go through a lot of teamwork and leadership. They expect residents to not only provide medical care but also, to teach others and lead teams that provide medical care.  The resident is going to need to learn how to interface with the social worker, the discharge coordinator, the primary care physician, and the student and the nurse. They have to keep those balls in the air and keep the team moving forward. They need to make sure there's a great plan of care for the patient and the patient's plan of care is being moved forward. [Related episode:  Resident Duty Hours and the Ripple Effect] [12:40] Taking Calls Taking calls is different depending on where you practice. In general, call for people who haven't done a lot of clinical exposure would be this long-term, multi-day experiences. You live in the hospital and you admit a lot of patients that you cared for longitudinally. Some programs are have gotten away from the 24-hour calls. This means you're in the hospital admitting for 24 hours. You can be in the hospital for up to 4-6 hours after that cleaning up before you go home the next day. Other programs like the night programs have gone to shift-based work where there is no long-term call. Residents will stay in the hospital and admit patients for a certain amount of time. They sign out to an overnight team who comes in to cover the patients and do the admissions overnight. [15:20] The 3 Kinds of Medical Students There are medical students who have no idea of what they want to do coming into their IM residency.  There are also those who are pretty sure and they're right. They end up doing what they think they wanted to do in the first place. Then there are medical students who are pretty sure and they're wrong. They try something out and realize it's not for them. Some of the disease processes you learned about as a medical student may be intriguing. But the most common diseases in a specialty, you might not find all that appealing. Figure out where you think your career is going. If the residency program you think you want to go to has never sent anyone to an Allergy-Immunology Fellowship and you're determined to be an allergist, you really need to think if that's going to be the right place or you. Consider what your experience is going to be like. Are you going to be with like-minded individuals? Are you going to have the clinical experiences and support you want? Is it going to get you where you want to go? The best way to determine that is if there's a track record of other people going there. Look at the schedule and who the leadership is. Look at where people went after residency. [Related episode:  The Nontraditional Medical Student: A Different Path to Med School] [19:10] The Training Path After Hilary finished medical school, she went into residency. She was undecided and she was one of the students who loved everything in medical school and thought she wanted to do everything. So she had difficulty choosing. You spend 36 months in your residency program. You should get exposed to a wide variety of different specialties. If you choose not to go into fellowship, you're ready to practice. You can then practice as internist without further training either in primary care or hospital medicine. But even these two are broader than you think. A hospital medicine doctor is going to practice exclusively in the inpatient realm of things. [Related episode:  The Role of Residency Training For Physicians] [21:08] How to Be a Competitive Applicant Looking at the 2019 match data, 97% of internal medicine spots filled and only 42% are filled by U.S. Seniors from allopathic medical schools. There are a lot of DO students entering IM as well as international medical graduates. To be most competitive, as with other specialties, they look at the internal medicine grades. Often, there's an IM clerkship, a primary care clerkship, and at least a sub-I in either medicine or one of the subspecialties. They also look at the surgery grade.  Hilary believes in the holistic review of the application. They look at the Step scores as a marker of someone's ability to pass the boards. They're also looking at experiences. It doesn't have to be a lot of research. Some students worry that they're in an institution that focuses more on clinical excellence or QI than basic science research. But what they're really looking for is curiosity, leadership, and desire to learn.  They want someone who has done research in GI and inflammatory bowel disease and can talk passionately about that. Or someone who has been involved in medical education, curriculum design, volunteer work. Other traits to be competitive include enthusiasm, eagerness, and a desire to make the world a better place. They also look at the letters and they want to see whether the person is a team player. Is the person able to carry a decent patient load? They look at the medical knowledge and clinical decision-making. And the letters or the Dean's letters are often the best way for them to see this. You may not match into neurosurgery or orthopedics so you need a backup. However, more than anything else, they want eager residents who want to be at their program. They can help you with things like if you have less exposure to a certain patient population or certain disease. But if you'd really rather be somewhere else, there's not a whole lot they can do about that. They look at any significant evidence that this student actually wants to be in a different specialty. And sometimes, this can be a bit subtle. [Related episode:  9 Med School Application Tips That Will Give You an Edge] [28:20] Common Mistakes Students Are Making in their Sub-I's and Away Rotations There are some specialties that you need to do away rotations for you to demonstrate that you're passionate about it. But you don't need to do this for internal medicine. In fact, an away rotation can even backfire.  That being said, Hilary thinks that an away rotation as an audition rotation makes a lot of sense. You just have to be careful and recognize that you're signaling to all the programs you're applying to that you have that interest. When it comes to sub-internships, the biggest mistake is not bringing in your enthusiastic game with you. It's a hard month. And if you only the minimum that's asked of you, the sub-I is the opportunity to do more. Hence, you need to bring your A-game. Bring in your enthusiasm. Do more than what's expected of you. Be a team player. If an attending asks you a question, make sure you're researched that and you can answer that the next day. Be the A-plus version of yourself independent of how tired you are and what else is going on in your life. [31:50] IM as a Team Sport Internal Medicine is a team sport. They're working in teams, not just teams of physicians but also multidisciplinary teams. When they say bring your A-game, it's not the student who's jumping over the other student to answer questions. But it's someone who is assertive and willing to help out other people in the team. They want to see that you care about the patients, about your team members, and also, you care about yourself. They're going to notice a student trying to get early everyday so they can study for their Shelf. Compared to someone who makes sure the patient is updated and see if there's anything else they can help with. [34:54] Common Application Mistakes One thing Hilary observes that students are doing is panicking. If you're planning to match in Internal Medicine and you have good mentorship, you're going to be okay. But students tend to over-apply. Personally, Hilary would see applications for people who she really doesn't think would be happy at their program. Hence, think about what you want in a residency program. Look and ask your mentor how competitive you are. Think of whether there are geographic restrictions. Or there's a certain population type that you want to take care of. Make sure that the residency programs you are applying to and interviewing at are going to give you that. Get as much information as you can. You don't want to be applying at programs you wouldn't actually be happy at. Stick to the ones you think are going to give you the experience that you want. [38:15] Thoughts on the Pass/Fail System Hilary doesn't think medicine is as impacted by the USMLE pass/fail. And that this system will help the people who are extremely dedicated but may not be great test-takers. What she worries about more is the trend of withholding all information from residency programs. More and more medical schools are going pass/fail in their clinical years. But if you don't have grades, it would be hard for them to tell whether you're going to do well in their program. [40:45] Final Words of Wisdom Be your authentic self. Be eager, enthusiastic, engaged, and a hard worker. Find a mentor. Wake up everyday thinking about what you can learn and how you can make the world a better place. Look for ways to engage and participate. And the path will become clear to you. Surround yourself with like-minded individuals. Seek your joy. Find out what diseases make you happy and what patients make you happy and what other providers you want to be with. Then you will figure out what the right place is for you. Links: Meded Media

<h2>Session 118</h2> <p>Where will you see the most variety of patients? Internal Medicine, of course! Dr. Hilary Ryder gives us a peek into subspecialties and the IM lifestyle.</p> <p>Hilary is the Internal Medicine program director at Dartmouth-Hitchcock Medical Center. She shares her internal medicine residency experience, how to pick a program, and how to stand out in your applications and rotations.</p> <p>If you haven’t yet, please do check out our other resources on <a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">Meded Media</a>.</p> <p><strong>Listen to this podcast episode with the player above,</strong> or keep reading for the highlights and takeaway points.</p> <h2>[01:13] Interest in Internal Medicine</h2> <p>Hilary was initially unable to make a decision about what specialty she wanted to go into. Into her fourth year, she thought she wanted to be a dermatologist. What drew her to it was the lifestyle having no nights and weekends. It felt like a lifestyle specialty that she could get into.</p> <p>During her third year clerkship in medicine, she really loved what she was seeing but she wasn't sure if she could handle the 30-hour shifts they were doing. Eventually, she did a medicine sub-internship in hospital medicine that didn't have any overnight shifts.</p> <p>She ended up falling in love with her team and with how diverse the cases she was managing. She started to take on more ownership of patients. <strong>She found it so rewarding that she found the 30-hour shifts to be all worth it.</strong></p> <p>The'res this idea of spending of 6-12 weeks on Internal Medicine doing some hospital medicine work, ambulatory care work, etc. Then you're going to figure out this is what you're going to do.</p> <p>And so a lot of people choose IM since they haven't really made their decision. But then when you're in your residency, you're stuck making another decision because there are so many different ways to be an internist. <strong>You have the breadth of opportunities all over again within internal medicine.</strong></p> <p>[Related episode: <a href="https://medicalschoolhq.net/ss-64-what-is-private-practice-internal-medicine-pediatrics/" rel="nofollow" target="_blank"> What is Private Practice Internal Medicine-Pediatrics?</a>]</p> <h2>[05:45] Types of Patients</h2> <p>Hilary explains that the types of cases an internist might manage basically depend on your geographic location. She's from New England and a lot of their primary care doctors are internists.</p> <p>If you travel more to the midwestern states, you're going to find that most of the primary care doctors are family medicine doctors. So you go into internal medicine planning to subspecialize.</p> <p>You can do an internal medicine residency and go into Sports Medicine, Allergy, Interventional Gastroenterology, Interventional Cardiology, Geriatrics, or Critical Care.</p> <p>If you go into Anesthesia or Psychiatry, you're going to do just a couple of months of medicine. If you're going into Neurology or Radiology, you're going to do a year of internal medicine. If you want to be an Endocrinologist, you're going to do a three-year IM residency. And then spend some more time in a fellowship subspecializing even more in terms of the types of patients you're going to take care of.</p> <p><strong>Many of the mentors you're going to see in your second year are internists.</strong> In your preclinical years, a lot of the physiology and the pathophysiology are going to be taught by internists.</p> <p>In Nephrology, you're going to learn your acid-base. And you're going to learn your electrolyte disturbances from internist. They completed their three years of internal medicine and they went on to a Nephrology fellowship.</p> <p>[Related episode: <a href="https://medicalschoolhq.net/mshq-076-5-traits-patients-want-their-doctors-to-have/" rel="nofollow" target="_blank"> 5 Traits Patients Want Their Doctors to Have]</a></p> <h2>[09:30] Typical Day</h2> <p><strong>Their internal medicine residents rotate through a variety of different specialties within internal medicine.</strong> A third-year clerkship student rotates through a variety of different departments.</p> <p>In their program, they have residents in the intensive care unit for a month. They have residents on the interventional cardiology service. They have those taking care of bone marrow transplant patients. They have residents in clinic and residents doing home visits.</p> <p><strong>In general, students know what the inpatient experience is, the interims of pre-rounding, then the rounding with the residents and seeing patients.</strong> What they may not see are some of the other work residents are doing.</p> <p><strong>Their residents do homecare visits with geriatric populations on their mandatory geriatrics rotation in the second year. </strong></p> <p>They have dedicated rotations on medical education to try and make their residents better teachers. Because they're an academic program, they want residents to be able to teach medical students. So they spend some time on medical education.</p> <p>In medicine, they work in teams. So residents are going to have to go through a lot of teamwork and leadership. <strong>They expect residents to not only provide medical care but also, to teach others and lead teams that provide medical care. </strong></p> <p>The resident is going to need to learn how to interface with the social worker, the discharge coordinator, the primary care physician, and the student and the nurse. They have to keep those balls in the air and keep the team moving forward. <strong>They need to make sure there's a great plan of care for the patient and the patient's plan of care is being moved forward.</strong></p> <p>[Related episode: <a href="https://medicalschoolhq.net/mshq-039-resident-duty-hours-and-the-ripple-effect/" rel="nofollow" target="_blank"> Resident Duty Hours and the Ripple Effect</a>]</p> <h2>[12:40] Taking Calls</h2> <p><strong>Taking calls is different depending on where you practice.</strong> In general, call for people who haven't done a lot of clinical exposure would be this long-term, multi-day experiences. You live in the hospital and you admit a lot of patients that you cared for longitudinally.</p> <p><strong>Some programs are have gotten away from the 24-hour calls.</strong> This means you're in the hospital admitting for 24 hours. You can be in the hospital for up to 4-6 hours after that cleaning up before you go home the next day.</p> <p><strong>Other programs like the night programs have gone to shift-based work where there is no long-term call.</strong> Residents will stay in the hospital and admit patients for a certain amount of time. They sign out to an overnight team who comes in to cover the patients and do the admissions overnight.</p> <h2>[15:20] The 3 Kinds of Medical Students</h2> <p><strong>There are medical students who have no idea of what they want to do coming into their IM residency. </strong></p> <p><strong>There are also those who are pretty sure and they're right.</strong> They end up doing what they think they wanted to do in the first place.</p> <p><strong>Then there are medical students who are pretty sure and they're wrong.</strong> They try something out and realize it's not for them. Some of the disease processes you learned about as a medical student may be intriguing. But the most common diseases in a specialty, you might not find all that appealing.</p> <p><strong>Figure out where you think your career is going.</strong> If the residency program you think you want to go to has never sent anyone to an Allergy-Immunology Fellowship and you're determined to be an allergist, you really need to think if that's going to be the right place or you.</p> <p><strong>Consider what your experience is going to be like.</strong> Are you going to be with like-minded individuals? Are you going to have the clinical experiences and support you want?</p> <p>Is it going to get you where you want to go? <strong>The best way to determine that is if there's a track record of other people going there.</strong> Look at the schedule and who the leadership is. <strong>Look at where people went after residency.</strong></p> <p>[Related episode: <a href="https://medicalschoolhq.net/mshq-027-the-non-traditional-medical-student-a-different-path-to-medical-school/" rel="nofollow" target="_blank"> The Nontraditional Medical Student: A Different Path to Med School</a>]</p> <h2>[19:10] The Training Path</h2> <p>After Hilary finished medical school, she went into residency. She was undecided and she was one of the students who loved everything in medical school and thought she wanted to do everything. So she had difficulty choosing.</p> <p>You spend 36 months in your residency program. You should get exposed to a wide variety of different specialties. <strong>If you choose not to go into fellowship, you're ready to practice.</strong></p> <p>You can then practice as internist without further training either in primary care or hospital medicine. But even these two are broader than you think. A hospital medicine doctor is going to practice exclusively in the inpatient realm of things.</p> <p>[Related episode: <a href="https://medicalschoolhq.net/mshq-084-the-role-of-residency-training-for-physicians/" rel="nofollow" target="_blank"> The Role of Residency Training For Physicians</a>]</p> <h2>[21:08] How to Be a Competitive Applicant</h2> <p>Looking at the 2019 match data, 97% of internal medicine spots filled and only 42% are filled by U.S. Seniors from allopathic medical schools. <strong>There are a lot of DO students entering IM as well as international medical graduates.</strong></p> <p>To be most competitive, as with other specialties, they look at the internal medicine grades. Often, there's an IM clerkship, a primary care clerkship, and at least a sub-I in either medicine or one of the subspecialties. <strong>They also look at the surgery grade. </strong></p> <p>Hilary believes in the holistic review of the application. They look at the Step scores as a marker of someone's ability to pass the boards. They're also looking at experiences. It doesn't have to be a lot of research.</p> <p>Some students worry that they're in an institution that focuses more on clinical excellence or QI than basic science research. <strong>But what they're really looking for is curiosity, leadership, and desire to learn. </strong></p> <p>They want someone who has done research in GI and inflammatory bowel disease and can talk passionately about that. Or someone who has been involved in medical education, curriculum design, volunteer work.</p> <p><strong>Other traits to be competitive include enthusiasm, eagerness, and a desire to make the world a better place.</strong></p> <p>They also look at the letters and they want to see whether the person is a team player. Is the person able to carry a decent patient load? <strong>They look at the medical knowledge and clinical decision-making. And the letters or the Dean's letters are often the best way for them to see this.</strong></p> <p>You may not match into neurosurgery or orthopedics so you need a backup. <strong>However, more than anything else, they want eager residents who want to be at their program.</strong></p> <p>They can help you with things like if you have less exposure to a certain patient population or certain disease. But if you'd really rather be somewhere else, there's not a whole lot they can do about that.</p> <p><strong>They look at any significant evidence that this student actually wants to be in a different specialty.</strong> And sometimes, this can be a bit subtle.</p> <p>[Related episode: <a href="https://medicalschoolhq.net/mshq-128-9-tips-to-successfully-submit-your-med-school-applications/" rel="nofollow" target="_blank"> 9 Med School Application Tips That Will Give You an Edge</a>]</p> <h2>[28:20] Common Mistakes Students Are Making in their Sub-I's and Away Rotations</h2> <p>There are some specialties that you need to do away rotations for you to demonstrate that you're passionate about it. But you don't need to do this for internal medicine. In fact, <strong>an away rotation can even backfire. </strong></p> <p>That being said, Hilary thinks that <strong>an away rotation as an audition rotation makes a lot of sense.</strong> You just have to be careful and recognize that you're signaling to all the programs you're applying to that you have that interest.</p> <p><strong>When it comes to sub-internships, the biggest mistake is not bringing in your enthusiastic game with you.</strong> It's a hard month. And if you only the minimum that's asked of you, the sub-I is the opportunity to do more.</p> <p>Hence, you need to bring your A-game. Bring in your enthusiasm. Do more than what's expected of you. Be a team player. If an attending asks you a question, make sure you're researched that and you can answer that the next day.</p> <p><strong>Be the A-plus version of yourself independent of how tired you are and what else is going on in your life.</strong></p> <h2>[31:50] IM as a Team Sport</h2> <p>Internal Medicine is a team sport. They're working in teams, not just teams of physicians but also multidisciplinary teams.</p> <p>When they say bring your A-game, it's not the student who's jumping over the other student to answer questions. But it's someone who is assertive and willing to help out other people in the team.</p> <p><strong>They want to see that you care about the patients, about your team members, and also, you care about yourself.</strong></p> <p>They're going to notice a student trying to get early everyday so they can study for their Shelf. Compared to someone who makes sure the patient is updated and see if there's anything else they can help with.</p> <h2>[34:54] Common Application Mistakes</h2> <p><strong>One thing Hilary observes that students are doing is panicking.</strong> If you're planning to match in Internal Medicine and you have good mentorship, you're going to be okay. But students tend to over-apply.</p> <p>Personally, Hilary would see applications for people who she really doesn't think would be happy at their program.</p> <p>Hence, <strong>think about what you want in a residency program.</strong> Look and ask your mentor how competitive you are. Think of whether there are geographic restrictions. Or there's a certain population type that you want to take care of.</p> <p>Make sure that the residency programs you are applying to and interviewing at are going to give you that.</p> <p>Get as much information as you can. You don't want to be applying at programs you wouldn't actually be happy at. <strong>Stick to the ones you think are going to give you the experience that you want.</strong></p> <h2>[38:15] Thoughts on the Pass/Fail System</h2> <p>Hilary doesn't think medicine is as impacted by the USMLE pass/fail. And that this system will help the people who are extremely dedicated but may not be great test-takers.</p> <p><strong>What she worries about more is the trend of withholding all information from residency programs.</strong></p> <p>More and more medical schools are going pass/fail in their clinical years. <strong>But if you don't have grades, it would be hard for them to tell whether you're going to do well in their program.</strong></p> <h2>[40:45] Final Words of Wisdom</h2> <p>Be your authentic self. Be eager, enthusiastic, engaged, and a hard worker. Find a mentor. Wake up everyday thinking about what you can learn and how you can make the world a better place.</p> <p>Look for ways to engage and participate. And the path will become clear to you. Surround yourself with like-minded individuals.</p> <p>Seek your joy. Find out what diseases make you happy and what patients make you happy and what other providers you want to be with. Then you will figure out what the right place is for you.</p> <h2>Links:</h2> <p><a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">Meded Media</a></p>

118: In the Internal Medicine Specialty, Sky Is the Limit!

