Podcasts about her interest

In this episode of Trivia Talks, We are honored to host Dhairya Gangwani. Dhairya is an Electric & Communication engineer who is currently working as an SAP Analyst with KPMG. Her Interest lies in Public speaking, management, consulting, and Content writing. In this episode, Dhairya shares her journey as a mentor and provides us a lot of tips and tricks on how to find the right mentor, managing time, and also on cracking Interviews. Listen to the full podcast and get valuable insight into the topic. Follow us on Instagram: www.instagram.com/trivia_talks Dhairya Gangwani- LinkedIn: https://www.linkedin.com/in/dhairya-gangwani Website: https://www.dhairyadecodes.com Tarun Mundhra- www.linkedin.com/in/tarunmundhra www.instagram.com/tarun_mundhra _____________________________________________________________________________________ Check out these cool products on Amazon- Maono AU-A04 podcast mic - https://amzn.to/2E9ljNF Mi Headphone - https://amzn.to/3cacdwO Green Screen - https://amzn.to/3hG1efJ Clip Mic - https://amzn.to/32EPK7W Flopper - https://amzn.to/35KRWwt Sunglasses: https://amzn.to/3iIJ3Y1. #Podcast #podcasts #podcasting #podcaster #podcasters #podcastlife #podcastshow #podcastlove #podcastaddict #podcasthost #podcastersofinstagram #podcastmovement #PodcastJunkie #podcastinglife #podcastnetwork #PodcastSeries #podcastincolor #podcastone #PodcastDay #podcastepisode #podcastrepublic #podcastnews #podcastawards #podcastlifestyle #podcastenespa #podcastlistening #PodcastMafia #podcastapp #podcastinterview #podcaststudio --- Send in a voice message: https://anchor.fm/trivia-talks/message

Sessions Wrestler and LFC prospect Gia Love is this week's guest on The LFC Podcast. Listen as she talks getting into sessions wrestling, Cosplaying, Gaming, Her Interest in LFC, And Much More. twitter.com/QueenGiaLove hubzter.com/profile/QueenGiaLove/ www.pscp.tv/QueenGiaLove/1ZkKzArmQkyxv www.instagram.com/queen_gialove/ lingeriefc.com/ twitter.com/LingerieFC www.instagram.com/lingeriefightingchampionships/ www.youtube.com/channel/UCAiXTBMJdbCLlWzJbWATYSw www.steveandmikeshow.com/ @mclarkin92 twitter.com/MCL92 twitter.com/SMShow1

Here is Episode 24 of The LFC Podcast With Wrestler Delyte Dalacruz. Listen as Delyte Discusses being trained by Kyla Luciano, Getting Into Sessions Wrestling, Working With Chloe Cummings, Working With Mark Gagliardi and Brutal Beauties, Her Interest in LFC, And Much More. lingeriefc.com/ www.facebook.com/lfcfighting www.instagram.com/lingeriefightingchampionships/ www.youtube.com/channel/UCAiXTBMJdbCLlWzJbWATYS www.steveandmikeshow.com/ @mclarkin92 twitter.com/MCL92 twitter.com/SMShow1 twitter.com/DDalacruz www.instagram.com/delytedalacruz/ www.sessiongirls.com/Delyte84/profile

Gia Deluca Stands at 6 Foot1 With An Amazing Stature and Overall Prowess. Listen as she discusses her Sessions Wrestling Work, The MMA-Wrestling Tie-In, Her Interest in LFC, And Much More. www.instagram.com/tallgoddessgia5.0/ twitter.com/tallgoddessgia tallgoddessgia.ca/ ubifan.com/user/gia-de-luca/ lingeriefc.com/ twitter.com/LingerieFC www.facebook.com/lfcfighting www.instagram.com/lingeriefightingchampionships/ www.youtube.com/channel/UCAiXTBMJdbCLlWzJbWATYSw www.steveandmikeshow.com/ @mclarkin92 twitter.com/MCL92 twitter.com/SMShow1

Check Out Episode 19 of The Official LFC Podcast as MMA Fighter Helena Padilla Discusses Her Training at Syndicate MMA, Her Interest in LFC, And Much more. lingeriefc.com/ twitter.com/LingerieFC www.facebook.com/lfcfighting www.instagram.com/lingeriefightingchampionships/ www.youtube.com/channel/UCAiXTBMJdbCLlWzJbWATYS www.instagram.com/syndicatemma/ www.facebook.com/SyndicateMMA twitter.com/SyndicateMMA www.facebook.com/HellenaconH www.instagram.com/hellenapadilla/ Soundcloud: User-392305049 – The-lfc-podcast-episode-19-mma-fighter-helena-padilla Stitcher: www.stitcher.com/podcast/michael-larkin Anchor: anchor.fm/lfc Tune In: tunein.com/podcasts/Sports--Re…C-Podcast-p1227604/ play.google.com/music/listen?gcli…xplsixqii6aer37oy

My guest, Taylor Pierce, is a therapist at the Center for Couples & Sex Therapy in Portland, Oregon. She works closely with couples to explore issues in relationships and sexuality and really loves connecting and working with the LGBQT community and ethically non-monogamous dynamics. In this episode, in particular, she explains the ins and outs of jealousy and how we can avoid it by diving deeper into the root causes of our insecurities and fears. Really important, powerful stuff that Taylor does a great job demystifying! Her Interest in Jealousy Taylor says that she first gained an interest in jealousy because she likes working with people who are in ethically non-monogamous relationships, and jealousy can come up a lot within that relationship dynamic. But Taylor soon began peeling back the layers of the jealousy onion and realized that jealousy is a basic, universal trait of many types of relationships. This led her even farther into a specialized interest in the trait and she has a lot to share about the subject! Control Issues Because of Jealousy Often, if a partner becomes jealous, they can forbid the other from seeing another person out of insecurity or fear. For example, let’s say that a couple in a monogamous relationship develop some trust issues. It can be common for one of the people in that relationship to assert too much control over the other because of underlying insecurities. Taylor says it’s never a good thing to let the jealousy morph into controlling situations because it’s often a sign of avoiding communication about the deeper issues at play: insecurity and a lack of trust. Primary and Secondary Emotions To understand jealousy on a deeper level, Taylor says that you can frame it through primary and secondary emotions. Primary emotions are your gut reactions. They are the most vulnerable and tend to act as defense mechanisms. They are also full of fear and display any insecurities that may have been circulating inside of you. Secondary emotions are reactions to those primary emotions, which in turn add to the complexity of the overall emotional reaction. Jealousy is a secondary emotion; it may arise after feeling angry, sad or hurt when your partner is flirting with someone else. Steps for De-escalating Jealousy Taylor reminds you to first be self-understanding because jealousy is a pretty common emotion to have. Almost everyone has felt jealous in a relationship before–if not now, then probably in the future. She says self-awareness of emotions or deeper core issues at play– like a fear of abandonment–can help mitigate the overall intensity and longevity of your jealousy. Taylor also encourages you to ask yourself questions to investigate the surrounding thoughts around your feelings of jealousy. And if you start having that regular dialogue with yourself, you’ll find that you come to the root cause of your jealousy and can often move past it. Identify What You Need to Feel Safe After you have identified what emotions or deeper insecurities are at play in your jealousy, Taylor encourages you to make a list for achieving a safe solution to your jealousy. She states that the list should be a balance between the work you do yourself and your partner could provide for you–for example, reassurance that you are not going to be abandoned. Create Self-Care Rituals Taylor says that creating a self-care ritual can really help if you’re struggling with jealousy. So often the main cause of jealousy is a feeling of inadequacy and insecurity, so reminding yourself just how strong you are, as well as empowering yourself with positivity, is never a waste of time! Negative Reactions to Jealousy Taylor says that shaming yourself for feeling jealous will only make you stuck in jealousy even more. She also states that trying to react to jealousy by controlling your partner is a bad idea as well because it will only keep you in that cycle of jealousy. More Sexual Connection Rather Than Avoidance Taylor says that avoiding jealousy is also a gateway for better, more connected sex with your partner. There are a lot of jealousy issues around porn use or your partner’s sexual history, but if you can dive deeper into the layers of your jealousy and not react automatically, you can come out the other side much more connected. Compersion The term compersion is often associated with the non-monogamous community. It is a direct antonym to sexual or romantic jealousy. Taylor describes it as the positive feeling you may have when someone you love is experiencing something positive and fulfilling in a romantic or sexual way. And although by definition this is the complete opposite of what you’d feel while you are jealous, just trying to imagine yourself full of compersion instead of jealousy is a powerful technique for overcoming your overwhelming feelings. You can approach it from less vulnerable places in order to build up to dealing with jealousy as well. Key Links for Taylor: Her Center for Couples & Sex Therapy profile: https://ccstpdx.com/meet-the-team/meet-taylor/ Taylor’s email: taylor@ccstpdx.com More info:Link to the free guide – Talking About Sex: http://bettersexpodcast.com/talkJoin my email list here: http://bettersexpodcast.com/listBook and New Course – https://sexwithoutstress.comWeb – https://www.bettersexpodcast.com/Sex Health Quiz – http://sexhealthquiz.com/If you’re enjoying the podcast and want to be a part of making sure it continues in the future, consider being a patron. With a small monthly pledge, you can support the costs of putting this show together. For as little as $2 per month, you can get advance access to each episode. For just a bit more, you will receive an advance copy of a chapter of my new book. And for $10 per month, you get all that plus an invitation to an online Q&A chat with me once a quarter. Learn more at https://www.patreon.com/bettersexpodcastBetter Sex with Jessa Zimmermanhttps://businessinnovatorsradio.com/better-sex/

