Podcasts about be competitive

Do you want to find out your biggest money block? In this episode of the Happy Hustle Podcast, I have my man, Ian Stanley, a serial entrepreneur, copywriter, author, and comedian. Ian and I talk about how to change your mindset about money and how to attract more. Ian also shares the 5 core money blocks that are keeping you financially stuck. Ian started his first business at the age of 12 stringing tennis rackets. He has now sold over $100,000,000 worth of products online over the past few years and is considered to be one of the best copywriters in the world. He recently sold an e-commerce company to the fastest-growing start-up in Canada.He is now on a mission to help people learn how to spend their time more effectively to make more money...while having more fun. If you're interested in getting rid of your money blocks, Ian created a money quiz where you can identify your unique money DNA and how to rewire it. Take the Money DNA quiz here: https://www.moneydnaquiz.com/sf/a855dd57 In this episode, we cover:[00:05:48:02] Don't Be Competitive in Business or Money[00:07:39:20] The 5 Core Money Blocks[00:11:13:13] Build and Determine Your Self-Worth[00:14:11:10] Money wants to FLOW[00:33:55:03] Choose a Skill and Master it[00:49:47:00] Happy Hustle Hacks [Health, Money, Entrepreneurship, Spirituality]What does Happy Hustlin mean to you? Ian says having extreme moments of activity and extreme moments of inactivity whether that's you know getting as high as humanly possible and watching impractical jokes and then you know then going training for a water walk you know a sixty-mile water walk I think to me happy hustlin is the space between the extremes.Connect with Ianhttps://www.instagram.com/becomingianstanley/https://www.facebook.com/ianstanleyconversions/https://www.youtube.com/channel/UCNDSraHVLiHKekQJ31BmfmQFind Ian on his website: https://www.persuasionhitman.com/ Connect with Cary!https://www.instagram.com/cary__jack/https://www.facebook.com/SirCaryJackhttps://www.linkedin.com/in/cary-jack-kendzior/https://twitter.com/thehappyhustlehttps://www.youtube.com/channel/UCFDNsD59tLxv2JfEuSsNMOQ/featuredGet a free copy of his new book, The Happy Hustle, 10 Alignments to Avoid Burnout & Achieve Blissful Balance https://www.thehappyhustlebook.com/Sign up for The Journey: 10 Days To Become a Happy Hustler Online Course http://www.thehappyhustle.com/JourneyApply to the Montana Mastermind Epic Camping Adventure https://caryjack.com/montana“It's time to Happy Hustle, a blissfully balanced life you love, full of passion, purpose, and positive impact!”Episode sponsorIf I asked you what is the #1 health problem people from all over the world are facing, would you know what it is?If you guessed sleep, you'd be right! Honestly, the majority of people are lacking energy throughout the day. But lack of energy is a symptom of a bigger problem that is very difficult to gain control over, and that problem is SLEEP.Sleep can affect your mood, hormones, weight gain, and many other factors negatively impacting you.If you're finding yourself staring at your ceiling only to still be awake hours later staring at your phone or if you're waking up in the morning feeling like you didn't get enough sleep, try this simple bedtime routine that works like a charm and helps you sleep like a baby every night.All it takes is a glass of water and two safe and natural https://www.magnesiumbreakthrough.com/hustle capsules 30 minutes before hitting the pillow.These 7 essential forms of magnesium included in this full spectrum serving help you relax, unwind, and turn off your active brain after a long, stressful day so you can rest peacefully and wake up feeling refreshed, vibrant, and alert.And for a limited time, https://www.magnesiumbreakthrough.com/hustle is offering additional bonus gifts for the next 1,000 customers or while supplies last. They are including free bottles of their full line of digestive health products, including their powerful digestive enzymes—MassZymes; their patented probiotic—P3-OM; and their HCL product to alleviate heartburn and acid reflux.That means you are getting FREE products to try that will support your digestive system so you experience less bloating and gas throughout the day. Having an optimized digestive system means less energy spent trying to digest foods and absorbing more nutrients from the foods you eat.Visit https://www.magnesiumbreakthrough.com/hustle and use hustle to activate this exclusive limited-time offer. 

Ian is a Finance graduate of Virginia Tech. He began his career in the Financial Development Program at Genworth Financial. He then joined Parkway Properties, a Class A Office REIT, as a member of the investments division. During his tenure at Parkway, Ian underwrote over a $1B in acquisitions and dispositions. Ian left to start Archimedes Group with Ryan Narus in Charlotte, NC. They have sourced, participated, and closed over $20,000,000 in deals since 2016. Currently, Ian focuses on growing and operating the portfolio. (00:01-02:59) Opening Segment - Introduction of the host into the show - Alpesh introduces the guest of the show, Ian Tudor - Ian shares something interesting about himself (03:00-32:38) Real Estate Investing Journey and How to Be Competitive in Mobile Home Parks - How and why did Ian get into real estate - Transition from single-family to mobile home parks - Ian's first mobile home park deal - How to find mobile home park opportunities - The process of cold calling for MHP opprtunities - How to be competitive in MHP - Ian's acquisition strategy - Types of MHP to target - Ian's strategy for MHP with lots of mobile park owners - Kinds of MHP to stay away from (32:39-32:56) Break (32:57-33:18 Second Segment) - Welcoming listeners and guest back to the show (33:19-38:22) Fire Round - Will Ian change the business strategy after Coronavirus? - Ian's favorite real estate, finance, or other related books - Tool or website Ian recommends - Ian's advice to beginner investors - How does Ian give back? - How can Wealth Matters Podcast listeners reach out to Ian? (38:23-38:47) Closing Segment Reach out to Ian via email info@mobilehomeparkmentors.com and LinkedIn Ian Tudor. Also, feel free to join their Facebook Group Mobile Home Park Mastermind.

Training alone works well for some; others need a helping hand or motivator to keep them going.The benefits of having a training partner will differ from person to person and from each training partner combination created On this podcast we talk about the following Increase fun More enjoyment in trying new classes and exercises Be Competitive (from time to time) Support During the Lows Variety The benefits of having a training partner will vary from person to person and entirely depends on what your training goals are. having a training partner can propel your training success further and help you achieve your goal quicker.