Session 96 Today, Dr. Brian Smith, a general surgery program director at UC Irvine, talks about his journey to becoming a surgeon and what he expects from applicants to be competitive in his program. Find out what you can do to be more competitive as an applicant and as a medical student. Please take a listen to all our other podcasts and get the resources you need. For medical students, we have the Board Rounds (with BoardVitals). For the premed students, come check out The Premed Years, OldPreMeds Podcast, and The MCAT Podcast. [01:30] Interest in General Surgery Brian's interest in general surgery started in his first year of medical school. When he started medical school, he wanted to be a family practitioner. He liked the idea of continuity and being able to take care of the whole patient. Very quickly after starting his rotations in the anatomy lab, he realized he had a tremendous love and passion for human anatomy. It was the first time he ever considered surgery. He knew that if he wanted to spend most of his career involved with human anatomy, then surgery would be a excellent way to do so. [03:00] Traits that Lead to Being a Good General Surgeon One of the basic traits of being a good proceduralist is that you like working with your hands as well as diagnosing or treating things. Do you like working with your hands or do you like working with your brain? Once you've answered that question and you've moved down to "working with hands" halfway, then you begin to figure out you're probably down the proceduralist path. Brian's inherent tendency is to enjoy fixing things. He used to enjoy working with his car. He likes tinkering with things. He has always had this inherent joy in taking a problem and giving it a definitive fix. Surgery initially became the clear choice for Brian. But general surgery became his choice when he was sure he needed the variety. He enjoyed the variety that comes with general surgery. [04:50] Risk of Running Out of Patients As Brian puts it, one of the beauties of general surgery is they take care of the whole patient. They take pride in the fact that they're really an internal medicine physician that operates. They're able to manage the entire patient and at the same time be able to operate and fix their derangements. There's a tremendous kinship with either family medicine or internal medicine who serves as the contractor for all of the patient's ailments and really manage them all. That being said, there's a drive or movement in the direction of increasing subspecialization of current trainees. This is a trend that's not going to dramatically change over the near future. But for those people with broad interests and really like to take care of the whole patient, general surgery has that to offer. Brian was concerned that subspecialization would narrow down his knowledge base. And he didn't want to give that up, hence, he chose general surgery. [07:00] The Bread and Butter for General Surgeons The bread and butter in 2019 is dictated by the community in which you serve. If you're a general surgeon in the midwest and there's not a lot of specialists in town, you're more likely to do more than the general surgeon in downtown Los Angeles. By and large, in the urban and suburban environments, the bread and butter for general surgeons is going to consist of gastrointestinal surgery, colons, gall bladders, hernias, endocrine surgery including thyroids, parathyroids, and adrenals. Occasionally, they deal with the liver, spleen, skin (melanoma and skin cancers), and extremity work (soft tissue tumors). [08:20] The Most and Least Liked Things About Being a General Surgeon Brian loves being able to take care of all the patient's needs. He's able to handle almost everything. From an operative perspective, he loves being able to travel all over the body. He rarely does two of the same operation in one day. He's constantly doing something different. And this forces him to keep up with the literature or current advancements in a specific area. It keeps him sharp and interested. And it never gets dull and boring. On the flip side, what Brian likes the least about his specialty is more on the administrative aspects that come with surgery in 2019. There's a lot of time spent charting on the electronic medical record. It's a wonderful thing, in and of itself. But it takes extra time that it becomes a distraction. Now he gets to have less time spent face-to-face with patients. It prevents him from having that human interaction and bonding that makes a good physician-patient relationship. [10:00] The Training Path and Career Trajectory The medical student basically applies for general surgery where they will match into a categorical internship followed by residency. In general surgery, they don't distinguish internship and residency because they're a single continuum. The first year is just the internship. There are six-year programs across the country where they will have one year of mandatory research. These are heavily focused on clinical outcomes research during the year of mandatory research. There are also seven-year programs where there will be two years of mandatory research, most of which is basic science research. The standard five-year programs are focused on training somebody to be clinically confident. A resident may or may not be expected to have some research productivity during that time. You can train in general surgery and go out to practice. Or you can do a one-year fellowship in minimally invasive surgery, bariatrics surgery, thoracic surgery, or spend several years doing cardiac surgery. You may also combine cardio thoracic fellowship. You can go do a year of colorectal fellowship. Or you can do additional training in plastic surgery or a year of breast surgery or endocrine surgery. You can stop after general surgery training and be the generalist, or you can still go down one of 10 or 12 different pathways now – some are ACGME-certified and a few are not. You can get specialized fellowship training in order to be better at a particular subsection of general surgery. Brian did general surgery but he also took one year fellowship in minimally invasive bariatrics surgery. That said, it's not the entire focus of what he does. He still gets to be a general surgeon but he has that specialized niche training which he enjoys several days of the week. [12:45] What They're Looking for in Applicants As previously mentioned, Brian is a program director for a general surgery residency. One of the first things they're looking for is somebody with a broad interest and is eager to learn. These are inherent traits that they need the applicants to bring with them. In terms of the more tangible level, they sort of move in this hierarchy of importance. First, applicants need to be academically qualified. Sadly, the best measure is still USMLE Step 1. Since not everybody has taken Step 2 by the time they apply, they can't use it as diligently as they do Step 1. So do well in Step 1. Ideally, they would then want to see somebody with a good, solid dean's letter. They also look at how they've done on their clinical clerkships, how many courses they've honored, and how they did in surgery. They also look at how the applicants did in their internal medicine rotation. Again, getting back to that kinship with internal medicine, somebody who's broadly interested really likes to take care of the whole patient. To him, this is an appealing characteristic. Then they look closely at letters of recommendation, research background, and personal characteristics, respectively. [14:40] Pass/No Pass for Step 1 Brian loves the idea of Pass/No Pass for Step 1 recognizing that students can have a bad day or they choke on the exam for some reason and they just don't achieve their potential. The magnitude of the high stakes Step 1 is a problem that needs to go away. But that being said, Brian's biggest concern is that we don't have another good surrogate. There's no other good, easily identifiable measure to help determine one's academic qualifications. Program directors need to look at an entire application and not just a Step 1 as a screening score, which many of them do. So he likes the concept of it not being a weeder or screener. But there should be a composite measure of one's academic qualifications. It doesn't mean that if one doesn't do well on the test, that they can't be a fantastic clinician. In fact, Brian says, some of the real gems that he found are not the people that completely knocked Step 1 out of the park. However, they also want to make sure that they did well enough on it so they won't struggle on their in-service exams or passing their written board exam. As a program director, one of his endpoints for students is for them to be able to easily get out and obtain their board certification. So while he likes the concept, he thinks additional surrogates are lacking which can serve as a good marker of academic qualifications. [17:10] Why the Need for Academic Qualifications A good residency program does a phenomenal job of developing clinical skills. But in your average five-year program, a resident who doesn't have a whole lot of book knowledge as a foundation can only continue to excel and do well until you get to the fourth year of residency. In the fourth year, there's so much clinical skill that now starts to rely on a solid foundation of knowledge. So you may be technically good in the operating room, but if you don't have the knowledge foundation to back up those clinical skills, that deficiency starts to get a spotlight on it right around the beginning of your fourth year. If that deficit in knowledge continues in the fifth year, it starts to be an anchor for a good resident. There's a tremendous knowledge base that backs up any clinical superstar. By academically qualified, it means being academically capable of sitting down and synthesizing and getting a tremendous knowledge base in their head. By doing so, they're able to back up their decision making and their instincts they've learned as residents. You should be able to establish that you have the study habits, the intellectual capacity, and capability to pack a lot of information into your brain about a particular specialty. Brian explains that you can train almost anybody as a surgeon. What is a tougher challenge is training a clinical superstar. [21:21] What Makes a Superstar Sub-I A superstar sub-I will oftentimes be almost seamless with an intern. A lot of time in the third year is spent on just learning how to function comfortably in the hospital environment. Then you begin to know how to accomplish patient care on a regular basis. A great sub-I is somebody who is functioning at the level of an intern. These are students that have a lot of charisma and are self-starters. They are able to figure out how to start a new rotation. They can quickly get up to speed with important details and facts. They're able to identify key interactions that need to occur and execute those efficiently. You have to master how to be efficient. A great sub-I reads about their patients and knows their patients backward and forward. A student will never have a better opportunity to solidify in their own mind all the details of the disease process as they will when they have a patient with that disease process. [24:19] What Medical Students Shouldn't Do Brian explains that the fastest way medical students shoot themselves in the foot is when they treat those beneath them with disdain. For instance, the medical student comes into the operating room and talks down to the circulating nurse or disrespectful to the ICU nurse. Nurses that do the same thing over and over for years know what they're doing very well. When medical students fail to recognize the knowledge and the expertise in the rest of the team involved in the patient's care, oftentimes, they shoot themselves in the foot. [25:55] Mistakes Medical Students Make with Their Application If your Step 1 is not a true reflection of what your knowledge and skills are, then study up and take Step 2. Let Step 2 prove that Step 1 was not an accurate reflection of what you're capable of. Somebody with average performance on a sub-I is somebody who's not going to do really well. Failing to recognize that the sub-I really is your audition and treating it as such is such a huge misstep. [27:40] How Important Are Elective Rotations An external rotation is a very easy way to get an interview at that institution. Especially for people with mediocre applications, they need to do external rotations to maximize the likelihood that they're going to perform at a really high level. This increases their chances of getting an interview. Brian encourages their students to do two external rotations and fill the rest of them in at their school of medicine. If your passion is simply based on one rotation you really like and go do general surgery, Brian hopes you have the maturity to recognize that it may mean there are a whole lot more rotations that you're going to go through that might grab you equally. [32:50] The Influence of Great Mentors Mentors have a lot of ability to sway or influence that "organic chemistry" with a specific specialty. If you really have a good mentor, then you'd naturally be drawn towards that specialty. And this is often how people end up deciding where they're going to apply for a residency. There is something very appealing with having really great mentors, particularly when you get the trainees actively involved. Brian pushes people to become content experts in general surgery early on in their residency. And this oftentimes naturally translates to falling in love with it. [34:30] Women in General Surgery Brian explains there are a lot of female general surgery mentors. Regardless of what lifestyle, you need to start with the specialty you love. There's no specialty within medicine that anybody is going to enjoy doing for 30 years if they're not passionate about that particular specialty. Once you have found something you love and enjoy, you can always find a career setting that allows you to balance work and life in a manner that works well for you. Brian has worked with amazing female clinicians who are even technically better than many of their male counterparts. Men and women have equal opportunities in general surgery. That being said, females may be more reluctant to choose a surgical career because they don't necessarily see people having as much of the balance they're looking for. Ultimately, find your passion and get trained in something you love. If doing it gives you the work-life balance that works for you. You will find that opportunity somewhere out there. Brian encourages female students to give general surgery a try. You can have it all. But having it all means doing something you love in the process. Then finally find the balance that works for you. Additionally, one of the beauties about being a specialist or proceduralist as a female is being able to work 2-3 days a week. But you still can make the same amount of money you would make 5 days a week as a primary care physician. This gives you financial liberty. It gives you more options to create the balance of work and life you're looking for. [38:25] Overcoming Bias Against DOs Brian thinks a lot of the bias is now starting to fall by the wayside. It's still important to take USMLE so it's easier for you to be compared to somebody else. Do those external rotations and sub-I's. Have competitive board scores. At the end of the day, a DO with a mediocre Step 1 but was an absolute clinical superstar on their sub-I, is way more appealing than somebody who's got a 265 on Step 1 and just an average sub-I participant from a top medical school. Brian is looking for people who are engaging for him to work with and train over the next five to seven years. They have to be easy to teach and fun to operate with. Be charismatic and be eager to learn. [40:05] Final Words of Wisdom Get out and spend some time shadowing. This is very important early on in the first and second year of medical school. This will give you a genuine flavor for what experience looks like in many of those specialties. On your third year, pay attention to sorting out where you want to be. Do you want to take care of patients with your brain or with your hands? Once you decide you want to become a proceduralist, you want to figure out whether you want to do something surgical or non-surgical with your hands. Ideally, you want to be able to figure these out by springtime of your third year, then you can start your sub-I's in the fall. Start looking for mentors in the specialty. People who figure out what they want to apply for late in their third year are at an inherent disadvantage. So try to sort things out earlier on the third year where your passions lie. Links: Board Rounds BoardVitals The Premed Years OldPreMeds Podcast The MCAT Podcast

<h2>Session 96</h2> <p>Today, Dr. Brian Smith, a general surgery program director at UC Irvine, talks about his journey to becoming a surgeon and what he expects from applicants to be competitive in his program. Find out what you can do to be more competitive as an applicant and as a medical student.</p> <p>Please take a listen to all our other podcasts and get the resources you need. For medical students, we have the <a href="https://medicalschoolhq.net/board-rounds-podcast/" rel="nofollow" target="_blank">Board Rounds</a> (with <a href="https://www.boardvitals.com/" rel="nofollow" target="_blank">BoardVitals</a>). For the premed students, come check out <a href="https://medicalschoolhq.net/thepremedyears/" rel="nofollow" target="_blank">The Premed Years</a>, <a href="https://medicalschoolhq.net/oldpremeds-podcast/" rel="nofollow" target="_blank">OldPreMeds Podcast</a>, and <a href="https://medicalschoolhq.net/mcat-podcast/" rel="nofollow" target="_blank">The MCAT Podcast</a>.</p> <h2>[01:30] Interest in General Surgery</h2> <p>Brian's interest in general surgery started in his first year of medical school. When he started medical school, he wanted to be a family practitioner. He liked the idea of continuity and being able to take care of the whole patient.</p> <p>Very quickly after starting his rotations in the anatomy lab, he realized he had a tremendous love and passion for human anatomy. It was the first time he ever considered surgery. <strong>He knew that if he wanted to spend most of his career involved with human anatomy, then surgery would be a excellent way to do so.</strong></p> <h2>[03:00] Traits that Lead to Being a Good General Surgeon</h2> <p>One of the basic traits of being a good proceduralist is that you like working with your hands as well as diagnosing or treating things.</p> <p>Do you like working with your hands or do you like working with your brain? Once you've answered that question and you've moved down to "working with hands" halfway, then you begin to figure out you're probably down the proceduralist path.</p> <p>Brian's inherent tendency is to enjoy fixing things. He used to enjoy working with his car. He likes tinkering with things. <strong>He has always had this inherent joy in taking a problem and giving it a definitive fix.</strong></p> <p>Surgery initially became the clear choice for Brian. But general surgery became his choice when he was sure he needed the variety. <strong>He enjoyed the variety that comes with general surgery.</strong></p> <h2>[04:50] Risk of Running Out of Patients</h2> <p>As Brian puts it, <strong>one of the beauties of general surgery is they take care of the whole patient.</strong> They take pride in the fact that they're really an internal medicine physician that operates. They're able to manage the entire patient and at the same time be able to operate and fix their derangements.</p> <p>There's a tremendous kinship with either family medicine or internal medicine who serves as the contractor for all of the patient's ailments and really manage them all.</p> <p>That being said, there's a drive or movement in the direction of increasing subspecialization of current trainees. This is a trend that's not going to dramatically change over the near future.</p> <p>But for those people with broad interests and really like to take care of the whole patient, general surgery has that to offer. <strong>Brian was concerned that subspecialization would narrow down his knowledge base.</strong> And he didn't want to give that up, hence, he chose general surgery.</p> <h2>[07:00] The Bread and Butter for General Surgeons</h2> <p><strong>The bread and butter in 2019 is dictated by the community in which you serve.</strong> If you're a general surgeon in the midwest and there's not a lot of specialists in town, you're more likely to do more than the general surgeon in downtown Los Angeles.</p> <p>By and large, in the urban and suburban environments, the bread and butter for general surgeons is going to consist of gastrointestinal surgery, colons, gall bladders, hernias, endocrine surgery including thyroids, parathyroids, and adrenals.</p> <p>Occasionally, they deal with the liver, spleen, skin (melanoma and skin cancers), and extremity work (soft tissue tumors).</p> <h2>[08:20] The Most and Least Liked Things About Being a General Surgeon</h2> <p>Brian loves being able to take care of all the patient's needs. He's able to handle almost everything.</p> <p>From an operative perspective, he loves being able to travel all over the body. He rarely does two of the same operation in one day. <strong>He's constantly doing something different.</strong> And this forces him to keep up with the literature or current advancements in a specific area. It keeps him sharp and interested. And it never gets dull and boring.</p> <p>On the flip side, what Brian likes the least about his specialty is more on the administrative aspects that come with surgery in 2019.</p> <p><strong>There's a lot of time spent charting on the electronic medical record.</strong> It's a wonderful thing, in and of itself. But it takes extra time that it becomes a distraction. Now he gets to have less time spent face-to-face with patients. <strong>It prevents him from having that human interaction and bonding that makes a good physician-patient relationship.</strong></p> <h2>[10:00] The Training Path and Career Trajectory</h2> <p>The medical student basically applies for general surgery where they will match into a categorical internship followed by residency. <strong>In general surgery, they don't distinguish internship and residency because they're a single continuum.</strong> The first year is just the internship.</p> <p>There are six-year programs across the country where they will have one year of mandatory research. These are heavily focused on clinical outcomes research during the year of mandatory research.</p> <p>There are also seven-year programs where there will be two years of mandatory research, most of which is basic science research.</p> <p>The standard five-year programs are focused on training somebody to be clinically confident. A resident may or may not be expected to have some research productivity during that time.</p> <p>You can train in general surgery and go out to practice. Or you can do a one-year fellowship in minimally invasive surgery, bariatrics surgery, thoracic surgery, or spend several years doing cardiac surgery. You may also combine cardio thoracic fellowship. You can go do a year of colorectal fellowship. Or you can do additional training in plastic surgery or a year of breast surgery or endocrine surgery.</p> <p><strong>You can stop after general surgery training and be the generalist, or you can still go down one of 10 or 12 different pathways now</strong> – some are ACGME-certified and a few are not.</p> <p>You can get specialized fellowship training in order to be better at a particular subsection of general surgery.</p> <p>Brian did general surgery but he also took one year fellowship in minimally invasive bariatrics surgery. That said, it's not the entire focus of what he does. He still gets to be a general surgeon but he has that specialized niche training which he enjoys several days of the week.</p> <h2>[12:45] What They're Looking for in Applicants</h2> <p>As previously mentioned, Brian is a program director for a general surgery residency. One of the first things they're looking for is somebody with a broad interest and is eager to learn. <strong>These are inherent traits that they need the applicants to bring with them.</strong></p> <p>In terms of the more tangible level, they sort of move in this hierarchy of importance. <strong>First, applicants need to be academically qualified.</strong> Sadly, the best measure is still USMLE Step 1. Since not everybody has taken Step 2 by the time they apply, they can't use it as diligently as they do Step 1. <strong>So do well in Step 1.</strong></p> <p>Ideally, they would then want to see somebody with a good, solid dean's letter. They also look at how they've done on their clinical clerkships, how many courses they've honored, and how they did in surgery. <strong>They also look at how the applicants did in their internal medicine rotation.</strong></p> <p>Again, getting back to that kinship with internal medicine, <strong>somebody who's broadly interested really likes to take care of the whole patient.</strong> To him, this is an appealing characteristic.</p> <p>Then they look closely at letters of recommendation, research background, and personal characteristics, respectively.</p> <h2>[14:40] Pass/No Pass for Step 1</h2> <p>Brian loves the idea of Pass/No Pass for Step 1 recognizing that students can have a bad day or they choke on the exam for some reason and they just don't achieve their potential.</p> <p><strong>The magnitude of the high stakes Step 1 is a problem that needs to go away.</strong> But that being said, Brian's biggest concern is that we don't have another good surrogate. There's no other good, easily identifiable measure to help determine one's academic qualifications.</p> <p>Program directors need to look at an entire application and not just a Step 1 as a screening score, which many of them do. So he likes the concept of it not being a weeder or screener. But there should be a composite measure of one's academic qualifications.</p> <p>It doesn't mean that if one doesn't do well on the test, that they can't be a fantastic clinician. In fact, Brian says, some of the real gems that he found are not the people that completely knocked Step 1 out of the park.</p> <p>However, they also want to make sure that they did well enough on it so they won't struggle on their in-service exams or passing their written board exam. As a program director, one of his endpoints for students is for them to be able to easily get out and obtain their board certification.</p> <p>So while he likes the concept, he thinks additional surrogates are lacking which can serve as a good marker of academic qualifications.</p> <h2>[17:10] Why the Need for Academic Qualifications</h2> <p><strong>A good residency program does a phenomenal job of developing clinical skills.</strong> But in your average five-year program, a resident who doesn't have a whole lot of book knowledge as a foundation can only continue to excel and do well until you get to the fourth year of residency.</p> <p><strong>In the fourth year, there's so much clinical skill that now starts to rely on a solid foundation of knowledge.</strong> So you may be technically good in the operating room, but if you don't have the knowledge foundation to back up those clinical skills, that deficiency starts to get a spotlight on it right around the beginning of your fourth year.</p> <p>If that deficit in knowledge continues in the fifth year, it starts to be an anchor for a good resident. <strong>There's a tremendous knowledge base that backs up any clinical superstar.</strong></p> <p>By academically qualified, it means being academically capable of sitting down and synthesizing and getting a tremendous knowledge base in their head. By doing so, they're able to back up their decision making and their instincts they've learned as residents.</p> <p><strong>You should be able to establish that you have the study habits, the intellectual capacity, and capability to pack a lot of information into your brain about a particular specialty.</strong></p> <p>Brian explains that you can train almost anybody as a surgeon. <strong>What is a tougher challenge is training a clinical superstar.</strong></p> <h2>[21:21] What Makes a Superstar Sub-I</h2> <p>A superstar sub-I will oftentimes be almost seamless with an intern. A lot of time in the third year is spent on just learning how to function comfortably in the hospital environment. Then you begin to know how to accomplish patient care on a regular basis.</p> <p>A great sub-I is somebody who is functioning at the level of an intern. These are students that have a lot of charisma and are self-starters. They are able to figure out how to start a new rotation. They can quickly get up to speed with important details and facts. They're able to identify key interactions that need to occur and execute those efficiently. <strong>You have to master how to be efficient.</strong></p> <p><strong>A great sub-I reads about their patients and knows their patients backward and forward.</strong> A student will never have a better opportunity to solidify in their own mind all the details of the disease process as they will when they have a patient with that disease process.</p> <h2>[24:19] What Medical Students Shouldn't Do</h2> <p>Brian explains that the fastest way medical students shoot themselves in the foot is when they treat those beneath them with disdain.</p> <p>For instance, the medical student comes into the operating room and talks down to the circulating nurse or disrespectful to the ICU nurse. Nurses that do the same thing over and over for years know what they're doing very well.</p> <p>When medical students fail to recognize the knowledge and the expertise in the rest of the team involved in the patient's care, oftentimes, they shoot themselves in the foot.</p> <h2>[25:55] Mistakes Medical Students Make with Their Application</h2> <p><strong>If your Step 1 is not a true reflection of what your knowledge and skills are, then study up and take Step 2.</strong> Let Step 2 prove that Step 1 was not an accurate reflection of what you're capable of.</p> <p>Somebody with average performance on a sub-I is somebody who's not going to do really well. <strong>Failing to recognize that the sub-I really is your audition and treating it as such is such a huge misstep.</strong></p> <h2>[27:40] How Important Are Elective Rotations</h2> <p><strong>An external rotation is a very easy way to get an interview at that institution.</strong> Especially for people with mediocre applications, they need to do external rotations to maximize the likelihood that they're going to perform at a really high level. This increases their chances of getting an interview.</p> <p>Brian encourages their students to do two external rotations and fill the rest of them in at their school of medicine.</p> <p>If your passion is simply based on one rotation you really like and go do general surgery, Brian hopes you have the maturity to recognize that it may mean there are a whole lot more rotations that you're going to go through that might grab you equally.</p> <h2>[32:50] The Influence of Great Mentors</h2> <p>Mentors have a lot of ability to sway or influence that "organic chemistry" with a specific specialty. <strong>If you really have a good mentor, then you'd naturally be drawn towards that specialty.</strong> And this is often how people end up deciding where they're going to apply for a residency.</p> <p>There is something very appealing with having really great mentors, particularly when you get the trainees actively involved.</p> <p>Brian pushes people to become content experts in general surgery early on in their residency. And this oftentimes naturally translates to falling in love with it.</p> <h2>[34:30] Women in General Surgery</h2> <p>Brian explains there are a lot of female general surgery mentors. Regardless of what lifestyle, you need to start with the specialty you love. There's no specialty within medicine that anybody is going to enjoy doing for 30 years if they're not passionate about that particular specialty.</p> <p><strong>Once you have found something you love and enjoy, you can always find a career setting that allows you to balance work and life in a manner that works well for you.</strong></p> <p>Brian has worked with amazing female clinicians who are even technically better than many of their male counterparts. <strong>Men and women have equal opportunities in general surgery.</strong></p> <p>That being said, females may be more reluctant to choose a surgical career because they don't necessarily see people having as much of the balance they're looking for.</p> <p><strong>Ultimately, find your passion and get trained in something you love.</strong> If doing it gives you the work-life balance that works for you. You will find that opportunity somewhere out there.</p> <p>Brian encourages female students to give general surgery a try. You can have it all. <strong>But having it all means doing something you love in the process.</strong> Then finally find the balance that works for you.</p> <p>Additionally, one of the beauties about being a specialist or proceduralist as a female is being able to work 2-3 days a week. But you still can make the same amount of money you would make 5 days a week as a primary care physician. <strong>This gives you financial liberty.</strong> It gives you more options to create the balance of work and life you're looking for.</p> <h2>[38:25] Overcoming Bias Against DOs</h2> <p>Brian thinks a lot of the bias is now starting to fall by the wayside. It's still important to take USMLE so it's easier for you to be compared to somebody else. Do those external rotations and sub-I's. Have competitive board scores.</p> <p><strong>At the end of the day, a DO with a mediocre Step 1 but was an absolute clinical superstar on their sub-I, is way more appealing than somebody who's got a 265 on Step 1 and just an average sub-I participant from a top medical school.</strong></p> <p>Brian is looking for people who are engaging for him to work with and train over the next five to seven years. They have to be easy to teach and fun to operate with. Be charismatic and be eager to learn.</p> <h2>[40:05] Final Words of Wisdom</h2> <p><strong>Get out and spend some time shadowing.</strong> This is very important early on in the first and second year of medical school. This will give you a genuine flavor for what experience looks like in many of those specialties.</p> <p><strong>On your third year, pay attention to sorting out where you want to be.</strong> Do you want to take care of patients with your brain or with your hands?</p> <p>Once you decide you want to become a proceduralist, you want to figure out whether you want to do something surgical or non-surgical with your hands.</p> <p>Ideally, you want to be able to figure these out by springtime of your third year, then you can start your sub-I's in the fall. Start looking for mentors in the specialty.</p> <p><strong>People who figure out what they want to apply for late in their third year are at an inherent disadvantage</strong>. So try to sort things out earlier on the third year where your passions lie.</p> <h2>Links:</h2> <p><a href="https://medicalschoolhq.net/board-rounds-podcast/" rel="nofollow" target="_blank">Board Rounds</a></p> <p><a href="https://www.boardvitals.com/" rel="nofollow" target="_blank">BoardVitals</a></p> <p><a href="https://medicalschoolhq.net/thepremedyears/" rel="nofollow" target="_blank">The Premed Years</a></p> <p><a href="https://medicalschoolhq.net/oldpremeds-podcast/" rel="nofollow" target="_blank">OldPreMeds Podcast</a></p> <p><a href="https://medicalschoolhq.net/mcat-podcast/" rel="nofollow" target="_blank">The MCAT Podcast</a></p>

96: A Look Into General Surgery With A Program Director 

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...