My guest, Taylor Pierce, is a therapist at the Center for Couples & Sex Therapy in Portland, Oregon. She works closely with couples to explore issues in relationships and sexuality and really loves connecting and working with the LGBQT community and ethically non-monogamous dynamics. In this episode, in particular, she explains the ins and outs of jealousy and how we can avoid it by diving deeper into the root causes of our insecurities and fears. Really important, powerful stuff that Taylor does a great job demystifying! Her Interest in Jealousy Taylor says that she first gained an interest in jealousy because she likes working with people who are in ethically non-monogamous relationships, and jealousy can come up a lot within that relationship dynamic. But Taylor soon began peeling back the layers of the jealousy onion and realized that jealousy is a basic, universal trait of many types of relationships. This led her even farther into a specialized interest in the trait and she has a lot to share about the subject! Control Issues Because of Jealousy Often, if a partner becomes jealous, they can forbid the other from seeing another person out of insecurity or fear. For example, let’s say that a couple in a monogamous relationship develop some trust issues. It can be common for one of the people in that relationship to assert too much control over the other because of underlying insecurities. Taylor says it’s never a good thing to let the jealousy morph into controlling situations because it’s often a sign of avoiding communication about the deeper issues at play: insecurity and a lack of trust. Primary and Secondary Emotions To understand jealousy on a deeper level, Taylor says that you can frame it through primary and secondary emotions. Primary emotions are your gut reactions. They are the most vulnerable and tend to act as defense mechanisms. They are also full of fear and display any insecurities that may have been circulating inside of you. Secondary emotions are reactions to those primary emotions, which in turn add to the complexity of the overall emotional reaction. Jealousy is a secondary emotion; it may arise after feeling angry, sad or hurt when your partner is flirting with someone else. Steps for De-escalating Jealousy Taylor reminds you to first be self-understanding because jealousy is a pretty common emotion to have. Almost everyone has felt jealous in a relationship before–if not now, then probably in the future. She says self-awareness of emotions or deeper core issues at play– like a fear of abandonment–can help mitigate the overall intensity and longevity of your jealousy. Taylor also encourages you to ask yourself questions to investigate the surrounding thoughts around your feelings of jealousy. And if you start having that regular dialogue with yourself, you’ll find that you come to the root cause of your jealousy and can often move past it. Identify What You Need to Feel Safe After you have identified what emotions or deeper insecurities are at play in your jealousy, Taylor encourages you to make a list for achieving a safe solution to your jealousy. She states that the list should be a balance between the work you do yourself and your partner could provide for you–for example, reassurance that you are not going to be abandoned. Create Self-Care Rituals Taylor says that creating a self-care ritual can really help if you’re struggling with jealousy. So often the main cause of jealousy is a feeling of inadequacy and insecurity, so reminding yourself just how strong you are, as well as empowering yourself with positivity, is never a waste of time! Negative Reactions to Jealousy Taylor says that shaming yourself for feeling jealous will only make you stuck in jealousy even more. She also states that trying to react to jealousy by controlling your partner is a bad idea as well because it will only keep you in that cycle of jealousy. More Sexual Connection Rather Than Avoidance Taylor says that avoiding jealousy is also a gateway for better, more connected sex with your partner. There are a lot of jealousy issues around porn use or your partner’s sexual history, but if you can dive deeper into the layers of your jealousy and not react automatically, you can come out the other side much more connected. Compersion The term compersion is often associated with the non-monogamous community. It is a direct antonym to sexual or romantic jealousy. Taylor describes it as the positive feeling you may have when someone you love is experiencing something positive and fulfilling in a romantic or sexual way. And although by definition this is the complete opposite of what you’d feel while you are jealous, just trying to imagine yourself full of compersion instead of jealousy is a powerful technique for overcoming your overwhelming feelings. You can approach it from less vulnerable places in order to build up to dealing with jealousy as well. Key Links for Taylor: Her Center for Couples & Sex Therapy profile: https://ccstpdx.com/meet-the-team/meet-taylor/ Taylor’s email: taylor@ccstpdx.com More info:Link to the free guide – Talking About Sex: http://bettersexpodcast.com/talkJoin my email list here: http://bettersexpodcast.com/listBook and New Course – https://sexwithoutstress.comWeb – https://www.bettersexpodcast.com/Sex Health Quiz – http://sexhealthquiz.com/If you’re enjoying the podcast and want to be a part of making sure it continues in the future, consider being a patron. With a small monthly pledge, you can support the costs of putting this show together. For as little as $2 per month, you can get advance access to each episode. For just a bit more, you will receive an advance copy of a chapter of my new book. And for $10 per month, you get all that plus an invitation to an online Q&A chat with me once a quarter. Learn more at https://www.patreon.com/bettersexpodcastBetter Sex with Jessa Zimmermanhttps://businessinnovatorsradio.com/better-sex/

My guest, Taylor Pierce, is a therapist at the Center for Couples & Sex Therapy in Portland, Oregon. She works closely with couples to explore issues in relationships and sexuality and really loves connecting and working with the LGBQT community and ethically non-monogamous dynamics. In this episode, in particular, she explains the ins and outs of jealousy and how we can avoid it by diving deeper into the root causes of our insecurities and fears. Really important, powerful stuff that Taylor does a great job demystifying! Her Interest in Jealousy Taylor says that she first gained an interest in jealousy because she likes working with people who are in ethically non-monogamous relationships, and jealousy can come up a lot within that relationship dynamic. But Taylor soon began peeling back the layers of the jealousy onion and realized that jealousy is a basic, universal trait of many types of relationships. This led her even farther into a specialized interest in the trait and she has a lot to share about the subject! Control Issues Because of Jealousy Often, if a partner becomes jealous, they can forbid the other from seeing another person out of insecurity or fear. For example, let’s say that a couple in a monogamous relationship develop some trust issues. It can be common for one of the people in that relationship to assert too much control over the other because of underlying insecurities. Taylor says it’s never a good thing to let the jealousy morph into controlling situations because it’s often a sign of avoiding communication about the deeper issues at play: insecurity and a lack of trust. Primary and Secondary Emotions To understand jealousy on a deeper level, Taylor says that you can frame it through primary and secondary emotions. Primary emotions are your gut reactions. They are the most vulnerable and tend to act as defense mechanisms. They are also full of fear and display any insecurities that may have been circulating inside of you. Secondary emotions are reactions to those primary emotions, which in turn add to the complexity of the overall emotional reaction. Jealousy is a secondary emotion; it may arise after feeling angry, sad or hurt when your partner is flirting with someone else. Steps for De-escalating Jealousy Taylor reminds you to first be self-understanding because jealousy is a pretty common emotion to have. Almost everyone has felt jealous in a relationship before–if not now, then probably in the future. She says self-awareness of emotions or deeper core issues at play– like a fear of abandonment–can help mitigate the overall intensity and longevity of your jealousy. Taylor also encourages you to ask yourself questions to investigate the surrounding thoughts around your feelings of jealousy. And if you start having that regular dialogue with yourself, you’ll find that you come to the root cause of your jealousy and can often move past it. Identify What You Need to Feel Safe After you have identified what emotions or deeper insecurities are at play in your jealousy, Taylor encourages you to make a list for achieving a safe solution to your jealousy. She states that the list should be a balance between the work you do yourself and your partner could provide for you–for example, reassurance that you are not going to be abandoned. Create Self-Care Rituals Taylor says that creating a self-care ritual can really help if you’re struggling with jealousy. So often the main cause of jealousy is a feeling of inadequacy and insecurity, so reminding yourself just how strong you are, as well as empowering yourself with positivity, is never a waste of time! Negative Reactions to Jealousy Taylor says that shaming yourself for feeling jealous will only make you stuck in jealousy even more. She also states that trying to react to jealousy by controlling your partner is a bad idea as well because it will only keep you in that cycle of jealousy. More Sexual Connection Rather Than Avoidance Taylor says that avoiding jealousy is also a gateway for better, more connected sex with your partner. There are a lot of jealousy issues around porn use or your partner’s sexual history, but if you can dive deeper into the layers of your jealousy and not react automatically, you can come out the other side much more connected. Compersion The term compersion is often associated with the non-monogamous community. It is a direct antonym to sexual or romantic jealousy. Taylor describes it as the positive feeling you may have when someone you love is experiencing something positive and fulfilling in a romantic or sexual way. And although by definition this is the complete opposite of what you’d feel while you are jealous, just trying to imagine yourself full of compersion instead of jealousy is a powerful technique for overcoming your overwhelming feelings. You can approach it from less vulnerable places in order to build up to dealing with jealousy as well. Key Links for Taylor: Her Center for Couples & Sex Therapy profile: https://ccstpdx.com/meet-the-team/meet-taylor/ Taylor’s email: taylor@ccstpdx.com More info:Link to the free guide – Talking About Sex: http://bettersexpodcast.com/talkJoin my email list here: http://bettersexpodcast.com/listBook and New Course – https://sexwithoutstress.comWeb – https://www.bettersexpodcast.com/Sex Health Quiz – http://sexhealthquiz.com/If you’re enjoying the podcast and want to be a part of making sure it continues in the future, consider being a patron. With a small monthly pledge, you can support the costs of putting this show together. For as little as $2 per month, you can get advance access to each episode. For just a bit more, you will receive an advance copy of a chapter of my new book. And for $10 per month, you get all that plus an invitation to an online Q&A chat with me once a quarter. Learn more at https://www.patreon.com/bettersexpodcastBetter Sex with Jessa Zimmermanhttps://businessinnovatorsradio.com/better-sex/