Session 113 Dr. Aaron Leetch one of the program directors at the University of Arizona for a combined residency in pediatrics and emergency medicine. It's actually a very rare residency program with only four programs in the country that offer this. Find out more about this, how it's different and much more! Dr. Leetch is the host of the Arizona EMCast. Also, check out all our other podcasts on Meded Media. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:27] Interest in Combined Pediatrics and Emergency Medicine Aaron has always been certain he was going to be a pediatrician as he loves working with kids. He also liked the compassion of it. It was when he started working at one of the local ERs as a scribe that he felt torn between pediatrics and emergency medicine. He loved the acuity and multitasking aspects of emergency medicine. In fact, he likens it to waiting tables which he used to do. Then he met the program director at the University of Arizona who trained at the combined emergency medicine and pediatrics program in Baltimore and started the program there. He asked Aaron why he wanted to do both and thought it was everything he had wanted to do. After five years of doing the training program, he still loved every minute of it and knew it was the kind of thing he wanted to do for the rest of his life. Aaron has always been amazed at people being torn between two specialties that are very dissimilar. For some people, pediatrics and emergency medicine are not the same. But he explains that there are aspects of both sides that he really liked. Aaron later realized that his pediatric training would be applicable when he sees children in the emergency department. To help them navigate that system in the ED is incredibly helpful to the patient.  [Related episode: What Does the Pediatric Residency Match Data Look Like?] [06:40] Traits that Lead to Being a Good Combined EM and Pediatrics Physicians You have to be patient considering that it's a five-year training. Be sure that you're willing to do five years since you can just do emergency medicine and still trained to see children. The first thing he looks for in applicants is why they want to do both programs. He also wants to know people have considered what they want to do after they're done with training. There are lots of EDs that can't afford to hire somebody who's only certified to see children and they need to see both. [Related episode: Advice From an Emergency Medicine Residency Director] [08:38] Getting Exposure for the Program Considering that there are only currently four programs doing this kind of training in the country, they're hoping to gain visibility through doing medical student podcasts. Plus, they also get the opportunity to talk to people about this. The most common for pediatric/emergency medicine is doing a peds or emergency medicine residency and then doing a fellowship. This is great as long as this is what fits with what you want to do. However, if you want to be a rural doctor and you want the general pediatrics knowledge or the subspecialty time with pediatric nephrology or neonatal ICU, you wouldn't be able to get this by just doing an emergency residency and the pediatric fellowship for two years. It would not give you the same level of intensity if you want to be a broader trained person rather than narrowing and being a specialist. [10:50] Types of Patients The types of patients you see depends on where you go. In Aaron's case, he does 60% peds and 40% adults. You have the potential to work in any emergency medicine department across the country. If you want to work in a pediatric-specific emergency department, that depends on the needs of that emergency department. You could open up your own clinic if you wanted to or work in places that need a general pediatric physician as a hospitalist. You can do a fellowship on the emergency side or on the pediatric side. Or you can do both. In their program, they've had people who did fellowships in pediatric critical care, simulation and medical education, toxicology, sports medicine, and some other ones. You've got a lot of opportunities when you're done assuming you keep your options opened for geography. Make sure you've got a good idea of where you're headed. As fellowships are becoming more common after residency training, you need to be able to stand out. However, you don't want to do this just to stand out because it's a long chunk of your life to spend. There are better things you can do. But it does help and it gives you a different philosophy for how you're approaching things. [Related episode: 5 Traits Patients Want Their Doctors to Have] [14:20] Trend in Medicine for More Specialized Specialties If you have an idea of where to go, then you need to email that institution and ask what you need to do to get the job. That said, there are plenty of places that are still clamoring to get somebody who is a specialist and wants to take ownership of pediatrics. There's a lot of literature suggesting that people who have done the pediatric EM fellowship stay in large academic centers. They don't go out into the community and work as they had hoped. In fact, many have now questioned whether centralizing everything at the children's hospital is still the best way to go. Aaron feels that if you've got extra training, you feel more comfortable seeing children. You feel more prepared to see a really sick kid out there because that's where the majority of these kids are going to end up going. For their program, Aaron explains you have to have the pediatric experience. You've seen kids, especially the really chronically ill kids, and the tech-dependent kids. You've seen them in the clinic. You've seen them at the subspecialist's office. You've seen them when they're really sick in the ICU. You've got a background on how to take care of children that you can pull from. And then you've got procedural competency and that critical care emergent time-management mindset from emergency medicine. The other five years of training just becomes a part of you. [18:30] How to Know If You Have the Procedural Competence If you can get any experience during medical school, you will decide very quickly whether you love procedures or you don't. There are a handful of environments where residents and attendings tell you how they've walked into X environment and they knew they're home. For some people, that's the O.R. For some, that's the clinic or the ICU or the ED. If you have the opportunity to do any kind of three-week elective or some experience ahead of time, do it. Email a physician and ask if you can shadow them even just for one shift or overnight or for one time that will allow you to get the best exposure. A lot of what they do in pediatric emergency medicine is to convince their kids are going to be okay as well as a lot of return precautions. If you don't like doing this then pediatric emergency medicine is probably not great for you. You're not constantly having critical children coming in.  Regardless of what you're considering, try to get some experience early and that will help you make your decision. [21:00] Work/Life Balance and Taking Shifts Aaron still gets to have a life outside of the hospital. But he believes you have to make time for it. He makes it a point to take time out apart from doing anything related to work to recuperate and refresh. With shift work, you've got to work 365 and somebody's got to work the holidays. Somebody's got to work the overnights. So you adjust to it. And if you're considering emergency medicine of any kind, you have to determine whether you can function at 2 am. And are you somebody that someone wants to be around at 2 am? Or do you turn into a werewolf that nobody wants to work with? You have to make it a point to do something that is not medical after work in order to restore yourself. At their program, they've got a handful of people that just do nights. They're offered a pay differential so you can make a little more. But they would usually split between mornings and evenings. The morning shift can start as early as 6 am. They work 9-hour shifts. And it can start as late as 5 pm and you get off at 2 am. But in an emergency, you get off when everything is done, especially as a resident when you're still trying to learn your flow and your management. But you will get better over time and things will get tolerable. As a resident, everybody rotates through in a circadian fashion so that you do as much as you can. But you do a lot more evening shifts because that's when the patients come in. Even if your sign out is done is at 4 and your relief comes in at 4, then you're not done for another 30 minutes so that the transition of care is appropriate. And this is expected. Aaron gets off when he's supposed to probably 60% of the time. Especially in pediatrics, most of the kids they see are not critically sick. So when he works his adult shifts, he always buffers knowing that a lot more adults are going to be critically sick and they're going to need his time. But you're never really prepared for that stuff. [Related episode: Balancing Family Life with Being a Premed and Medical Student] [26:45] The Training Path If you want to do pediatric emergency medicine, you can do a three-year pediatric residency and the three-year pediatric emergency medicine fellowship. You can do a three or a four-year emergency medicine residency. Then another two or three years in pediatric emergency medicine fellowship. At their school, they have a five-year program where you have to fulfill all of the requirements for emergency medicine and all of the requirements for general pediatrics. They're doing this concurrently. They do somewhere between 2 and 6 months in the emergency department doing trauma surgery, ICU at the VA, emergency medicine, anesthesia. Then you'll flip and do 2-6 months of general pediatrics, neonatal ICU, pediatric pulmonology, inpatient wards, clinic. Then you keep flip-flop back and forth until you reach your five years. Aaron likens their training to children growing up in a bilingual household. They don't necessarily keep the same verbal milestones compared to a kid growing up in a single language household. They're learning two different words, two different idioms, and two different ways to say the same thing. But once they do, they catch up pretty quickly and they speak two languages. With their program, they're going to teach you how to speak pediatrician and how to speak emergency physician. Although, it takes a little bit longer.  