28: What is Trauma Surgery? Dr. Darko Shares His Story

Session 4 In this episode, Ryan talks with Dr. Patrick Pickett, an anesthesiologist who practices in the community hospital in Oklahoma as he shares about his path to anesthesiology, his typical day at work, work-life balance, as well as the things that he like most and least about being an anesthesiologist. Finally, he gives his opinion on the future of anesthesiology specifically merging with CRNAs. Here are the highlights of the conversation with Patrick: Choosing the kind of setting to practice in:  Always thinking he wanted to do academics Realizing he didn't want to do academic setting after doing a fellowship in critical care medicine Started looking for jobs and happened to find a community job and realized it was a better fit for him  When he knew he wanted to be an anesthesiologist:  Patrick majored in engineering and volunteered at a biomedical engineering department at a hospital and realized it wasn't something he wanted to do. Getting to watch surgeries and working with the anesthesia side of it Went through shadowing and didn't like it but after going through rotation and training, he had a turnaround  What caused him to like anesthesiology after rotation:  Coming from a family with medical background, he knew what specialties he didn't like Thinking he wanted radiology coming into medical school Not liking clinic and liking hospital setting Liked being in the operating room but not liking to be a surgeon Choosing the specialty through the process of elimination  Traits that lead to being a good anesthesiologist:  Flexibility in time and treatment options Thinking on your feet Being well-versed and liking different things Having broad knowledge Being able to change gears quickly Being able to get along with people and the team Being able to assume leadership role at times  A typical day in the say of an anesthesiologist:  Starting before 7 am and ending the day 4-5 pm on average There is no one typical day since you will be working at different locations for different cases If in the operating room: 3-5 cases on average for 1-2 hours each If in the GI lab: 10-15 cases for 30 minutes each If in neurosurgery/spine surgery/cardiac: 1-2 cases for 4-8 hours each  If in general surgery:  Meets with patients; talks about the plan, risks, and alternatives and then to the operating room Walks patients through the procedure to reduce anxiety; manages vital signs, making sure all things are in place At the end of the surgery, takes them to the recovery room  Taking calls: Less frequent calls but more likely to go to the hospital to be there Work-life balance:  Yes.This is one of Patrick's pre-requisites in choosing a specialty because he wanted something that would give him some flexibility. 55-60 hours a week Some days are predictable so he gets to see his kids more. Being on call is part of the deal but it's manageable.  What makes a competitive applicant for anesthesia:  It's almost like Emergency Medicine in terms of the board scores and the grades Intangible aspect: Being appropriately aggressive, knowing when to step back and when to step forward to help out Doing well in your rotations It's not a small field as there are many programs in anesthesiology (around 1500 spots)  What residency looks like:  4 years - Intern year (medicine, surgery, EM, ICU, etc.) + 3 years (general rotations) Most programs won't put you in the OR by yourself on day 1 of that 2nd year More independence and advanced rotations as you go along Pain management as a multidisciplinary field in anesthesiology similar to critical care Less calls than surgeons but more than some others and almost always in-house and they couple a senior and a junior on-call  Orals boards:  2 hours 2 rooms (an hour each room and with 2 examiners in each room) Each candidate has the same stem of the case but which direction each goes is up to the examiners. It probes the limits of your knowledge and the format can be intimidating. Written board exam first before taking the oral exams Not a question of content but about being able to think on your feet  Bias among DOs vs. MDs: Any bias perceived is not deserved. Sub-specialties:  Pain management:   Neurologist Psychiatrist PMnR Internal Medicine   Critical Care:   ICU medicine   Other sub-specs:   Pediatric anesthesia Cardiac anesthesia &gt; echocardiography Obstetric anesthesia Liver transplant anesthesia  What he wished he knew going into anesthesiology that he knows now:  Job opportunities available The business side of medicine  Other specialists he works the closest with:  All surgical fields expanding to procedural fields such as: GI - endoscopy Cardiology Internal radiologist MRI (they may provide sedation for really young patients)  Special opportunities outside of clinical medicine:  Expert witness testimony Research Quality improvement Expansion of training Quality management  What he wished other specialties knew about anesthesiologists:  Their focus on safety particularly a combination of three: Patient and their medical problems The surgery and how it affects the body The anesthetic and how it affects the body They have different ways of looking at patients. Pre-anesthesia process to decide who's a good candidate and who's not and what they can do to make them a good candidate They try to get everybody on the same page.  What he likes most as an anesthesiologist:  Variety of the things they do everyday They also have their share of excitements but he also likes the routine stuff  What he likes the least being an anesthesiologist: Night calls Would he still choose anesthesiology if he were to do it again? Yes, it's the right fit for him. You have to go through it to find out what works for you. The future of anesthesiology vs. CRNA's merging: The Anesthesia Care Team is a very safe approach. Patrick finds that although the topic is controversial, most people working get along just fine. For premeds, you should be prepared to supervise nurses and you should be prepared to do your own cases because you can do both. Some pieces of advice for those considering anesthesiology for a specialty: If you like the fast-paced hospital-based specialty, give it a try. Give it a rotation and if you don't like it, there are plenty other fields to choose from but if you do, it can be a great career. Links and Other Resources: www.mededmedia.com

<h1>Session 4</h1> <p>In this episode, Ryan talks with Dr. Patrick Pickett, an anesthesiologist who practices in the community hospital in Oklahoma as he shares about his path to anesthesiology, his typical day at work, work-life balance, as well as the things that he like most and least about being an anesthesiologist. Finally, he gives his opinion on the future of anesthesiology specifically merging with CRNAs.</p> <h2>Here are the highlights of the conversation with Patrick:</h2> <h3>Choosing the kind of setting to practice in:</h3> <ul> <li>Always thinking he wanted to do academics</li> <li>Realizing he didn't want to do academic setting after doing a fellowship in critical care medicine</li> <li>Started looking for jobs and happened to find a community job and realized it was a better fit for him</li> </ul> <h3>When he knew he wanted to be an anesthesiologist:</h3> <ul> <li>Patrick majored in engineering and volunteered at a biomedical engineering department at a hospital and realized it wasn't something he wanted to do.</li> <li>Getting to watch surgeries and working with the anesthesia side of it</li> <li>Went through shadowing and didn't like it but after going through rotation and training, he had a turnaround</li> </ul> <h3>What caused him to like anesthesiology after rotation:</h3> <ul> <li>Coming from a family with medical background, he knew what specialties he didn't like</li> <li>Thinking he wanted radiology coming into medical school</li> <li>Not liking clinic and liking hospital setting</li> <li>Liked being in the operating room but not liking to be a surgeon</li> <li>Choosing the specialty through the process of elimination</li> </ul> <h3>Traits that lead to being a good anesthesiologist:</h3> <ul> <li>Flexibility in time and treatment options</li> <li>Thinking on your feet</li> <li>Being well-versed and liking different things</li> <li>Having broad knowledge</li> <li>Being able to change gears quickly</li> <li>Being able to get along with people and the team</li> <li>Being able to assume leadership role at times</li> </ul> <h3>A typical day in the say of an anesthesiologist:</h3> <ul> <li>Starting before 7 am and ending the day 4-5 pm on average</li> <li>There is no one typical day since you will be working at different locations for different cases</li> <li>If in the operating room: 3-5 cases on average for 1-2 hours each</li> <li>If in the GI lab: 10-15 cases for 30 minutes each</li> <li>If in neurosurgery/spine surgery/cardiac: 1-2 cases for 4-8 hours each</li> </ul> <p><strong>If in general surgery:</strong></p> <ul> <li>Meets with patients; talks about the plan, risks, and alternatives and then to the operating room</li> <li>Walks patients through the procedure to reduce anxiety; manages vital signs, making sure all things are in place</li> <li>At the end of the surgery, takes them to the recovery room</li> </ul> <h3>Taking calls:</h3> <p>Less frequent calls but more likely to go to the hospital to be there</p> <h3>Work-life balance:</h3> <ul> <li>Yes.This is one of Patrick's pre-requisites in choosing a specialty because he wanted something that would give him some flexibility.</li> <li>55-60 hours a week</li> <li>Some days are predictable so he gets to see his kids more.</li> <li>Being on call is part of the deal but it's manageable.</li> </ul> <h3>What makes a competitive applicant for anesthesia:</h3> <ul> <li>It's almost like Emergency Medicine in terms of the board scores and the grades</li> <li>Intangible aspect: Being appropriately aggressive, knowing when to step back and when to step forward to help out</li> <li>Doing well in your rotations</li> <li>It's not a small field as there are many programs in anesthesiology (around 1500 spots)</li> </ul> <h3>What residency looks like:</h3> <ul> <li>4 years - Intern year (medicine, surgery, EM, ICU, etc.) + 3 years (general rotations)</li> <li>Most programs won't put you in the OR by yourself on day 1 of that 2nd year</li> <li>More independence and advanced rotations as you go along</li> <li>Pain management as a multidisciplinary field in anesthesiology similar to critical care</li> <li>Less calls than surgeons but more than some others and almost always in-house and they couple a senior and a junior on-call</li> </ul> <h3>Orals boards:</h3> <ul> <li>2 hours</li> <li>2 rooms (an hour each room and with 2 examiners in each room)</li> <li>Each candidate has the same stem of the case but which direction each goes is up to the examiners.</li> <li>It probes the limits of your knowledge and the format can be intimidating.</li> <li>Written board exam first before taking the oral exams</li> <li>Not a question of content but about being able to think on your feet</li> </ul> <h3>Bias among DOs vs. MDs:</h3> <p>Any bias perceived is not deserved.</p> <h3>Sub-specialties:</h3> <ol> <li><strong>Pain management:</strong></li> </ol> <ul> <li>Neurologist</li> <li>Psychiatrist</li> <li>PMnR</li> <li>Internal Medicine</li> </ul> <ol> <li><strong>Critical Care:</strong></li> </ol> <ul> <li>ICU medicine</li> </ul> <ol> <li><strong>Other sub-specs:</strong></li> </ol> <ul> <li>Pediatric anesthesia</li> <li>Cardiac anesthesia &gt; echocardiography</li> <li>Obstetric anesthesia</li> <li>Liver transplant anesthesia</li> </ul> <h3>What he wished he knew going into anesthesiology that he knows now:</h3> <ul> <li>Job opportunities available</li> <li>The business side of medicine</li> </ul> <h3>Other specialists he works the closest with:</h3> <ul> <li>All surgical fields expanding to procedural fields such as:</li> <li>GI - endoscopy</li> <li>Cardiology</li> <li>Internal radiologist</li> <li>MRI (they may provide sedation for really young patients)</li> </ul> <h3>Special opportunities outside of clinical medicine:</h3> <ul> <li>Expert witness testimony</li> <li>Research</li> <li>Quality improvement</li> <li>Expansion of training</li> <li>Quality management</li> </ul> <h3>What he wished other specialties knew about anesthesiologists:</h3> <ul> <li>Their focus on safety particularly a combination of three:</li> <li>Patient and their medical problems</li> <li>The surgery and how it affects the body</li> <li>The anesthetic and how it affects the body</li> <li>They have different ways of looking at patients.</li> <li>Pre-anesthesia process to decide who's a good candidate and who's not and what they can do to make them a good candidate</li> <li>They try to get everybody on the same page.</li> </ul> <h3>What he likes most as an anesthesiologist:</h3> <ul> <li>Variety of the things they do everyday</li> <li>They also have their share of excitements but he also likes the routine stuff</li> </ul> <h3>What he likes the least being an anesthesiologist:</h3> <p>Night calls</p> <h3>Would he still choose anesthesiology if he were to do it again?</h3> <p>Yes, it's the right fit for him. You have to go through it to find out what works for you.</p> <h3>The future of anesthesiology vs. CRNA's merging:</h3> <p>The Anesthesia Care Team is a very safe approach. Patrick finds that although the topic is controversial, most people working get along just fine.</p> <p>For premeds, you should be prepared to supervise nurses and you should be prepared to do your own cases because you can do both.</p> <h3>Some pieces of advice for those considering anesthesiology for a specialty:</h3> <p>If you like the fast-paced hospital-based specialty, give it a try. Give it a rotation and if you don't like it, there are plenty other fields to choose from but if you do, it can be a great career.</p> <h2>Links and Other Resources:</h2> <p><a href="http://www.mededmedia.com" rel="nofollow" target="_blank">www.mededmedia.com</a></p>

4: What is Anesthesiologist? A Community Doc Shares His Story

Session 102 Dr. Ryan Matika Residency Program Director in Anesthesiology talks about what he's looking for in his applicants. He also shares what his residents look for when students are doing rotations. Specialty Stories is part of the Meded Media. If you haven’t yet, please check out all the other resources we provide to help premeds, medical students, and residents on their medical journey! [01:07] Interest in Anesthesiology Ryan got interested in anesthesiology when he was in his second year in medical school. They had a program where they were assigned a mentor who happened to be an anesthesiologist.  He went into medical school not thinking about anesthesiology. In fact, he was leaning into internal medicine. But from his rotations, he eventually got drawn towards anesthesiology. He thought about this halfway through his third year because of his mentor. Ryan thinks there is a major element in picking your specialty based on the personality and that element of finding your people. There's a certain type of personality that's a better fit for a specialty than others. But that said, he doesn't think any specialty has one personality. [03:10] Traits that Lead to Being a Good Anesthesiologist The longer he has done this, the more he thinks that there are more traits to being a good doctor. Those traits pretty much transcend the type of residency. He thinks all residents of different specialties have a lot of things in common. First is what drives you, what keeps you up in the morning. That type of work ethic and that type of positive drive would make good residents. For anesthesiology in general, they're meticulous. Although being OCD is not necessary, but you might notice a lot of OCD behaviors evident in anesthesiologists. [05:10] What an Anesthesiologist Does They say that the only thing an anesthesiologist does is putting patients to sleep and waking them up after surgery is one of the misconceptions. There are times your services are requested by a surgeon and part of that is keeping patients calm. But one of the most important things is delivering the anesthetic methods essentially rendering someone in a medically induced coma to tolerate surgery. Also during that time, you're managing the patient's physiology, most importantly the cardio and pulmonary physiology. They could give medications to make patients very hypotensive. The patients can be put through all kinds of cardiovascular difficulties and you have to manage them through. The anesthetics would give necessary poisons and the management they do is to offset those poisons in a healthy patient. And this could get even more tricky for patients with chronic, significant or uncompensated diseases. A lot of the time is focused on physiology and the vitals. While a little bit less time is spent on ensuring that patients are in a medically induced coma as they have to ensure patients are asleep throughout the surgery. [07:40] The Residency Training Path There are two types of programs – the categorical and the advanced programs. Almost everything was advanced in the good old days. Then categorical has gotten more popular. the difference is how you treat that first or intern year. About 75% of the spots are categorical. When you match with an anesthesiology program, you're doing a four-year program. But the first year is essentially mostly off-service rotations. Its purpose is to meet the qualifications of your intern year which is either a medicine year or a surgery year. The advanced year is where you match those two years into separate ones. So you have the intern year where you match into a medicine transitional or surgical year. Then you start your formal anesthesiology three-year training afterward. During those three years, you do the same cases over and over again. You do more simplicity, a lot of airway work. You're getting the basic skills you need for anesthesiology. During the latter half of your residency, you're doing subspecialties. You deal with much sicker patients such as cardiac cases. Each program has a different way of doing that but essentially, there are more similarities than there are differences. After four years and you've met all of your requirements, you can then sit for your final written boards. [09:50] Manual DExterity for Procedures: Is This Necessary? The most important thing you have to have is your mind. The cerebral side of it is the hard part. In terms of the procedural part, anybody with two hands can be trained to do the procedures as you will be doing it over and over again. In fact, Ryan has never seen a resident that has not completed training because of a procedural aspect. 90% of the problem with residents would be medical knowledge or professionalism. And 0% with procedures. There are some people who are better sooner than others but everybody will get there. [11:05] What They Look For in Applicants Generally speaking, one thing that has changed about applicants is the basic exam, which is part of the American Board of Anesthesiology done at the end of your PGY. You need to pass this exam to be able to complete your residency. So they always look at your USMLE scores. They essentially tell you how good you are in studying and passing an exam. Many programs have a certain average score they're looking at. If you have a lower score than that, then you may have to make up for it with different qualities. Ryan personally looks a lot at the Dean's letter, your medical school transcripts, the comments made, grades on your clerkships (particularly medicine and surgery). Most people have positive letters of recommendation. There are various levels of strength on that. So this may be a little bit less important than the other two mentioned above. Another thing that gets underestimated is the volunteering aspect. They want to see students getting more involved with different activities at their medical school or at their local communities. They basically want to see what you were doing during your medical school time beyond just studying and getting the best grades possible. Research is not necessary. But Ryan takes this into account in looking at grades and scores but it doesn't necessarily overcome a bad grade. [16:10] On Pass/Fail System Ryan admits that the ability to evaluate students based on the pass/fail system can be more challenging. A large percentage of medical schools has already gone to not give a class rank. The opposite effect is what they were going for. There's only one score to tell you about their academic abilities.  Making USMLE's into a pass/fail is fine. But now they're going to have to put more emphasis on different factors. They want more information. The board exam process is very difficult. It's not something to be taken lightly. [18:49] On Away Rotations Ryan has done round table events at their schools and he's one of the few people who think that away rotations aren't much help. He personally thinks that away rotation only helps you at the program you're interviewing at. It doesn't really help much when you're going out on your interviews. If there's a program you're really interested in or if you have a place to stay with then that's totally fine. But with the medical school debt and the financial concerns in medicine, the cost of it to go somewhere and rotate wouldn't pay the dividends unless you're really set on one location. [21:55] On Osteopathic Medical Students The osteopathic medical students have been increasingly been more successful in getting anesthesiology spots over the last 10-15 years. You're now seeing DOs in spots that you won't previously see.  Ryan says that the DOs at their programs typically have a little bit higher board scores than the allopathic residents in general. But it's only a minor difference. [23:35] What Makes a Good Anesthesiologist Ryan explains that they look for qualities like work ethic, personality, and professionalism. A lot of anesthesiologists are introverts. So you don't have to make small talk or be the most likable person in the world. You must be willing to help, want to know more, and ask questions. Another important thing is for residents to be able to follow directions. But procedural skills are often emphasized by applicants than they are by their faculty. Hence, you really don't have to worry about the procedural aspect. If you really don't enjoy the procedures and dread doing it hen it's a nice thing to know that this is not a great fit for you. You should enjoy it but you don't necessarily have to be good at it.  [28:00] Personal Statement Tips After reading so many personal statements, you start to see certain trends in personal statements. The most important thing outside of the why and "tell me about yourself" is explaining any kind of deficiency in your application. Ryan needs you to explain what went on in a greater context. This needs to be explained and acknowledged in the personal statement. Ryan isn't sure if a great personal statement makes up for any trouble on the application. But a bad personal statement could raise a few eyebrows and lose you a few interviews. Bad personal statements are going to be things that are too negative. [30:45] A Typical Day in the Resident's Life When you're on your medical student rotation in anesthesiology, you're already getting a piece of it. The classic anesthesia medical student rotation is you come in early and leave early.  The residency is not going to be like this. You've got to come in early and you've got to stay late. This means long hours. As an attending physician, you come in early in the morning. As a resident, give yourself around 20-30 minutes to set up for your case. This means getting your medications, monitors, and equipment ready. If you have morning didactics, you'd have to come in earlier. Then you'd have to go see your first patient in the morning. You can look up the patient the day before so you can have a plan. The next morning, you see the patient and ensure they're ready for surgery. You get their IV in (depending on the institution). When it's time to go back, you're going to take that first patient back. If it's a cardiac case, it's going to take longer since there is more pre-evaluation. Throughout the day, you're going to be doing a variety of cases if you're in the operating room. It's a lot of work to stay vigilant. It's a lot of work to get different cases going. Just like you're taking off and landing, you're going to be doing that for each patient. You really need to individualize things. If you're at a tertiary care center, you're going to have some very complex patients. Each patient needs a careful evaluation. As for the resident level, this needs to be done the night before so they have time to prepare, research, and plan out. The simplest part of it is how to keep them asleep. But the most difficult part of it is how to keep them safe throughout the surgery. [34:20] Taking Calls Calls vary greatly between residencies. They can be specific to a rotation or they can just be a general pool for different services. At their program, different rotations have different calls. When you're doing the general emergency cases, usually residents do one to two nights a week and one to two weekend nights a week. [35:40] Final Words of Wisdom There are a lot of spots for anesthesiology. There are about 1400-1500 spots in the country per year. So your chances aren't bad even if you have some issues with your grades. In general, applicants with lower board scores have to really focus on their clinical rotations. Make this your priority. Also, take a month off after your third year is over. Really dedicate yourself to the Step 2 exam. A much higher Step 2 and a low Step 1 is fine with them. But it can be concerning to have two low Step scores. Ultimately, they need residents that they know are going to pass the boards. If possible, try to get some face time with a program director or someone involved in the selection process. Links: Meded Media