My guest, Taylor Pierce, is a therapist at the Center for Couples & Sex Therapy in Portland, Oregon. She works closely with couples to explore issues in relationships and sexuality and really loves connecting and working with the LGBQT community and ethically non-monogamous dynamics. In this episode, in particular, she explains the ins and outs of jealousy and how we can avoid it by diving deeper into the root causes of our insecurities and fears. Really important, powerful stuff that Taylor does a great job demystifying! Her Interest in Jealousy Taylor says that she first gained an interest in jealousy because she likes working with people who are in ethically non-monogamous relationships, and jealousy can come up a lot within that relationship dynamic. But Taylor soon began peeling back the layers of the jealousy onion and realized that jealousy is a basic, universal trait of many types of relationships. This led her even farther into a specialized interest in the trait and she has a lot to share about the subject! Control Issues Because of Jealousy Often, if a partner becomes jealous, they can forbid the other from seeing another person out of insecurity or fear. For example, let's say that a couple in a monogamous relationship develop some trust issues. It can be common for one of the people in that relationship to assert too much control over the other because of underlying insecurities. Taylor says it's never a good thing to let the jealousy morph into controlling situations because it's often a sign of avoiding communication about the deeper issues at play: insecurity and a lack of trust. Primary and Secondary Emotions To understand jealousy on a deeper level, Taylor says that you can frame it through primary and secondary emotions. Primary emotions are your gut reactions. They are the most vulnerable and tend to act as defense mechanisms. They are also full of fear and display any insecurities that may have been circulating inside of you. Secondary emotions are reactions to those primary emotions, which in turn add to the complexity of the overall emotional reaction. Jealousy is a secondary emotion; it may arise after feeling angry, sad or hurt when your partner is flirting with someone else. Steps for De-escalating Jealousy Taylor reminds you to first be self-understanding because jealousy is a pretty common emotion to have. Almost everyone has felt jealous in a relationship before–if not now, then probably in the future. She says self-awareness of emotions or deeper core issues at play– like a fear of abandonment–can help mitigate the overall intensity and longevity of your jealousy. Taylor also encourages you to ask yourself questions to investigate the surrounding thoughts around your feelings of jealousy. And if you start having that regular dialogue with yourself, you'll find that you come to the root cause of your jealousy and can often move past it. Identify What You Need to Feel Safe After you have identified what emotions or deeper insecurities are at play in your jealousy, Taylor encourages you to make a list for achieving a safe solution to your jealousy. She states that the list should be a balance between the work you do yourself and your partner could provide for you–for example, reassurance that you are not going to be abandoned. Create Self-Care Rituals Taylor says that creating a self-care ritual can really help if you're struggling with jealousy. So often the main cause of jealousy is a feeling of inadequacy and insecurity, so reminding yourself just how strong you are, as well as empowering yourself with positivity, is never a waste of time! Negative Reactions to Jealousy Taylor says that shaming yourself for feeling jealous will only make you stuck in jealousy even more. She also states that trying to react to jealousy by controlling your partner is a bad idea as well because it will only keep you in that cycle of jealousy. More Sexual Connection Rather Than Avoidance Taylor says that avoiding jealousy is also a gateway for better, more connected sex with your partner. There are a lot of jealousy issues around porn use or your partner's sexual history, but if you can dive deeper into the layers of your jealousy and not react automatically, you can come out the other side much more connected. Compersion The term compersion is often associated with the non-monogamous community. It is a direct antonym to sexual or romantic jealousy. Taylor describes it as the positive feeling you may have when someone you love is experiencing something positive and fulfilling in a romantic or sexual way. And although by definition this is the complete opposite of what you'd feel while you are jealous, just trying to imagine yourself full of compersion instead of jealousy is a powerful technique for overcoming your overwhelming feelings. You can approach it from less vulnerable places in order to build up to dealing with jealousy as well. Key Links for Taylor: Her Center for Couples & Sex Therapy profile: https://ccstpdx.com/meet-the-team/meet-taylor/ Taylor's email: taylor@ccstpdx.com More info: Link to the free guide – Talking About Sex: http://bettersexpodcast.com/talk Join my email list here: http://bettersexpodcast.com/list Book and New Course – https://sexwithoutstress.com Web – https://www.bettersexpodcast.com/ Sex Health Quiz – http://sexhealthquiz.com/ If you're enjoying the podcast and want to be a part of making sure it continues in the future, consider being a patron. With a small monthly pledge, you can support the costs of putting this show together. For as little as $2 per month, you can get advance access to each episode. For just a bit more, you will receive an advance copy of a chapter of my new book. And for $10 per month, you get all that plus an invitation to an online Q&A chat with me once a quarter. Learn more at https://www.patreon.com/bettersexpodcast Better Sex with Jessa Zimmerman https://businessinnovatorsradio.com/better-sex/More info and resources: How Big a Problem is Your Sex Life? Quiz – https://www.sexlifequiz.com The Course – https://www.intimacywithease.com The Book – https://www.sexwithoutstress.com Podcast Website – https://www.intimacywithease.com Access the Free webinar: How to make sex easy and fun for both of you: https://intimacywithease.com/masterclass Secret Podcast for the Higher Desire Partner: https://www.intimacywithease.com/hdppodcast Secret Podcast for the Lower Desire Partner: https://www.intimacywithease.com/ldppodcast

Tai Emery is an LFL All Star, Model, And is Relatively New to the MMA World. Listen as she discusses her time in The LFL and becoming friends With Lauren the Animal Fogle Of LFC, Attending LFC 26 at The Nerd Bar, How she is feeling after her recent ACL Surgery, Her Interest in LFC, And Much More in a conversation with a very positive, And Beautiful Human Being Both Inside and Out. www.instagram.com/tai_emery/ twitter.com/tai_emery lingeriefc.com/ twitter.com/LingerieFC www.facebook.com/lfcfighting www.instagram.com/lingeriefightingchampionships/ www.youtube.com/channel/UCAiXTBMJdbCLlWzJbWATYS www.steveandmikeshow.com/ @mclarkin92 twitter.com/MCL92 twitter.com/SMShow1

