Podcasts about board rounds

The guys get together to make a consensus draft board for half point PPR leagues.

Mike Natter didn't always think he was cut out for med school. Today, he is a physician, artist, Instagram presence, and my cohost on the Board Rounds podcast too! Links: Full Episode Blog Post Meded Media Board Rounds podcast Follow Mike on Instagram @mike.natter

Session 111 Pediatric orthopedic surgery is great for inquisitive doctors who love working with kids. Dr. Philip Ashley joins me to talk about subspecialties and more. Out of training for a few years now, he shares his path as he changed careers mid-college and how he reached out to a mentor which changed his trajectory in life. Are you a premed student? Check out The Premed Years podcast where I feature physicians, medical students, admissions committee members, and more. Everything you need to know about your premed path is right there. If you're already a medical student, check out Board Rounds, where I partnered with BoardVitals, a test prep company. We're breaking down questions to help you with your USMLE Step 1 and COMLEX Level 1 test preparation. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:45] Interest in Pediatric Orthopedic Surgery Philip went to medical school already wanting to be a pediatric orthopedic surgeon He changed his career track in the middle of college. He initially took engineering and did a summer internship at NASA. At that point, he looked to other options. He broke his finger bone when he was still a child. The person who operated him ended up being his mentor. He contacted him and consulted him about changing careers so he asked if he could shadow him over the holidays. Philip got hooked after that. Philip loved the idea of being able to work with hands and do something in the operating room that made an immediate difference in somebody's life. As a pediatric orthopedic surgeon, he loves being able to develop a relationship with the patient and be an inspiration for them. [Related episode: What Does the Pediatric Residency Match Data Look Like?] [04:15] Traits that Lead to Becoming a Pediatric Orthopedic Doctor First off, one has to enjoy being around kids. Attention to detail is also required because you will be doing something that could impact the rest of their lives. You will be interviewing and examining children who oftentimes are in pain.  Although he also looked into trauma as a subspecialty in orthopedics, he ended up getting into pediatrics. [Related episode: Orthopedic Surgery Match Data Deep Dive] [06:17] Types of Patients and Typical Day Philip gets to be a generalist operating on the spine, hips, feet, and broken forearms. The bread-and-butter is taking care of fractures in kids, the most common is humerus fracture.  You may also be taking care of clubbed foot which involves a lot of casting as well as some procedures down the line. Other common cases include hip dysplasia, herpes, and scoliosis. His typical day would involve two different kinds. Some days, he's in the clinic and some days, he's in the operating room. His clinic starts at 8:30 am. He takes care of any loose ends from the day before. He sees 35-40 patients on any given day. Usually, he has a resident working with him where they both collaborate and discuss cases. Their clinic days typically end at 4:30 pm and dictate clinic notes until they get home before 5 pm. On O.R. days, they get in at around 6:30-7am to check people in the operating room. By 7:30, they start with the operation and handle as many as 3-4 cases or 1-2 big cases. 1 in 10 patients that he sees on a given day ends up in surgery. Some of them may also be follow-ups from prior surgeries. But for new patients, he estimates 1 in 5 of them end up being in surgery. In pediatrics orthopedics, it's a lot more clinic-heavy than adult orthopedics since most kids recover from fractures and can be managed conservatively. [Related episode: 6 Tips For Improving Patient Communication] [11:00] Taking Calls and Work-Life Balance In his practice, Philip has three partners and they share calls in their institutions. They do it one week at a time and take one week every four weeks. Philip says he has great work-life balance. Part of the reason he went into pediatric orthopedics is that most of the pediatric orthopedic surgeons tend to care a lot about their family life. Pediatric orthopedic surgeons get paid less than other orthopedic surgeons. This is because they're not working as much as their counterparts. They essentially make the conscious decision to spend time with their families. [Related episode: Balancing Family Life with Being a Premed and Medical Student] [12:40] The Training Path Most orthopedic surgeons finish medical school and then get into a 5-6 year residency program. There are also some programs that give you a year to do research. After that, you're going to apply to a one-year pediatric orthopedic fellowship. In some of the bigger centers, you may have to take a second fellowship to subspecialize. Philip recalls pediatric orthopedic fellowship as one of the less competitive programs to apply for from a fellowship standpoint.  