<h2>Session 102</h2> <p>Dr. Ryan Matika Residency Program Director in Anesthesiology talks about what he's looking for in his applicants. He also shares what his residents look for when students are doing rotations.</p> <p>Specialty Stories is part of the <a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">Meded Media</a>. If you haven’t yet, please check out all the other resources we provide to help premeds, medical students, and residents on their medical journey!</p> <h2>[01:07] Interest in Anesthesiology</h2> <p>Ryan got interested in anesthesiology when he was in his second year in medical school. <strong>They had a program where they were assigned a mentor who happened to be an anesthesiologist. </strong></p> <p>He went into medical school not thinking about anesthesiology. In fact, he was leaning into internal medicine. But from his rotations, he eventually got drawn towards anesthesiology. He thought about this halfway through his third year because of his mentor.</p> <p>Ryan thinks there is a major element in picking your specialty based on the personality and that element of finding your people. <strong>There's a certain type of personality that's a better fit for a specialty than others.</strong> But that said, he doesn't think any specialty has one personality.</p> <h2>[03:10] Traits that Lead to Being a Good Anesthesiologist</h2> <p>The longer he has done this, the more he thinks that there are more traits to being a good doctor. Those traits pretty much transcend the type of residency. He thinks all residents of different specialties have a lot of things in common.</p> <p><strong>First is what drives you, what keeps you up in the morning.</strong> That type of work ethic and that type of positive drive would make good residents.</p> <p>For anesthesiology in general, they're meticulous. Although being OCD is not necessary, but you might notice a lot of OCD behaviors evident in anesthesiologists.</p> <h2>[05:10] What an Anesthesiologist Does</h2> <p>They say that the only thing an anesthesiologist does is putting patients to sleep and waking them up after surgery is one of the misconceptions. There are times your services are requested by a surgeon and part of that is keeping patients calm.</p> <p><strong>But one of the most important things is delivering the anesthetic methods essentially rendering someone in a medically induced coma to tolerate surgery.</strong> Also during that time, you're managing the patient's physiology, most importantly the cardio and pulmonary physiology.</p> <p>They could give medications to make patients very hypotensive. The patients can be put through all kinds of cardiovascular difficulties and you have to manage them through.</p> <p>The anesthetics would give necessary poisons and the management they do is to offset those poisons in a healthy patient. And this could get even more tricky for patients with chronic, significant or uncompensated diseases.</p> <p><strong>A lot of the time is focused on physiology and the vitals.</strong> While a little bit less time is spent on ensuring that patients are in a medically induced coma as they have to ensure patients are asleep throughout the surgery.</p> <h2>[07:40] The Residency Training Path</h2> <p><strong>There are two types of programs – the categorical and the advanced programs.</strong> Almost everything was advanced in the good old days. Then categorical has gotten more popular. the difference is how you treat that first or intern year.</p> <p><strong>About 75% of the spots are categorical.</strong> When you match with an anesthesiology program, you're doing a four-year program. But the first year is essentially mostly off-service rotations. Its purpose is to meet the qualifications of your intern year which is either a medicine year or a surgery year.</p> <p>The advanced year is where you match those two years into separate ones. So you have the intern year where you match into a medicine transitional or surgical year. Then you start your formal anesthesiology three-year training afterward.</p> <p>During those three years, you do the same cases over and over again. You do more simplicity, a lot of airway work. You're getting the basic skills you need for anesthesiology.</p> <p><strong>During the latter half of your residency, you're doing subspecialties.</strong> You deal with much sicker patients such as cardiac cases. Each program has a different way of doing that but essentially, there are more similarities than there are differences.</p> <p>After four years and you've met all of your requirements, you can then sit for your final written boards.</p> <h2>[09:50] Manual DExterity for Procedures: Is This Necessary?</h2> <p><strong>The most important thing you have to have is your mind.</strong> The cerebral side of it is the hard part. In terms of the procedural part, anybody with two hands can be trained to do the procedures as you will be doing it over and over again.</p> <p>In fact, Ryan has never seen a resident that has not completed training because of a procedural aspect. 90% of the problem with residents would be medical knowledge or professionalism. And 0% with procedures. <strong>There are some people who are better sooner than others but everybody will get there.</strong></p> <h2>[11:05] What They Look For in Applicants</h2> <p>Generally speaking, one thing that has changed about applicants is the basic exam, which is part of the American Board of Anesthesiology done at the end of your PGY. You need to pass this exam to be able to complete your residency.</p> <p>So they always look at your USMLE scores. They essentially tell you how good you are in studying and passing an exam. Many programs have a certain average score they're looking at. <strong>If you have a lower score than that, then you may have to make up for it with different qualities.</strong></p> <p>Ryan personally looks a lot at the Dean's letter, your medical school transcripts, the comments made, grades on your clerkships (particularly medicine and surgery).</p> <p>Most people have positive letters of recommendation. There are various levels of strength on that. So this may be a little bit less important than the other two mentioned above.</p> <p><strong>Another thing that gets underestimated is the volunteering aspect.</strong> They want to see students getting more involved with different activities at their medical school or at their local communities.</p> <p>They basically want to see what you were doing during your medical school time beyond just studying and getting the best grades possible.</p> <p>Research is not necessary. But Ryan takes this into account in looking at grades and scores but it doesn't necessarily overcome a bad grade.</p> <h2>[16:10] On Pass/Fail System</h2> <p>Ryan admits that the ability to evaluate students based on the pass/fail system can be more challenging. A large percentage of medical schools has already gone to not give a class rank. The opposite effect is what they were going for. <strong>There's only one score to tell you about their academic abilities. </strong></p> <p>Making USMLE's into a pass/fail is fine. But now they're going to have to put more emphasis on different factors. They want more information. The board exam process is very difficult. It's not something to be taken lightly.</p> <h2>[18:49] On Away Rotations</h2> <p>Ryan has done round table events at their schools and he's one of the few people who think that away rotations aren't much help. <strong>He personally thinks that away rotation only helps you at the program you're interviewing at.</strong> It doesn't really help much when you're going out on your interviews.</p> <p>If there's a program you're really interested in or if you have a place to stay with then that's totally fine. But with the medical school debt and the financial concerns in medicine, the cost of it to go somewhere and rotate wouldn't pay the dividends unless you're really set on one location.</p> <h2>[21:55] On Osteopathic Medical Students</h2> <p>The osteopathic medical students have been increasingly been more successful in getting anesthesiology spots over the last 10-15 years. <strong>You're now seeing DOs in spots that you won't previously see. </strong></p> <p>Ryan says that the DOs at their programs typically have a little bit higher board scores than the allopathic residents in general. But it's only a minor difference.</p> <h2>[23:35] What Makes a Good Anesthesiologist</h2> <p><strong>Ryan explains that they look for qualities like work ethic, personality, and professionalism.</strong></p> <p>A lot of anesthesiologists are introverts. So you don't have to make small talk or be the most likable person in the world. You must be willing to help, want to know more, and ask questions.</p> <p>Another important thing is for residents to be able to follow directions. <strong>But procedural skills are often emphasized by applicants than they are by their faculty.</strong> Hence, you really don't have to worry about the procedural aspect.</p> <p>If you really don't enjoy the procedures and dread doing it hen it's a nice thing to know that this is not a great fit for you. <strong>You should enjoy it but you don't necessarily have to be good at it. </strong></p> <h2>[28:00] Personal Statement Tips</h2> <p>After reading so many personal statements, you start to see certain trends in personal statements. <strong>The most important thing outside of the why and "tell me about yourself" is explaining any kind of deficiency in your application.</strong> Ryan needs you to explain what went on in a greater context. This needs to be explained and acknowledged in the personal statement.</p> <p>Ryan isn't sure if a great personal statement makes up for any trouble on the application. <strong>But a bad personal statement could raise a few eyebrows and lose you a few interviews.</strong> Bad personal statements are going to be things that are too negative.</p> <h2>[30:45] A Typical Day in the Resident's Life</h2> <p>When you're on your medical student rotation in anesthesiology, you're already getting a piece of it. <strong>The classic anesthesia medical student rotation is you come in early and leave early. </strong></p> <p>The residency is not going to be like this. <strong>You've got to come in early and you've got to stay late.</strong> This means long hours.</p> <p>As an attending physician, you come in early in the morning. <strong>As a resident, give yourself around 20-30 minutes to set up for your case.</strong> This means getting your medications, monitors, and equipment ready. If you have morning didactics, you'd have to come in earlier.</p> <p>Then you'd have to go see your first patient in the morning. You can look up the patient the day before so you can have a plan.</p> <p>The next morning, you see the patient and ensure they're ready for surgery. You get their IV in (depending on the institution). When it's time to go back, you're going to take that first patient back. If it's a cardiac case, it's going to take longer since there is more pre-evaluation.</p> <p>Throughout the day, you're going to be doing a variety of cases if you're in the operating room. <strong>It's a lot of work to stay vigilant. It's a lot of work to get different cases going.</strong></p> <p><strong>Just like you're taking off and landing, you're going to be doing that for each patient.</strong> You really need to individualize things. If you're at a tertiary care center, you're going to have some very complex patients. Each patient needs a careful evaluation.</p> <p>As for the resident level, this needs to be done the night before so they have time to prepare, research, and plan out. <strong>The simplest part of it is how to keep them asleep. But the most difficult part of it is how to keep them safe throughout the surgery.</strong></p> <h2>[34:20] Taking Calls</h2> <p>Calls vary greatly between residencies. They can be specific to a rotation or they can just be a general pool for different services.</p> <p>At their program, different rotations have different calls. When you're doing the general emergency cases, usually residents do one to two nights a week and one to two weekend nights a week.</p> <h2>[35:40] Final Words of Wisdom</h2> <p>There are a lot of spots for anesthesiology. There are about 1400-1500 spots in the country per year. So your chances aren't bad even if you have some issues with your grades.</p> <p><strong>In general, applicants with lower board scores have to really focus on their clinical rotations.</strong> Make this your priority.</p> <p>Also, take a month off after your third year is over. <strong>Really dedicate yourself to the Step 2 exam.</strong> A much higher Step 2 and a low Step 1 is fine with them. But it can be concerning to have two low Step scores.</p> <p>Ultimately, they need residents that they know are going to pass the boards. If possible, try to get some face time with a program director or someone involved in the selection process.</p> <h2>Links:</h2> <p><a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">Meded Media</a></p>

102: An Anesthesiology Program Director on His Specialty

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

<h2>Session 56</h2> <p>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.</p> <p>Neurosurgery is one of those residencies that are super hard to get into. Ryan has had an academic neurosurgeon previously on <a href="https://medicalschoolhq.net/specialty-stories-podcast/" rel="nofollow" target="_blank">Episode 20</a> of this podcast.</p> <p>Please subscribe to this podcast. We're on <a href="https://open.spotify.com/view/podcasts-page" rel="nofollow" target="_blank">Spotify</a> 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 <a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">MedEd Media Network</a>.</p> <p>Let's dive into today's data...</p> <p>All information here are based on the <a href="http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Results-and-Data-2017.pdf" rel="nofollow" target="_blank"> NRMP Main Residency Match 2017</a>, <a href="http://www.nrmp.org/wp-content/uploads/2016/09/Charting-Outcomes-US-Allopathic-Seniors-2016.pdf" rel="nofollow" target="_blank"> Charting the Outcomes 2016</a>, <a href="https://www.medscape.com/features/slideshow/lifestyle/2017/overview" rel="nofollow" target="_blank"> Medscape Lifestyle Report 2017</a>, and <a href="https://www.medscape.com/slideshow/compensation-2017-overview-6008547" rel="nofollow" target="_blank"> Medscape Compensation Report 2017</a>. 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.</p> <h3>[02:30] Match Summary for 2017</h3> <p>Looking at Table 1 of <a href="http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Results-and-Data-2017.pdf" rel="nofollow" target="_blank"> NRMP Main Residency Match 2017</a> 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.</p> <p>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.</p> <p>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.</p> <p><em>"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."</em></p> <p>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.</p> <p>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.</p> <h3>[06:45] Summary of Students: U.S. Seniors, U.S. Grads, IMGs, Osteopaths</h3> <p>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.</p> <p>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.</p> <p><em>"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."</em></p> <p>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.</p> <h3>[09:22] Yearly Trends</h3> <p>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.</p> <p>Looking at Table 8 shows the number of positions offered and the percent filled by U.S. Seniors versus all applicants.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p><em>"Out of the 27,688, only 0.8% of those are matching into neurosurgery. So it's a very, very small specialty."</em></p> <h3>[12:35] Unmatched U.S. Seniors and Independent Applicants, SOAP</h3> <p>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.</p> <p>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.</p> <p>Table 18 shows the SOAP (Supplemental Offer and Acceptance Program). Neurosurgery had 0 unfilled programs so no neurosurgery programs needed to participate in SOAP.</p> <h3>[14:00] Charting the Outcomes 2016</h3> <p>Digging into the <a href="http://www.nrmp.org/wp-content/uploads/2016/09/Charting-Outcomes-US-Allopathic-Seniors-2016.pdf" rel="nofollow" target="_blank"> Charting the Outcomes 2016</a>, 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.</p> <p>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.</p> <p><em>"To match, you have to rank a lot of programs. The more programs you rank, the higher the chance that you will match."</em></p> <p>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.</p> <p>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.</p> <h3>[17:23] Ranking by Specialty and Step 1, Step 2 Scores</h3> <p>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.</p> <p><em>"Don't have a plan B of being a PA... If you want to be a physician, figure out how to get there."</em></p> <p>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.</p> <p>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.</p> <p><em>"You need to have great board scores, if you're planning on being competitive for neurosurgery."</em></p> <h3>[20:21] Scores, Research, Publications, AOA</h3> <p>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.</p> <p><em>"Research is very important for neurosurgery."</em></p> <p>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.</p> <p>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.</p> <h3>[22:27] Burnout Rates and Compensation</h3> <p>Moving on to the data of <a href="https://www.medscape.com/features/slideshow/lifestyle/2017/overview" rel="nofollow" target="_blank"> Medscape Lifestyle Report 2017</a>, Neurosurgery is not on the list since there are only a few number of them. And looking at <a href="https://www.medscape.com/slideshow/compensation-2017-overview-6008547" rel="nofollow" target="_blank"> Medscape Compensation Report 2017</a>, it's the same thing, Neurosurgery did not have enough representation to be in this list.</p> <p>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.</p> <h2>Links:</h2> <p><a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">MedEd Media Network</a></p> <p><a href="https://medicalschoolhq.net/specialty-stories-podcast/" rel="nofollow" target="_blank">Specialty Stories Podcast Episode 20</a></p> <p><a href="http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Results-and-Data-2017.pdf" rel="nofollow" target="_blank"> NRMP Main Residency Match 2017</a></p> <p><a href="https://www.medscape.com/features/slideshow/lifestyle/2017/overview" rel="nofollow" target="_blank"> Medscape Lifestyle Report 2017</a></p> <p><a href="https://www.medscape.com/slideshow/compensation-2017-overview-6008547" rel="nofollow" target="_blank"> Medscape Compensation Report 2017</a></p> <p><a href="http://www.nrmp.org/wp-content/uploads/2016/09/Charting-Outcomes-US-Allopathic-Seniors-2016.pdf" rel="nofollow" target="_blank"> Charting the Outcomes 2016</a></p> <p><a href="https://medicalschoolhq.net/thepremedyears/" rel="nofollow" target="_blank">The Premed Years Podcast</a></p>

56: How Hard is the Neurosurgery Match? A Look at the Data.