Session 77 Dr. Janani Krishnaswami talks about Academic Preventive Medicine including what drew her to it, and what she likes and doesn't like about prev med. Janani is a preventive medicine physician in University of Texas, Rio Grande Valley. To learn more about preventive medicine, check out all the available resources at the American College of Preventive Medicine. Also, be sure to take a listen to all our other podcasts on MedEd Media Network. [01:22] Her Interest in Preventive Medicine Janani says a lot of preventive medicine physicians basically end up stumbling into the specialty. Relatively a nontrad student, she had a background in investment banking and her background was in economics, public health, public policy, and international studies. And she has always been interested in the systems level aspect of medicine. When she started doing her third year clerkship, she saw the same patterns of patients coming into the clinic with conditions that didn't seem to be cured as well as who got the illness and who suffered the most. So she got interested in attacking that angle. Then she found out about preventive medicine as she was scouring through different programs during third year. She saw a program in internal medicine - preventive medicine track, which she thought was perfect for her. She loves interacting with patients but there was that systems element that she craved. Then she hunted around to find out more about the specialty and she was just amazed about it. "I just hunted around to find out more about this specialty and I was just so amazed. I felt I had found a diamond in the ruff as it were." [03:14] Why is Preventive Medicine So Hidden? Janani thinks that even on a national level, we talk about prevention and we all know the benefits of it. But at an actual practice level, we just don't have those opportunities. And she thinks it all comes down to the financial incentives. The way residency programs are funded and the residents are paid is tied to a certain type of funding. In short, hospitals are paid to have residents in hospitals and not in community settings, not really doing prevention. And Janani believes this is a huge part of the problem. Their incentives are misaligned with their verbiage about prevention. And if there were more aligned incentives, Janani thinks you would see preventive medicine as one of the most foundational medicines in medical school itself. "Hospitals are paid to have residents in hospitals and not really in community settings, not really doing prevention, and I think that's a huge part of the problem." [05:40] Traits that Lead to Being a Good Preventive Medicine Physician Janani says you have to be comfortable switching the big picture of population health and the individual patient, which has a bit of tension between the two. You also have to be very enterprising and proactive. Janani explains that the path is not always clear-cut especially if you want to do some combination of clinical medicine, public health, and you want to tie those worlds together. Additionally, Janani thinks you have to be an early adopter as there's not a lot of preventive medicine physicians out there. She really believes that this is something that is a foundational discipline in the future. But we're not there yet. So it takes somebody who have that vision, perseverance, and passion for the field and its components. "Systems change is very difficult and it takes somebody with perseverance and willingness to see opportunities." [07:38] Being Initially Pulled Toward Primary Care As she was going through medical school training, Janani admits also being pulled by other specialties such as family medicine, internal medicine, and all those bread and butter primary care specialties. The reason is that she just loves to connect with people. And that there's evidence now that the way a doctor communicates is integral to the health and improvement of a patient. And she was fascinated by this aspect. Ultimately, she wanted to do preventive medicine knowing that she couldn't change systems one patient at a time. So she needed to look at the big picture, apply her skills in systems based thinking in upstream medicine to really make a difference. She was just so troubled by the idea that somebody should be living years less on average of their lives or poor quality of lives as a function of their race or income status. This was what pushed her to keep going with the preventive world. [09:30] Types of Patients Janani explains that different preventive medicine physicians are doing slightly different things. But with her experience, she works with a primarily indigent, underserved, highly diverse community by design. She adds that the communities that are often helped by preventive efforts actually tend to be at relatively lower risk for disease. While people at a higher risk for disease often miss the benefits of these types of preventive efforts. So even if these efforts are well-designed, you can still potentially widen the gap between the health disparities between rich and poor, or the different socio-economic classes. As a result, she intended to come to an area with a tremendous medical need such as border communities like Texas-Mexico. So the patients she sees primarily fall into this class. The theory of who tends to bear the burden of chronic disease that is on average underserved minorities, that bears out in this region. They have epidemic rates of diabetes and obesity which are very preventable conditions - not just in terms of incidence and prevalence, but also the severity of these conditions. Much of her work is trying to create systems to better address the social determinants of health and promote the health behaviors that are conducive to prevention and optimizing the quality of life. [11:40] Typical Day In her role as program director of the Preventive Medicine Residency Program, a lot of her time is dedicated to refining the curriculum, making sure they're meeting their goals of promoting health equity and health literacy. They're focusing on building the program's network, designing optimal educational initiatives for her residents, leading didactic sessions, and a lot of education. She would also see patients in the clinic, working with lifestyle medicine and addressing chronic disease determinants. So her days would be a mix of administrative work, patient care, general strategic thinking, team meetings, and a lot of education. As an academic physician, Janani works closely with medical students. She is also the director of student wellness so she inculcates the principles of preventive medicine and spread awareness of the field at the school of medicine as well. [13:30] Three Major Directions for a General Preventive Medicine Physician Janani describes their residency as being an uplift version of the traditional hospital-based residency. Typically, most hospital-based residencies, despite being primary care, residents tend to spend about 80-90% of their time in the hospital, maybe 10-20% of their time in a clinic or a community setting. Janani explains that their residency is split on that. They are 80% in the community and 20% in the hospital, like a tertiary care setting. "What preventive medicine physicians do is intimately connect to the community." Generally, a traditional general preventive medicine job and career pathway would involve working in public health and county and state health departments. Part of the job may be doing surveillance of the entire populations and communities at a local district, county, or state level. Janani stresses the importance of understanding how is the health of the community improving and changing at a population health level. In an academic setting, the major role for preventive medicine is as program directors or faculty in preventive medicine residency programs. The other hat for general preventive medicine is working in hospital systems as health administrators or in quality improvement, data analysis, data management, statistical analysis, journals, and research. This being said, a lot of preventive medicine physicians she knows are operating sizable research initiatives and grants. [16:20] Beyond Epidemiology Janani explains that a major asset an MD will add to your training is the ability to actually understand the clinical system and have that perspective and option of caring for patients. For instance, a regional director for Texas and a preventive medicine board-certified MD/MPH will routinely get cases of people with complex tuberculosis. And as a physician, she can write their management plan. She can prescribe the medications and mandate directly observed therapy. At the same time, as an epidemiologist, she's able to understand how the case fits into the general patterns of TB prevalent outbreaks in the community. It's a great asset in that you can also care for patients. You can understand the symptomology, the complications, as well as understand the big picture population health dynamics of those conditions. [17:42] Taking Calls Janani says that the one situation that is a possibility for preventive medicine is this pathway of working in the Centers for Disease Control (CDC) as an Epidemic Intelligence Officer for public health. So if there's an outbreak of an illness and you need to figure out where it starts from, your work as an officer is finding and discovering like interviewing. Then this is the situation where you might be on call because if something is happening, then you're deployed to that site. But this is a specific career path. Moreover, public health officers, especially if you're working in a county, state, or federal government level, national disaster is another big thing for preventive medicine. They would have a lot of training in emergency preparedness. So if you're skilled in that area of national disaster, then you'd more likely be called down to that site. "National disaster is another big thing for preventive medicine." Janani says that a class well-loved by their residents is Disease Detection where they simulate outbreaks and figure out where they started, which is a very systematic and interesting process. [20:50] The Training Path to Preventive Medicine You can go into preventive medicine as a pure primary care physician. It requires one year of an ACGME accredited by the residency. It could be a transitional year or a prelim year. Then you would then matriculate into a preventive medicine residency program. Janani explains this path has its pros and cons. The pro being that it's a two-year residency so the entire year of training is completed in three years. For somebody who doesn't really want to have clinical practice as their backbone then this could be a good option. But if you see yourself in primarily clinical practice, another way to go into preventive medicine is a second residency or a fellowship or a combined program which was what Janani did. So you can finish any residency and then do a preventive medicine fellowship or residency on top of that. For the combined programs, either of family medicine, pediatrics, or internal medicine can be combined with preventive medicine. Choosing the right one among these three paths depends on what you want to do with your training after you graduate. Janani says that if you see yourself doing more than 20% clinic a week and you enjoy interacting with patients and likes that one-on-one patient care, she recommends doing additional training beyond just a transitional year. "The ability to handle complex cases can be strengthened by additional clinical training." Janani mentions another viable path. A preventive medicine field called Lifestyle Medicine is focused entirely on clinical care. This is a scenario where you could do a one-year transitional and two-year preventive medicine and then practice lifestyle medicine. Moreover, if you see yourself working in health policy or at a local, state, federal, or county office and you see yourself doing the big picture activities, outbreak investigation, and working at CDC, then your traditional one year transitional and two years preventive medicine makes more sense. If you have any chance to practice a lot of clinical medicine that is not lifestyle medicine, Janani recommends doing preventive medicine as a fellowship. [24:40] Competitiveness in Residency Training Janani says this depends on the location. There are very competitive programs that are hard to get into. You really have to have a background in public health or be able to demonstrate some type of vision and mission for your work in preventive medicine. Other programs are not as competitive. So it depends on the geographic locale and the prestige of the institution. All this being said, preventive medicine is a small field. So program directors tend to know who the top candidates are as a group. She also noticed that the competitiveness of the field is increasing each year. To be competitive, students must have some type of commitment. Experience doesn't have to be extensive, but you should be able to demonstrate a commitment to public health. In their program, they have a very strong emphasis on underserved medicine and health equity. So they're looking for somebody who has done work in underserved populations and is knowledgeable about the topics of community engagement, participatory research. They should be able to show aptitude in biostatistic epidemiology either through coursework or work in medical school. "Research is a big cornerstone of what we do in preventive medicine... but the interview for us is key because that's where you can really tell if somebody understands the field." Additionally, Janani reveals that the interview is key for them because this is where you can tell if somebody understands the field. [27:20] Opportunities to Subspecialize Aside from general preventive medicine, other subspecialty opportunities include occupational medicine, environmental medicine, aerospace medicine, addiction medicine, and lifestyle medicine. Many times general preventive medicine can be a stepping stone to these. But what's interesting about preventive medicine is that a lot of times, they will take the equivalent experience to be able to certify in some of these added specialties. You don't necessarily have to do general preventive medicine first for many of these types of disciplines. Lifestyle medicine, and to some extent, addiction medicine, lends itself well to the general preventive medicine track. If one is interested in environmental medicine, which includes toxicology, exposures, pesticides and workers, plastics in the environment, several colleagues completed a general preventive medicine residency and then gone on to do an environmental health fellowship. That being said, the path is not that linear so if there's a specific interest, there are likely different pathways to get to that outcome. [29:15] Working with Other Primary Care Physicians There's an argument whether preventive medicine is primary care or not. What bothers her tremendously as the director of student wellness is the rising rates of physician burnout, physician substance abuse, physician suicide, and the opioid epidemic. She thinks primary care physicians are burned out because they feel like they can't really help their patients to the extent they want to. "I think, increasingly, primary care physicians are burned out because they feel like they can't really help their patients to the extent that they want to." And the system of medicine is part of the problem and this can really precipitate the cycle of burnout. So Janani wishes that primary care physicians knew about their work. For lifestyle medicine practice, the goal is to help patients adhere to and comply with some of these evidence-based prescriptions for better health like diet, exercise, and emotional wellness. In that end, they're actually helping their primary colleagues get to the goal they want of healthier patients. But the problem is they tend to work separately. Public health systems are often quite separate from clinical systems and that makes it hard on both the public health and the primary care physician. So if they only had knowledge and information exchange between both entities, then there could be a healthier physician workforce. "Public health systems are often quite separate from clinical systems and that makes it hard on both the public health and the primary care physician." If people knew that this field of preventive medicine and lifestyle medicine existed and had opportunities for collaboration, you would see dramatic changes in the rate of chronic disease in the country, the epidemics of opioid addiction and physician burnout, and overall would just be a lot healthier. Lifestyle is responsible for 80% of the disease. It's a staggering figure that even outweighs genetics. And we all know this stuff works but we just need to set up the communication channels and realize that each other exists. We must learn how to collaborate for better health for all. [32:00] Working with Other Specialties Janani they have partnerships in their school with the Department of Pediatrics, as well as those of internal medicine, obstetrics and gynecology, and family medicine. They work with issues including childhood obesity, child abuse, healthy pregnancy and postpartum care, and connecting women to contraception and promoting women's health and women's rights. They work with ensuring a healthy and safe pregnancy. So there's a variety of programs and specialties they're working with. [33:15] Special Opportunities Outside Clinical Medicine Janani says many of the public health workforces are part of the US Public Health Service Corps. These are physicians who work on promoting the health of the military, Air Force, etc. In terms of completely nonclinical, you could work at a state, local, or county public health departments. Your title is usually Regional Director or Local Public Health Officer or State Public Health Officer, or County Official. Janani describes these as very eye-opening roles for a new graduate. You get to learn so much from those roles. Although many times too, a lot of the job openings can be in more small, rural communities scattered across the nation. This way, you can really have the ability to shape the health of your community. This is rewarding because your decisions, your understanding, the research that you do, and the initiatives you recommend can transform health. "You really can have the ability to shape the health of your community." [35:40] What She Knows Now That She Wished She Knew Janani shares that she wished someone would have told her that change comes slowly and it doesn't mean your initiative is wrong or is not working. But patients would be the most important thing as a preventive medicine physician. It took two decades for smoking, which was once regarded as healthy and doctors recommended it, for that needle to shift. Now, we understand smoking as a harmful habit that creates lots of diseases. So the needle may move slowly but the evidence will come out in the end. Moreover, she came into preventive medicine wanting to help impact the entire populations. But she wants to reinforce with herself that it doesn't discount the fact that even if you can just help one patient, that's still an achievement. It's not always the population impact that makes the most difference. "Even if you can just help one patient, that's still an achievement. It's not always the population impact that makes the most difference." Janani adds that food is driving a lot of our illnesses now. There's even evidence suggesting that sugar, ADHD, autism, preservatives, are all linked. And we will start to see a shift. It will take some time but that's her hope. [39:15] What She Likes the Most and the Least What she likes about preventive medicine is how multifaceted it is and she feels like she's ever doing the same thing. She gets excited about constant learning. It's cool to see how the different dimensions of society affect health. And she feels lucky and fulfilled to be able to work on the fundamental problem of health equity in the nation. She feels she's doing her part to help address these disparities in the country through her work. "Every facet of life is really public health." Conversely, what she likes the least is the lack of name recognition so they constantly have to explain ourselves about what they do and their value to society. And it's ironic how everyone recognizes that prevention is important and is needed. She also doesn't like the fact how everyone agrees on the rationale for preventive medicine. So they really have to stand up for themselves and find their sources of funding. [42:30] Major Changes Coming to the Field and Final Words of Wisdom Janani explains that the U.S. is spending so much money and with so little to show for it in terms of population and outcomes. She sees Medicare as going bankrupt. US health care spending is going to be a third of GDP. And something has to change. She sees preventive medicine as one of the beacons of that change. She can only see their value and strength increases as the years go on. If she had to do it again, she'd still have chosen to be a preventive medicine physician. Ultimately, she encourages students interested in preventive medicine to check out their website and you'll find a lot of resources there. Also, you don't have to do it right out of medical school. Preventive medicine is superior to just an MPH since you get to do a lot of rotations in applied public health. First, they fund your MPH and they pay you a salary. Second, you have the benefit of doing rotations with the county departments to learn how to apply those skills. Links: American College of Preventive Medicine Send us your stories at ryan@medicalschoolhq.net MedEd Media Network