It's a different growth curve of how you're going to progress along in your understanding of both specialties. But once you do, you're going to catch up. You may even surpass some of the residents from either the emergency medicine or the pediatrics program itself because you now speak two languages. [29:45] How to Be Competitive for This Program The four programs that offer the combined residency include the University of Arizona, University of Maryland in Baltimore, Indiana University in Indianapolis, and LSU in Louisiana. There are only 8 or 9 spots in country. Aaron says that you have to consider if you're crazy enough to do five years. You have to love this enough that you want to do five years To make yourself competitive, have a backup either in pediatrics or emergency medicine. Some people choose both. And even if you don't match into one of these spots, you can still do emergency medicine and a fellowship or pediatrics and a fellowship. They've even had several residents that graduated from one program and then re-entered the match and did the other ones. So they did six years to do the same. Well, it's not quite the same because you're taking it in chunks instead of intermingling it. Aarons recommends that you strengthen your application packet towards whichever is going to be your backup. So if your backup is emergency medicine, then strengthen your packet towards emergency medicine. Show that you're going to be a good emergency medicine resident. Doing away rotations is great as well as interview rotations to have a good idea of what's there.  Do pediatric emergency medicine or pediatric ICU as they're going to be helpful whether you do the combined EM/peds program, EM on its own, or pediatrics on its own. Both are going to intersect with peds/EM and peds-ICU. This will help strengthen your packet for the combined program and for whatever your backup is going to be. [33:40] Applying as a DO and How to Stand Out in Rotations Two of their residents at their program are osteopaths and they're fantastic. If you're applying to a place that already has unfavorable opinions set on osteopaths, go for it if you want to be the trailblazer and try to rotate there. Otherwise, consider if it's really the best place for you if you're not going to be viewed as an equal with the other residents. Aaron adds that you can strengthen your application just as you would for any other place. But if you feel like that may be a hindrance for you, doing an audition rotation is a great way to show how good you are. To stand out at these rotations, you have to show initiative and that you can work well with a team. They want to see that you've done some of the work on your own. There's also the 2 am test. Are you somebody they want to be working with at 2 am? You have to be reliable. A fit in personality is also important to consider. Their program wants to see that you fit well. So you have to consider whether you're a good fit at a certain program and determine if you like them. [Related episode: The One Thing You Need to do to Stand Out as a Premed] [37:30] What He Wished He Knew That He Knows Now Aaron wished he had done a much better job with self-care and making sure that he took time (that he now takes) for family, for friends, for hobbies, and for things that help maintain his sanity. Although residency is not as a brain-drain that medical school can be where you feel like you're drinking from the firehose, it is time and energy-taxing. You have to put effort into the things that you want to be around when residency is around like family and friends. Because you can't just push pause and come back in 3 to 5 years and feel like everything is still going to be the same. [38:50] The Most and Least Liked Things What Aaron likes the most about the combined residency is that they are people who like to have fun and have a broad perspective of medicine. What he likes the least about the pediatric emergency medicine is that when it's bad, it's really bad. They deal with cases like child abuse, pediatric sexual assault, drownings, SIDS, and cancer diagnosis. Often, those will happen in the ED. What he realized that really affected him is that they can't help everyone. They want to take care of everybody that's there. They want to try to help every person that comes into the emergency department. But there are so many people that come in with complaints that they can't help. He tries to provide hope for people in a hopeless situation when they come in at midnight on a Saturday. For him, this is frustrating when you can't offer what they want. [42:35] The Overlap of Pediatric Care and Adult Emergency Medicine Especially during residency, you spend a lot of time in the clinics and on the wards. They even joke around that kids are not little adults but adults really are just big kids. Aaron says he can do a lot of the same things that he does with children. He's able to apply some of that to adults especially among the 20-year-old's where the overlap is not quite there yet. In pediatrics, one of the first questions they ask themselves is whether the patient needs an IV. In adults, before they even get their chief complaint, they've already gotten an IV. They're getting a dose of antibiotics and they're on their way to the CT scanner. All those being said, he gets to have a different perspective. If he had to do it all over again, he'd still be a combined EM pediatric physician. And even his wife just recently told him that if he had to do it all over again, she would still support him all the way through. [45:25] Final Words of Wisdom To those interested in getting into this specialty, try to get experience in both emergency medicine and pediatrics because they want to train people in both. They want you to be a pediatrician. They want you to be an emergency physician. Then they're going to train you on how to be a pediatric emergency physician. Make sure you really want to do both because the last thing they want for somebody is to be halfway through and say they hate this. They want you to go in with eyes wide open. Links: Meded Media Arizona EMCast

Bulls Podcasting Legends See Red Fred @cbefred and Doug Thonus @Doug_Thonus take out the Big Red Bus for a ride to chat about the Beloved Bulls. Topics include: The Slower Offense of the Boylen Era / Hoiberg to Boylen and Trading Parker 6:00 / The Bulls Need to Be Competitive 16:15-ish / Replication of the 2004 Bulls 19:10 / Will this Player Be on the Team to Start Training Camp in 2019 & Trading LaVine 27:00 / Lauri for Simmons? 35 Email the show: chicagobullseye@gmail.com Follow See Red Fred on Twitter: @cbefredThe post The Big Red Bus #23 – Putting the Brakes On appeared first on Chicago Bullseye.

Bulls Podcasting Legends See Red Fred @cbefred and Doug Thonus @Doug_Thonus take out the Big Red Bus for a ride to chat about the Beloved Bulls. Topics include: The Slower Offense of the Boylen Era / Hoiberg to Boylen and Trading Parker 6:00 / The Bulls Need to Be Competitive 16:15-ish / Replication of the 2004 Bulls 19:10 / Will this Player Be on the Team to Start Training Camp in 2019 & Trading LaVine 27:00 / Lauri for Simmons? 35 Email the show: chicagobullseye@gmail.com Follow See Red Fred on Twitter: @cbefredThe post The Big Red Bus #23 – Putting the Brakes On appeared first on Chicago Bullseye.

CREATE SOMETHING AWESOME TODAY PODCAST 32 - DOMINATE YOUR NICHE IN SOCIAL MEDIA Being the same as everyone is else, is the easiest way to get lost in the noise. If you really want to stand out in social media, you have to set yourself apart from the crowd and sometimes that is going to mean either being a misfit or stepping up your game to be world class. SHOW NOTES FOR CSAT PODCAST 32 Ways to Stand Out and Be Competitive in Your Niche Visual Branding and Presentation Quantity of Content and Consistency Not competing for Trends Higher Level Production Values Having a Unique Voice and Personality TODAY’S SPONSORS & DISCOUNTS http://awesomecreatoracademy.com 33% OFF CODE FOR YOUTUBE STARTER KIT: AWESOMEPODCAST http://www.awesomecreatoracademy.com/store/dPpRoH8h RESOURCES FOR YOUR BIZ: Build a Website With Bluehost and Get a Discount! Bluehost http://robertoblake.com/bluehost Start Email Marketing with LeadPages and ConvertKit LeadPages http://robertoblake.com/leadpages ConvertKit http://robertoblake.com/convertkit Disclaimer: Some of the links above are affiliate links, which means that if you choose to make a purchase, we will earn a commission. This commission comes at no additional cost to you. Please do not spend any money on these products unless you feel you need them or that they will help you in achieving your goals and creating something awesome.

Session 60 Dr. Taylor Inman is an academic Pediatric Pulmonologist who is also a locums physician. She has been one and a half years out of fellowship training. We discussed her path into the specialty, what it's like, and much more. Check out MedEd Media for more podcasts. If you have some premed friends, kindly tell them about The Premed Years Podcast. If you have suggestions who would make a great guest on the show, please email me at ryan@medicalschoolhq.net. [01:20] Interest in Pediatric Pulmonology Taylor realized she wanted to be a pediatric pulmonologist when she got to her second year of residency. She always knew she wanted to get into medicine at a young age, having had Type I diabetes and getting diagnosed at five years old. She has been exposed to medicine at a young age with her mom being a nurse and her dad having a PhD. So always knew she was going to do something in medicine. Then when she got into pediatrics residency, she knew wanted to specialize. She likes interesting kids and she's been trying to figure out which interests her and pulmonology just fit the bill. [03:27] Traits that Lead to Being a Good Pediatric Pulmonologist Taylor describes that one of the traits that lead to become a good pediatric pulmonologist is being able to pay attention to details. Especially in pulmonology, there are a lot of details that you have to tease about patients to help optimize their treatment. Another trait that can be a hard thing to learn is the ability to listen to families. Working together is important to figure out a plan. this being said, building long term relationships with patients and their families is very important. "You need to listen to the parents who take care of the kids because a lot of times, they do know more than you do about their child's condition." [04:23] Being a Locums Physician in an Academic Setting Taylor says she actually fell upon her practice as a locums physician by chance. She trained in San Diego and her husband's family is in Las Vegas, where they moved after her training since at that time, they had a 22-month-old and a 3-month-old. She wanted a break so they needed to live somewhere where the cost of living was lower. Her plan was to take six months off, study for boards, take boards, and then start working locally. Only to discover that it wasn't as easy as she thought it would be to get a job locally in a pediatric subspecialty. Then she found the locums position in Fresno, California where they're desperate for a pediatric subspecialist. They have a huge pediatric hospital with over 300 beds so they needed help with their inpatient service. So Taylor travels to Fresno one week at a time where she gets on-call and does rounds. They pay for her rental car and her hotel. And she finds having a work-life balance and she's been doing this for about eight months now. So she works one week, and then have three weeks off to be home with the kids. The hospital she's working at started their own pediatric residency only this year. They have residents rotating through. They can do a pulmonology elective and they can have residents covering some of their CF (cystic fibrosis) patients. But for the most part, most of the patients in the hospital are taken care of mainly by attending physicians along with the resident service. So it's nice to have that balance of residents covering for them at night. [07:10] Types of Patients and Primary versus Consulting Majority of their patients have cystic fibrosis. They do see a lot of asthma patients as well as chronic patients. They have a separate service for all the chronically ill patients and they do consult on them. When she trained back in San Diego, they were oftentimes the primary physician for these patients although they're dealing with multi-system problems. Other cases are patients with pneumonia, embolism-type stuff, and TB, bronch patients. As a primary physician, you're in charge of everything - feeding, breathing, medications, discharge, etc. As a consulting physician, as a specialist, you just consult on your special field. She can make suggestion about other organ systems but she's primarily responsible for the lung organ system. A lot of times too, as physicians, they don't write orders for the patients since the hospitalists do that. But they make recommendations and then hospitalists get to decide to follow her recommendations or not. "Primary in a hospital, when somebody is admitted, doesn't necessarily mean primary care doctor." So you can have a specialty service and admit people to that specialty service.  