Moreover, there are many fellowships that have opened up so you have an almost one-to-one rate of applicants to fellowship positions. To be competitive as an applicant, some interest in research has been shown to help. Also, be able to work closely with the orthopedic surgeons at your institution and develop relationships with them. Get good letters of recommendation from them. Overall, just make sure that you're well-respected within your institution. [15:55] Subspecialty Opportunities Another area people are interested in is limb deformity. There is only one or two that can do a specific fellowship in limb deformity correction. Other subspecialties include neuromuscular conditions (e.g. cerebral palsy), pediatric hand fellowship. [18:25] Overcoming Bias Against DOs Philip thinks there's a good number of orthopedic residents that get in because they rotated at that institution. And the faculty of that institution got to see their work ethic, their interaction with patients, and their fondness of knowledge. Additionally, your interpersonal skills and your drive can help overcome that. [19:55] Working with Primary Care and Other Specialties and Special Opportunities Outside of Clinical Medicine Philip wished primary care providers knew about tibial torsion where he gets a number of consults for. It's normal and it will improve on its own. And so they're more than qualified to see and evaluate that. Other specialties he works the closest with include PM&R, Anesthesia, Prosthetics & Orthotics. In terms of special opportunities outside of clinical medicine, you could do research. In any field of orthopedics, you can deal with the legal side of things. You could also get involved with companies that sell products specifically for pediatric orthopedics. Currently, people are developing monitoring devices for different orthotics. [23:05] The Most and Least Liked Things About the Specialty and Major Changes in the Field Philip loves getting to know families and see how their children grow and respond to their treatment. What he likes the least, on the contrary, is an infection or complication as a result of something they've done. In terms of major changes in the field, there are a lot of research and efforts focused on how to deal with the growing spine and scoliosis. There are now treatments for correcting scoliosis without fusing the spine. [27:00] Final Words of Wisdom If he had to do it all over again, Philip would still have chosen the same specialty. Finally, he wishes to impart to students that while it's worth it in the end, it's certainly a long road. So you and your family have to be prepared for that. It's a big-time commitment on the front end to do orthopedic residency and afterward. Be prepared for a difficult and challenging residency that will test your stamina. But be willing to do it and approach it with a cheerful attitude and inquisitive mind. Links: The Premed Years Board Rounds

Session 104 Dr. Bruce Chamberlain tells me why he sees palliative medicine as more of a calling than a specialty. We discuss empathy, communication, and avoiding burnout. Bruce has been out of his training now for 29 years and has been practicing hospice and palliative care medicine all around the country. In case you may not have come across it yet, please do check out Board Rounds podcast, which I do with BoardVitals, a USMLE/COMLEX Step 1/Level1 test prep company. They offer QBanks for both Step 1 and Level 1. They also have amazing QBanks for your SHELF exams for your clinical years. Going back to the episode today, palliative and hospice medicine is a specialty that is important. But not a lot of people know about this and not a lot of people actually consult palliative medicine early enough. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:50] Interested in Palliative and Hospice Care Bruce got into this specialty without a plan, in fact, he had never heard of it before. He was board-certified in internal medicine and practicing in a clinic doing internal medicine. Seeing that the majority of his patients were elderly, he began to notice a trend in his patients. They often had a functional limitation as a result of pain, whether they had osteoarthritis or low back pain. Bruce started self-educating in noninvasive pain management as well as some low-level injections. He partnered with a physical therapist. They started to become more aggressive with pain management and saw great success. As a result, a fair part of his clinic was devoted to geriatric pain management. Through the course of time, one of his patients ended up in the hospice. The hospice called him and asked to help them with pain management. So during his day off, he'd work at the hospice. Bruce considers working in hospice or palliative care as more of a calling than a job. You just feel like this is where you belong and what you're supposed to be doing.  And this happened to him. He began looking forward to half-day of the week going to the hospice. It was when he felt it was being the kind of doctor that he wanted to be. Because of this, he slowly increased his hospice time and decreased his clinic time. Until finally, the clinic asked for his commitment and asked him to fish or cut bait. While at that time, the hospice offered him a full-time position so he cut bait. From then on, he never looked back. He has done hospice and palliative care full-time or part-time for over 20 years now. [Related episode: Palliative Care - There is Always Something You Can Provide] [05:20] On Being Around Death All The Time Bruce explains that in hospice, you have to change your mindset in that you have to accept the reality that people die. Physicians are trained in the combat mode, fighting disease. And they are taking it as a personal and professional failure when a patient dies even though that's going to happen to all of us. When you accept the reality of death, then success becomes – was the patient comfortable? Were they able to have closure on outstanding emotional issues? Was the family able to be there? Were they able to die at home as opposed to being plugged into 15 different tubes and monitors in the ICU? Yes, it's sad that they died. But it's great that they died in a way they wanted to and they were comfortable.  