Session 71 Dr. Serena Sah is an academic Pediatric Cardiologist in the California area. We talk about what drew her to the specialty, what she likes about it, and more. Serena has been out of training now for three years. By the way, do you know of someone whom you think would make a great guest on this show? Email me at ryan@medicalschoolhq.net. [01:25] Her Interest in Pediatric Cardiology Serena enjoys working with kids so she knew she wanted to do Pediatrics. She had a six-month-old cardiac patient that had an interesting physiology. Knowing nothing about cardiac disease, she was freaking out and that encounter with the patient was what really got her intrigued by the physiology of the heart. Additionally, pathophysiology made sense to her. She likes being able to figure out the causes of the disease. Going through medical school, she initially didn't have that interest in Cardiology as much as when she encountered that experience. She thought she would do general pediatrics at first but she already had the mindset of going into cardiology. She admits her intern year was rough and thought of not going any further. But that rotation in cardiology and her interest just peaked again. She also considered neonatology which had intensive care to it. Still, she was interested in the cardiac patients. [07:11] Traits that Lead to Being a Good Pediatric Cardiologist Serena says you have to enjoy working with kids and being around kids a lot. Understand that pathophysiology is interesting to you. Some of these kids can get pretty sick so just having a sense of calm under stressful situations. "You have to be able to know that you'll see kids of both spectrums of severity of illness. You have to be comfortable in that kind of environment." [08:25] Types of Patients and Her Typical Week A lot of the patients that get referred into their clinic are teenagers with chest pains, fainting spells, arrhythmia, or minor heart diseases. She would also have a portion of patients where she does neonatal surgery or infant surgery where patients are born with a single ventricle. They would need to have a series of operations and you need to follow them throughout their life. Basically, it's a good mixture of people who have cardiac-related symptoms, heart murmurs, and those diagnosed during their neonatal period and she just follows them through. Of her patients who come in already diagnoses, Serena calculates it's about quarter to a third of them and she's just following them up. The next quarter to half of them are people that come in with symptoms and they diagnose it. Also, a quarter of them get screened but get discharged without any cardia diagnosis. Serena works at an academic institution with a large group of cardiologists or pediatric cardiologists so majority of their time is spent on outpatient. Then they do a rotation of inpatient service a week at a time and it happens less frequently. Her typical week would be one to two days of outpatient clinic. She reads heart ultrasounds for 2 to 2 1/2 days of the week. She also does a couple of half day sessions of administrative time or research time. [12:37] Academics vs. Community Serena chose academics over community for convenience. She felt she could go either way. But she enjoys teaching trainees. In fact, she looked to both places but it just worked out that her home institution had a position that opened up so she grabbed it. And it worked geographically. "It wasn't the only thing I was looking at, but it ended up being where I was at." [13:40] Doing Procedures, Work-Life Balance, and Taking Calls As a pediatric cardiologist, cardiology is one specialty in pediatrics that is a medical specialty but provides a way for you to do hands-on things. They have a specialty in catheterization and put on cats and heart stents. You can also go into cardiac ICU as a subspecialty which is a third level of training. Then you can do a lot of procedures. Doing ultrasounds is not invasive but these are two subspecialties within pediatric cardiology where you get to work with your hands. Serena says she has a very demanding position from a clinical standpoint so there's a lot of clinical work involved. Being in a larger group, their call schedule is more spread out. So she's not on call as much versus as she were in a smaller private practice group. That being said, she still wishes she had more time for family and things outside of work. They usually handle home calls. They do have fellows that do first call where they're screened and their just escalated to them. So they rarely go to the hospital when they're home at night. But during service, they would also cover the weekend which means going to the hospital to round and be there if there are emergency situations. Their fellows also take phone calls so they go in if they need to. [17:07] The Training Path to Pediatric Cardiology After four years of medical school, you match into residency for Pediatrics. Then the application cycle has changed since she applied. You have to apply in your second year so you know where you're going by the end of your third year as you graduate from residency. But they've just changed the fellowship application cycle. You apply on your second year and then match in the fall of your third year. Pediatrics is three years and Cardiology is another three years. If you want to do the subspecialty within Cardiology, the trend is to have another year or two of training. Then there's five to six different subspecialties within Cardiology - Heart Failure, Transplant, Imaging, Electrophysiology, Catheterization, and ICU. Some are also doing a fellow, fourth year, in Hypertension so it makes six years all in all. Others do Preventive Cardiology since there's growing obesity in the younger population. There's Cardiac Genetics. "There's seven or eight subspecialties that you can potentially train for as an extra year of training if there's something specific in Cardiology that you want to do." Serena says the more competitive fields are neonatology, critical care, or PICU within pediatrics to match into since a lot of people want go into it. But generally, all are pretty competitive although she doesn't really have the numbers of it. [21:50] Bias Towards DOs and Working with Primary Care and Other Specialties Serena doesn't see any negative bias towards DO in general. As with working with primary care, she feels for the pediatricians seeing a lot of patients. When they see referrals from pediatricians, it's difficult for them. So if there's something they're uncomfortable with, then pass them onto them. But they don't mind seeing patients that need to be seen to help the general practitioners figure out who needs further care. Other specialties she works the closest with are the ICU people, neonatology, pediatric ICU, general pediatrics, hematology-oncology, nephrology, and GI. As with special opportunities outside of medicine, she knows of several pediatric cardiologists who have gone medical mission trips to help different places and countries. They also have people who work with developing technologies and devices. Research is also one since genetics is becoming a big field that people are interested in that relates to both bench research and genetics research. "Genetics is becoming a big field that people are interested in."  For nonclinical things, there are opportunities for teaching. For Serena, her job is more clinical so it's most of what her know. That said, there are people that do AI type of technology that incorporates cardiac information. [30:57] What She Knows Now that She Wished She Knew Serena says she has a conflicting view of things. She loves the action of intensive care but she dreads it at the same time being a stressful situation since patients have various outcomes. So she loves and dreads it at the same time. She finds herself gravitating more towards the outpatient stuff where she can be involved in the action but not as directly. All this being said, she wished she knew more about call in general in that it can be pretty rough during residency and training. What she likes most about her specialty is thinking through the heart diseases and diagnosing them. She likes being able to educate the family about it which she finds fascinating and rewarding. She likes being able to work the families and helping them through the process. What she likes the least on the flip side is handling difficult cases and if there's nothing they can do for tough conditions as well as that feeling of being responsible even though you're not if the outcome isn't good. [35:27] Major Changes in Pediatric Cardiology in the Future Serena says there's a lot of new technology being developed within interventional cardiology and imaging. They're working a lot with 3D stuff, printing or imaging modalities. They also work very closely with bioengineers. So if you're thinking about going to medical school, Serena says having this background helps. And if you're already in medical school, just be aware of all the technologies up and coming that are potential things to explore going into it. "There's a lot of emerging technology that will come into play very prominently in the field." Although she loves medicine and the intellectual stimulus of it, but if she were to go into medicine again, she would still be in pediatric cardiology. If she didn't go into medicine, she would probably be into graphics design or any design-related field. Finally, her advice to those who are considering this specialty is to be persistent as cardiology training is difficult. Persevere and maintain your motivation and persistence, Have an attitude of learning everything as much as possible within your training time. It's a great field and a very interesting and fulfilling and rewarding field. The process is long but there's a lot of rewards that come out at the other end. Links: ryan@medicalschoolhq.net