That means there are other patients there that consult other specialties. Taylor explains that for cystic fibrosis patients, they are the primary physicians for the patients when they're in the hospital. She actually feels like they're their primary care physicians too, although they do require that their CF patients have a primary care physician outside of the pulmonologist. Unless they come in with a complaint for another organ system, these are different services and Taylor can just consult for those patients. [10:53] Clinic versus Inpatient Taylor illustrates how clinic setting is being a little bit more low-keyed than an inpatient. For clinics, it's nice to be able to get longer appointments. For instance, they can spend 45 minutes with an asthma patient for the first time. They'd figure out what's going on and what they can do to help. CF patients come in one specific day where they have a multidisciplinary clinic with a social worker, a dietitian, a specific CF nurse, pharmacist, and respiratory therapist to all help with the care. In regular pulmonary clinics, they see a lot of asthma and all different respiratory complaints. They take care of patients with sleep disorder, breathing, and sleep apnea. They also have patients who are on long-term ventilators at home or patients that have a tracheostomy that they care for. "It's good variety of different things. No two days are ever the same in pulmonary clinic." [12:10] Percentage of Patients Coming In Taylor estimates 30-40% of the patients are new and the rest are follow ups requiring management. Especially once the asthma patients are stable, they try to have their nurse practitioners follow those patients up because there is such a high demand for pulmonologist in Fresno and there aren't very many pediatric pulmonologists. Because of this, she's seeing more of new diagnosis instead of follow-ups. A typical day for Taylor would be getting to the hospital at 8:30 or 9 am, unless she has a bronchoscopy schedule where they're scheduled first thing in the morning. They'd do outpatient or inpatient bronchoscopy. Then she'd come in a bit later in the morning to check her CF patients. She looks through her list for new consults coming in. She reviews them on the computer the night before and then she'd see all the patients and talk with other specialists she's consulting with or on. In the afternoon, she spends a few hours writing notes, which is her least favorite part of medicine. Then she'd get down around 5:30 pm depending on how the day goes But usually, she's out at a reasonable hour. "I spend a few hours in the afternoon writing notes. That's really my least favorite part of medicine." [14:15] The Training Path to Pediatric Pulmonology The first step is to match into Pediatrics residency. After you do three years of Pediatrics residency, you match to become a Pediatric Pulmonologist. This happens in the Fall of your third year. This gives you more time to do some electives and figure out what exactly you want to do. Taylor adds that you have to know what you want to do by the beginning of your second year. "It doesn't really matter where you do pediatric residency for becoming a specialist." Pediatric pulmonology is an additional three years of training. And most of the pulmonology fellowships require a lot of research, which is good. At her fellowship, she had almost two years of full dedicated research time and a year of clinical time, spaced out over the course of three years. So she did mostly clinical her first year and mostly research on her second and third year. For most of the pediatric subspecialties, most of them are three years in length. Pediatric neurology can be combined to become a 5-year instead of 6-year training program. Even pediatric emergency medicine is another three years of training. So it doesn't matter where you're going to, since it's going to be six years in total. In terms of competitiveness, Taylor doesn't think it really is a very competitive field compared to other programs. When she was matching, half of the spots were unfilled each year because there are so many spots and so few people who want to go into pediatric pulmonology. "If you have your heart set on going to one specific place, it may be competitive in a given year... but for the most part, if you want to be a pediatric pulmonologist, you can do it." The reason for the few applicants being that the pay isn't that great in pediatrics. A lot of time you spend mastering your subspecialty and when you go out, your paying potential isn't that great. Plus, a lot of people who get into Pediatrics just aren't interested in pulmonology. [18:15] How to Be Competitive for a Pulmonology Fellowship Taylor recommends doing as much research as possible during your residency. Even if just writing case reports is better than nothing. Get to any research you can get involved with. She also mentions having great recommendation letters. "Even if your research doesn't seem like it's going to apply to your field, it's still helpful to have the experience of research as early as possible." Ultimately, it comes down to where you would work well and where you'd fit in well. She further adds that people who are smart and play nice with others can really go far in pediatric pulmonology. [19:45] Bias Against DOs, Working with Primary Care and Other Specialties Taylor hasn't really seen any negative bias towards the DOs since you're basically doing the same pediatrics training. So when you're applying for fellowship, you've already been working and doing the same thing for the last three years. So it doesn't really matter at that point. In terms of working with primary care, Taylor says that she feels that 90% of refractory asthma patients they get from primary care doctors are non-compliant. They're not doing their meds and they're lying or they're not doing it correctly. But she gets how this can be challenging in gen peds when you're practice in jam-packed. Taylor points out that most of the poorly controlled asthma is all about taking the meds and taking them correctly. And she's happy to see those kids in her clinic. As well, she's happy she has the support staff to help call and find out if families are refilling their prescriptions and picking them up. "For the primary care doctors, you're doing everything right. It's just a matter of the patients taking the medicine or doing it correctly." And for their CF patients, they appreciate primary care doctors who are seeing patients when they're sick and really working together. Taylor admits that as pulmonologists, a lot of times, they don't have sick visit appointments. But parents will call them when they're sick. Although their obligated to do something, Taylor says it's nice to have someone lay eyes on the child and be able to tell them if they do look sick or not. This being said, they value the input of primary care doctors even for the complicated kids that they do a lot of management for. In the hospital, other specialties they work the closest with include hospitalists, PICU, NICU, etc. With outpatient, they work with all the specialists in all different capacities. They work with ENT, Cardiology, GI, Allergy, Rheumatology, Hematology and Oncology. [23:23] Special Opportunities to Further Subspecialize and Outside of Clinical Medicine Taylor explains that you can do an extra PICU or NICU training. This would be an additional two years of training but she doesn't really know if doing this would make you better of an intensivist. The fields are split especially in Pediatrics. So they have each their own subspecialty. Moreover, Taylor doesn't like the lifestyle in PICU. The opportunities outside of clinical medicine are endless for research. Fellowship requires a research project and most fellowships give you substantial time to complete the project. They really encourage you to continue research after you've completed your fellowship. This said, there are tons of grants you can write and funding you can apply for to do research. The Cystic Fibrosis Foundation has all kinds of different funding pathways for physicians to do additional research. "All the research you could ever want to do is possible in pediatric pulmonology." [24:55] What She Wished She Knew and the Things She Most and Least Liked Taylor admits there were times she was envious of NPs or PAs who started at the same time as her and they finished and are already working and making more than her as a resident even though they're the same age. And a lot of the NPs and PAs don't have to take calls as much as physicians do. But she's still glad that she went through it all. It wasn't easy. But now she's on the other side of things, no one can take that MD away from you. There are still a lot of opportunities too as Taylor points out. You can go practice gen peds if you want to or do urgent care and take care of low acuity patients in the ER if you want to. So she's still happy she did it. Looking back, she thinks it was more fun that she thought that it was. It's pretty cool that as a 26-year-old that she was admitting kids to the hospital and deciding treatment for them with a senior resident. The thing she likes the most about being a pediatric pulmonologist is how fun it is. Most of their kids get better. Also, you get to know the families well and see the patients grow and get better and graduate from pulmonary clinic. "Regardless of what you do, a lot of them will get better. So you don't have to be the smartest person to figure out what to do." On the flip side, what she likes the least are having patients who are chronically ill and not going to get better. A lot of them eventually will have respiratory problems and breathing is the one thing that can make them live or die. So they end up being involved with families making decisions whether or not to place tracheostomy or place patients on ventilators. She says that a lot of times, it doesn't feel right making that decision. She also finds it hard if she doesn't feel like she agrees with the family. For instance, she sees that the patient is not going to get better but the family wants to have them live as