Session 86 Dr. Joseph DeRose is an academic Cardiothoracic Surgeon. Today, he discusses the length of his training, the competitiveness of his field, and why he loves it! Meanwhile, please don’t miss all our other podcasts on the MedEd Media Network so you can get all the resources you need in every step of the way towards finally becoming a physician! [01:00] Interest in Cardiothoracic Surgery As a third-year medical student, Joseph liked almost everything. He even thought he was going into interventional cardiology. But he realized it's a medical specialty which means doing three years of medicine and three years of cardiology and then interventional cardiology. But he realized he liked surgery more than medicine. At that time there was no direct pathway to cardiac surgery. He went to general surgery training and found there were a lot of areas in surgery that he liked, but still much very interested in the heart. After doing multiple rotations, he decided to do cardiothoracic surgery based upon the thought process built around whether you can't be happy doing anything else. [03:45] Traits that Make a Good Cardiothoracic Surgeon First, you have to be interested in acute care. Most of the cardiac surgery is care that's high intensity but very focused on temporal relation. You're taking care of severe and critical issues but you're taking care of them in small periods of time. So you have to like being in a hospital and critically ill patients. You have to also like other things because cardiac surgery is not just a mechanical field. You really have to enjoy pathophysiology and a bit of cardiology since a lot of patient care goes on. Because cardiac surgery is a hospital-based practice, there are other things that go into being a cardiac surgeon regardless of whether you work for an academic institution or private practice. This includes enjoying teaching. There's constant education going on even if you don't have a fellowship. You're educating PAs, nurses, perfusionists, and junior faculty. Apparently, research is an intimate part of the field. This occurs even if you're not in an academic program. Cardiac surgeons are frequently involved in clinical trials and clinical research even if they're not academic, per se. If you like those three, this can be a great field for you. In terms of traits, you have to have a lot of mental and physical stamina to be a cardiac surgeon. You have to be even-keeled as things can get very up and down. So you have to be able to take different things as they come. Going into this, Joseph initially considered vascular surgery for some time and to the last minute, he decided it wasn't for him. [07:14] Types of Patients Coronary artery disease is the most common he sees but there are many ways to take care of that now – regular, conventional bypass surgery, stents, robotic surgery, minimally invasive surgery. Another common disease would be valve problems – aortic valve, mitral valve, leaky valves, stenotic valves, etc. There are situations where patients can be offered various options such as open surgery, minimally invasive surgery, transcatheter, structural heart interventions. Other areas of specialty include aortic diseases involving aortic dissections which are a high-intensity part of the pathology. Heart failure is another common disease among patients which includes things like heart transplantation and artificial hearts. Cardia surgeons are sort of tertiary or quarternary referrals. So patients have typically seen the medical doctor or cardiologist before they're being called. However, even if you're called with a specific diagnosis, that doesn't always mean the diagnosis is completely worked up or correct. It doesn't mean that the person has been completely evaluated as to whether they're a potential candidate for different interventions. The evaluation of cardiac surgical patients for the cardiac surgeon is much different than any other surgical specialty because we're expected to evaluate every part of the patient's body. That said, appreciating the subtleties of every patient is what makes you successful or not. And that's what makes it so fun as well. [11:30] Typical Day As an academic heart surgeon, Joseph does research and runs the residency program. He also has a very busy clinical practice and does about 300 cases a year. A typical day would be getting in at 7 am working on academic things before going to the OR. He also makes rounds with the whole team and sees all the patients in the ICU and the floor before going to the operating room, which starts at about 7:30 am. They can have 1-3 operations going simultaneously, being involved in the OR most of the day and being available to respond to other issues and concerns in between operations. Once out of the operating room, Joseph gets on his computer. At the end of the day, they round up with fellows and PA's and see patients they've just operated on or patients that are having issues throughout the day. They also see patients that they've gotten called about for consultation and assess them to see them if workup is needed or surgery. Then he could also be on conference calls for clinical research trials he's involved in a couple of times a week. He may also go to administrative type dinner whether it's for planning or recruitment, etc. A full day for him, yet enjoyable. [13:30] Taking Calls and Work/Life Balance Joseph points out that call is something that every surgeon needs to take probably for the rest of his life. Taking calls for them is a bit unusual because they cover things like regular bread and butter heart surgery as well as heart transplantation, lung transplantation, aortic dissection, ECMO (extracorporeal membrane oxygenation). Generally, they take about 6-8 calls a month including one weekend. In heart surgery, it involves making rounds on the patients in the ICU and the floor every day of the weekend. They also cover emergencies that occur at night and when they do, the operations can take long for about 6 hours. Having been in practice now for 17 years, Joseph is married to an internist and now have two children, 21 and 18. He coached his son's soccer team and baseball team since he was in 3rd grade until 8th grade. Then when he got to high school, he played varsity lacrosse and went to every game whether home or away. He did all this with planning. And it can always be done. He also coached his daughter's soccer team. Moreover, Joseph is lucky to be working in a big group of people he's known for a long time and they're all very supportive of each other's family life. [16:45] The Residency Path: Traditional The traditional path requires four years of medical school and then you apply to general surgery residency, typically taking 5 years. With most cardiac surgeons of today, they'd all spend an additional year of research in cardiac surgery because the application process is incredibly competitive. A lot of applicants that are now going through the traditional path mostly don't do extra research. But by the time you get to your fourth year, you have to apply to either a 2- or 3-year fellowship. That's in cardiothoracic surgery. So that's 4 years of medical school, 5 years of residency, and 2-3 years fellowship. Joseph recommends that even though you've done the traditional path, spend an additional year thereafter focusing on a super fellowship in a higher intensity-focused area. For example, do an extra year in heart transplantation or if you want to do thoracic surgery, do an extra year of minimally invasive thoracic surgery for instance. In cardiac surgical fellowship, you have to train for 2-3 years in three areas: adult cardiac surgery, general thoracic surgery (including lung-esophageal surgery), and pediatric heart surgery. This is a lot to learn in a short period of time, hence, Joseph recommends an additional year. That's a total of 8 years in training on the traditional pathway. [18:25] The Residency Path: The I-6 Program In 2012, there were less and less applicants for cardiac surgery and one of the reasons is the sacrifice it takes to be a heart surgeon. And a lot of people were less inclined to make those sacrifices. The second reason is the reimbursement concern where people didn't feel they were well-compensated. This prompted the association to develop an I-6 program where you apply directly out of medical school and you're being matched into cardiac surgery. You still do about 3 years of the traditional general surgery training and within the final three years in cardiac surgery includes weeks and months of specialties important for cardiac surgery such as interventional cardiology, echocardiography, perfusion. This cuts off two years the training length although many of the programs also do an additional year of research. Those that finish the I-6 program will also take an additional year of super fellowship training. The I-6 application process is more competitive because of a much larger group of people looking at it with a smaller number of spots. There are about two applicants for every spot. To be competitive, you have to have great grades, with at least one or two publications already and have done some research in medical school. You don't need as high a qualification coming from a general surgery program. That being said, there are still some excellent traditional training fellowship programs as well as I-6 programs that aren't so good. This is something students should consider as well. Interestingly, of the people that don't match in the I-6 program and go to general surgery, only about 5% of them that while they're in general surgery, decide they're going into cardiac surgery. [22:52] Super Fellowships For instance, you've done three months of congenital heart surgery and like it, you can't be a pediatric heart surgeon. You've got to spend an extra year doing congenital heart surgery. If you're a thoracic surgeon and non cardiac thoracic surgeon, there are super fellowships in any number of specialty areas for that. It could be an extra year in surgical oncology or in minimally invasive esophagectomy, or an extra year in lung failure or lung transplantation. So there are a number of areas where you can get additional training. In adult cardiac surgery, the major ones would be another year in adult heart surgery. But the three most common ones are heart transplants, minimally invasive heart surgery and mitral valve repair surgery. [24:10] Challenges Osteopathic Students Should Overcome An osteopathic medical student has to go into a general surgery residency training program. It can be an osteopathic training program but must be approved by the ACGME. However, if you do that going through the traditional pathway, there are no obstacles. If you're a good candidate, you can absolutely become a cardiac surgeon. In fact, in their training program, they have several DOs over the years and many of them have been outstanding. However, this is not offered in the I-6 pathway. [25:15] Working with Primary Care Physicians and Other Specialties Primary care has changed a lot over the years. Internal medicine has been very stratified with inpatient and outpatients where they no longer have their own individual patients. Because heart surgery is so much of an evaluation process that includes the entire patient, cardiac surgeons need help in evaluating their patients for their end-organ dysfunction. But a lot has been fractionated where they'd call the specific specialties. But Joseph points out that this is not so helpful since each specialty will focus on their specialty area. What you need is someone like the heart surgeon like an internist who's evaluating the whole patient and all of their medical problems to assess whether an intervention is going to make them either live longer or feel better. And this can still be improved upon, Joseph believes so. Other specialties they work closely with include cardiology, GI, pulmonary, and renal to help manage patient's post-op. There are people in his team where each one may direct a program upon which, you're almost always directing that program with a medical cardiology person specialized on the medical side. [27:45] Special Opportunities Outside of Clinical Medicine Cardiothoracic surgeons are a totally different breed. From the beginning of your training, you're taught that it's not just about doing surgery but it's also about being a leader and learning how to talk publicly and learning how to expand your horizons. Most cardiac surgeons aspire to do other things such as politics, media, administration or lead a department. So there are immense opportunities out there but a lot of it has to do with the training. Moreover, Joseph points out that training is really hard. Things have changed with hour restrictions but it's part and parcel of all of it in making you think about not just about being a technician. As to gender demographics, Joseph seems not to notice any division as people are going into fellowship. He recently looked at the applications and there were 40% women and 60% men. [30:45] Two Areas Not Being Taught in School Joseph says that when you go through medical school and in training, we're not really taught how we exist in relation to the real world. We only know how we exist within the confines of our training programs. There are a lot of things that you need to learn by mistake to figure out how to function better the next time. This is common in areas like the medical-legal area. It has nothing to do with mortality/morbidity or with right or wrong. So you have to learn how to appropriately document what you do in the chart to protect yourself. The other area is on the business end. Not having an idea about how the business of medicine works puts you at a disadvantage when you're trying to negotiate your first contract, or realize what's important to the hospital versus what's important to you from a financial standpoint. In cardiac surgery, though they get exposure to outpatient medicine, it's only by experience that you start figuring out all the interpersonal dynamics that occur when you see a patient in the office or on the floor for heart surgery. You need to understand what the interplay is between a patient's family members and what you're going to talk to them about. You have to understand the reactions of patients when you talk about life and death. [33:44] Least and Most Liked About the Specialty Joseph loves that it's something new and different everyday and how it's all a dynamic process. There are so many things that go on beyond just the operation and you have to be very intuitive and be very careful about when it comes to managing patients after surgery. He also loves the educational and research parts of it. Many students do cardiac surgery for the excitement, but after a while, surgery becomes the easy part as it can get to be a routine. But it's the different interplays in patients and each pathology are just amazing. Ultimately, he loves being there for the patient in their most trying times, whether that's saving their life or sometimes helping them die. What he likes the least is the litigation portion of it. There are lots of lawsuits in cardiac surgery and there's nothing more painful than to have to go through that, says Joseph. Though 95% of all lawsuits get dropped and 5% just go through the trial and ever settled, it's a part of life and it's something any doctor wouldn't want. [35:45] Turf Wars with Other Fields Joseph believes you have to take a broader perspective on it. He has been seeing and hearing how stents are going to take away coronary bypass grafting. But cardiac surgeons are always intimately involved with new technology whether on the research end or on the clinical end. New developments are in terms of the structural end and cardiac surgeons will continue to be involved in, as well as heart failure area with all the devices coming out. They're becoming less and less invasive, helping more and more patients. That being said, Joseph definitely sees a brighter future for cardiac surgery. In terms of job perspective, there's a lack of cardiac surgeons going into the field about 5-10 years ago. A lot of the surgeons retiring in the last 5-10 years has left a huge opening for cardiac surgical positions. So getting a job in cardiac surgery is much easier now. [38:05] Final Words of Wisdom Finally, if he had to do it all over again, Joseph would still do the same. He loved what he does and still loves coming to work everyday. He thinks there is no other job that's as exciting as they do but you have to have the right personality to take on the challenges that it brings. Yes, you get to save lives but people die as well so you have to be able to deal with that. Ultimately, he wishes to impart to students that medicine is the noblest of all professions. It's something you have for yourself forever. It is not a job. In cardiac surgery, Joseph explains it's the same kind of discussion, except that it's on steroids. People may ask you why you want to sacrifice your life to do those kinds of things as you're not going to make as much money or things are going to be hard and there are lawsuits. But you're doing it for something else. You're going into it because you love it and if you do it this way, there's nothing more gratifying than this. Links: MedEd Media Network

<h2>Session 86</h2> <p>Dr. Joseph DeRose is an academic Cardiothoracic Surgeon. Today, he discusses the length of his training, the competitiveness of his field, and why he loves it!</p> <p>Meanwhile, please don’t miss all our other podcasts on the <a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">MedEd Media Network</a> so you can get all the resources you need in every step of the way towards finally becoming a physician!</p> <h2>[01:00] Interest in Cardiothoracic Surgery</h2> <p>As a third-year medical student, Joseph liked almost everything. He even thought he was going into interventional cardiology. But he realized it's a medical specialty which means doing three years of medicine and three years of cardiology and then interventional cardiology. But he realized he liked surgery more than medicine.</p> <p>At that time there was no direct pathway to cardiac surgery. He went to general surgery training and found there were a lot of areas in surgery that he liked, but still much very interested in the heart. After doing multiple rotations, he decided to do cardiothoracic surgery based upon the thought process built around whether you can't be happy doing anything else.</p> <h2>[03:45] Traits that Make a Good Cardiothoracic Surgeon</h2> <p>First, you have to be interested in acute care. Most of the cardiac surgery is care that's high intensity but very focused on temporal relation. You're taking care of severe and critical issues but you're taking care of them in small periods of time. So you have to like being in a hospital and critically ill patients. You have to also like other things because cardiac surgery is not just a mechanical field. You really have to enjoy pathophysiology and a bit of cardiology since a lot of patient care goes on.</p> <p>Because cardiac surgery is a hospital-based practice, there are other things that go into being a cardiac surgeon regardless of whether you work for an academic institution or private practice. This includes enjoying teaching. There's constant education going on even if you don't have a fellowship. You're educating PAs, nurses, perfusionists, and junior faculty.</p> <p>Apparently, research is an intimate part of the field. This occurs even if you're not in an academic program. Cardiac surgeons are frequently involved in clinical trials and clinical research even if they're not academic, per se.</p> <p>If you like those three, this can be a great field for you. In terms of traits, you have to have a lot of mental and physical stamina to be a cardiac surgeon. You have to be even-keeled as things can get very up and down. So you have to be able to take different things as they come.</p> <p>Going into this, Joseph initially considered vascular surgery for some time and to the last minute, he decided it wasn't for him.</p> <h2>[07:14] Types of Patients</h2> <p>Coronary artery disease is the most common he sees but there are many ways to take care of that now – regular, conventional bypass surgery, stents, robotic surgery, minimally invasive surgery.</p> <p>Another common disease would be valve problems – aortic valve, mitral valve, leaky valves, stenotic valves, etc. There are situations where patients can be offered various options such as open surgery, minimally invasive surgery, transcatheter, structural heart interventions.</p> <p>Other areas of specialty include aortic diseases involving aortic dissections which are a high-intensity part of the pathology. Heart failure is another common disease among patients which includes things like heart transplantation and artificial hearts.</p> <p>Cardia surgeons are sort of tertiary or quarternary referrals. So patients have typically seen the medical doctor or cardiologist before they're being called. However, even if you're called with a specific diagnosis, that doesn't always mean the diagnosis is completely worked up or correct. It doesn't mean that the person has been completely evaluated as to whether they're a potential candidate for different interventions.</p> <p>The evaluation of cardiac surgical patients for the cardiac surgeon is much different than any other surgical specialty because we're expected to evaluate every part of the patient's body. That said, appreciating the subtleties of every patient is what makes you successful or not. And that's what makes it so fun as well.</p> <h2>[11:30] Typical Day</h2> <p>As an academic heart surgeon, Joseph does research and runs the residency program. He also has a very busy clinical practice and does about 300 cases a year. A typical day would be getting in at 7 am working on academic things before going to the OR. He also makes rounds with the whole team and sees all the patients in the ICU and the floor before going to the operating room, which starts at about 7:30 am. They can have 1-3 operations going simultaneously, being involved in the OR most of the day and being available to respond to other issues and concerns in between operations.</p> <p>Once out of the operating room, Joseph gets on his computer. At the end of the day, they round up with fellows and PA's and see patients they've just operated on or patients that are having issues throughout the day. They also see patients that they've gotten called about for consultation and assess them to see them if workup is needed or surgery. Then he could also be on conference calls for clinical research trials he's involved in a couple of times a week. He may also go to administrative type dinner whether it's for planning or recruitment, etc. A full day for him, yet enjoyable.</p> <h2>[13:30] Taking Calls and Work/Life Balance</h2> <p>Joseph points out that call is something that every surgeon needs to take probably for the rest of his life. Taking calls for them is a bit unusual because they cover things like regular bread and butter heart surgery as well as heart transplantation, lung transplantation, aortic dissection, ECMO (extracorporeal membrane oxygenation). Generally, they take about 6-8 calls a month including one weekend.</p> <p>In heart surgery, it involves making rounds on the patients in the ICU and the floor every day of the weekend. They also cover emergencies that occur at night and when they do, the operations can take long for about 6 hours.</p> <p>Having been in practice now for 17 years, Joseph is married to an internist and now have two children, 21 and 18. He coached his son's soccer team and baseball team since he was in 3rd grade until 8th grade. Then when he got to high school, he played varsity lacrosse and went to every game whether home or away. He did all this with planning. And it can always be done. He also coached his daughter's soccer team. Moreover, Joseph is lucky to be working in a big group of people he's known for a long time and they're all very supportive of each other's family life.</p> <h2>[16:45] The Residency Path: Traditional</h2> <p>The traditional path requires four years of medical school and then you apply to general surgery residency, typically taking 5 years. With most cardiac surgeons of today, they'd all spend an additional year of research in cardiac surgery because the application process is incredibly competitive.</p> <p>A lot of applicants that are now going through the traditional path mostly don't do extra research. But by the time you get to your fourth year, you have to apply to either a 2- or 3-year fellowship. That's in cardiothoracic surgery. So that's 4 years of medical school, 5 years of residency, and 2-3 years fellowship.</p> <p>Joseph recommends that even though you've done the traditional path, spend an additional year thereafter focusing on a super fellowship in a higher intensity-focused area. For example, do an extra year in heart transplantation or if you want to do thoracic surgery, do an extra year of minimally invasive thoracic surgery for instance.</p> <p>In cardiac surgical fellowship, you have to train for 2-3 years in three areas: adult cardiac surgery, general thoracic surgery (including lung-esophageal surgery), and pediatric heart surgery. This is a lot to learn in a short period of time, hence, Joseph recommends an additional year. That's a total of 8 years in training on the traditional pathway.</p> <h2>[18:25] The Residency Path: The I-6 Program</h2> <p>In 2012, there were less and less applicants for cardiac surgery and one of the reasons is the sacrifice it takes to be a heart surgeon. And a lot of people were less inclined to make those sacrifices. The second reason is the reimbursement concern where people didn't feel they were well-compensated. This prompted the association to develop an I-6 program where you apply directly out of medical school and you're being matched into cardiac surgery. You still do about 3 years of the traditional general surgery training and within the final three years in cardiac surgery includes weeks and months of specialties important for cardiac surgery such as interventional cardiology, echocardiography, perfusion. This cuts off two years the training length although many of the programs also do an additional year of research. Those that finish the I-6 program will also take an additional year of super fellowship training.</p> <p>The I-6 application process is more competitive because of a much larger group of people looking at it with a smaller number of spots. There are about two applicants for every spot. To be competitive, you have to have great grades, with at least one or two publications already and have done some research in medical school.</p> <p>You don't need as high a qualification coming from a general surgery program. That being said, there are still some excellent traditional training fellowship programs as well as I-6 programs that aren't so good. This is something students should consider as well. Interestingly, of the people that don't match in the I-6 program and go to general surgery, only about 5% of them that while they're in general surgery, decide they're going into cardiac surgery.</p> <h2>[22:52] Super Fellowships</h2> <p>For instance, you've done three months of congenital heart surgery and like it, you can't be a pediatric heart surgeon. You've got to spend an extra year doing congenital heart surgery. If you're a thoracic surgeon and non cardiac thoracic surgeon, there are super fellowships in any number of specialty areas for that. It could be an extra year in surgical oncology or in minimally invasive esophagectomy, or an extra year in lung failure or lung transplantation. So there are a number of areas where you can get additional training. In adult cardiac surgery, the major ones would be another year in adult heart surgery. But the three most common ones are heart transplants, minimally invasive heart surgery and mitral valve repair surgery.</p> <h2>[24:10] Challenges Osteopathic Students Should Overcome</h2> <p>An osteopathic medical student has to go into a general surgery residency training program. It can be an osteopathic training program but must be approved by the ACGME. However, if you do that going through the traditional pathway, there are no obstacles. If you're a good candidate, you can absolutely become a cardiac surgeon. In fact, in their training program, they have several DOs over the years and many of them have been outstanding. However, this is not offered in the I-6 pathway.</p> <h2>[25:15] Working with Primary Care Physicians and Other Specialties</h2> <p>Primary care has changed a lot over the years. Internal medicine has been very stratified with inpatient and outpatients where they no longer have their own individual patients. Because heart surgery is so much of an evaluation process that includes the entire patient, cardiac surgeons need help in evaluating their patients for their end-organ dysfunction. But a lot has been fractionated where they'd call the specific specialties. But Joseph points out that this is not so helpful since each specialty will focus on their specialty area. What you need is someone like the heart surgeon like an internist who's evaluating the whole patient and all of their medical problems to assess whether an intervention is going to make them either live longer or feel better. And this can still be improved upon, Joseph believes so.</p> <p>Other specialties they work closely with include cardiology, GI, pulmonary, and renal to help manage patient's post-op. There are people in his team where each one may direct a program upon which, you're almost always directing that program with a medical cardiology person specialized on the medical side.</p> <h2>[27:45] Special Opportunities Outside of Clinical Medicine</h2> <p>Cardiothoracic surgeons are a totally different breed. From the beginning of your training, you're taught that it's not just about doing surgery but it's also about being a leader and learning how to talk publicly and learning how to expand your horizons. Most cardiac surgeons aspire to do other things such as politics, media, administration or lead a department. So there are immense opportunities out there but a lot of it has to do with the training.</p> <p>Moreover, Joseph points out that training is really hard. Things have changed with hour restrictions but it's part and parcel of all of it in making you think about not just about being a technician.</p> <p>As to gender demographics, Joseph seems not to notice any division as people are going into fellowship. He recently looked at the applications and there were 40% women and 60% men.</p> <h2>[30:45] Two Areas Not Being Taught in School</h2> <p>Joseph says that when you go through medical school and in training, we're not really taught how we exist in relation to the real world. We only know how we exist within the confines of our training programs. There are a lot of things that you need to learn by mistake to figure out how to function better the next time. This is common in areas like the medical-legal area. It has nothing to do with mortality/morbidity or with right or wrong. So you have to learn how to appropriately document what you do in the chart to protect yourself. The other area is on the business end.</p> <p>Not having an idea about how the business of medicine works puts you at a disadvantage when you're trying to negotiate your first contract, or realize what's important to the hospital versus what's important to you from a financial standpoint.</p> <p>In cardiac surgery, though they get exposure to outpatient medicine, it's only by experience that you start figuring out all the interpersonal dynamics that occur when you see a patient in the office or on the floor for heart surgery. You need to understand what the interplay is between a patient's family members and what you're going to talk to them about. You have to understand the reactions of patients when you talk about life and death.</p> <h2>[33:44] Least and Most Liked About the Specialty</h2> <p>Joseph loves that it's something new and different everyday and how it's all a dynamic process. There are so many things that go on beyond just the operation and you have to be very intuitive and be very careful about when it comes to managing patients after surgery. He also loves the educational and research parts of it. Many students do cardiac surgery for the excitement, but after a while, surgery becomes the easy part as it can get to be a routine. But it's the different interplays in patients and each pathology are just amazing. Ultimately, he loves being there for the patient in their most trying times, whether that's saving their life or sometimes helping them die.</p> <p>What he likes the least is the litigation portion of it. There are lots of lawsuits in cardiac surgery and there's nothing more painful than to have to go through that, says Joseph. Though 95% of all lawsuits get dropped and 5% just go through the trial and ever settled, it's a part of life and it's something any doctor wouldn't want.</p> <h2>[35:45] Turf Wars with Other Fields</h2> <p>Joseph believes you have to take a broader perspective on it. He has been seeing and hearing how stents are going to take away coronary bypass grafting. But cardiac surgeons are always intimately involved with new technology whether on the research end or on the clinical end. New developments are in terms of the structural end and cardiac surgeons will continue to be involved in, as well as heart failure area with all the devices coming out. They're becoming less and less invasive, helping more and more patients.</p> <p>That being said, Joseph definitely sees a brighter future for cardiac surgery. In terms of job perspective, there's a lack of cardiac surgeons going into the field about 5-10 years ago. A lot of the surgeons retiring in the last 5-10 years has left a huge opening for cardiac surgical positions. So getting a job in cardiac surgery is much easier now.</p> <h2>[38:05] Final Words of Wisdom</h2> <p>Finally, if he had to do it all over again, Joseph would still do the same. He loved what he does and still loves coming to work everyday. He thinks there is no other job that's as exciting as they do but you have to have the right personality to take on the challenges that it brings. Yes, you get to save lives but people die as well so you have to be able to deal with that.</p> <p>Ultimately, he wishes to impart to students that medicine is the noblest of all professions. It's something you have for yourself forever. It is not a job. In cardiac surgery, Joseph explains it's the same kind of discussion, except that it's on steroids. People may ask you why you want to sacrifice your life to do those kinds of things as you're not going to make as much money or things are going to be hard and there are lawsuits. But you're doing it for something else. You're going into it because you love it and if you do it this way, there's nothing more gratifying than this.</p> <h2>Links:</h2> <p><a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">MedEd Media Network</a></p>