Moreover, usually at the very end of hospice care, there would be months before death takes places where you just manage their symptoms. It's about improving their quality of life for the time they have left because they were able to aggressively manage their symptoms. And oftentimes, they get positive feedback before the death as well as after the death with family comes up to thank them. [Related episode: This Physician Wants to Change The Narrative Around Death] [08:35] Traits that Make a Great Hospice and Palliative Care Physician You have to be patient and have empathy. But you also have to have the ability to draw that fine line between empathy and getting too emotionally involved with what's going on. You have to be able to relate and have the patients feel like you actually understand them or you're there for them.  A good hospice and palliative care doctor is very skilled at pain and symptom management. In geriatrics, you would usually review the patient's medication list. [10:25] Hospice vs. Palliative Care Hospice has been defined by Medicare – a patient with a medical condition that if it continues as anticipated, we expect the patient to die within six months. Bruce doesn't actually like this definition because nobody is that good at prognostication. But Medicare is looking to change that definition to allow for earlier care. Bruce defines hospice as the point of the sphere of palliative care which is an aggressive end of life care. Palliative care refers to aggressive quality of life interventions, symptom management, and communication with the patients and their families. It's important the patient's family knows what's going as you can't have informed consent if you're not informed. They also ask the hard questions such as the resuscitation status that people are often reluctant to do or do incredibly badly. Aggressive symptom management includes pain management with patients who are post-op. Palliative care is a broader spectrum of quality of life interventions and symptom management that includes, but is not limited to, end of life care. Whereas hospice is end-of-life care. It's part of palliative care but palliative care is much more. [13:22] Diagnosing Patients Bruce explains that palliative care is not called upon to be expert diagnosticians. Usually, they already know what's happening. And they work in conjunction with other doctors. For instance, the surgeons are still taking care of the surgical issues while Bruce does symptom management. [14:30] Typical Day Bruce is currently working as an inpatient palliative care doctor. He comes in the morning and works with the nurse practitioner and two nurses who are liaisons with the hospice system. First, they review consults that have come in from yesterday afternoon and after the shop has closed down and through the next morning. Then they make up a list of all their patients for review. They look at the plans and look at whether some other interventions are needed. They then split up the consults. Bruce would usually attend to the multidisciplinary ICU rounds. The rest of the day is spent doing new consults and doing follow-up visits. They also educate them on what their discharge options are from facility rehab to long-term care facility to hospice. They would often have to explain what hospice is as what they have in their minds is the 1960s setting.  They have to explain that modern hospice involves aggressive management. You could stay on your medications. They will talk to you about risks and benefits but it's your choice. They try to keep you out of the hospital and go through the benefits involved. Most people are very surprised to hear that this is what hospice is. During family meetings, they would usually discuss the patient's condition, the current treatment plan of care, and then options going forward. Then together they make decisions when the patient is unable to participate in that decision-making process. [17:55] What He Loves About Being a Palliative Care Doctor What Bruce loves about being a palliative care doctor is having enough time. As a hospitalist, you're in and out. You have to see all these patients. You get them admitted and discharged. It's a constant rush. In palliative care, he just spends an hour and a half in a family meeting with a patient in the ICU. There was no rush. He was able to spend all the time that the family needed to answer the questions and give them the information and help them come to a decision. Bruce says there's nobody else in the hospital that can do this. Both in hospice and palliative care, they have a strong emphasis on engaging a multi-disciplinary team. They often bring in a social worker or a chaplain or a spiritual care worker. As a palliative care doctor, he would assess the needs of the patient and access the other resources. And to be able to relieve that by providing information is incredibly rewarding for Bruce. [21:18] Taking Calls In the hospice he's working in, there are only two of them and they provide an 8am-5pm service. They're a very new service to be doing the more aggressive types of interventions they're doing now. That being said, they still have to prove themselves before they can grow and get JCAHO-certified. (JCAHO stands for Joint Commission Accreditation for Hospice Organizations) And to get certified, you have to have 24/7 coverage, which can't be done as of the moment with only two of them. [22:20] The Training Path When hospice and palliative care became an ACGME one-year fellowship, it had more boards that endorsed it than he believes any other subspecialty has.  