long as possible even though they don't have a good quality of life. These are very challenging cases for her to see kids who are not going to get better and to know that they're not going to get better. [28:35] Major Changes in the Field of Pediatric Pulmonology For asthma, they have some new treatments for asthma monoclonal antibodies that will target to lower IGE and kids who have allergic asthma. They have made a big difference in treatments.She thinks there will be more specific, targeted therapies to come in the future. Also, trying to use personalized medicine to classify patients with asthma and figure out what type of asthma they have or what specific medications will work best for them. Taylor reveals there a lot of stuff that are just on the cusp of discovery. And it's a very exciting time for cystic fibrosis with all the new medications coming out. There are two drugs currently available and more drugs are on the horizon. She does hope the price of the therapies comes down soon too (right now, it's over $300,000 a year). Nevertheless, it's exiting to have new treatment options for their patients. Ultimately, if she had to do it again, she still would have chosen Pediatric Pulmonology. Although at the back of her mind, she does wonder if she would enjoy being an endocrinologist. Having lived with diabetes her whole life has made her feel like she's an expert so it could be easier to make a difference in the field of endocrinology. [31:40] Final Words of Wisdom Taylor recommends to aspiring pediatricians or pediatric pulmonologists out there to try to get as much exposure as possible, even as a med student and resident. Try to get involved. Shadow in a clinic and see what kinds of patients are seen. It's a lot of fun and a lot of variety so it's a good balance of having excitement and seeing patients who are sick. And there's good work-life balance since they're not being called in overnight to come in and do procedures. As a mom. Taylor says it's a good specialty to pick. "It's a lot of fun. It's a lot of variety. It's a good balance of having excitement and seeing patients who are sick." Links: The Premed Years Podcast Cystic Fibrosis Foundation

Session 53 Dr. Jacqueline Bernard is an academic Neurologist who specializes in treating patients with multiple sclerosis. She is a physician at OHSU (Oregon Health and Science University). We talk about the specialty and so much more. Tune in every week to hear different stories of specialists even if you're interested in going into primary care. One of the questions I ask them is what they wish primary care doctors knew about their specialty. Also, check out all our other podcasts on MedEd Media. This week, I interview Jacqueline who has been in practice now and out of her training for many years now. She has been in the community-based setting and is now back in an academic setting. I was diagnosed with MS about three and a half years ago so this episode hits home for me. So we chat about her career as an MS specialist, what drew her to it, what keeps her happy, things she didn't like about it, and her advice to you if this is something you're interested in. [02:04] What Do Her to Becoming an MS Specialist Jacqueline says her interest grew in her. As a woman, her practice was getting referred a lot of female patients with neurological disease. And a large percentage of them were patients with MS. She realized very early on how this was a very compelling group of people. They were trying to educate themselves as much as they could about this disease process and what treatments are out there. This grabbed her pretty quickly once she was in the region of the country where it was disproportionately highly prevalent compared to other places. Minnesota for instance, has a lot of MS cases. So it was the volume of patients she was seeing that grew quickly. Within a couple of years from moving to the state, this impacted her. "MS is a very tricky disease. You have to be able to detect it. That's also true about Neurology in general." Jacqueline explains how MS is a tricky disease and you would have to be able to detect it to figure out what's going on because it can relapse and remits. So you'd have to look at the circumstantial evidence. It might  involve various parts of the nervous system such as optic nerve, spinal cord, or the brain. So you get to see the impact of the inflammation in a lot of different ways. The most compelling part for her is how people are able to manage it and how they bounce back and continue to really live with the disease. Another piece about it is that people with MS can have really severe attacks. Jacqueline says you can help them get through that and bounce back. Ans this is something that inspires her to help patients. [05:45] Traits that Lead to Being a Good MS Specialist Jacqueline says you have to be curious about the path of MS and having interest in all the different ways you can suppress inflammation. If you're interested in neuro immunology, Jacqueline things it's one of them most interesting parts of clinical medicine today. "It's really an interesting disease to watch over the last 20 years because in the process of trying figure out ways to stop inflammation, a lot of science is being uncovered." Jacqueline was initially drawn to Epilepsy seeing how it has interesting science and mechanisms. In fact, it's more interesting now that there are certain antibodies found to be associated with refractory epilepsy. She was also interested in moving disorders, having had some of the country's best moving disorder specialties in their school. They actively engaged them into going rounds and invited them to hang out. They taught all the perils along with their fascination and passion about moving disorders. She specifically cited one of the editors of Handbook of Neurology who was their teacher - a big supporter of medical students. In fact, 10% of each class went into Neurology because of his teaching. Teachers have a huge impact in the way they bring the top of the live and how that inspires students. Anyway, she ended up doing MS which for her was workable for someone trying to raise a family. "MS was more amenable to trying to have a career and a family." [09:23] Patient Types and Over Diagnosis of MS Classic patient demographics are those between the ages of 20 and 40, women to men ratio of 3:1. However, they're now seeing much more pediatric MS. These are cases of children down to age 10. They're also seeing first time diagnosis for people in their 50's and even in their 70's going to their clinic. "It means that something about the way we live. Not for ascertainment but probably the prevalence is increasing. It also means people are living longer with MS." That said, they have a huge age range of patients at the MS clinic across the country. And by ascertainment, we're not just getting better at testing and finding MS. Instead, there's more people developing MS. And now that we have an MRI machine in every corner, it's much easier. In fact, people are over diagnosing MS. This was at a recent meetings at European Clinical Trials MS Meeting in October saying this. Spots on an MRI does not equal MS. So it's important we make sure we're following criteria and that we're able to sit with a little bit of ambiguity until we collect all the appropriate data before we tell people they definitely have MS. Three years ago, I was diagnosed with MS and it was a question of whether I have MS or was it something else. It's interesting to hear that there's a lot of over diagnosis. It seems pretty simple. It's not a test but a clinical diagnosis through the McDonald Criteria for MS. Jacqueline explains that the good thing about this criteria is we could now incorporate MRI neurological information into out decision-making. Then use that to help us proof of dissemination and space and time. Those criteria are actually being decided upon for possible revision. She adds the need to be able to have clear evidence of dissemination in space and time. Otherwise, we're going to see more people having lumbar punctures to try to find evidence of abnormalities to help substantiate this. This being said, more corroboration will be needed. There are the clinically isolated syndrome but even before that, people talk about radiologically isolated syndrome, which are spots on the MRI obtained for other reasons. And this is probably the most common reason people are having an MRI. [13:55] Percentage of Patients Already Having a Diagnosis of MS and Typical Day Jacqueline sees patients in the MS clinic as well as some general neurology patients. Most of the patients in the MS clinic have been given a diagnosis. They're asking for second opinion on the diagnosis or regarding some new treatments that may be out. "75-80% of the patients they see in the MS center already have a diagnosis. 20% wonder if they have it or are worried they might have it. But most likely, they don't have it." In the general neurology clinic, they get a lot of questions about numbness and abnormal MRIs. Some of them turn out to be MS but not all numbness equals MS and not all abnormal MRIs equal MS. A typical MS day for Jacqueline may include having a medical assistant in the clinic with them. They have an MS-certified nurse and three fellows and several MS faculty. They get people roomed. They also have two city coordinators in the clinic, who see who could be patients appropriate for studies. They have 12-14 desktops in their workroom so they can pull the MRI results there and get a lot of discussions. So Jacqueline sees 50-50 percentage of her time spent on MS versus general neurology. She also has another administrative role being the Vice Chair for Clinical Operations in her Department. She does a lot of work around access in the state of Oregon. She sees patients and learns about how they get referred in.So she's still trying to understand referral patterns, access, and improving it in every way they can. [18:06] Taking Calls in an Academic Setting vs. Private Practice In academic medicine, Jacqueline their calls to be a little different. A couple of weeks may be spent on the teaching service. Their residents are taking the call for the general neurology ward as well as the stroke service. When they're covering the neurology ward, they're not covering the stroke service. But for at least the first week of their two-week stint, they're covering the transfer service. Any doctor in the state of Oregon, and sometimes the state of Washington, Idaho, or Montana can call into HSU if they have a neurology question. Or if they have a potential transfer. They take those calls. She describes the transfer center as very organized and data-driven that they call it command control. They monitor all calls that come in. Everything's recorded. They give advice and they may follow the patient. Or if it's a critical patient, they suggest they transfer the patient and their transfer center makes it happen if there's a bed available. "Bed availability of course, is a problem at academic medical centers around the country." Moreover, they partner with other community hospitals. Some of the less acute neurology transfers might go to one of their community partners rather than all the way into the university hospital. Her calls are intermittent during the