Session 58 Dr. Kathrin LaFaver is an academic Neurologist who specializes in Movement Disorders. We talk all about her job and what you need to know if you're interested. Check out all our other podcasts on MedEdMedia Network. And don't forget to subscribe on whatever medium you have. Going back to today's discussion is a movement disorder specialist who has now been four years out of training. She talks about why she chose her career, what it takes to become one, and so much more! [01:54] Her Interest in Movement Disorder Kathrin was a neurology resident and she got to shadow or do an elective in movement disorders. She found a great mentor and she was just fascinated by it, including the personal connections they formed. So from day one she knew it's what she wanted to do. The great thing about movement disorders, Kathrin says, is that you see the problem in front of you. So you can often make a diagnosis as they come into the room. On the other hand, there are people with too much movements and you can describe and see what's wrong. Then you can make your own conclusions from just observing the patient. "It's a really interesting specialty, a lot of treatments available, and the opportunity to follow people long term." Ultimately, she enjoys the connection with movement disorder patients. Treatment-wise, the medication for Parkinson's disease that was discovered way back in the 1960's, it still remains as the mainstay treatment for Parkinson's disease. [05:15] Traits that Lead to Being a Good Movement Disorder Specialist Kathrin says you have to have good observation skills - seeing them, finding the pattern, and fitting them into the right category. Over time that you've done it for a while, it becomes natural to see those specific disorders, which may not be so obvious for someone who's not specifically trained in it. Other skills include being able to enjoy logic thinking and fitting clues together, which are actually things common to neurologists. [06:40] Types of Patients and Cases Parkinson's Disease is the mainstay for most people in this practice. Unfortunately, this disease has been on the rise. In fact, one in 37 patients is expected to have Parkinson's Disease. "One in 37 patients is expected to have Parkinson's disease so it's actually a very common disease. Whether you do neurology or not, you're going to see people with Parkinson's disease." Parkinson's disease affect people, young and old, and there are different treatments, both medication and non medical treatments. It also affects not only the motor system, but also sleep, mood, and other symptoms. So Kathrin says this is an interesting area to be active. There are a lot of things to be researched on and discovered. Most common disorders spans the whole spectrum from age ranges such as dystonia, tourette's syndrome that often affects children and teenagers. Tremor can also be present in younger adults. Others would be genetic forms of movement disorders often presented in midlife. They also encounter other forms of dystonia as well as tremors. Kathrin explains that many are still diagnosed although essential tremor and Parkinson's disease are so common. She says it's easy to tell them apart, but not everyone behaves like a textbook. So it's not always as easy. "Surprisingly often, they're misdiagnosed either by a primary care physician or a neurologist who might not be very well-trained in movement disorders per se." Being at a tertiary academic center, Kathrin says they do get patients where they have to dig deeper to look for the missing clues to get to the diagnosis. That said, she has challenging cases every week where they have to be thorough with their history and examination to get to the diagnosis. [10:55] Academic versus Community versus Private Practice Kathrin has always been interested in human psychology, and movement disorder was just so interesting for her. Although they're called movement disorders, they are so much more. All these disorders like Parkinson's disease and Huntington's disease have behavioral manifestations as well. Depression and anxiety for example, are common in Parkinson's disease. Anger and depression are very common in Huntington's disease, too. "We're still just at the beginning of understanding all these diseases and finding better treatments and cure for them." This said, Kathrin knew she wanted to be in a place where she can continue exploring and help contribute to gaining new knowledge about diseases. [12:40] A Typical Day - The Parkinson Buddy Program Being the director of the Parkinson's Disease and Movement Disorders Clinic at the University of Louisville, she spends 50% of her time in research. She's involved in several medication studies for Parkinson's and Huntington's. These are studies run in multiple sites across the US and Europe. This gives patients an opportunity to try new treatments or be involved in new treatment efforts.They're currently looking for treatment for anxiety affected by Parkinson's. So she doesn't see clinic patients. Rather, she's involved in teaching medical students as well as community outreach. Three years ago, they started the Parkinson's Buddy Program where they team up first year medical students with Parkinson's patients in the community, This is an opportunity for these students to experience how someone with Parkinson's lives and what challenges they face in their lives. So when they get paired with a patient, they get some mentoring sessions with her. But the goal of the program is to let them meet with the patient in social settings so they can explore and experience it. Kathrin is involved in other teaching community activities, fundraising, etc. And the other half of her time, she does patients in the office. Kathrin sees 100% movement disorder patients in the outpatient setting. All neurologists in their group the alternate call as well. One week every 2-3 months, she spends a week in the inpatient general neurology service. At this time, she'd supervise residents and see all patients with general neurology conditions like epilepsy, multiple sclerosis, etc. While all of his outpatient time is spent with movement disorder patients. [15:50] Work-Life Balance and the Residency Path Kathrin is married with two kids, ages 2 and 4. And her work is fairly busy. She explains her time outside of the hospital is spent with her family. In terms of the path to being a movement disorder specialist, Kathrin outlines the process. First, you do the neurology residency which is usually a year of internships, one year of internal medicine, and three years of neurology. "Movement disorder fellowship is actually not an accredited fellowship so the pathways are a little bit more flexible." There are also fellowships that are one year, mostly clinical. And many are two years - one clinical and one research year. As well, there are some additional opportunities to get intensive training in deep brain stimulation surgery. This is a surgical treatment for mostly Parkinson's disease and essential tremors. Kathrin describes it as a teamwork where the neurosurgeon does the procedure and then the neurologist or movement specialist would do the programing and follow-up care for the patient. For Kathrin, she did one year of clinical fellowship in Boston. Then spent two years of research fellowship. In terms of the competitiveness, Kathrin points out the shortage of neurologists. Some programs are more competitive than others. But if you're flexible with your location or willing to go, it's not really extremely competitive to get into a fellowship. One of the challenges in the movement disorder sphere right now is the epidemic of Parkinson's disease coming upon us in the next 20-30 years. The trends she sees coming in the future is telemedicine, especially in rural areas, in the hope of meeting the demand for movement specialists. [19:36] Negative Bias Against DOs and Special Opportunities Kathrin doesn't really see any bias going on against DOs. Moreover, if you're interested in surgical treatment options like deep brain stimulation surgery, it requires special training. [20:38] How Deep Brain Stimulation Surgery Works The patient essentially gets a pacemaker for the brain. Electrodes get placed in targeted areas and in order to make sure this is done correctly, the procedure is done while the patient is on an anesthesia. Then the electrode is advanced and the patient wakes while a mapping is being done. Then they actually listen to the cells as the electrode is advanced. And this is how the actual training plays in. "Cells and the different parts of the basal ganglia have all characteristic sounds." Imaging plays an important role but most centers still do the microelectrode recording as additional means of finding the right location for these electrodes. Doing this procedure is a team effort - they have the neurosurgeon, the neuro electrode physiologist. Then a neurologist helps with listening to the cells and doing testing on the patient. If they're in the right spot, they turn the stimulation briefly on. Then they look on where the tremor gets better. So they're able to see immediate effect in the O.R. as it confirms that the space is the correct spot where the electrode is placed. Although results are not guaranteed, but there have been many cases where the tremor has really stopped. For many patients, it's a really miracle surgery. [23:58] Working with Primary Care and Other Specialities Kathrin's message to primary care physicians is to not be afraid of referring a patient to a neurologist or movement specialist. Because Parkinson's and essential tremor are so common, sometimes the internist or the primary care physicians become the main providers treating patients. And often, it works out just fine. But it's important for people without special training to realize the limitations and first-end treatment does not go so well. So if patient still experience the tremor, then they should not hesitate referring them. In many cases, we really have very effective treatments which can make a huge difference and even for people in more advanced stages, treatments like the Deep Brain Stimulation Surgery may be an option. "Don't hesitate asking for help for someone with Parkinson's disease or tremor and we can often make a big difference." Other specialties they work the closest with are Psychology, physical therapy, speech therapy, and occupational therapy. Many centers, in fact, run special multidisciplinary clinics, where they have a monthly clinic for Parkinson's or Huntington's disease. People can see multiple specialists at the same time. This is very helpful in facilitating care for the patient as they try to streamline care. It also helps to get input from multiple specialties as to how to serve the patient best and work all together. They also work with social workers in their clinic. Kathrin stresses the importance of understanding how movement disorder affects someone's work or social life in, especially in later stages. Special opportunities outside of clinical medicine include research. Some have actually pursued a full time research career. Other options are private practice or working in academia. She adds your career can actually change multiple times throughout your life. "Just being in medicine in general and being a physician, getting expert knowledge, you can really forge your own path and find your niche." [27:55] What She Wished She Knew and Major Changes in the Field Kathrin explains there are many changes in medicine. They can be burdensome and taking too much time. But as a medical student, you don't really see that side. Nobody will tell you that in the anatomy class. And in the real world, you spend a lot of time on the phone as you try to get your patient's medication approved due to insurance issues. And this is a hidden truth. "That's a hidden truth right now that our physicians are maybe not as autonomous as we would like to be... oftentimes, insurances mandate the medications we can prescribe." That said, Kathrin saw really no surprises from the neurologic side of things. Rather, it's about how you deal with the whole business side of medicine. What she likes most about her job is working in a setting where she gets to see the patients, doing interactive trainings and teachings as well as research. There can be lots of challenging times but in the end, Kathrin says it's all worth it. Having success in one area can sometimes compensate for another disappointment so it balances things out. Alternatively, what she likes the least are the regulatory burdens and dealing with insurances. She's hopeful though that this gets resolved in the coming years and physicians will gain a little bit of autonomy. Major changes she sees in the field are developments in multiple areas. One is the Deep Brain Stimulation Surgery that has already been mentioned and that these could be more individualized soon. Another interesting area is genetics. They can now do a whole genome sequencing for $5,000 which was years ago, was unthinkable to do that. So there's more discoveries and insights to come in the future. Additionally, Kathrin wants people to understand the interplay of environment and genetic factors and how that impacts complex disorders like Parkinson's disease and other movement disorders. Hopefully, we can learn more about how to intervene and really make differences. Lastly, Kathrin says that if she had to do it all over again, she would still have chosen the same subspecialty. [33:55] Last Words of Wisdom Kathrin encourages students to do an elective in neurology. That said, there are lots of opportunities to get engaged in research. She has students working with her during the summer break. And this is a good opportunity to have a good hands-on experience. Also do a little research project like see someone in their day to day or get some patient contact. See if this is something that interests you. Links: Parkinson's Disease and Movement Disorders Clinic MedEd Media

Alyson Stoner is a 24-year old Up & Comer. She is most known for her singing, acting, and dancing careers that have all had storied success for her age. From roles in Cheaper by the Dozen, to the Step Up series, to Camp Rock, The Suite Life of Zach and Cody, and much more. Her career has entailed roles and appearances in over 50 films and shows, alongside a successful dancing and singing career.   Beyond the statistics and accomplishments to her name, Alyson has experienced the weight of social responsibility that comes with notoriety at a young age.   Beginning her career in the entertainment industry at age 6, the life she has lived is rare and complicated. She has been forced to grow up faster than most, and has dealt with many of the ramifications that come from never having experiencing a normal childhood. Through both the opportunities and challenges, she has developed a deep-seeded ambition to pursue excellence in creativity, as well as the desire to understand her self and the workings of her mind, in order to find balance in an increasingly imbalanced world and profession.   In this conversation, Adam, Thane, and Alyson talk through her background, her journey of faith, what it means to live a life of contribution, the importance of community, and much more. This episode is fascinating and riveting, and it is a conversation you do not want to miss.   For the full show notes, visit theupandcomersshow.com/episodes/alyson   Time-Markers:   5:30 - What Song Alyson Sings in The Shower 8:30 - Favorite Nickname She's Been Given 10:30 - Where Alyson Comes From 14:00 - Alyson's Career Progression 18:45 - Alyson's Personal Transformation 22:00 - Discovering Purpose and Meaning in Life 27:00 - The Role of the Church in Her Upbringing 40:00 - The Life of Faith and Contribution 43:45 - What Alyson Has Learned from Africa 46:30 - Importance of Community 51:30 - Her Interest in Neuroscience 55:15 - Dance Talk 1:00:00 - Deciding Between Singing, Dancing, and Acting 1:07:00 - What Class Alyson Would Teach 1:08:45 - Alyson's Approach to Social Media 1:13:10 - Her Favorite Disney Role 1:14:10 - Book That's Left Biggest Impact on Her 1:15:30 - Who She Thinks of when She hears the word “Success” 1:16:45 - Morning Text Reminder She Would Send 1:18:30 - Where to Find Alyson