86: The Ins and Outs of Academic Cardiothoracic Surgery

Session 107 Emergency medicine residency training requires lots of interpersonal skills. Dr. David Snow has been out of training for 6 years now. Today, he tells us more about the acuity, variety, and steep learning curve in EM. Meanwhile, be sure to check out all our other resources on Meded Media. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:15] Interest in Emergency Medicine Coming to the end of the third year in medical school, David was choosing between surgery, psychiatry, and emergency medicine. Ultimately, there were things about EM that appealed to him. [Related episode:  What is Emergency Medicine?] [04:22] Traits that Lead to Become a Good EM Physician When you get to a shift, it can get as busy as any other time during any other shifts in their life. They sometimes work at 5 am and 11 pm and it doesn't matter what comes before that. They just have to be ready as they walk in the door. This is not unique to EM at all, but it is unique across all the fields of EM. As an EM doctor, you have to understand the unpredictable nature of the specialty.  Additionally, interpersonal skills are important as you could be speaking to patients from all walks of life. Alongside, you'd also be networking with clerks, nurses, medical students, and division chairmen. You have to be able to work with the challenges of that environment and do so with a smile on your face. David has been evaluating residency applications for 7 years now. A few years ago, they added a new piece to the application for emergency medicine called the Standardized Letter of Evaluation. In any of the rotations you do, you will have one of these letters written for you. This is a movement away from the Letter of Recommendation that students ask from an EM physician. It compares you to applicants from the current cycle and the previous year. The letter also lists a set of attributes that talk about your success within those attributes as well as your work ethic, professionalism, etc. There are also specific pretext parts to the document where people speak very candidly about the applicant. Emergency physicians are looking for the same things. They somewhat know what to write.  [Related episode:  Looking at Emergency Medicine Match Data and Surveys] [10:50] Pass-Fail System Evaluating Students David thinks there are so many facets to a pass-fail system. He believes it could be hard from the student's standpoint as a sub-average USMLE Step 1 score can be very detrimental to an applicant. Programs can use filters based on USMLE or COMLEX scores and that one score can be very hard for them to move past to ensure the reviewer doesn't get stuck on that. There's no recommendation an applicant needs to have taken Step 2. But if the Step 1 score is below the mean, it's encouraged that they take Step 2 so they can work past that. This being said, it adds a lot of pressure to all of it. [Related episode:  What Step 1 Score or Level 1 Score Should I Try to Get?] [13:40] How to Stand Out in Rotations David recommends getting in touch with EM faculty and to start interacting with them as early as possible so they can start asking questions. Most medical schools that have EM departments have some way to get shadow shifts with EM faculty. Nevertheless, he doesn't think there should be pressure for students to get in front of PD during their second or third year. You just have to do what has to be done to figure out that EM is for you. If meeting with a program is the way to do that then fine. But don't feel like you need to do that in order to bolster your application. Ultimately, just enjoy your rotations during third year as your learnings are all going to be very useful for your future training. Donald underlines understanding the key attributes of an EM physician. They are hardworking. They don't complain about the work before them. They try to enjoy as much as they can. It's important to have that positive outlook and the desire to come in and take care of patients. Be able to come in wiith those attributes without trying to be held back by your nerves. Understand you're still a student and not a resident yet so your level of knowledge is obviously below the residents. Donald notices how many students come in during rotations where they feel this need to prove they know what they're doing. He advises students to step back from this. ED is challenging itself. Just find your team and enjoy your time. Anything you can do to help out a resident would be golden. They would thank you and love you for that. Try not to think about the importance of the rotation and just be yourself. Be that motivated and driven medical student on the rotation who's there to learn and work. Being so focused on proving and performing would only limit yourself from feeling what it might be like to be that person in the field. [24:55] The Biggest Misconceptions About Emergency Medicine Many students are drawn into EM by trauma and acute resuscitation. Although this is a huge part of what they do, it's far from being a true EM clinical life. It's a big part but it's not a huge part of an EM physician's life. Another misconception about Emergency Medicine is the idea of burnout. David believes that so much of this is born out of the habits formed during residency. You might do all of that right and end up in a job that makes you very unhappy but then you must change jobs because if you don't, you'll fit in that burnout spectrum. David clarifies it's not a false label as this is what's being shown on the survey. But he doesn't think this should preclude you or stop you from going into a career in emergency medicine. [29:20] The Training Path What differentiates EM from other programs is that by Day 1, you may have the sickest patients of your residency training. In most programs, the system is set up to where you might not be going to an operating room or ICU during your first year. They would still build up your knowledge and experience before you're exposed to that. In emergency medicine, the learning curve is steep. It can be truly overwhelming in terms of the knowledge needed and every patient encounter you have for the first several months. But there will be an attending physician with them throughout the process. You will also be doing 5-7 off-service rotations during the first year. You will go to ICU's and do orthopedics, anesthesia, and obstetrics. On your second and third year, it will progress to increased patient care responsibilities. You will start to lead teams. There will be teaching and mentoring aspect to that. When you get to your third year, you will start to lead the areas you're working in. And when you're done with your training, you need to be able to handle whatever comes through those doors at any point of the day. [32:33] How Students Can Evaluate What Programs They Can Apply To David thinks the program has become so competitive that there's no standardized way of mentoring an applicant as no two applicants are the same. That said, the applicants themselves don't know where they stand on the bigger scale of applicants. Because of the varying degrees of mentoring, students are picking up a lot of interview spots early when they probably don't need to. Then they cancel a lot. So there's a whole bigger issue here. David recommends that students seek someone who has experience in reviewing applications. They can look at your file and compare you to other applicants to give you a clear sense of what's important and where you might fall on that spectrum. This way, you can start thinking about how many applications you should be submitting. Ultimately, David outlines two things to know if this is something for you. First is to get into EM if you really think that EM is right for you. Second, experience at least two different types of EM programs. This could be an affiliate with the college of medicine. Or there could be close ties between the medical school and the ER department. There's also a community program that doesn't have a medical school in the area. There are also hybrid models that exist. At the end of the day, see if the message of the chair is something you would put your faith in. Pay attention when they're speaking. Then try to see if you like the residents and you fit in. [39:30] Bias Against Osteopathic Students David doesn't think there is any negativity that needs to be overcome. He believes allopathic and osteopathic students are viewed in the same way. However, he feels there may be still some programs that will require a USMLE score. Because of this, it could be hard for them to mentor an osteopathic student and tell them they need a USMLE score. He hopes there is some way to measure this going forward where programs are moving away from requiring USMLE scores. [Related episode:  6 Myths of Osteopathic Medical School] [42:45] Final Words of Wisdom Don't be afraid to reach out to people and residency leadership to ask for advice. They want to find people that can do the work that's put before them. Most importantly, just be yourself and enjoy the time in the clinical setting. He assures you will get way more out of this. Links: Meded Media

<h2>Session 107</h2> <p>Emergency medicine residency training requires lots of interpersonal skills. Dr. David Snow has been out of training for 6 years now. Today, he tells us more about the acuity, variety, and steep learning curve in EM.</p> <p>Meanwhile, be sure to check out all our other resources on <a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">Meded Media</a>.</p> <p><strong>Listen to this podcast episode with the player above,</strong> or keep reading for the highlights and takeaway points.</p> <h2>[01:15] Interest in Emergency Medicine</h2> <p>Coming to the end of the third year in medical school, David was choosing between surgery, psychiatry, and emergency medicine. Ultimately, there were things about EM that appealed to him.</p> <p>[Related episode: <a href="https://medicalschoolhq.net/ss2-what-is-emergency-medicine-a-community-em-docs-story/" rel="nofollow" target="_blank"> What is Emergency Medicine?</a>]</p> <h2>[04:22] Traits that Lead to Become a Good EM Physician</h2> <p>When you get to a shift, it can get as busy as any other time during any other shifts in their life. They sometimes work at 5 am and 11 pm and it doesn't matter what comes before that. <strong>They just have to be ready as they walk in the door.</strong> This is not unique to EM at all, but it is unique across all the fields of EM. <strong>As an EM doctor, you have to understand the unpredictable nature of the specialty. </strong></p> <p>Additionally, <strong>interpersonal skills are important</strong> as you could be speaking to patients from all walks of life.</p> <p>Alongside, you'd also be networking with clerks, nurses, medical students, and division chairmen. You have to be able to work with the challenges of that environment and do so with a smile on your face.</p> <p><strong>David has been evaluating residency applications for 7 years now.</strong> A few years ago, they added a new piece to the application for emergency medicine called the Standardized Letter of Evaluation. In any of the rotations you do, you will have one of these letters written for you.</p> <p>This is a movement away from the Letter of Recommendation that students ask from an EM physician. It compares you to applicants from the current cycle and the previous year. The letter also lists a set of attributes that talk about your success within those attributes as well as your work ethic, professionalism, etc.</p> <p>There are also specific pretext parts to the document where people speak very candidly about the applicant. <strong>Emergency physicians are looking for the same things. They somewhat know what to write. </strong></p> <p>[Related episode: <a href="https://medicalschoolhq.net/ss-14-looking-at-emergency-medicine-match-data-and-surveys/" rel="nofollow" target="_blank"> Looking at Emergency Medicine Match Data and Surveys</a>]</p> <h2>[10:50] Pass-Fail System Evaluating Students</h2> <p>David thinks there are so many facets to a pass-fail system. He believes it could be hard from the student's standpoint as a sub-average USMLE Step 1 score can be very detrimental to an applicant.</p> <p>Programs can use filters based on USMLE or COMLEX scores and that one score can be very hard for them to move past to ensure the reviewer doesn't get stuck on that. There's no recommendation an applicant needs to have taken Step 2. <strong>But if the Step 1 score is below the mean, it's encouraged that they take Step 2 so they can work past that.</strong> This being said, it adds a lot of pressure to all of it.</p> <p>[Related episode: <a href="https://medicalschoolhq.net/br-5-what-step-1-score-or-level-1-score-should-i-try-to-get/" rel="nofollow" target="_blank"> What Step 1 Score or Level 1 Score Should I Try to Get?</a>]</p> <h2>[13:40] How to Stand Out in Rotations</h2> <p>David recommends getting in touch with EM faculty and to start interacting with them as early as possible so they can start asking questions. <strong>Most medical schools that have EM departments have some way to get shadow shifts with EM faculty.</strong></p> <p>Nevertheless, he doesn't think there should be pressure for students to get in front of PD during their second or third year. You just have to do what has to be done to figure out that EM is for you. If meeting with a program is the way to do that then fine. <strong>But don't feel like you need to do that in order to bolster your application.</strong></p> <p>Ultimately, just enjoy your rotations during third year as your learnings are all going to be very useful for your future training.</p> <p><strong>Donald underlines understanding the key attributes of an EM physician.</strong> They are hardworking. They don't complain about the work before them. They try to enjoy as much as they can. It's important to have that positive outlook and the desire to come in and take care of patients.</p> <p><strong>Be able to come in wiith those attributes without trying to be held back by your nerves.</strong> Understand you're still a student and not a resident yet so your level of knowledge is obviously below the residents.</p> <p><strong>Donald notices how many students come in during rotations where they feel this need to prove they know what they're doing.</strong> He advises students to step back from this. ED is challenging itself. Just find your team and enjoy your time.</p> <p><strong>Anything you can do to help out a resident would be golden.</strong> They would thank you and love you for that.</p> <p><strong>Try not to think about the importance of the rotation and just be yourself.</strong> Be that motivated and driven medical student on the rotation who's there to learn and work. Being so focused on proving and performing would only limit yourself from feeling what it might be like to be that person in the field.</p> <h2>[24:55] The Biggest Misconceptions About Emergency Medicine</h2> <p><strong>Many students are drawn into EM by trauma and acute resuscitation.</strong> Although this is a huge part of what they do, it's far from being a true EM clinical life. It's a big part but it's not a huge part of an EM physician's life.</p> <p><strong>Another misconception about Emergency Medicine is the idea of burnout.</strong> David believes that so much of this is born out of the habits formed during residency. You might do all of that right and end up in a job that makes you very unhappy but then you must change jobs because if you don't, you'll fit in that burnout spectrum.</p> <p>David clarifies it's not a false label as this is what's being shown on the survey. But he doesn't think this should preclude you or stop you from going into a career in emergency medicine.</p> <h2>[29:20] The Training Path</h2> <p>What differentiates EM from other programs is that by Day 1, you may have the sickest patients of your residency training.</p> <p>In most programs, the system is set up to where you might not be going to an operating room or ICU during your first year. They would still build up your knowledge and experience before you're exposed to that.</p> <p><strong>In emergency medicine, the learning curve is steep</strong>. It can be truly overwhelming in terms of the knowledge needed and every patient encounter you have for the first several months. But there will be an attending physician with them throughout the process.</p> <p><strong>You will also be doing 5-7 off-service rotations during the first year.</strong> You will go to ICU's and do orthopedics, anesthesia, and obstetrics.</p> <p>On your second and third year, it will progress to increased patient care responsibilities. You will start to lead teams. <strong>There will be teaching and mentoring aspect to that.</strong></p> <p><strong>When you get to your third year, you will start to lead the areas you're working in.</strong> And when you're done with your training, you need to be able to handle whatever comes through those doors at any point of the day.</p> <h2>[32:33] How Students Can Evaluate What Programs They Can Apply To</h2> <p>David thinks the program has become so competitive that there's no standardized way of mentoring an applicant as no two applicants are the same. That said, the applicants themselves don't know where they stand on the bigger scale of applicants.</p> <p><strong>Because of the varying degrees of mentoring, students are picking up a lot of interview spots early when they probably don't need to.</strong> Then they cancel a lot. So there's a whole bigger issue here.</p> <p><strong>David recommends that students seek someone who has experience in reviewing applications.</strong> They can look at your file and compare you to other applicants to give you a clear sense of what's important and where you might fall on that spectrum. This way, you can start thinking about how many applications you should be submitting.</p> <p>Ultimately, David outlines two things to know if this is something for you. First is to get into EM if you really think that EM is right for you.</p> <p>Second, <strong>experience at least two different types of EM programs.</strong> This could be an affiliate with the college of medicine. Or there could be close ties between the medical school and the ER department. There's also a community program that doesn't have a medical school in the area. There are also hybrid models that exist.</p> <p>At the end of the day, see if the message of the chair is something you would put your faith in. Pay attention when they're speaking. Then try to see if you like the residents and you fit in.</p> <h2>[39:30] Bias Against Osteopathic Students</h2> <p><strong>David doesn't think there is any negativity that needs to be overcome.</strong> He believes allopathic and osteopathic students are viewed in the same way. However, he feels there may be still some programs that will require a USMLE score.</p> <p>Because of this, it could be hard for them to mentor an osteopathic student and tell them they need a USMLE score. <strong>He hopes there is some way to measure this going forward where programs are moving away from requiring USMLE scores.</strong></p> <p>[Related episode: <a href="https://medicalschoolhq.net/mshq-026-6-myths-of-osteopathic-medical-school/" rel="nofollow" target="_blank"> 6 Myths of Osteopathic Medical School</a>]</p> <h2>[42:45] Final Words of Wisdom</h2> <p><strong>Don't be afraid to reach out to people and residency leadership to ask for advice.</strong> They want to find people that can do the work that's put before them. Most importantly, just be yourself and enjoy the time in the clinical setting. He assures you will get way more out of this.</p> <h2>Links:</h2> <p><a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">Meded Media</a></p>

107: Advice From an Emergency Medicine Residency Director 

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&amp;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&amp;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&amp;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

<h2>Session 69</h2> <p>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.</p> <p>By the way, <em>The Premed Playbook: Guide to the MCAT</em> 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 <a href="http://www.mcatbook.com/" rel="nofollow" target="_blank">MCATbook.com</a> to sign up and be notified. Also check out our other books <a href="https://medicalschoolhq.net/the-premed-playbook-guide-to-the-medical-school-interview/" rel="nofollow" target="_blank"> <em>The Premed Playbook: Guide to the Medical School Interview</em></a> and another one coming up in August is <a href="http://www.personalstatementbook.com" rel="nofollow" target="_blank"><em>The Premed Playbook: Guide to the Medical School Personal Statement</em></a>.</p> <p>If you have any suggestions for physicians whom you think would make great guests (only attending physicians), shoot me an email at <a href="mailto:ryan@medicalschoolhq.net">ryan@medicalschoolhq.net</a>.</p> <h3>[02:00] An interest in Orthopedics</h3> <p>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.</p> <p>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.</p> <p><em>"I could not believe how excited I was and just the adrenalin that was pumping when trauma came into the trauma bay."</em></p> <p>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.</p> <h3>[06:15] Pushback as a Female Surgeon</h3> <p>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&amp;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.</p> <p>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.</p> <p>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.</p> <p><em>"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."</em></p> <p>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.</p> <h3>[09:00] Patient Types and Her Choice to Do General Orthopedics vs. a Subspecialty</h3> <p>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.</p> <p>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.</p> <p><em>"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."</em></p> <p>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.</p> <h3>[11:35] Private Practice</h3> <p>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.</p> <p><em>"I just really wanted the flexibility to do what I want, when I want on my own terms."</em></p> <p>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).</p> <h3>[13:40] Diagnosis in Patients Coming to Her</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p><em>"There are patients coming in diagnosed with carpal tunnel syndrome in their hand and really what they have is a trigger finger."</em></p> <p>Pamela recommends to primary doctors to carry with them <em>The Handbook for Fractures</em>. 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.</p> <p>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.</p> <p>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&amp;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.</p> <h3>[17:50] Typical Week, Taking Calls, and Work-Life Balance</h3> <p>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.</p> <p>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.</p> <p><em>"Usually when you're brand new, you want to take that ER call because that's how you get some patients into your office."</em></p> <p>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.</p> <h3>[21:30] The Path to Being an Orthopedic Surgeon</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p><em>"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."</em></p> <h3>[24:30] Bias Against DOs</h3> <p>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.</p> <p><em>"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."</em></p> <p>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.</p> <h3>[26:20] Working with Primary Care and Other Specialties</h3> <p>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.</p> <p>Other specialties they work the closest with are pain management, PM&amp;R, and internal and family medicine.</p> <p>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.</p> <p>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.</p> <h3>[29:20] What She Wished She Knew and Her Advice to the Male Doctors</h3> <p>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.</p> <p>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.</p> <p><em>"Keep an open mind to think about two or three other different specialties."</em></p> <p>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.</p> <h3>[33:20] Things She Likes the Most and Least</h3> <p>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.</p> <p>On the flip side, what she likes the least as with any other surgical field is infection and pus.</p> <p>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.</p> <p>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.</p> <p><em>"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."</em></p> <h2>Links:</h2> <p><a href="https://www.amazon.com/Handbook-Fractures-Kenneth-Egol-MD/dp/1451193629" rel="nofollow" target="_blank"> Handbook of Fractures</a></p> <p><a href="https://medicalschoolhq.net/thepremedyears/" rel="nofollow" target="_blank">The Premed Years Podcast</a></p> <p><a href="mailto:ryan@medicalschoolhq.net">ryan@medicalschoolhq.net</a></p> <p><a href="http://www.mcatbook.com/" rel="nofollow" target="_blank">MCATbook.com</a></p> <p><a href="https://medicalschoolhq.net/the-premed-playbook-guide-to-the-medical-school-interview/" rel="nofollow" target="_blank"> <em>The Premed Playbook: Guide to the Medical School Interview</em></a></p> <p><a href="http://www.personalstatementbook.com" rel="nofollow" target="_blank"><em>The Premed Playbook: Guide to the Medical School Personal Statement</em></a></p>

69: Private Practice General Orthopedics and More

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 &amp; 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 &amp; 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

<h1>Session 26</h1> <p>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.</p> <p>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.</p> <h3>[02:10] Keep an Open Mind</h3> <p>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.</p> <h3>[03:38] Academic/Community, Urban/Rural Settings</h3> <p>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.</p> <p>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.</p> <p>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 <a href="https://medicalschoolhq.net/ss-16-a-private-practice-nephrologist-who-also-is-in-academics/" rel="nofollow" target="_blank"> Episode 16</a>. 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.</p> <p>Start thinking about those settings. Start thinking about where you want to go to residency. Have those ideas in mind regardless of the specialty.</p> <h3>[07:00] Introvert or Extrovert</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p>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 <a href="http://medicalschoolhq.net/ss-24-what-is-forensic-pathology-dr-melinek-shares-her-story/" rel="nofollow" target="_blank"> episode 24</a>. 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.</p> <h3>[09:30] Stressful Situations</h3> <p>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.</p> <h3>[10:38] Length of Training and Variety</h3> <p>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.</p> <p>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 <a href="http://medicalschoolhq.net/ss2-what-is-emergency-medicine-a-community-em-docs-story/" rel="nofollow" target="_blank"> episode 02</a> 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.</p> <h3>[12:50] Blood and Guts</h3> <p>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 <a href="http://medicalschoolhq.net/ss-24-what-is-forensic-pathology-dr-melinek-shares-her-story/" rel="nofollow" target="_blank"> Episode 24</a>, 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.</p> <h3>[13:55] I Am Not Good with My Hands!</h3> <p>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.</p> <h3>[14:35] Medicine or Surgery</h3> <p>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.</p> <p>To get started, go to the <a href="https://www.aamc.org/cim/" rel="nofollow" target="_blank">AAMC Careers in Medicine</a> 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.</p> <p>On the other hand, <a href="https://www.facs.org/about-acs" rel="nofollow" target="_blank">F.A.C.S. (Fellow of the American College of Surgeons)</a> 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.</p> <p>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 (<a href="http://medicalschoolhq.net/ss-25-an-academic-urologist-shares-his-thoughts-on-the-field/" rel="nofollow" target="_blank">Episode 25</a>). 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.</p> <p>Do you like procedures? Dermatology is huge with procedures.  I've talked with Dr. Chris Sahler back in <a href="https://medicalschoolhq.net/ss-13-what-is-physiatry-physical-medicine-rehabilitation/" rel="nofollow" target="_blank"> Episode 13</a> about Physical Medicine &amp; 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?</p> <p>There's a great <a href="http://theunderweardrawer.blogspot.com/p/scutmonkey-comics.html" rel="nofollow" target="_blank">ScutMonkey Comics</a> by the blog site The Underwear Drawer that presents <em>The 12 Medical Specialty Stereotypes</em>, 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.</p> <h3>[18:37] Final Words</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p>If you have something else that you want to add to this list to help choose a specialty, shoot me an email at <a href="mailto:ryan@medicalschoolhq.net">ryan@medicalschoolhq.net</a>.</p> <h2>Links:</h2> <p><a href="https://medicalschoolhq.net/ss-16-a-private-practice-nephrologist-who-also-is-in-academics/" rel="nofollow" target="_blank"> Specialty Stories Podcast Session 16: A Private Practice Nephrologist Who Also is in Academics</a></p> <p><a href="http://medicalschoolhq.net/ss-24-what-is-forensic-pathology-dr-melinek-shares-her-story/" rel="nofollow" target="_blank"> Specialty Stories Podcast Session 24: What is Forensic Pathology? Dr. Melinek Shares Her Story</a></p> <p><a href="https://medicalschoolhq.net/ss2-what-is-emergency-medicine-a-community-em-docs-story/" rel="nofollow" target="_blank"> Specialty Stories Podcast Session 2: What is Emergency Medicine? A Community EM Doc's Story</a></p> <p><a href="http://medicalschoolhq.net/ss-25-an-academic-urologist-shares-his-thoughts-on-the-field/" rel="nofollow" target="_blank"> Specialty Stories Podcast Session 25: An Academic Urologist Shares His Thoughts on the Field</a></p> <p><a href="https://medicalschoolhq.net/ss-13-what-is-physiatry-physical-medicine-rehabilitation/" rel="nofollow" target="_blank"> Specialty Stories Podcast Session 13: What is Physiatry? (Physical Medicine &amp; Rehabilitation)</a></p> <p><a href="https://www.aamc.org/cim/" rel="nofollow" target="_blank">AAMC Careers in Medicine</a></p> <p><a href="https://www.facs.org/about-acs" rel="nofollow" target="_blank">Fellow of the American College of Surgeons</a></p> <p><a href="http://mededmedia.com/" rel="nofollow" target="_blank">MedEd Media Network</a></p> <p><a href="http://medicalschoolhq.net/mcat-podcast/" rel="nofollow" target="_blank">The MCAT Podcast</a></p> <p><a href="http://medicalschoolhq.net/subscribe/" rel="nofollow" target="_blank">The Premed Years Podcas</a><a href="http://medicalschoolhq.net/subscribe/" rel="nofollow" target="_blank">t</a></p> <p><a href="http://www.oldpremeds.org/" rel="nofollow" target="_blank">The OldPreMeds Podcast</a></p> <p><a href="http://theunderweardrawer.blogspot.com/p/scutmonkey-comics.html" rel="nofollow" target="_blank">ScutMonkey Comics</a></p> <p><a href="mailto:ryan@medicalschoolhq.net">ryan@medicalschoolhq.net</a></p>

26: How to Think About Choosing a Residency & Specialty

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?