day and at night for the first week of her two weeks. They also cover 24/7. Jacqueline differentiates this from taking calls in private practice, which she did for a number of years. That would be you're on call 24/7 for a full week and you're taking primary call, mostly people you see in consultation on the same day or next. Or you get call from the ER for acute stroke or a huge hemorrhage. As a neurologist, they're consultative when they're working in private practice. At academic institutions, they typically have a neurology ward where they do their teaching. So it's a little bit different. Typically, when neurologists go out of private practice, they're strictly consultative. They're not running a ward. [21:44] Work-Life Balance Her decision to leave private practice and go back into academics was that because her kids were getting bigger, she can spend more time running papers and grants. "A neurologist spends, on average, five hours more per week outside of work doing computer back up work, five hours more per week than other specialties." Jacqueline thinks there is a demand of time that is difficult to balance with having a family. It takes resources to raise a family. So it made more sense for her to cut back when her children were younger and then when they're older, she's now able to dedicate more bandwidth to her work. At this point in her life, she considers herself busier than most people by choice considering the opportunity to take her leadership position. But she believes it's hard to achieve a balance when your children are younger. [23:55] The Training Path Typically, you can take a one-year or two-year fellowship after four years of general neurology. These are not yet funded in the same way a stroke fellowship would be funded for instance. So it's not ACGME-funded at this time. Most of their MS fellows find their funding either through pharma and other national MS society funders. They often go out and write their own application to entities that do fund. Jacqueline advises to plan this ahead of time. "Essentially for any fellowship, you've got to be ready by about PGY-2 to start thinking about it for sure." Talk to some people and places and so some electives. See if that's really what you want to do. Start to get your applications going. The training is pretty popular as Jacqueline would describe. They would receive plenty of applications for their one or two spots they take each year. She thinks the MS prevalence has increased and the number of things they can do has increased. MS was also the place where they talk about neuro immunology which has grown so much. In fact, at the American Academy of Neurology, there's not just an MS section but they now have an neuro immunology section. They call their fellowship MS under immunology but it may by at some be split off and it will be either/or. A lot of these disorders are associated with unusual antibodies. So there are different ways to think about your fellowship. [26:42] How to Be Competitive for Fellowship If you're a resident interested in MS fellowship, during your PGY-2 when you're trying to get exposed to everything, set up some electives. This way, you can spend more time to expose yourself. Second reasons is to get people to know you and like you and write letters for you. If you have a research interest which is hard to do in your PGY-2 year, but if you can think of something where you can do over your residency in that field, go ahead. Have at least some project you can submit as a poster or write a paper, a review or part of the chapter with your MS faculty. Inquire early as to what they're working on and where can you fit in. "Get to know the faculty where you are so that they can tell you what you need to do, maybe get to like you, and try to help you stay there or write letters for you." Another important thing is to try to present at meetings to help you get to see what other people are doing. Get inspired by them and that will help you determine whether you want to do the fellowship. [28:27] Bias Towards DO and Working with Primary Care and Other Specialties and Special Opportunities Outside of Clinical Medicine Jacqueline has not seen any bias towards DOs. She has worked with fellow who had osteopath training. They fit in absolutely with the other fellows. What she wished primary care providers knew is that not everything that is white spots equals MS and that not everything that is none is MS. It's important to look for other entities and exclude other entities who are writing out e-consult guidelines to help our primary care doctors. At least, they do something to work up before sending patients over to them so they can help them know and also become more efficient and appropriate with their time and who they see in clinic. "If somebody has numbness, do a good neurological exam." That's why neurology is so important in medical student education so people can start to put together all this random cranial nerves and motor reflexes. Learn that so that you can do these exams. Maybe it's a peripheral neuropathy and it's not MS. Or maybe it's a migraine and not MS. So try to get a good neuro exam to get good history if you can. Other specialties she works the closest with include ophthalmology, rheumatology, and hematology oncology. Special opportunities outside of Clinical Medicine for MS specialists include pharma aspects. People can work in the lab and direct a drug development or in clinical trial design for potential drug candidates. Then those people putting drugs to the FDA. There are people who zoomed into pharma early in the career and they get an intensive experience getting a drug through the FDA. It's a 24/7 stuff where you have your SWAT team. Others who have worked in the MS centers for many years can get scooped up and get offers to go to different pharma companies to run their different clinical development program. [33:55] What She Knew Now, Women in Neurology, and Major Changes in the Field Jacqueline says there are no guidelines being a woman and having kids. But if she had known it's going to work out then it would have been good. But she had no choice otherwise. "As I look at women today, many women are choosing to have their children in residency and somehow that all works out just fine." It's common to see women in neurology now that more than 50% of medical school classes are women. Interestingly, they have a disproportionate number of women applying to neurology in their region. This reflects that more women are in medical school. What she likes most being an MS specialist is the patients being so compelling as well as the science. MS has really led a lot of interesting science. The neuro immunology has exploded over the last 20 years. It's a perfect mix of clinical with really interesting science. On the flip side, what she likes the least is generic to neurology, which is all the time they have spend on the computer. There are other people in the room with them that are from insurance companies. So it's a whole different field now. Still good, but a lot more has changed. In terms of the major changes in the MS field, she thinks patient continue to be very educated about what they choose to take. She just hopes people can maintain their healthcare coverage so they can continue to get the access to important medications. If she had to do it all over again, she would still have chosen the same filed. She thinks it's the most interesting filed, not to mention having great colleagues across the world. They're working hard to improve treatments and assessments. All the aspects of it is interesting. [38:01] Final Words of Wisdom Jacqueline says that by 2025, they are predicting neurology desserts in at least five states because of the graying of the population. So there are more neurodegenerative disorders. So there's job security in MS. And if you're in general neurology, you can see MS and other things too. Parkinson's, Dementia, migraines, etc. You get to see a variety of people and lots of different kinds of diseases that help affect the nervous system and impact families hugely. Neurologists impact patients everyday. Links: MedEd Media European Clinical Trials MS Meeting in October McDonald Criteria for MS OHSU (Oregon Health and Science University)

Session 44 Dr. Michael Egnor is an academic Pediatric Neurosurgeon based in NY. We discuss his long career in the field and his thoughts about what you should know. Michael has been out of fellowship training now for 26 years and is currently a faculty member at Stony Brook University. Also, check out MedEd Media Network for a selection of podcasts to help you on this journey to becoming a physician. [01:25] His Interest in Medicine When Michael was very young, his mother had a brain aneurysm that ruptured. She survived but she had some neurological sequelae. So even when he was young, he was already involved with neurosurgeons. He thought that to be a neurosurgeon was the pinnacle of what one could accomplish in terms of profession. Moreover, he found medicine fascinating. He recalls that he read a book Not as a Stranger back in high school. It was a novel about a doctor but the title just fascinated him. The title actually came from a passage in the Chapter 19 of Job in the Bible. Job was asked how he deals with all of the horror he experienced and all the terrible things he has seen. He knows what he's going through ultimately will allow him to see life and actually to see God, not as a stranger. That is if you would come to know him and what it means to be him in an intimate way. "To be a physician, you get to see in an intimate way what life is all about and understand what it means to be a human being." He was also inspired by Dr. Christiaan Barnard who was the first surgeon to perform a heat transplant. He recalls seeing the news about it as a kid and got fascinated by it. He is specifically fascinated by congenital heart defects. As well, the  brain fascinated him. That said, he knew he wanted to be a doctor and a surgeon, just not sure as to what kind. Then he went to the army in high school because he needed money to go to college. He served as a medic in the army for three years. And getting accepted to college, it gave him a deferred admission so he started college when he was 20. Right after college, he went to medical school. Being older going to college, he considers himself being more focused than some of his classmates. He knew what he wanted to do so he worked really hard to get into medical school. Out of medical school, still undecided between neurosurgery and cardiac surgery, he started general surgery internship in Mt. Sinai in New York. And halfway through his internship, he realized he wanted to do neurosurgery. He knew that 20-30 years down the road, he would still be fascinated by the brain and not as much by the heart. So he applied outside of the match. He called neurosurgery programs.They needed a resident at the University of Miami so he went there with his newly married wife. He spent six years in Miami, training in neurosurgery and came back to Long Island where his wife's family is from. Then he got a job at Stony Brook as one of the faculty. [05:50] Brain versus Heart Not that the heart isn't a wonderful topic of research, it struck him as a fascinating machine. But with the