Session 42 Dr. Vanessa Baute is a Neuromuscular Neurologist. She has been in the academic setting for the last five years out of her fellowship training. We discuss what drew her towards it, what she likes and what she doesn’t, and much more. Also, check out all our other podcasts on the MedEd Media Network. [01:16] Her Interest in Neurology and Neuromuscular Medicine, Patient Types, and Procedures As a medical student, Vanessa was completely blown away by cranial nerves and their complex, visual system. She would read about it and study it and it didn't feel like work. The neuromuscular part evolved from having good mentors in the area for neuromuscular medicine. She enjoys doing procedures as well as the patient population. Not to mention, there was a fellowship spot available. She still sees general neurology patients as with her inpatient work. She considers 75% of her practice as neuromuscular, which is a good chunk. Although she also sees patients having issues of neuropathic pain, different forms of neuropathy, and other neuromuscular diseases. She likes the variety of cases as well as the teaching part of it. Some of the procedures she does to patients include occipital nerve blocks with ultrasound guidance, carpal tunnel injections with steroids, EMGs (which are a big part of her practice), skin biopsies, lumbar punctures, BOTOX for migraine and facial spasms. "A big part of my practice is procedural." [04:34] Traits that Lead to Becoming a Good Neuromuscular Neurologist Vanessa cites some traits that lead to becoming a good neuromuscular physician would be the ability to stay with the patient through the journey and explain every step of the way. Every patient is going to be different so you have to be able to tailor your approach. It's not always black and white. [06:20] The Misconception about Localizing and Being Able to Do Anything About It Vanessa gives her take on the concept of localizing but not being able to do anything about it once you localize it. She thinks of this as a misconception considering the number of genetic therapies coming out as well as a whole slew of medications used to treat disease. When you think of neuropathic pain and other forms of pain in neurology like headache or disc diseases, this brings on a whole holistic, integrated approach they can offer patients. This involves lifestyle medicine. "There aren't many times in my career where I feel I can't do anything for a patient." By this, Vanessa means doings things like walking with them in trying to figure out their diagnosis. For her, the ultimate goal depends on the person. Some people don't want to take a pill to have everything fixed. For other people, their healing journey is figuring out what's going on and how it's affecting their family. How can they live with it? Is their doctor going to be with them? Are their doctors listening to them? So she sees a lot of these in her practice just counseling patients. "Even if I can't figure it all out in one visit and fix everything, that's not really a lot of people's goal." Nevertheless, Vanessa assures there are cures for epilepsy as well as medications and treatments for MS. They have a lot of good treatments apparently. So she feels that her patients could be empowered. And maintaining their neurologic health, it's not always a big neurologic disorder they're coming with. [08:40] Other Specialties She Considered Vanessa describes herself as a happy person so she likes everything. She knew the complexity of neurology but she also loved her prelim medicine year. in almost everything she rotated through. She knew though that surgery wasn't for her even if she likes procedures. Funny as it may sound but she actually broke the sterile field on her first day of surgery rotation when her pants fell off. She likes hematology oncology and found it's similar to neurology in some ways in terms of its complexity and the diversity of diseases. She loved the nephrology rotation, but not the acuity part of it. She is not a neuro-intensivist, but more of looking for bread and butter ways to look at preventive medicine. Nevertheless, there was nothing strong enough to pull her away from her chosen field. "There cannot be anything in this life other than a neurologist." [10:52] Types of Diseases, and Followup Care Vanessa considers her bread and butter neurology practice as a lot of peripheral neuropathy, neuromuscular junction disorders (ex.myasthenia gravis), cervical disc disease, lumbar disc disease, weakness, or a referral for motor neuron disease, ALS or an ALS variant. Being an adult neurologist, she doesn't see children with muscular dystrophies. But they do have patients with adult muscular dystrophies such as myotonic dystrophy and imb-girdle disease. In some of her general neurology practice, she deals with headaches and migraines where she gets lots of referrals for. She also notice how this has recently increased with the levels of stress as well as dietary influence. But she finds this exciting because of good treatment and good counseling options. According to Vanessa, in most days, even if it's difficult news and diagnosis, she's still able to instill hope in them and offer them all the different treatments. She walks with them in the path which she finds very rewarding. There are several instances where she does followup care when the patient comes to her already with diagnosis of ALS for example. About 80% of her patients come in having seen somebody, whether another neurologist or primary care doctor. Somebody has already labeled them and thought they had a certain diagnosis. This is something she always harps on with education is going blind. It doesn't matter what somebody else had said because today is today and they're clearly here in our office. They always question the diagnosis whether right or wrong. We don't know what was happening when that person was in that doctor's office. They look at how the patient was diagnosed, the workup, the labs, the CK and the ENG report. They think from a critical standpoint if those were the things they would have measured. She always teaches her students to take a critical look at how these diagnoses are made. "Some of the treatments are heavy-hitters and even just the labeling of the diagnosis. So we want to make sure." And sometimes, they're able to take that diagnosis away and label away. And a lot of times, for a better one. For instance, Vanessa explains how ALS can be difficult to diagnose initially. So it's a big thing to tell somebody they have ALS if they don't or vice versa. So they take their time with all the information. Oftentimes, they repeat some of the tests until they both the physician and patient would feel good. [15:27] Typical Day As a neuromuscular surgeon, every single day is different. But she does this on purpose since she likes to be doing different things at different times. But a typical day for her would be a neruomuscular clinic. She works with neuromuscular fellows.her favorite part of the job is being able to watch the process done by the fellow or the trainee. Vanessa also enjoys catching up with the patients. She sees from five to eight patients in a half day. And then the rest of the day is spent giving lectures to students or practicing integrative neurology. She does a lot of work in education, specifically, curriculum design, nutrition counseling. She also does a little bit of research. [17:05] Academic versus Community Setting Vanessa chose academic versus community-based setting for the primary reason that she loves the educational aspect of it which involves a lot of teaching. She also likes the mentorship. Medical training is challenging. And her personal experience with that stayed with her. It's almost traumatizing and hard. "The educational standpoint is so redeeming. I can be there with the student or whoever it is I'm talking to." She just can't imagine not having this part of it. Another thing about academics that she loves is being able to see a complicated neuromuscular patient and she can talk about it for two hours. She can talk about it with whoever - patients, doctors, nurses, colleagues. They can conference about the case and talk about it forever. [19:03] Percentage of Patients She Does Procedures On Vanessa mentions having a few sessions of EMG lab in procedures. Apart from her clinic, she has sessions devoted solely for procedures. So does separate her procedure clinic and her patient clinic. In her patient clinic where she sees patients, about 40% of them are ordered a procedure on - something with a needle. Then she will put them in her either procedure or EMG lab clinic which comprises half clinic and half procedure ratio. A lot of her patients in procedure clinic are those who were people she met in the community. Not everybody likes procedures but since she loves them, she is known for it. So her colleagues will refer the different procedures to her. "The referral base is good and I like being the person that is known for doing these procedures." [20:49] Taking Calls and Clinical Coaching Vanessa hardly takes any call otherwise the call she takes is voluntary. She still does a bit of inpatient service and that where she takes a call. She does this primarily because of the teaching aspect. Their calls are a mandatory process. She does four weeks per year of general inpatient neurology. A lot of this is neuromuscular cases like myasthenic crisis, Guillain-Barre, or transverse myelitis, etc. She sees this as an opportunity for her to get exposed to the residents and do a lot of bedside teaching, physical exam review, and clinical coaching. With clinical coaching, she partners with a third year medical student and kind of takes them under her wing. She goes and sees patients and watch them do history interviews. Then they'd have a feedback session afterwards. The call she takes is home call, which she has taken as a junior faculty. So likes to keep it fresh and keep up with the educational part of things. [22:22] Work-Life Balance Vanessa admits she tries to have a good work-life balance. Her goal is to show up at work and do something so fun that it doesn't feel like work. "My goal is to show up at work and so something that's so fun that it doesn't feel like work and then go home and be at home." Her goal is to use her training and what she's passionate about and what she loves, feel good about it, and then go home and be able to have that part of her life just as important. This is another thing she thinks a lot of people struggle with because you're not going to be an MD all the time. Your other roles are important too. She stresses the importance of focusing on those roles too as much as we're in the MD role. Nevertheless, the transition is challenging as we try to just sweep in. Know that you don't have to fix everything. "You're not an MD all the time. It's important to be whatever other role you play in your life." [24:22] Neuromuscular Fellowship, Bias Against DOs, Subspecialty Opportunities Vanessa describes neuromuscular fellowship as not being very competitive in the sense that a lot of programs are looking for neuromuscular fellows. They're trying to recruit good fellows. There have been changes in the reimbursement in the last five years, specifically with EMG reimbursements. She's not sure if this motivates people to not go into neuromuscular medicine. Although it shouldn't because Vanessa stresses that if you're not loving what you do, it doesn't matter all - getting reimbursement or how much you're getting paid - if you're not into it. But this may have some influence in it. Again, she wouldn't consider it as a very competitive fellowship. In terms of bias against DOs in the field, she doesn't really see this. Many of the fellows they trained are DOs. Vanessa says DOs have a lot to offer and a lot to bring to neuromuscular medicine. She finds it as a unique background even if she's not  DO. But she's heard a lot about it from the people she works with and she acknowledges how beneficial DOs are. "DOs bring a lot to the table, especially with the manipulation, the musculoskeletal component, and anatomical component." In terms of subspecialty opportunities, many will do just either neuromuscular fellowship with research. Most would do neuromuscular fellowship in one year. Some people will do a clinical neuro-physiology fellowship with several varying months of neuromuscular EMG training. If you're interested in something specific after that, it's normally within that fellowship that you're going to get that training. In many cases, she knows people who went back and did something specific within neuromuscular medicine. Some people spend more time doing EMG while others spend more time looking at neuromuscular junction disorders. Neuromuscular ultrasound is an emerging field, which is something she teaches at workshops and meetings. She noticed that more people want the training. There are different courses available for this - muscular dystrophy for instance. [28:00] The Path to Neuromuscular Fellowship From graduating medical school to being a neuromuscular neurologist, you do your first year or transition year as your first year of residency. You look at all the specialties and then you have three years of neurology. Most programs are front-loaded. Your PGY2 year may involve taking a lot of inpatient calls or seeing acute stroke - things like high-acuity neurology. Then it tends to get more clinical in most programs. You may also be exposed to EMG. It's rare to have EMG exposure early on in neurology residency although there are definitely programs able to do that. EMGs are mostly outpatient and most residency training is patient. After your three-year neurology, you go into your one-year fellowship. Sometimes, this can extend to two years especially if you're interested in research opportunity. [29:35] Working with Primary Care and Other Specialties When Vanessa sees referrals from primary doctors, she wished they knew the neurologic exam. Sometimes she takes a referral over the phone asking about a neurologic questions. They would describe a neuromuscular disease to her and she would as how their reflex is doing. And then they say they didn't learn it. She considers this a travesty. This is where Vanessa thinks clinical coaching is very helpful for students. Getting your neurologic exam down no matter what specialty you're going into. And basic things are important such as doing reflexes. A great resource for learning this is the book Neuroanatomy Through Clinical Cases by Hal Blumenfeld. And practice this with your friends and family. Then have your neurology rotation. Do neurologic exams and have a neurologist watch you do it and coach you through it at least once. Record that. Take notes on that. And a neurology resident would be happy to do that too. "Everybody needs to have some form of neurology exposure and medical training." So one of Vanessa's biggest pet peeves is people not knowing if the patient has reflexes or Guillain-Barre. She would want them to at least know the level of sensory loss, especially if it's a spinal cord lesion. It's not that complicated but just a matter of education. It's a matter of learning that and practicing. Vanessa again stresses the importance of knowing the neurologic exam early in your training. Aside from primary care physicians, other specialties she often works with include neurosurgery, orthopedics, hand surgeons, physiatry, PM&R, and rheumatology. [34:18] Special Opportunities Outside of Clinical Medicine and What She Wished She Knew There are also special opportunities outside of clinical medicine in terms of advocacy and administration within the hospital. It's a general personality trait as she describes it so it's not only unique to neurology. There is also a big split between a clinical role and a research role. What she knows now that she wished she knew about her specialty is that reassurance. So had she seen this practice she has going on where she unites neuromuscular medicine with integrative medicine with education and mentorship, she'd be relieved. "Everything feels very intimidating when you're in training and you don't see how it can be." They've also had some surprises in the field with genetic therapies, spinrasa (nusinersen) and intrathecal administration for SMA. These are new things on the horizon. Looking at herself as a fellow looking at her now, she'd probably be surprised how fulfilling neurology can be as well as neuromuscular medicine. She'd be surprised in how far you can really go. Just keep going one day at a time. Keep going. Keep working. And you're going to be landing your dream job. [37:05] The Most and Least Liked Things About Her Specialty What she likes the most about being a neuromuscular neurologist is her colleagues and the chance to be able to work with the neuromuscular fellows. They have two fellows for year so they get to be intimate in their learning which she finds very rewarding. She loves how she's able to make a difference in the patient's lives while educating. What she likes the least is paperwork. Again, not unique to neuromuscular medicine. She finds it challenging to implement and get people in the room, coordinating the referrals, and scheduling. Unfortunately. medicine has pitfalls in terms of bureaucratic processes which aren't what you want to be doing. So she tries to minimize this by building a good team and having meetings with everyone. "Every person is essential. I'm only as good as my support staff... we all have to work intricately as a team." [39:37] Major Changes in Neuromuscular Neurology Vanessa notices that for muscle diseases, they have traditionally done their muscle testing and muscle biopsies in certain cases. Now, with genetic testing, they're able to talk to a patient. Send off a gene test. Then you may no longer be needing a muscle biopsy. They're not exactly there right now but hopefully, more innovations and drug therapies are coming out soon. If she had to do it all over again, she still  would have chosen neuromuscular medicine with integrative medicine. For Vanessa, the two have to go hand in hand. She loves the patient population, her trainees, and her colleagues. She adds it's something you can tailor to what you're interested in. And if you know what that is in your own life then you can ask for that. Go for that. And you can make your practice really rewarding. [41:25] Final Words of Wisdom to Students Vanessa encourages students who like neuroanatomy and have done neuro rotation, or even if you're just curious if you're going to like it, go shadow a neuromuscular neurologist. And if you think it's challenging, it is! They're not easy. But don't get discouraged by that. As long as you like it and you're dedicated to it, know yourself and know what you're interested in and just go for it. [42:42] Last Thoughts One of the biggest takeaways for me during this interview was how much she loves procedures. As a neurologist, it's finding the ability to do procedures. Typically, neurology isn't considered to be a very procedure-heavy field. But she has found a niche for herself in doing these procedures because that's what she loves to do. If you're thinking about something and disappointed because it's not very procedure-heavy, think again. You might be able to find a niche for yourself. And do the procedures you want while also seeing the pathologies and treating the patients that you want. If you know somebody who would be a great guest here on the show, please shoot me an email at ryan@medicalschoolhq.net and we'll try to get them on the podcast. Links: MedEd Media Network Neuroanatomy Through Clinical Cases by Hal Blumenfeld