In almost all of the boards you could think of, as you go through your residency, you can then apply for a 12-month fellowship. In short, there are a lot of different paths that you can take to get there. In line with this, they believe that primary care physicians should have basic knowledge of palliative care. They should have basic pain management skills. They should be able to talk through advanced directives. They want to see primary care doctors educate themselves enough to get the basics and know when to defer to a palliative care specialist. So they want more of them trained. Part of this is because there is a growing demand for doctors doing palliative care due to the increasing aging population. Bruce says this is a field in medicine that is in high demand and will continue to be based on just population demographics. [26:00] The Challenge in a Lot of Hospitals In smaller hospitals, full-time palliative care is somewhat limited that it becomes an extra duty for the hospitalist. Previously, Bruce implemented inpatient palliative care as part of his hospitalist practice. The hospital paid him a stipend to manage it. However, it doesn't pay for itself in a silo. Instead, they save a lot of money by getting patients out of the ICU sooner and getting them discharged sooner. In the big picture, every study that has been done has shown that inpatient palliative care saves the hospital money. Unfortunately, hospitals just look at the cost. This becomes challenging for smaller hospitals to want to go out and bring in a full-time palliative care doctor. In this regard, hospitals are using nurse practitioners in that role. And the issue is they don't make tons of money with what they do. [27:44] Working with Primary Care Doctors The first thing Bruce wishes that primary care doctors knew is that they don't have to wait until their patient is actively dying to get palliative care involved.  If you have an elderly patient with multiple chronic medical problems, those are patients that palliative care can help with. They can help with symptom management. They can take the time that primary care doctors don't have in the clinic. They can provide this service. Don't wait until end of life and don't let their patients suffer. If they're having trouble managing pain, they can help with this. In fact, this is an increasing problem, with opioids not being prescribed by a lot of doctors anymore because they're so nervous about it. [29:50] Special Opportunities Outside of Clinical Medicine There a lot of academic opportunities for palliative care doctors. Many of them actually move up into administration. Other opportunities include research and teaching. On another note, what Bruce likes the least about being a hospice and palliative care doctor is the fact that most people don't understand what they do. They just see him as the "death doctor" without really understanding the broader picture. He also doesn't like the current financial picture. [31:50] Major Changes in the Field With the workforce shortage and the aging population, Bruce thinks that there has got to be a change in the Medicare regulations for the hospice benefit. Hopefully, there's more involvement in palliative care in residencies and medical schools. This way, there's more exposure and a better understanding of what they do. Ultimately, if he had to do it all over again, Bruce thinks this actually is a hard question. Where he came from, there were very few full-time jobs in hospice and palliative care medicine. So he had multiple job changes and each time, there was significant stress. All those being said, in terms of his personal path, he wouldn't mind doing something more stable and consistent. But in terms of the work he does, he feels this is more of a ministry. He loves what he does. [33:50] Final Words of Wisdom If you're a student doing rotation, go spend some elective time. It's a great way to see what they do. Volunteer with a hospice. They always need volunteers. Go shadow a hospice doctor.  Bruce also draws the difference between inpatient palliative care, outpatient palliative care, and hospice. Each has a very special skill set and special population. So go out there and get exposed to it! [34:50] Interview with Dr. BJ Miller I had a previous interview with Dr. BJ Miller, a triple amputee from an accident he had while in college He went on to medical school and became a hospice and palliative care medicine specialist. He has made it his life's mission to help people die in a better way. Check out that interview on The Premed Years Podcast Episode 301. Links: Board Rounds podcast BoardVitals The Premed Years Podcast Episode 301 with Dr. BJ Miller: Near-Death Experience Led This Physician to Help People Die

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

Session 03 Board Rounds is back with BoardVitals and Dr. Andrea Paul to discuss when you should start preparing for the USMLE Step 1 and COMLEX Level 1 exams. This week, we're going to dive into when you should start preparing for these exams. The Step 1/Level 1 are going to be one of the most important pieces in your residency journey. And so we need to make sure you're preparing as best as possible and when you start doing that. [02:11] When to Start Thinking About Preparing for the Boards Sit down and start with setting a goal. Which specialty are you planning to apply to or would you like to be able to apply to? What's the minimum score would you feel is acceptable or competitive for those areas. Then look at your schedule to see what time you're available or what time do you want to dedicate for studying. And sticking to that is really important. Be present and work harder on those hours. Always have some flex days, especially towards the end. [04:49] Setting Dedicated Time You need to schedule dedicated time during all those classes. So if you're doing biochemistry, you need to carve