brain, he thinks you can take the knowledge much further. The other thing that enthralled him was neuroanatomy and how the brain was structured. To him, it was like almost as I if he was learning a secret to what life was all about and it was in the structure of the brain. So he felt the brain would keep him interested indefinitely. While the heart for him was to mechanical for him. "Almost as I if I was learning a secret to what life was all about and it was in the structure of the brain." [07:17] His Path to Pediatric Neurosurgery He didn't get out of training as a pediatric neurosurgery, He did general neurosurgery but he has always liked pediatrics. He likes the patients and has a fair amount of empathy for parents. He also has a personality for it. And in some ways, he thinks neurosurgeons and pediatricians are thought a being at the opposite ends of the spectrum of medical personalities. Pediatricians tend to be warm, nice people who are nice to the family and patients. Neurosurgeons are thought of to be egostistical and dysfunctional people who just operate like crazy. But these stereotypes are not entirely true. Pediatricians respond well to neurosurgeons and vice versa. What happened at Stony Book was for a couple of years, they didn't have a pediatric neurosurgeon. Since pediatricians like him, they sent him a lot of patients. So the chairman of pediatrics ultimately asked if he was willing to just become a designated pediatric neurosurgeon. And so he agreed. So there's a way to get boarded in pediatric neurosurgery outside of the fellowship track.It was a matter of submitting case logs for several years and taking a written exam. [09:30] Traits to Lead to Becoming a Good Pediatric Neurosurgeon Michael explains it's a blend of two very different species. Pediatricians tend to be people who are warm, nice people. They love kids and want to take care of them. Neurosurgeons are egotistical people and surgically oriented. This path is great if you find you love the surgery and are fascinated by the brain. You like some of the technical challenges of neurosurgery and on the other hand you want to take care of kids. For example, you find conditions like hydrocephalus to be very challenging and fascinating from a scientific standpoint. "It's a hybrid of two different ways of practicing medicine." Neurosurgery is an interesting specialty. As much as he has met the nicest people who are neurosurgeons, there are those who are crazy too. Michael says, neurosurgeons have to have some degree of almost irrational confidence in their abilities. It's something normal human beings don't want to do. You're taking tumor out of someone's brain where you stand a reasonable chance of killing them if you make a mistake. It's not something even people who are inclined to surgery have a particular comfort of doing it. So you have to be fairly egotistical to do this for a living. And how does one pull that off in the real world? Neurosurgeons have different ways of doing it. Some neurosurgeons just concentrate on being technically as good as they possibly can. Others are psychopaths in a non-criminal way. What Michael means is some of them don't take into account the humanity on the other end of the operating table. they just do the job as well as they can and then if it works out, great. If not, they'd call out the next patient. Some neurosurgeons limit their practice so that they only do things they feel comfortable doing. While others don't put it together well at all and don't do such a good job. [12:25] Types of Cases and Patients As a pediatric neurosurgeon, a large fraction of his practice is children with hydrocephalus. And he follows them into adulthood so he also has a fair amount of adult patients. Michael mentions the issue in pediatric neurosurgery that pediatric neurosurgeons who work in adult hospitals question as to where they will follow their pediatric patients when they grow up and become adults? Some pediatric neurosurgeons who work in children's hospitals can't do that. This is because patients can't be cared for at the hospital they work at. In Michael's practice, he deals a lot with hydrocephalus in both children and adults. He also deals with hydrocephalus in older people. He sees elderly people who have normal pressure hydrocephalus. Other cases he deals with are brain tumors, Chiari malformations in both children and adults, as well as syringomyelia in their spinal cortices. He also sees patients with craniosynostosis, infants with deformed skulls, and of course, trauma both adult and pediatric. As to what percentage of patients coming to him that already have a known issue, Micheal says it's a very common scenario to see a child with brain tumor. And the pediatrician feels a lot of guilt about it because almost a child who has brain tumor has several months of symptoms. And pediatricians work up a child with some vomiting and headache. And after 1-2 months of evaluation, they get scanned and the tumor is found. And so he tells them that in some sense, the neurosurgeon has the easiest job because virtually, patients come to him already with scans showing what's wrong with them. The primary care people, the pediatricians, or the internists for adults have a tougher job because they see a large volume of patients. Only a small fraction of them have serious problems. Then they have to find the ones who have the serious problems. The major issues he faces are: is the patient's diagnosis responsible for the patient's symptoms? This can be tricky. People can have headaches from the chiari malformation and don't need surgery. Michael finds it a challenge to sort out whether the symptoms of the patients are really caused by the disease identified on the scan. You have to be sure since the remedy you're offering is surgery. You want to make sure you're operating for good reasons. "That's one issue I face quite a bit is making sure the diagnosis is the cause of the symptoms." [16:25] Typical Week of a Pediatric Neurosurgeon. Taking Calls, and Percentage of Patients Ending Up in the O.R. Michael describes his week since it basically depends on whether the hospital has a lot of trauma or not. But his typical week would be that he'd be on call once or twice during that week at night. He takes a general surgery call. During the day, he has two operative days a week. On average, he takes 2-5 cases a week. He has 2-3 half-day clinics a week where he sees 15-20 patients per clinic. He has some academic time, usually one and a half days a week where he writes papers. They don't have residency in neurosurgery so he's a residency director for a program without a residency. This said, he's in the process of applying for residency. He teaches medical students as they rotate through the service he teaches and in the ethics class. Of the patients he sees in clinics, only a relatively small percentage, about 10%-20%, go to the operating room. Many of the patients he sees are follow-ups after the surgery. Many of them are children with shunts he sees annually. They don't need surgery but he sees them manually. It's very important that if you have a shunt for hydrocephalus, you have a neurosurgeon that knows you. And that you know them and that they neurosurgeon is always available to you. He finds that annual visits keep everything fresh so they know each other. Common cases would be a kid who bumps his head on the baseball field, has a mild headache and gets a scan. And something would be seen on the scan that has pathological significance but the primary care doctor sends the child to him. Most of the calls he takes would be coming to the hospital for surgery. They don't have residents so any surgery is done by the attending. They have physician extenders but he still has to come in and do the surgery. Nowadays, generally, residents don't operate alone so even if they had residents, he would have to come in. About a third of his calls, he would have nights coming in. [19:45] The Path to Pediatric Neurosurgery, Competitiveness, and Research Basically, neurosurgery residencies have been for five or six years including the internship year. That's followed by a year or two of fellowship, if you want to do it. This past two years, the ACGME and the residency review committee (RRC) for neurosurgery have standardized neurosurgical training. Now, it's a seven-year program including a year of fundamental clinical skills, which used to be the internship. And then six years of explicit neurosurgical training. Now they try to fold in the fellowship experience into the seven-year residency. So you don't have to do fellowship after you do it during the residency. There is research involved in neurosurgery. In fact, programs are required to have a research curriculum, whether it's training or research methods. Residents are expected to be academically active, to publish during their residency. And programs are reviewed by the RRC based in part on the research output of their faculty and residents. "It's a major emphasis in the residency review committee in neurosurgery to foster research in neurosurgery." Although he doesn't have the numbers, Michael thinks that half of the applicants get into programs. He would rate it as moderately competitive. It's a small specialty with about a hundred programs in the country. There are a whole lot of people interested in going into it but his sense is about 50% of applicants get in. As to the reason for it competitiveness, it appeals to a fair number of people, particularly people who are highly motivated. You have to really want to practice medicine at a fairly intense level to want to get into neurosurgery. Moreover, people may be attracted by the status or the financial aspects. Most neurosurgeons do fairly well financially. And there aren't enough people repelled by the volume or nature of the work. "It's fairy popular given what a small specialty it is." According to my data, there are are only 218 physicians. Michael agrees this is just about right. Pediatric neurosurgery is one of the less popular neurosurgical specialties. Within the neurosurgical profession, popular subspecialties include spinal neurosurgery, general neurosurgery, vascular. The reason for this is people don't like dealing with shunts. Many neurosurgeons, too, don't like dealing with kids or with families. Another reason is pediatric neurosurgery doesn't pay as well as other neurosurgical specialties. It seems to be a general rule across all pediatric subspecialties is that the pay isn't as good as it is for adults. But Michael points out you don't go into it for the money. [24:00] How to Be Competitive for a Residency Spot Besides being a good student and being a human being which always help you, Michael cites two things students should focus on. First is research. Have some publications appealing to a neurosurgical residency program. The second is to have some hands-on experience particularly with the programs you're applying to. When he was a resident in Miami, they took two residents a year. There was an unwritten rule that one resident was taken based on the CV and the other based on personal experience. When somebody would rotate through their service, you get to know them personally. It turned out that the people who did the best in the residency were almost the people