<h2>Session 67</h2> <p>Dr. Elaine Reno is an academic Emergency Medicine physician in Denver. She talks about why she choose academics, her work-life balance and more.</p> <p>First off, check out all our other podcasts on <a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">MedEd Media</a>. If you're a premed student, be sure to take a listen to <a href="https://medicalschoolhq.net/thepremedyears/" rel="nofollow" target="_blank">The Premed Years</a> 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 <a href="mailto:ryan@medicalschoolhq.net">ryan@medicalschoolhq.net</a>.</p> <p>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.</p> <p>Back in <a href="https://medicalschoolhq.net/ss2-what-is-emergency-medicine-a-community-em-docs-story/" rel="nofollow" target="_blank"> Session 2</a>, 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.</p> <h3>[02:10] An Interest in Emergency Medicine</h3> <p>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.</p> <p>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.</p> <p><em>"A lot of my day is much more routine than what most people think."</em></p> <h3>[04:05] Traits that Make a Good Emergency Medicine Doctor</h3> <p>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.</p> <p><em>"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."</em></p> <h3>[06:00] Types of Patients and Typical Week</h3> <p>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.</p> <p>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.</p> <h3>[08:05] Academic vs. Community-Based or Private Practice</h3> <p>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.</p> <p><em>"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."</em></p> <h3>[09:20] Is Emergency Medicine a Good Fit for You?</h3> <p>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.</p> <p><em>"If you really like the flavor of emergency medicine but didn't like the big procedures, you could do something like urgent care."</em></p> <h3>[10:20] Taking Calls and Work-Life Balance</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p><em>"I do feel like it's actually very conducive towards a family life. You have to be creative about how you make it work."</em></p> <p>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.</p> <h3>[14:14] The Residency Path to Become an Academic EM Doctor</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <h3>[16:18] Bias Towards DOs and Special Opportunities</h3> <p>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.</p> <p>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.</p> <p>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.</p> <h3>[20:00] Working with Primary Care and Other Specialties</h3> <p>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.</p> <p><em>"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."</em></p> <p>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.</p> <h3>[23:18] What She Wished She Knew that She Knows Now</h3> <p>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.</p> <p>What she likes the most about being an EM doctor is the variety. And the least thing she likes is the circadian rhythm disruption.</p> <h3>[24:45] Major Changes in the Future of Emergency Medicine</h3> <p>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.</p> <p><em>"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."</em></p> <p>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.</p> <p>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.</p> <p><em>"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."</em></p> <h2>Links:</h2> <p><a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">MedEd Media</a></p> <p><a href="https://medicalschoolhq.net/thepremedyears/" rel="nofollow" target="_blank">The Premed Years</a></p> <p><a href="https://medicalschoolhq.net/ss2-what-is-emergency-medicine-a-community-em-docs-story/" rel="nofollow" target="_blank"> PMY 02: What Is Emergency Medicine?</a></p>

67: What Does Academic Emergency Medicine Look Like?

Session 85 Dr. Dave Winchester, a fellow Gator, joins me today to talk about why he chose academic Cardiology, how Cardiology is changing, and why he enjoys what he does! David has been out of training now for 8 years. He graduated from the University of Florida where he now works as an academic. Meanwhile, please do check out all of our other podcasts on MedEd Media Network so you get to have as many resources you need, as you journey along this path to one day becoming a physician! [01:15] Interest in Cardiology Dave's interest in cardiology started with medical school onwards. He enjoyed doing it more than other things. But he didn't really commit to it until halfway through his first year of internal medicine residency. He also loved the first rotation he did in Cardiology. And since then he knew it was something he wanted to do. Halfway through his first year of internal medicine residency, he loved his first cardiology clinical rotation. Compared to other similar specialties, they've all got acute inpatient conditions that can be exciting and have got chronic outpatient management. But it was something about acute MI management and reading. Although he had little interest in pulmonary critical care as he found it to be challenging, fulfilling, exciting, he saw the same in cardiology as well. [03:35] Academic vs. Community Dave chose the academic route over the community setting as he enjoys the opportunity to stay highly engaged with teaching. He also wanted to do his own teaching and he thinks the only way to do this substantially is within an academic setting. [04:30] Types of Patients and Typical Day David does both clinic and ICU, as well as imaging and in-patient hospital care. He sees cases like MIs, heart failures, atrial fibrillation, and dysrhythmias. He does preventative care – pretty much everything within cardiology. At their institutions, services are being broken up a week at a time. He'll have one week as the ICU attending and one week as the clinic attending. As an academic, he has some grant support so some weeks, he doesn't have a clinical responsibility and his job is to teach write papers and grants. When in the clinic, he's doing full time at their VA hospital and they have a team approach where he sees patients in clinic but he sees almost every patient with either a resident, fellow, nurse practitioner, or a physician assistant. A full day of clinic for him would be 8-10 new patients in a half day where the patient has initially been seen by someone else. Then he comes in and helps with the assessment and plan. When he's at the ICU, Dave takes care of all the in-patient consults for the day as well as rounds composed of which the unit has 16 beds with 4 of them, typically cardiac patients. In academics, Dave says there is not so much opportunity for the general cardiology to work with their hands. There are subspecialty cardiologists that do most of the procedural stuff. There are still some though that do invasive procedures in the community. [07:21] Taking Calls and Work-Life Balance As an academic cardiologist, Dave illustrates a layered call structure. He might be responsible for any number of facilities, with at least a cardiology fellow on call with him, who's going to take the majority of calls up front. When he's in clinic, they'll be responsible for the primary assessment of that patient then they call him to go over what's going on with the patient. He may take the call from home or come in and see the patient himself. He may also see the patient first thing in the moment when he comes in. When on the ICU, he'd be on call 24/7 but he'd only have to come in rarely or occasionally. With 11 cardiologists at the VA that share duty, each of them gets to take about 1 week of call every 11 weeks. As an academic and having some grant fundings supporting his effort, his clinical responsibilities are reduced to match what's not offset by his research grants. His research productivity is up to him. As long as he's generating research findings and getting them published and pursuing additional funding, his clinical demands are relatively easy to meet. That being said, he considers himself to have a good work-life balance. [09:33] Getting Grants and Doing Research The opportunity is always there. Not everybody avails himself of the opportunity and academic medicine has changed a lot over the last couple of decades. There are a lot of people now that are in the academics or academically affiliated but may be doing 100% clinical work. It doesn't matter whether you have a PhD or not. Dave doesn't have one and he says it hasn't affected anything for him. But he's a relatively nontraditional researcher. He doesn't have a lab, he doesn't have mice, or any testing near him. He describes all of his research as being built around health services research or health systems science. He's looking more at the bigger picture of things – outcomes, quality of care, reducing low-value care, and things that don't require a traditional lab. While you can get advanced degrees in those fields, there are very few researchers that he networks with who are MDs that also have PhDs. That said, there are PhDs in those fields, but very few that are both. [12:00] Path to Cardiology Residency First, you go through three years of internal medicine residency and three years of general cardiology training as the basic. There are a couple of variations with some programs where you might do a year or two of research. If you want to work in a genetics lab or a pharmacology lab or something else, there are opportunities to do that. You might spend a year doing that and it could give you a leg up on some of the grants. In terms of competitiveness, Cardiology is pretty more competitive than it is with Internal Medicine. This is based on some medicine residents that he gets to work with and mentor every year. Some of them don't get in so it can be pretty challenging. To be a competitive candidate, sometimes it starts with what program you're coming out of. Are you coming out of a highly respected academic internal medicine program, or are you coming out of one that doesn't have a track record of producing people with an interest in academics? This is actually one of the things that some programs look at in their decision process. Some programs still look pretty highly on USMLE scores, and so that can continue to be an important factor along down the road. Moreover, there are opportunities for medicine residents to do research and to do other sorts of extracurricular things. That said, being involved in that as early on as you can I think is certainly not going to hurt and it can be quite helpful. [14:24] Subspecialty Opportunities Within the field of cardiology, there are three ACGME recognized fellowships that are officially sanctioned by the governing body for residencies and fellowships, namely: Invasive Cardiology (1 year), Electrophysiology (two years), and Heart Failure Transplant (1 year). There are non-ACGME approved fellowships in things like structural heart disease. So if you wanted to be an invasive cardiologist and then also do percutaneous valve procedures, that's a fellowship that you could consider doing, and imaging is another one. Dave is the program director for an imaging fellowship at UF, and those are variable depending on what the needs of the program are. Some of them are based on cardiac MR, or cardiac CT, cardiac echo, etc. [15:30] Bias Against DO One of his classmates in his fellowship class was a DO and he is an incredible guy. He had no concerns or reservations, and there was no distinction made between MD and DO. So there's not a whole lot of difference, but there are some institutions in some regions of the country that don't have similar views. [16:21] Working with Primary Care and Other Specialties Dave wishes that referring providers felt a little bit more comfortable with symptoms that occur in the chest. There are a lot of people out there who, when a patient describes any kind of chest pain, will immediately and reflexively send them straight to the emergency department. They’d call up frantic for a stat consult. Sometimes that's necessary, but frequently, it's not. It not only puts strain on the systems of care, but it can harm the patient too if somebody tells them, "Go to the ER or you might die," when in reality they've got either non-cardiac symptoms or it's a patient with known coronary disease and they have stable angina that's completely manageable with medical therapy. Moreover, Dave has also noticed, in general, a lot of use of the pronoun 'they' on rounds and in clinical care. 'Cardiology wants this or they ordered such-and-such test.' People have names and so they have to be specifically mentioned – people that are speaking to specialists, and specialists, when they're getting back to referring teams, could do a better job of. Additionally, there are primary care docs who simply don’t want to get their hands on “heart stuff” and Dave appreciates their honesty. But he has also encountered other people who are terrified that something bad is going to happen to the patient. Dave totally understands this but if the patient had a stress test three months ago and they're on all the appropriate therapies that they need to be on, then they don't need to go down that road again. They don't need to send them straight to the cath lab or repeat a nuclear stress test. Other specialties they work the closest with include cardiothoracic surgery, anesthesiology, hospital medicine, and the emergency department. The emergency room is where a lot of chest pain shows up and begins their evaluation. And there are better and not so great ways of conducting those initial evaluations. Dave works with their emergency medicine specialists to try and develop some streamlined models of care for chest pain [21:16] Special Opportunities Outside of Clinical Medicine Dave has done routinely done lectures for their fellows, as well as for our internal medicine residents. In the past, he has done career development curricula for medicine residents and helped them trying to figure out which specialties they want to go into. You could also do some teaching. Dave is currently teaching medical students on the first, second, and third year at a different number of settings. He also did some undergraduate teaching. [22:38] Decision to Stay in General Cardiology One of the things that drew Dave to Cardiology early on was that there was the opportunity to continue to decide further if he wanted to pursue a subspecialty or not. Dave got some advice during medical school that he thinks is a useful thought exercise. He actually was on his OB/GYN rotation, and one of the faculty asked him, "What do you want to be doing at 3:00 AM?" And the concept was that as a doctor, you're going to be on call, there's at some point in the middle of the night when somebody is going to call your phone. It's going to be 3:00 AM, and what do you want them to be calling you about? What are you motivated or excited to go and do at that time? And Dave has reflected back on that at a number of different stages in his career, and that was one of the things that he thought about when trying to decide whether he wanted to do a subspecialty fellowship or not. In particular, the one sub-specialty he was the most interested in was invasive cardiology. He enjoyed being in the cath lab, but not the difficult cases. And that was his thought process for not pursuing it as a career. He admits not having the temperament for that, and so he was best served and the patients were best served by doing something he was more passionate about, which was imaging and general cardiology. [25:08] Most and Least Liked in Cardiology What he likes most about cardiology is something about the disease processes. He enjoys providing explanations to patients about what's going on with them. And what he finds to be one of the most rewarding experiences in cardiology is taking that time with patients and really helping them to understand their disease process. On the flip side, what he likes the least is how some doctors can be uncomfortable with taking some cases. However, he’s willing to help since it’s for the best interest of the patient anyway. That’s his job as a specialist and so he needs to make the best of it. [27:14] Major Change in the Field Some exciting changes in the future include structural procedures where they’re now alter structural elements in the heart, which is just amazing. So that's continuing to be advanced and refined. In imaging, there's three-dimensional imaging coming online, particularly with echocardiography, as well as new advances in CT technology that may be able to let us make functional assessments of stenoses, whereas CT normally just gives us pictures. There's PET imaging and neurotracers coming online for positron emission tomography that has the potential to further improve diagnostic accuracy prognosis for patients. Moreover, Dave believes that prevention is something he sees more and more interest in within the cardiology community. [29:11] Final Words of Wisdom If he had to do it all over again, Dave certainly would. He’s happy coming to work every day, and he points out that this is really what you want in any kind of a career. Finally, he advises premeds and medical students to go out there and experience as many things as you can. Get a broad exposure to a variety of different specialties. For some people, they just know it’s the path they want to take. But for other people, they just don’t. And they get to the end of their medical training, and they're just not quite sure what to do, and even if that's the case, there are plenty of good jobs to go out there and get started doing. All this being said, continue looking for that thing that's really going to be fulfilling for a long and fruitful career. Links: MedEd Media Network

<h2>Session 85</h2> <p>Dr. Dave Winchester, a fellow Gator, joins me today to talk about why he chose academic Cardiology, how Cardiology is changing, and why he enjoys what he does! David has been out of training now for 8 years. He graduated from the University of Florida where he now works as an academic.</p> <p>Meanwhile, please do check out all of our other podcasts on <a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">MedEd Media Network</a> so you get to have as many resources you need, as you journey along this path to one day becoming a physician!</p> <h2>[01:15] Interest in Cardiology</h2> <p>Dave's interest in cardiology started with medical school onwards. He enjoyed doing it more than other things. But he didn't really commit to it until halfway through his first year of internal medicine residency. He also loved the first rotation he did in Cardiology. And since then he knew it was something he wanted to do.</p> <p>Halfway through his first year of internal medicine residency, he loved his first cardiology clinical rotation. Compared to other similar specialties, they've all got acute inpatient conditions that can be exciting and have got chronic outpatient management. But it was something about acute MI management and reading. Although he had little interest in pulmonary critical care as he found it to be challenging, fulfilling, exciting, he saw the same in cardiology as well.</p> <h2>[03:35] Academic vs. Community</h2> <p>Dave chose the academic route over the community setting as he enjoys the opportunity to stay highly engaged with teaching. He also wanted to do his own teaching and he thinks the only way to do this substantially is within an academic setting.</p> <h2>[04:30] Types of Patients and Typical Day</h2> <p>David does both clinic and ICU, as well as imaging and in-patient hospital care. He sees cases like MIs, heart failures, atrial fibrillation, and dysrhythmias. He does preventative care – pretty much everything within cardiology.</p> <p>At their institutions, services are being broken up a week at a time. He'll have one week as the ICU attending and one week as the clinic attending. As an academic, he has some grant support so some weeks, he doesn't have a clinical responsibility and his job is to teach write papers and grants.</p> <p>When in the clinic, he's doing full time at their VA hospital and they have a team approach where he sees patients in clinic but he sees almost every patient with either a resident, fellow, nurse practitioner, or a physician assistant. A full day of clinic for him would be 8-10 new patients in a half day where the patient has initially been seen by someone else. Then he comes in and helps with the assessment and plan.</p> <p>When he's at the ICU, Dave takes care of all the in-patient consults for the day as well as rounds composed of which the unit has 16 beds with 4 of them, typically cardiac patients.</p> <p>In academics, Dave says there is not so much opportunity for the general cardiology to work with their hands. There are subspecialty cardiologists that do most of the procedural stuff. There are still some though that do invasive procedures in the community.</p> <h2>[07:21] Taking Calls and Work-Life Balance</h2> <p>As an academic cardiologist, Dave illustrates a layered call structure. He might be responsible for any number of facilities, with at least a cardiology fellow on call with him, who's going to take the majority of calls up front. When he's in clinic, they'll be responsible for the primary assessment of that patient then they call him to go over what's going on with the patient. He may take the call from home or come in and see the patient himself. He may also see the patient first thing in the moment when he comes in. When on the ICU, he'd be on call 24/7 but he'd only have to come in rarely or occasionally.</p> <p>With 11 cardiologists at the VA that share duty, each of them gets to take about 1 week of call every 11 weeks.</p> <p>As an academic and having some grant fundings supporting his effort, his clinical responsibilities are reduced to match what's not offset by his research grants. His research productivity is up to him. As long as he's generating research findings and getting them published and pursuing additional funding, his clinical demands are relatively easy to meet. That being said, he considers himself to have a good work-life balance.</p> <h2>[09:33] Getting Grants and Doing Research</h2> <p>The opportunity is always there. Not everybody avails himself of the opportunity and academic medicine has changed a lot over the last couple of decades. There are a lot of people now that are in the academics or academically affiliated but may be doing 100% clinical work.</p> <p>It doesn't matter whether you have a PhD or not. Dave doesn't have one and he says it hasn't affected anything for him. But he's a relatively nontraditional researcher. He doesn't have a lab, he doesn't have mice, or any testing near him. He describes all of his research as being built around health services research or health systems science.</p> <p>He's looking more at the bigger picture of things – outcomes, quality of care, reducing low-value care, and things that don't require a traditional lab. While you can get advanced degrees in those fields, there are very few researchers that he networks with who are MDs that also have PhDs. That said, there are PhDs in those fields, but very few that are both.</p> <h2>[12:00] Path to Cardiology Residency</h2> <p>First, you go through three years of internal medicine residency and three years of general cardiology training as the basic. There are a couple of variations with some programs where you might do a year or two of research. If you want to work in a genetics lab or a pharmacology lab or something else, there are opportunities to do that. You might spend a year doing that and it could give you a leg up on some of the grants.</p> <p>In terms of competitiveness, Cardiology is pretty more competitive than it is with Internal Medicine. This is based on some medicine residents that he gets to work with and mentor every year. Some of them don't get in so it can be pretty challenging.</p> <p>To be a competitive candidate, sometimes it starts with what program you're coming out of. Are you coming out of a highly respected academic internal medicine program, or are you coming out of one that doesn't have a track record of producing people with an interest in academics? This is actually one of the things that some programs look at in their decision process. Some programs still look pretty highly on USMLE scores, and so that can continue to be an important factor along down the road.</p> <p>Moreover, there are opportunities for medicine residents to do research and to do other sorts of extracurricular things. That said, being involved in that as early on as you can I think is certainly not going to hurt and it can be quite helpful.</p> <h2>[14:24] Subspecialty Opportunities</h2> <p>Within the field of cardiology, there are three ACGME recognized fellowships that are officially sanctioned by the governing body for residencies and fellowships, namely: Invasive Cardiology (1 year), Electrophysiology (two years), and Heart Failure Transplant (1 year).</p> <p>There are non-ACGME approved fellowships in things like structural heart disease. So if you wanted to be an invasive cardiologist and then also do percutaneous valve procedures, that's a fellowship that you could consider doing, and imaging is another one. Dave is the program director for an imaging fellowship at UF, and those are variable depending on what the needs of the program are. Some of them are based on cardiac MR, or cardiac CT, cardiac echo, etc.</p> <h2>[15:30] Bias Against DO</h2> <p>One of his classmates in his fellowship class was a DO and he is an incredible guy. He had no concerns or reservations, and there was no distinction made between MD and DO. So there's not a whole lot of difference, but there are some institutions in some regions of the country that don't have similar views.</p> <h2>[16:21] Working with Primary Care and Other Specialties</h2> <p>Dave wishes that referring providers felt a little bit more comfortable with symptoms that occur in the chest. There are a lot of people out there who, when a patient describes any kind of chest pain, will immediately and reflexively send them straight to the emergency department. They’d call up frantic for a stat consult.</p> <p>Sometimes that's necessary, but frequently, it's not. It not only puts strain on the systems of care, but it can harm the patient too if somebody tells them, "Go to the ER or you might die," when in reality they've got either non-cardiac symptoms or it's a patient with known coronary disease and they have stable angina that's completely manageable with medical therapy.</p> <p>Moreover, Dave has also noticed, in general, a lot of use of the pronoun 'they' on rounds and in clinical care. 'Cardiology wants this or they ordered such-and-such test.' People have names and so they have to be specifically mentioned – people that are speaking to specialists, and specialists, when they're getting back to referring teams, could do a better job of.</p> <p>Additionally, there are primary care docs who simply don’t want to get their hands on “heart stuff” and Dave appreciates their honesty. But he has also encountered other people who are terrified that something bad is going to happen to the patient. Dave totally understands this but if the patient had a stress test three months ago and they're on all the appropriate therapies that they need to be on, then they don't need to go down that road again. They don't need to send them straight to the cath lab or repeat a nuclear stress test.</p> <p>Other specialties they work the closest with include cardiothoracic surgery, anesthesiology, hospital medicine, and the emergency department. The emergency room is where a lot of chest pain shows up and begins their evaluation. And there are better and not so great ways of conducting those initial evaluations. Dave works with their emergency medicine specialists to try and develop some streamlined models of care for chest pain</p> <h2>[21:16] Special Opportunities Outside of Clinical Medicine</h2> <p>Dave has done routinely done lectures for their fellows, as well as for our internal medicine residents. In the past, he has done career development curricula for medicine residents and helped them trying to figure out which specialties they want to go into.</p> <p>You could also do some teaching. Dave is currently teaching medical students on the first, second, and third year at a different number of settings. He also did some undergraduate teaching.</p> <h2>[22:38] Decision to Stay in General Cardiology</h2> <p>One of the things that drew Dave to Cardiology early on was that there was the opportunity to continue to decide further if he wanted to pursue a subspecialty or not.</p> <p>Dave got some advice during medical school that he thinks is a useful thought exercise. He actually was on his OB/GYN rotation, and one of the faculty asked him, "What do you want to be doing at 3:00 AM?" And the concept was that as a doctor, you're going to be on call, there's at some point in the middle of the night when somebody is going to call your phone. It's going to be 3:00 AM, and what do you want them to be calling you about? What are you motivated or excited to go and do at that time?</p> <p>And Dave has reflected back on that at a number of different stages in his career, and that was one of the things that he thought about when trying to decide whether he wanted to do a subspecialty fellowship or not.</p> <p>In particular, the one sub-specialty he was the most interested in was invasive cardiology. He enjoyed being in the cath lab, but not the difficult cases. And that was his thought process for not pursuing it as a career.</p> <p>He admits not having the temperament for that, and so he was best served and the patients were best served by doing something he was more passionate about, which was imaging and general cardiology.</p> <h2>[25:08] Most and Least Liked in Cardiology</h2> <p>What he likes most about cardiology is something about the disease processes. He enjoys providing explanations to patients about what's going on with them. And what he finds to be one of the most rewarding experiences in cardiology is taking that time with patients and really helping them to understand their disease process.</p> <p>On the flip side, what he likes the least is how some doctors can be uncomfortable with taking some cases. However, he’s willing to help since it’s for the best interest of the patient anyway. That’s his job as a specialist and so he needs to make the best of it.</p> <h2>[27:14] Major Change in the Field</h2> <p>Some exciting changes in the future include structural procedures where they’re now alter structural elements in the heart, which is just amazing. So that's continuing to be advanced and refined.</p> <p>In imaging, there's three-dimensional imaging coming online, particularly with echocardiography, as well as new advances in CT technology that may be able to let us make functional assessments of stenoses, whereas CT normally just gives us pictures.</p> <p>There's PET imaging and neurotracers coming online for positron emission tomography that has the potential to further improve diagnostic accuracy prognosis for patients. Moreover, Dave believes that prevention is something he sees more and more interest in within the cardiology community.</p> <h2>[29:11] Final Words of Wisdom</h2> <p>If he had to do it all over again, Dave certainly would. He’s happy coming to work every day, and he points out that this is really what you want in any kind of a career.</p> <p>Finally, he advises premeds and medical students to go out there and experience as many things as you can. Get a broad exposure to a variety of different specialties.</p> <p>For some people, they just know it’s the path they want to take. But for other people, they just don’t. And they get to the end of their medical training, and they're just not quite sure what to do, and even if that's the case, there are plenty of good jobs to go out there and get started doing. All this being said, continue looking for that thing that's really going to be fulfilling for a long and fruitful career.</p> <h2>Links:</h2> <p><a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">MedEd Media Network</a></p>