out an hour on few days a week where you're going to do biochemistry related questions on your USMLE prep materials. This way, you're able to connect them earlier. To help you score higher, start preparing early. Know what scores you need and test yourself to see if you're getting towards that. "If you start making those connections early... it all helps you down the road." [08:30] What Resources to Use and Average Study Time Andrea thinks that paper textbooks are not always the most user-friendly. The great thing about online resources is that you can take them anywhere. You also get to customize what you're learning. Most students study for Step 1 during their preclinical curriculum, during the first year of medical school. And then the intensity increases during that dedicated time. Most of them would average 11 hours of studying per day for 35 days, usually covering 4000 practice sessions during that amount of study time. "Most students now are averaging about 11 hours of studying per day for Step 1 and that's for about 35 days. That's an incredible number of hours to study." Moreover, their data says that the number of days people study didn't correlate with their scores. Right around the midpoint was when the scores were highest. But students think more and more is better. So this is something to keep in mind. Also, their strongest correlation with high scores is the number of practice questions they took and their grades in school. Ultimately, Andrea says it's all about a combination of someone's work ethic and being a good test-taker that leads to a good score. [14:42] Simulating the Test Environment and Eliminating Distractions When you're interrupted with a text message or when you're on your phone, it takes about 15-20 minutes to get back into the flow of where you were before that interruption. if you add those three into an hour, well, it's not a very effective hour, isn't it? It is therefore important to simulate the test environment. When you're in a question bank and doing questions, you're not going to have the phone or someone knocking on the door, or any distractions. That being said, you want to make the most of your study time. Put that phone somewhere else or turn it off. And simulate that same environment as much as you can. Even when you need to utilize your resource online, don't have other things or windows open. Keep a spreadsheet maybe open and just minimized so you could take notes. Avoid breaking up the actual studying with looking up some side information you might have thought of. Instead, keep that checklist and make quick notes of what you need to go back or what you need to go and review more on. Otherwise, it's best not to open another tab or window. "It's will power but it's a month of your life and it will be worth it and you'll be glad that you didn't worry about your social media for a few days." [18:38] Practice Questions and Reviews Just use the question bank and there's a sheer number of questions you can look at and practice to help you. Again, this was the strongest correlation with the high score. So look at it as doing blocks of questions in different ways. For instance, today, look at the cardiovascular system and do a full day of questions in that area. This way, you're randomizing different materials and your mind has to go to all those different places. Additionally, after answering the question, immediately click a box to open the explanation to see if you're right or wrong and why. Their explanation will then go through each option why it was not the correct answer. This is the best way to start out since you're still in the knowledge-gathering phase, more so than the assessment phase. Then as you progress and you see your scores get closer to your goal, that's the time you can go to the test mode and do more assessment. With BoardVitals, you can create any length of the exam you like and any format you like. So you can set your own time. On average, the time students spend on each question is based on about a minute and a half. If you focus around that minute mark, that's going to get you finished on time. [23:44] Predicting Your Score Andrea says you can't really predict that but you can't fully simulate a real test environment or each person's knowledge on the specific topics they're going to get on that day. There's always going to be variation.Finally, just do as many questions as possible and even if the topic may not be exactly the same. [28:00] Manage Your Life "Make sure that dedicated study time is truly dedicated as possible." Exercise. Start your day doing something active. This way, you're going to enhance your ability to retain knowledge so much more than just staring for four to five hours. It's really all about being intentional with your day to set yourself up to success. Use the promo code BOARDROUNDS to sign up and get 15%. In every sign up, BoardVitals will donate a vaccine to a child in need through the GIVEVACS program. Links: BoardVitals