who had rotated to the service and who they knew personally. You're going to work with the resident for seven years in fairly intimate ways in the middle of the night, saving lives, and doing all these stressful things. You really want to be somebody who you know you can work with, somebody you can trust and stand with for seven years. "The residency in neurosurgery is so long and it's such a stressful process. It's almost like a short marriage." Michael suggests that for people interested in neurosurgery, try to arrange external rotations at the programs you're most interested in applying to. This way, when your application comes across their desk, they would know who they're dealing with. Nevertheless, the research is a big deal. But the programs have a lot of stress on them from the ACGME and from the RRC to have residents that do research. It's one of the criteria by which re-certification of the program is determined. Plus, if you already have an established researcher in your program, it's more likely for them to make their program look good. That said, having a research background is very appealing to programs. In the long run, having research background makes you a better resident and a better neurosurgeon. [26:45] Biases Against DOs and Subspecialty Opportunities Michael's personal experience with osteopaths has been uniformly positive. Some of the best doctors he knows are osteopaths and his personal doctor is an osteopath. He thinks osteopaths are great doctors generally. He also knows that osteopathic programs have been brought into the ACGME. There are osteopaths at neurosurgery programs that do well. Although now, he's not sure how it's working into allopathic training. But osteopathic students are in an excellent profession and they can be very good doctors and very good neurosurgeon. In terms of other subspecialty opportunities, there is a boarding process for pediatric neurosurgeons. Although they're not ACGME-certified. So there are boards but they are not same status as the neurosurgery boards or the internal medicine boards. Beyond that, he's not aware of any certification process. But there are pediatric neurosurgeons who have particular interest in areas like hydrocephalus, epilepsy surgery, vascular, tumor. So you can develop a niche within the pediatric neurosurgery world. [28:50] Message to Pediatricians, Working with Other Specialties, and Turf Wars Michael says it's nice for neurosurgeons and pediatricians to become friends in terms of personal relationships. The pediatrician knows you personally. He gets a lot of calls from pediatricians just asking common sense questions. He finds that in the relationship between pediatricians and neurosurgeons, it's nice to form long-term friendships. In return, there are also situations where he calls the pediatricians. He will have a patient who has a neurosurgical issue but also has some pediatric issues. Then he'll speak with pediatrician about helping them out with that. Michael works a lot with other specialists like intensivist both adult and pediatric, orthopedists, otolaryngologists, and neurologists. For somebody who wants to go into neurosurgery because they're interested in doing spine surgery, Michael explains that in general surgery, most of the operative stuff is spinal. General neurosurgeons deal with spine in generally 80% of their cases. And most of the spine they do overlaps with orthopedics. Most general surgery particularly in private practice deal with spine. And there are movements right now in general surgery to relinquish cranial privileges if you're a private practice neurosurgeon. Many of them find that the cranial surgery, because it only forms only a small fraction of the cases they do, it does form a very large fraction of the difficult situations they encounter. So it's not just worth it. Also, it makes the call much worse. If you're doing cranial neurosurgery, you're called in at night for that subdural in the ER. But if your practice is restricted to spinal neurosurgery, you don't have to be called in for the cranial problem. So many of pediatric neurosurgeons restrict the practice of the spine. He actually has a friend in Florida who has been doing this for fifteen years. It makes for a very nice practice. In terms of overlap with orthopedics, Michael sees a lot of them. He never thought of it as something very competitive although his spine colleagues might feel differently about that. But they have a good relationship with their orthopedic colleagues at Stony Brook. The difference in the work they do is that neurosurgeons don't tend to do congenital deformities with scoliosis. On the other hand, Orthopedists don't do intradural surgery. "Kids with scoliosis still tend to be treated only by orthopedists and not by neurosurgeons." [35:10] What He Wished He Knew Now Michael doesn't think he would have done anything differently. He thought a lot about it. He likes pediatric neurosurgery. He is very interested in hydrocephalus from a research standpoint. Most of his research is in hydrocephalus dynamics and the cranium related to it. That said, there are tons of specialties within neurosurgeries that are great including spinal neurosurgery, tumor neurosurgery. But each of them has their drawbacks. For spinal neurosurgery, you have to want to deal with spine patients who can be very difficult to deal with. They're in chronic pain. So it should be something you like doing. Michael finds it's not for him. Tumor work is fascinating but many of your adult patients are dying. And to go into clinic everyday and see patient after patient with terminal illness is a hard thing to do. Cerebrovascular neurosurgery is very powerful specialty now with a lot of good work but they deal with some very difficult clinical situations. And the call can be brutal because you're taking call for strokes. Functional neurosurgery is great work for people who are fascinated by the intellectual aspects of epilepsy and movement disorders. But you have to have a certain personality to do that. Functional cases are very detailed, high tech cases that you have to like doing. [37:15] What He Likes the Most and Least about Pediatric Neurosurgery Michael likes fixing shunts. Even some pediatric neurosurgeons don't like that too much. But he finds hydrocephalus a fascinating condition. He's very interested in the dynamics of it and thinks there's much we don't understand about it. Hydrocephalus is the one neurosurgical condition where you can come into the hospital near death and walk out of the hospital a day or two later just fine. You can come blowing a pupil and go home in two days if they fix your shunt in time and the pupil comes down. In hydrocephalus, you can get incredibly dramatic results. I find managing shunts to be frankly challenging. "Doctors who deal with critically ill patients the most are neurosurgeons as much as any." What he likes the least about his specialty is seeing patients not doing well. This something all doctors need to deal with to some extent. Even if an objective observer wouldn't think of the outcome as a mistake, you still hold it in your heart and hod it in your head. That if you could have done something differently, could this patient have done better. Michael adds that one of the most important things about being a neurosurgeon is that you have to deal with the outcome. A neurosurgeon who has a major complication of 1%, you're a good neurosurgeon. A good complication rate for major cases. But if you're doing 200 cases, it means that two patients a year are going to have major complications. And if you're doing it for 30 years, there are 60 people out there who had major complications that's your responsibility and you live with those faces in your head. So he tells students going into neurosurgery is you have to be able to deal with that. That can be hard. In fact, some neurosurgeons quit. And some do dysfunctional things. They drink. They take drugs. They become egotistical creeps. They have different ways of dealing with that. Some become religious. Some limit their practice to things they can do safely. But you deal with stressful cases and bad outcome and dealing with litigation which is every neurosurgeon's pain. It's hard and it's a major part of the stress neurosurgeons go through. "Over the years, you get faces of people in your head who didn't survive or who were hurt for whom you feel some responsibility." There's a neurosurgeon named Henry Marsh who wrote a book called Do No Harm. He is a very prominent British neurosurgeon and did doctors tend not to. He wrote a book about all his bad outcomes. So the book wasn't about how gifted he was and all the great successes he had. Although he was a great neurosurgeon, the book was about his catastrophes. It's a very honest book. Michael recommends this book to people thinking about going into neurosurgery. [41:50] Future Changes in Neurosurgery The most dramatic change that's occurred in neurosurgery during his career has been cerebrovascular surgery with endovascular techniques. The ability to treat aneurysms with endovascular methods to treat AVMs and strokes. None of that was possible when he was training so this has been a real revolution. It primarily affects endovascular neurosurgeons but it's still a big change. In terms of pediatric neurosurgery, he's not seeing much changes except that they're seeing a lot less spina bifida than they used to. Due to folate supplementation in bread and milk and other foods, it's reducing the incidence of this condition. And also, prenatal diagnosis. Many of these babies are being aborted prenatally. There's a lot of research in tumors but the basic management of tumors has not changed all that radically. In spine, there was a study done back looking at which neurosurgical operations are under performed and which are over performed. They felt that functional neurosurgery was under performed. While the spinal surgery was over performed. So the reality is there are more people having spinal surgery than really need spinal surgery. Many people could recover from their spinal problems with good physical therapy and non surgical management. What's he's concerned about over the years is that insurance and the government will decide to reimburse spine in a much lower level and be much more stringent in the reimbursement which would affect neurosurgery in a very profound way. Because most of their income stream comes from the spinal surgery. [44:10] Michael's Final Words of Wisdom Consider this path if it's going to something that's going to be in your heart, it's your passion and not something you do for money. You also have to take into account the emotional stress that comes with dealing with people's lives on an intense personal level. He didn't actually feel this stress until he became an attending. You're going to have patients who don't do well so you have to have the psychological and spiritual resources to deal with that. "You have to take into account the emotional stress of dealing with people's lives on such an intense personal level." Links: If you have suggestions on people we should have on this podcast, shoot me an email at ryan@medicalschoolhq.net. We're looking for great guests! MedEd Media Network Not as a Stranger by Morton Thompson Do No Harm by Henry Marsh