85: An Academic Cardiologist Shares His Specialty

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

<h2>Session 54</h2> <p></p> <p>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.</p> <p>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.</p> <p>Also, check out all our podcasts on <a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">MedEd Media</a>. For suggestions of physicians you want interviewed here on the Specialty Stories, shoot Ryan an email at <a href="mailto:ryan@medicalschoolhq.net">ryan@medicalschoolhq.net</a>.</p> <h3>[01:07] An Interest in OB/GYN</h3> <p>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.</p> <p><em>"It's a good mix of both the patient side, the continuity of care, and the surgical aspect of care."</em></p> <p>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.</p> <h3>[03:47] Traits that Lead to Becoming a Good OB/GYN</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p><em>"In order to be a good OB/GYN, you have to be a good clinician and have that clinical acuity."</em></p> <h3>[05:18] Academic vs. Community Setting</h3> <p>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.</p> <p>They do a lot of grand analysis and statistics and a lot of academic activities sprinkled in throughout her week. And she enjoys those.</p> <p>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.</p> <h3>[06:37] Types of Patients, Typical Day, and Taking Calls</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p><em>"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."</em></p> <h3>[09:45] Percentage of Patients in the OR</h3> <p>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.</p> <p>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.</p> <h3>[10:44] Work-Life Balance</h3> <p>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.</p> <p><em>"Work-life balance is what you make of."</em></p> <h3>[11:25] The Training Path to Become an OB/GYN and Competitiveness</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p><em>"People always put their best face forward, or at least, should be putting their best face forward."</em></p> <p>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.</p> <h3>[14:35] Bias Towards DOs and Working with Primary Care and Other Specialties</h3> <p>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.</p> <p>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.</p> <p><em>"There are a lot of misinformed statements floating around out there about contraceptives."</em></p> <h3>[17:02] Special Opportunities Outside Clinical Medicine, What She Wished She Knew, and the Most and Least Liked Things</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <h3>[19:20] Major Changes in the Field of OB/GYN and the Future of Residencies</h3> <p>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.</p> <p><em>"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."</em></p> <p>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.</p> <p>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.</p> <h2>Links:</h2> <p><a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">MedEd Media</a></p>

54: Academic OB/GYN Discusses Her Journey to the Specialty

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&amp;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&amp;M? M&amp;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...

20: An Academic Neurosurgeon Discusses What His Job is Like

Pediatric Neurosurgery

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]...

44: A Look at Academic Pediatric Neurosurgery

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

<h2>Session 57</h2> <p>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.</p> <p>By the way, check out all our other podcasts on the <a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">MedEd Media Network</a>.</p> <h3>[01:03] His Interest in Critical Care Medicine</h3> <p>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.</p> <p>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.</p> <p><em>"I was hooked. Right away, I just love the excitement of the physiology and meeting a broad swath of knowledge about the various systems."</em></p> <p>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.</p> <h3>[04:55] Types of Patients</h3> <p>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).</p> <p>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.</p> <p>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.</p> <p>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.</p> <h3>[09:15] Typical Week</h3> <p>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.</p> <p>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.</p> <h3>[10:35] Is It Procedure-Heavy?</h3> <p>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.</p> <p><em>If you really don't like procedures, then it's probably not the specialty for you."</em></p> <h3>[12:00] Work-Life Balance</h3> <p>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.</p> <p>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.</p> <p><em>"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."</em></p> <h3>[13:45] The Training Path</h3> <p>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.</p> <p>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.</p> <p><em>"There is no particular disadvantage to hiring a critical care fellowship only."</em></p> <p>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.</p> <h3>[17:24] Negative Bias Towards DO Physicians and Special Opportunities</h3> <p>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.</p> <p>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.</p> <p><em>"As with everything, subspecialization continues to involve. There aren't formal training programs but emphasis or subspecialization has developed in recent years."</em></p> <h3>[20:10] Working with Primary Care and Other Specialties</h3> <p>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.</p> <p>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.</p> <p><em>"In the medical world, having good relationship with your critical care trained surgeons makes a big difference."</em></p> <p>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.</p> <p>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.</p> <h3>[23:40] What He Wished He Knew that He Knows Now</h3> <p>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.</p> <p><em>"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."</em></p> <p>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.</p> <p>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.</p> <h3>[25:20] What He Likes Most and the Least and Major Changes in the Future</h3> <p>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.</p> <p><em>"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."</em></p> <p>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.</p> <p>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.</p> <p>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.</p> <h3>[29:30] Personal Takeaways</h3> <p>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.</p> <p>Go back and listen to <a href="https://medicalschoolhq.net/ss2-what-is-emergency-medicine-a-community-em-docs-story/" rel="nofollow" target="_blank"> Episode 2 of Specialty Stories</a> 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.</p> <p>If you have a physician you want to be interviewed here on the podcast, shoot me an email at <a href="mailto:ryan@medicalschoolhq.net">ryan@medicalschoolhq.net</a>.</p> <h2>Links:</h2> <p><a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">MedEd Media Network</a></p> <p><a href="mailto:ryan@medicalschoolhq.net">ryan@medicalschoolhq.net</a></p> <p><a href="https://medicalschoolhq.net/ss2-what-is-emergency-medicine-a-community-em-docs-story/" rel="nofollow" target="_blank"> Episode 2 of Specialty Stories</a></p>

57: What Does a Pulm Critical Care Medicine Doc Do?

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

<h1>Session 45</h1> <p>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.</p> <p>Check out <a href="https://medicalschoolhq.net/pmy-256-a-look-at-carle-illinois-college-of-medicine-with-dean-li/" rel="nofollow" target="_blank"> The Premed Years Podcast Episode 256</a> where I interviewed the dean of the brand new medical school, Carle Illinois College of Medicine. Also check out all our other podcasts on <a href="https://medicalschoolhq.net/meded-media/" rel="nofollow" target="_blank">MedEd Media</a>.</p> <h3>[01:35] Why He Chose Cardiac Anesthesiology</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <h3>[05:15] Traits that Lead to Becoming a Good Cardiac Anesthesiologist</h3> <p><em>"Being a team leader, regardless of the setting is the most important trait."</em></p> <p>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.</p> <h3>[07:10] Why Anesthesiology Subspecialty is Important</h3> <p>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.</p> <p><em>"You need a certain group of people that get advanced training in that particular field to provide the best care for the patient."</em></p> <p>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.</p> <h3>[09:10] Types of Cases</h3> <p>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.</p> <p>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.</p> <p>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.</p> <h3>[11:06] Community versus Academic and Taking Calls</h3> <p>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.</p> <p>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.</p> <p><em>"You get to teach residents which also would keep you on your toes and keep your skills up to speed."</em></p> <p>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.</p> <h3>[13:20] Work-Life Balance</h3> <p>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.</p> <p><em>"One of the benefits of being in anesthesia, your life is a little it more structured."</em></p> <p>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.</p> <h3>[14:25] The Path to Residency and Fellowship</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p><em>"There's understanding the intensity that goes with it and seeing if this the right field for you."</em></p> <h3>[17:10] Bias Against Osteopaths and Working with Primary Care and Other Specialties</h3> <p>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.</p> <p>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.</p> <h3>[19:33] Special Opportunities Outside of Clinical Medicine</h3> <p>Maninder doesn't see a lot of opportunities outside of clinical medicine but there's teaching on one hand.</p> <p>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.</p> <p><em>"Cardiac anesthesia and cardiac surgery is booming because of all that's going on in the industry."</em></p> <h3>[21:02] What He Wished He Knew that He Knows Now</h3> <p>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.</p> <p>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</p> <p><em>"It's okay to ask for help from the standpoint of just having a fresh set of eyes."</em></p> <h3>[22:52] What He Likes the Most and Least</h3> <p>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.</p> <p>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.</p> <h3>[24:05] Major Changes in the Future and Collaboration Between Specialties</h3> <p>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.</p> <p>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.</p> <p>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.</p> <p>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.</p> <p><em>"Even though we are not actually deploying the valve, we are actually telling them exactly where to deploy the valve."</em></p> <p>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.</p> <h3>[28:50] Final Words of Wisdom</h3> <p>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.</p> <h3>[30:06] Last Thoughts</h3> <p>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.</p> <h2>Links:</h2> <p><a href="https://medicalschoolhq.net/pmy-256-a-look-at-carle-illinois-college-of-medicine-with-dean-li/" rel="nofollow" target="_blank"> The Premed Years Podcast 256: A Look at Carle Illinois College of Medicine with Dean Li</a></p>

45: What is a Cardiac Anesthesiologist?

Session 03 In this episode, Ryan talks with a neurologist, Dr. Allison Gray, as they discuss all things about neurology. Notice that Ryan follows a standard regimen of questions in his episodes so you can compare each of the answers to hopefully help enlighten you in choosing your residency. Allison is working as a neurologist at a large medical group in a community setting in Colorado. Here are the highlights of the conversation with Allison: When Allison knew she wanted to pursue Neurology:  Getting fascinated at neuroscience Her father being a neuropsychologist  Why community versus academic: Being drawn more to clinical practice Types of patients:  Of all ages - teenagers and up (Pediatric Neurology is a separate specialty with a separate board of accreditation) Fairly healthy and dealing with chronic conditions like migraine People very debilitated by acute neurologic problem like stroke or chronic problem like ALS  A typical day in the life of Allison: 8am - 5pm Sees 10 patients a day (This is a lot for neurologists since they have long examinations and they take long histories.) Breakdown of her 10 patients-  6 new consults 1 procedure (ex. EMG) 4 follow up visits  On work-life balance:  Where she works has emphasis on creating work-life balance Flexibility in setting her schedule Work-life balance is a challenge for her being a mom Getting amazing support from staff who let her do physician work because they take as much administrative stuff off her plate as possible  Traits that lead to being a good neurologist:  Being cerebral (focusing not just on what the problem is and the best treatment, but where the problem is) Interest in solving a puzzle Being able to dive into action quickly (ex. stroke patient)  What makes a competitive applicant for neurology:  Getting better grades Getting good board scores Depends on geography (Neurology as a whole is not as competitive as orthopedic surgery or radiology) Good shadowing experience Find a way to participate in a neurology elective  Is matching competitive for Neurology? Middle range - It depends on geography and whether you're going to a very competitive program at a big name institution. Do you see any bias between MDs and DOs for Neurology? None that she's aware of. What is residency like for Neurology?  Her residency was volume-heavy and she was seeing a great deal of patients Great in-patient heavy doing a lot of in-patient rotations in stroke and acute neurology and Neuro-ICU Out-patient time depends on the academic institution Residency is 4 years (1 year of Internal Medicine and 3 years of Neurology residency)  What she wished she knew going into Neurology? Appreciating that Neurology was sad sometimes considering there is still no good treatments for Alzheimer's, Dementia, ALS, etc. So you see people facing very devastating illnesses that are chronic, debilitating, and even deathly. Also, Neurology is acutely devastating sometimes. It really takes guts to see someone suffering. However, Neurology has a great promise and they're seeing wonderful new therapies coming out. Compared to 20 years ago, now there's a huge difference in the way they treat things like MS and genetic disorders. What do you wish primary care providers knew about Neurology? Neurologists are here to help and they're happy to help primary care physicians and they can always ask for help. Specialties she works the closest with:  Neurosurgeons Orthopedic surgery Spine clinic Physical therapy  Special opportunities outside of clinical medicine for Neurology: Working with industries to discover new treatments What Allison likes most about being a Neurologist:  A wide variety of problems in a day She enjoys helping people and their families in difficult situations.  What she likes least about being a Neurologist: The difficulty in not being able to offer someone something to fix a problem Would she have chosen Neurology if she had to do it all over again? Yes, Allison thinks the brain is the most fascinating thing in the human body because it defines who we are as people and human beings. Sub-specialty opportunities for a Neurologist:  Epileptologists Neuromuscular specialists Behavioral neurologists Headache specialists Movement disorder specialists Sports neurology Neuro-infectious disease specialists  The future of Neurology:  Expanding the knowledge of the nervous system and its treatments Huge number of new therapies coming out  Some pieces of advice for those thinking about entering Neurology:  Explore both sides of Neurology - inpatient and outpatient. Do an elective and go to another institution to see what neurology is like there. Get to see as much as you can because there is a wide variety in neurology and you don't want to miss out on what you think it encapsulates just by seeing a piece of it.  Links and Other Resources: ryan@medicalschoolhq.net

<h1>Session 03</h1> <p>In this episode, Ryan talks with a neurologist, Dr. Allison Gray, as they discuss all things about neurology. Notice that Ryan follows a standard regimen of questions in his episodes so you can compare each of the answers to hopefully help enlighten you in choosing your residency.</p> <p>Allison is working as a neurologist at a large medical group in a community setting in Colorado.</p> <h2>Here are the highlights of the conversation with Allison:</h2> <h3>When Allison knew she wanted to pursue Neurology:</h3> <ul> <li>Getting fascinated at neuroscience</li> <li>Her father being a neuropsychologist</li> </ul> <h3>Why community versus academic:</h3> <p>Being drawn more to clinical practice</p> <h3>Types of patients:</h3> <ul> <li>Of all ages - teenagers and up (Pediatric Neurology is a separate specialty with a separate board of accreditation)</li> <li>Fairly healthy and dealing with chronic conditions like migraine</li> <li>People very debilitated by acute neurologic problem like stroke or chronic problem like ALS</li> </ul> <h3>A typical day in the life of Allison:</h3> <p>8am - 5pm</p> <p>Sees 10 patients a day (This is a lot for neurologists since they have long examinations and they take long histories.)</p> <p>Breakdown of her 10 patients-</p> <ul> <li>6 new consults</li> <li>1 procedure (ex. EMG)</li> <li>4 follow up visits</li> </ul> <h3>On work-life balance:</h3> <ul> <li>Where she works has emphasis on creating work-life balance</li> <li>Flexibility in setting her schedule</li> <li>Work-life balance is a challenge for her being a mom</li> <li>Getting amazing support from staff who let her do physician work because they take as much administrative stuff off her plate as possible</li> </ul> <h3>Traits that lead to being a good neurologist:</h3> <ul> <li>Being cerebral (focusing not just on what the problem is and the best treatment, but where the problem is)</li> <li>Interest in solving a puzzle</li> <li>Being able to dive into action quickly (ex. stroke patient)</li> </ul> <h3>What makes a competitive applicant for neurology:</h3> <ul> <li>Getting better grades</li> <li>Getting good board scores</li> <li>Depends on geography (Neurology as a whole is not as competitive as orthopedic surgery or radiology)</li> <li>Good shadowing experience</li> <li>Find a way to participate in a neurology elective</li> </ul> <h3>Is matching competitive for Neurology?</h3> <p>Middle range - It depends on geography and whether you're going to a very competitive program at a big name institution.</p> <h3>Do you see any bias between MDs and DOs for Neurology?</h3> <p>None that she's aware of.</p> <h3>What is residency like for Neurology?</h3> <ul> <li>Her residency was volume-heavy and she was seeing a great deal of patients</li> <li>Great in-patient heavy doing a lot of in-patient rotations in stroke and acute neurology and Neuro-ICU</li> <li>Out-patient time depends on the academic institution</li> <li>Residency is 4 years (1 year of Internal Medicine and 3 years of Neurology residency)</li> </ul> <h3>What she wished she knew going into Neurology?</h3> <p>Appreciating that Neurology was sad sometimes considering there is still no good treatments for Alzheimer's, Dementia, ALS, etc. So you see people facing very devastating illnesses that are chronic, debilitating, and even deathly. Also, Neurology is acutely devastating sometimes. It really takes guts to see someone suffering.</p> <p>However, Neurology has a great promise and they're seeing wonderful new therapies coming out. Compared to 20 years ago, now there's a huge difference in the way they treat things like MS and genetic disorders.</p> <h3>What do you wish primary care providers knew about Neurology?</h3> <p>Neurologists are here to help and they're happy to help primary care physicians and they can always ask for help.</p> <h3>Specialties she works the closest with:</h3> <ul> <li>Neurosurgeons</li> <li>Orthopedic surgery</li> <li>Spine clinic</li> <li>Physical therapy</li> </ul> <h3>Special opportunities outside of clinical medicine for Neurology:</h3> <p>Working with industries to discover new treatments</p> <h3>What Allison likes most about being a Neurologist:</h3> <ul> <li>A wide variety of problems in a day</li> <li>She enjoys helping people and their families in difficult situations.</li> </ul> <h3>What she likes least about being a Neurologist:</h3> <p>The difficulty in not being able to offer someone something to fix a problem</p> <h3>Would she have chosen Neurology if she had to do it all over again?</h3> <p>Yes, Allison thinks the brain is the most fascinating thing in the human body because it defines who we are as people and human beings.</p> <h3>Sub-specialty opportunities for a Neurologist:</h3> <ul> <li>Epileptologists</li> <li>Neuromuscular specialists</li> <li>Behavioral neurologists</li> <li>Headache specialists</li> <li>Movement disorder specialists</li> <li>Sports neurology</li> <li>Neuro-infectious disease specialists</li> </ul> <h3>The future of Neurology:</h3> <ul> <li>Expanding the knowledge of the nervous system and its treatments</li> <li>Huge number of new therapies coming out</li> </ul> <h3>Some pieces of advice for those thinking about entering Neurology:</h3> <ul> <li>Explore both sides of Neurology - inpatient and outpatient.</li> <li>Do an elective and go to another institution to see what neurology is like there.</li> <li>Get to see as much as you can because there is a wide variety in neurology and you don't want to miss out on what you think it encapsulates just by seeing a piece of it.</li> </ul> <h2>Links and Other Resources:</h2> <p><a href="mailto:ryan@medicalschoolhq.net">ryan@medicalschoolhq.net</a></p>

3: What is Neurology : A General Neurologist's Story

Dr. Jonesco is an academic Sports Medicine physician at Ohio State. Today we discuss what drew him to the specialty, the patient base he sees, and why he loves it!

<p>Dr. Jonesco is an academic Sports Medicine physician at Ohio State. Today we discuss what drew him to the specialty, the patient base he sees, and why he loves it!</p>

95: A Sports Medicine Physician Shares His Journey

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