Session 01 The Medical School Headquarters and BoardVitals are going to help you prepare for your first board exam with questions, pearls of information, and guidance to make sure you have what it takes to score high and match into your specialty of choice! Board Rounds is a podcast for medical students as they prepare for Step 1 or Level 1 of the USMLE or COMLEX exams. Please follow us along with all our other podcasts on MedEd Media Network. BoardVitals is an amazing test prep company that helps medical students and almost everybody in health care with their exams. Whether it's the Shelf Exam while you're doing rotations or your clinical years, or even later on as a physician studying for your boards, BoardVitals has got something that will help you every step of the way! Today, we're joined by Dr. Andrea Paul and learn all about her journey and all about BoardVitals. [02:00] About Dr. Paul and BoardVitals A physician by training, Andrea took the Internal Medicine route and transitioned to Pathology residency until she decided to pursue her business idea before proceeding with her clinical training. Hence, the birth of BoardVitals, which she has been running since 2013. What got her into the field of medicine was having family influence having family members who are doctors. Following the traditional path, she enjoyed science and realized she loved learning and being involved in the education component more than the practice of medicine. [03:10] Her Thought Process in Jumping on the Education Route In residency, Andrea realized that the way people were studying and learning was inefficient and really low tech. She thought it was crazy and that she had to figure out a way to put content into a material that's more accessible and that it can be used wider than just one residency program. This was when the idea was born, starting with some medical specialties and working backward. Then they ended up focusing on all the medical student exams. Over the last five years, BoardVitals is now in 60 different all professional and medical exam areas covering everything from surgical tech, radiology tech, and nursing, all the way through to medical students, pharmacy students, and nursing students. Plus, the various medical subspecialties as well as some of the dental and podiatry areas. "Once we had a good platform and system, we realized that you just need to insert the content into that same learning system and it really works for every different area." [05:35] What Correlates to a Good Score Andrea explains that what correlates to a great score is to spend a number of questions that people take -- simulated exam questions with good, detailed explanations. Textbooks, lectures, or other things didn't move the meter as far as getting into that top core area but the number of questions that people did really made the difference. This then became their sole area of focus. They have questions along with detailed, informative explanations for each question. [06:45] Finding People to Write Their Questions The company has over 400 physicians, nurses, etc. across all areas that are creating their content. They look for people who have recently taken the exam or those involved in academics teaching students to prepare for a specific test. It's an expensive series of review afterwards. The initial writers go through medical editing and copyediting. Then, the get some feedback about any updates or changes that recently came out submitted right to their editors, who respond within two business days. [08:40] Medical Students Preparing for the Boards Andrea points out that Step 1 is so high stake and so important that they would recommend people to start using it as soon as they start medical school. The great thing about their platform is that they're questions. You're getting immediate feedback so you could see your areas of strength and weakness right of the getgo. So if you continue to use those, as they questions change and evolve over time, you can definitely see how your strengths and weaknesses improve and position yourself to get a really high score. "There's no reason that you shouldn't be continually self-assessing." [10:15] Students Who Are Auditory in Their Learning Style Andrea explains that learning can be broken down into active and passive. Passive learning involves things like audio prep, reading, and things where you're absorbing and taking in without having to provide any kind of active engagement or response. What they've found with the audio material, in general, is that people's attention waxes and wanes. Hence, if you're doing audio, listen to it more than once. Repetition is key because there may be times you could miss something so when you go back and listen again, hopefully, you catch it the second or third time around. Something that requires an active amount of active learning is effectiveness since you don't have that opportunity to zone out. "Combining those depending on what works for your individual learning style is really important." [11:40] The Future of BoardVitals Andrea says her company is continuing to expand. Currently, they're covering most of the medical specialty areas and they could see themselves expanding. Now that they have an active learning component, they're looking to go after some other passive components of doing things like audio and video materials that will help you as well. Part of that is this podcast covering Step 1 and Level 1. "Step 1 or Level 1 is such an important part of your residency journey." Links: BoardVitals MedEd Media Network

Session 19 Today, I'm going to do a deep dive into some match data for Orthopedic Surgery, which is one of the more competitive specialties out there. Let's look at the data to see if this holds true and find out who you can set yourself up for success early on if this is something you’re interested in. In general, Orthopedic Surgery is a surgical specialty. It's a five-year residency with a lot of subspecialties after that. I had Dr. Muppavurapu to talk about being a hand surgeon back in Episode 05 and he talked about the many other things you can do like joints, spine, hand, and so much more. Today we're going to talk generically about ortho residency matching as a medical student. [02:55] Number of Programs, Spots, U.S. Seniors NRMP is the MD application. (If you're reading this way in the future, words like ACGME and AOA won't really mean much because the MD and DO residency programs will have merged assuming all goes well as planned out for 2020.) Looking at Table 1 for the NRMP Results and Data 2016 Main Residency Match, there are 163 programs in the country for orthopedic surgery. Just to give you an idea of the number of programs for other specialties, Anesthesiology had 119 PGY-1 spots and 77 PGY-2 spots, a total of 196 compared to 163 for Orthopedic Surgery. Neurosurgery had 105 programs, Emergency Medicine had 174 programs. This somehow gives you an idea of how many programs are out there for Orthopedic Surgery. Another important number to look at here is the number of spots available. Orthopedic Surgery had 163 programs with 717 different spots available so that's average of 4.398 spot per program. Comparing to other programs, Emergency Medicine had only 11 more programs but more than double the number of spots offered. Out of the 63 programs for Orthopedic Surgery, none of the programs went unfilled. Many residency programs here had 100% fill rate so it's not unusual but again, an important thing to keep in mind. As you think about your specialty, how competitive is it for you to match into? How spots are going to be available? If you don't match for some reason, can you do the Supplemental Offer and Acceptance Program (SOAP)? Can you find an open program? For something competitive like Orthopedics, you probably won't be able to find one and it's going to be much, much harder for programs that typically go completely filled. There were 717 available spots while there were 1,058 total applicants. 874 of those were U.S. Seniors. Note that the number of U.S. Seniors applying are even more than the spots offered. Out of the number of students that matched, 650 were U.S. Seniors. That means U.S. Seniors make up 90.6% of students that matched into orthopedic residency. U.S. Seniors here are allopathic U.S. Seniors (students at MD Programs). Ortho do not have any programs that match directly into PGY-2 positions. They are all categorical spots where you apply for ortho, you do your internship right there in that one program for five years. [07:25] Allopathic and Osteopathic Students There is always this DO versus MD "competitiveness" going on in the premed world. Here is where there is some bias among residencies. Orthopedic Surgery has been known historically as one of the biggest residency programs out there that has some negative bias towards DOs. NRMP Match Data Table 2 shows matches by specialty in applicant type and looking at Orthopedic Surgery with 717 positions, 717 filled, 650 were U.S. Allopathic Seniors, 49 were U.S. Grads (this refers to those who either took some time off and didn't apply during the normal time you're supposed to apply to residencies or maybe didn't match the first time, went and got some research opportunities and ended up matching after graduating), and only 4 of the 717 were osteopathic students. That is just about half of 1%. Compared to other specialties, Anesthesiology seemed very favorable to DO's with osteopathic students comprising 14.4% of all that matched. While in Emergency Medicine, 11.8% of those that matched in the filled spots were osteopathic students. Apparently, Orthopedic Surgery stuck with the the tried and true position of not being very "DO friendly." Remember that osteopathic schools and students can apply to osteopathic residencies and you can also apply to the MD residencies which accounts for the number of osteopathic numbers on the NRMP (allopathic) data. But in the osteopathic world, there are orthopedic surgery residencies. Therefore, don't think that just because you only got into an osteopathic school that your chances of getting into an orthopedic surgery residency are going to be slim to none. Based on the AOA Match Data for 2016, there are 40 Orthopedic Surgery programs in the osteopathic world, with 121 positions, 118 were filled, 3 went unfilled. In the MD world, it's highly unusual to have unfilled orthopedic spots. [11:06] Growth, Positions Filled, U.S. Seniors and All Applicants NRMP Match Data Table 3 shows the growth of each of the specialties over the period of five years (2012-2016). Orthopedic Surgery is among those growing at a good pace around 2.5% each year. With 682 spots in 2012, it has grown to 717 in 2016 which suggests a pretty steady growth. This is good for you especially if you're thinking about Orthopedics since it means there are more and more spots offered. The data in Table 7 confirms how Orthopedic Surgery is usually a specialty that doesn't go unfilled. There were no available spots in 2016, 2015 and 2012, only 2 spots in 2014, only 1 spot in 2013. Looking at Table 8, it shows the Positions Offered and Percent Filled by U.S. Seniors and All Applicants (again, U.S. Seniors being MD Seniors that have graduated from an MD school). In 2012, 94% of those offered a position consist of U.S. Seniors. This percentage dipped to 91.9% in 2013 and went back up to 93.4% in 2014, and 94.3% in 2015, and then dropped down further to 90.7% in 2016. This tells us that there are a lot of students who are non-U.S. Seniors filling these spots. They could be international medical graduates or U.S. grads that were not Seniors who are people that have taken some time off. [14:15] PGY-1 for All Applicants and Osteopathic Students and Unmatched Students Table 9 shows the percentage of applicants that have matched to a PGY-1 spot in each specialty compared to the whole. Anesthesiology is at 4%, Emergency Medicine with 7.1%, Family Medicine 11.5%. Orthopedics is 2.7% which is pretty small compared to some of the bigger ones like Family Medicine, Internal Medicine, and Pediatrics. Even Psychiatry is pretty big at 5.1%. For the Osteopathic students looking at the NRMP Match Data Table 11 shows the percentage of students that are osteopathic graduates that matched into Orthopedics with only 0.2% of all osteopathics students that matched did match into Ortho that means only 0.05% osteopaths matched into a spot. And comparing this to the bigger programs, Anesthesiology at 6.4%, Emergency Medicine at 9.3%, and Family Medicine at 15.9%. Again, it is very hard for an osteopathic student into a MD orthopedic surgery residency. NRMP Match Data Figure 6 shows the percentages of unmatched U.S. Seniors and independent applicants who ranked Ortho and other specialties. 25.1% of all those that applied to Orthopedic Surgery went unmatched, 20.8% were U.S. Seniors, 56.6% were unmatched independent applicants (the DOs and international medical grads). As a non-US allopathic medical school grad, it's very hard to match into an allopathic orthopedic surgery residency. [17:05] Charting the Outcomes for U.S. Allopathic Seniors Looking at the data found in NRMP Charting the Outcomes 2016, Table 1 breaks down the number of applicants per position for Orthopedic Surgery. With 717 positions offered and 1,034 applicants, there were 1.4 applicants per position. Outside of four other specialties, Orthopedic Surgery is the most competitive. Dermatology is last at 1.4, General Surgery at 1.49, Psychiatry at 1.54, and Vascular Surgery at 1.91. This goes to show how Orthopedic Surgery is a highly competitive residency. Chart 4 shows the Median Number of Contiguous Ranks of U.S. Allopathic Seniors. This is the ranking of how many programs they've ranked, they've matched and didn't match. And this is always one of the biggest question marks if you don't match into a residency, which is: Did you apply to enough spots? The answer is usually no. This is very similar to medical school application where if you didn't get it, you'd have to ask yourself if you applied to enough schools to increase your odds. For Orthopedic Surgery, the median number of contiguous ranks was 12. Those that did not match was only 6. So if you only ranked half of those that matched, then you'd have a much better shot at not getting in. [19:15] USMLE Step 1 Scores, Research Experiences, and AOA If you're a medical student getting ready to study for the Boards or if you're in your first year and just preparing, we are launching a Step 1 Level 1 Board Review Podcast called Board Rounds in the next couple of weeks so stay tuned for that! Subscribe to it now. Charting the Outcomes 2016 also shows the USMLE Step 1 scores for U.S. Allopathic Seniors. For Orthopedic Surgery, it's at the top spot with some of the other more competitive specialties with those that matched averaging at 248-250 and those that did not match were right there on 240. Therefore, you need to do well on Step 1 to match into Ortho. One of the misconceptions about Orthopods is them being dumb jocks but that's not true of course. You need to get really great board scores to get into Ortho and research experience doesn't lack either. Based on Chart 8, the mean number of research experiences is 4 for those that matched and 8 for those that did not match. So if you're interested in Orthopedics, do some research as it seems important based on this data. Chart 12 shows the percentage of U.S. Allopathic Seniors who are part of AOA (Alpha Omega Alpha), the honor medical society that highlights the students who do well the first couple years of medical school. For Orthopedic Surgery, 34% of those that matched are AOA students while 12% for those that did not match. The takeaway here is to start off medical school doing really very well so you can try to get AOA. [21:47] Medscape Lifestyle Report 2017 The Medscape Lifestyle Report 2017 presents data on burnout, bias, race, etc. Orthopedic Surgery is in the bottom half of the burnout chart at 49%. Yes, this is still a lot but this is the bottom half of the chart. The biggest takeaway is that a lot of physicians are burned out and Orthopedics is one of the least, which is good. How severe is the burnout? Orthopedic Surgery is in the lower half of the chart. Which physicians are the happiest? Orthopods make up the top half with 37% saying they're happy at work and 71% saying they're happy outside of work. This is another pretty good data compared to the rest. [23:00] Medscape Physician Compensation Report 2017 Looking at the recently updated Medscape Physician Compensation Report 2017, Orthopedics is at the top of the list for most compensated physicians with an average annual compensation of $489,000. If you're interested in Orthopedics then you will probably make a very good income which is well-deserved. And this is up 10% from last year. Only 48% of Orthopods feel fairly compensated and this is strange considering they're the highest paid of all the specialties. 79% of Orthopods say they'd choose Medicine again, and unsurprisingly, 95% of Orthopods say that they'd choose Orthopedics again. In general, Orthopods are pretty happy with their career choice. [24:29] My Final Thoughts I hope this helped you get some clarity with Orthopedics Surgery if this is something you're interested in. I hope you're also pretty early on in your journey because as I've mentioned, research is necessary and you need to do well on Step 1 as well as try to get AOA. Therefore, you need to start setting yourself up for success as soon as you can. Links: NRMP Results and Data 2016 - Main Residency Match AOA Match Data for 2016 NRMP Charting the Outcomes 2016 Medscape Lifestyle Report 2017 Medscape Physician Compensation Report 2017 Board Rounds Podcast SS 05: What Does the Life of an Orthopedic Hand Surgeon Look Like? NRMP ACGME AOA Supplemental Offer and Acceptance Program (SOAP) AOA (Alpha Omega Alpha)