Session 41 Dr. Denia Ramirez is a general academic Pediatric Neurologist. She talks about her journey to becoming a pedi neuro doc and other things about her specialty. Several weeks ago, we had a pediatric neurologist who specializes in headache medicine. She has been out in practice now for five and a half years after her residency in pediatric neurology. She is in a combined academic and community setting at the University of Tennessee Medical Center (UTMC). Check out our other podcasts on the MedEd Media Network to help you on your journey to medical school. [01:33] Her Interest in Pediatric Neurology When she did her pediatric residency in Costa Rica, she got amazed by how a child gains milestones. She got interested in how things changed, and how they can shift from being so little and happy to somebody and completely against anybody who's a stranger at eight or nine months old. Her father-in-law was also a neurologist. It was around that time when she met her husband. So she got to see more of what a neurologist is not only inside but outside. This is basically what sparked her interest in neurology. Other specialties that piqued her interest include emergency medicine. She realized the demands and the amount of time she was going to be out of home if she decided to go that route was probably too much for her. Since she still had to take care of family and do other things as well. [03:20] Traits that Lead to Becoming a Great Pediatric Neurologist First of all, you'd have to like kids. Not only for peds but also for adult neurology, you have to know your neuroanatomy. You have to know your localization well and learn the process in which we're taught to think to try to reach a diagnosis. More often than not, you're going to hear people you have to be smart to do this or that subspecialty. "You have to like it. You have to enjoy it. You have to be dedicated. That holds true for any single subspecialty you get yourself into." For Denia, one of the most wonderful things is when she's in clinic, she's essentially being paid to play with kids. She loves what she does and she loves talking to kids. She loves talking to parents. She loves to work with them and this makes her job much easier. [04:40] Types of Patients Denia says she sees almost anything. Child neurology has been a relatively new thing. She gets kids with epilepsy and the whole spectrum of those kids. There are those who come every six months. She helps them walk through the process and helps them until they outgrow it. She also sees kids with severe brain lesions or have genetic epilepsies. They also see kids with headaches. A lot of very normal kids who had one or two febrile seizures and parents are understandably worried and concerned about what that means. They also see kids with developmental delay with learning problems or kids struggling in school. Everybody wants to make sure that they're not missing something that is bigger. They see kids with neurodegenerative diseases. They see a lot of other different things like difficulty in walking, kids with ataxia, and so much more. "The nice thing about pediatric neurology that is a relatively small field, there's not a lot of us." Being a very small field, Denia says how they're so open and very supportive of each other regardless of the training program. And as much as they want kids with movement disorders to be seen by a movement disorder specialist, for example, but you don't always have that luxury. You reach out for them but you continue to take are of those kids. [07:00] Generalist vs. Subspecialty and A Typical Day and Work-Life Balance Denia cites three reasons for choosing to generalize instead of specializing. First, she has already done her residency training once back home and she'd have to repeat it. She felt she was at a point where she really needed to be more productive and do something. Additionally, she likes the idea that she gets to have all sorts of patients. Melinda adds she doesn't want to be stuck in a small bucket of things she sees over and over. She likes that she can see almost anything. "The diversity continues to be a good stimulation for my knowledge, for my learning, and for continuing learning." A typical day for her would be doing rounds. They don't have admitting services but they have consulting services. For the most part, she sees patients at East Tennessee Children's Hospital, not affiliated with UTMC. Then she holds clinic between 10 and 11 am. She does reading and goes through a couple of journals to see if there is anything new that can contribute to her knowledge. Then in the afternoon, she sees patients. At the end of the day, she normally checks the charts for the next day. She finishes her notes and then her day is over. She describes 50% of her time is spent doing clinics and another 50% is on doing rounds. Half of the time would be spent in the hospital. Some days, if they don't have any consults. she spends mornings catching up with any undone work. She'd call patients and see patients in the afternoon. In terms of taking calls, she's available when it's needed but she doesn't have to be available. At the University of Virginia where she was at recently, they'd do one week of call. Some of them did more weeks of the year, some did less. It basically varies depending on your track. And then on the week you're on call, you have to be available for your residents 24/7 for the entire week. Denia says having good work-life balance. As anything in medicine, you have to be organized at it. As long as you're organized, as long as you keep your priorities, you can do it.Denia still gets to cook everyday and go out on weekends. They don't have kids but if she had kids, she still thinks she'd be able to do things with her children. "In peds neurology, once you're comfortable with it, it's easy to get yourself into that process." [12:14] The Residency Path of a Pediatric Neurologist The classical path includes two years of pediatrics and three years of neurology. In those three years of neurology, you'd do a year of adult neurology and then the last two years are allocated for pediatric neurology. So it's all five years in total. Some people join a program after they've decided they wanted to do pediatrics. They've finished the whole three years of pediatrics and then they'd do the next three years. Another path available to some is you can do a year of internal medicine, a year of pediatrics, and then the three years of neurology, whether adult neurology or pediatric neurology. There are some residents who start as adult neurologist and really like pediatric neurology. For them to be eligible to sit for child neurology, they're required to do an extra year of pediatrics aside from the year of internal medicine they've already done. Then they''ll have to do a year of child neurology and they're done. This path is a little bit longer. Nowadays, most programs have the five-year path. When Denia started, there weren't that many programs that would give two years of pediatrics and three of pediatric neurology. You had to go into two different programs. Some pediatric programs didn't like it because they were losing the resident. But most of the programs now have the options where they can do five years as a pediatric neurology resident. You can be dual certified in pediatrics and pediatric neurology if you do two pediatrics and three neurology years. But you have to make sure you meet the criteria that the AAP has established for you to be able to sit for the peds boards. The reason people like to be dual certified is because some still like to be able to do pediatrics. "Some stand-alone children's hospitals would ask you to be dual certified in pediatrics and pediatric neurology." Denia cites what her mentor told her that there is so much shortage that you end up not using your pediatrics board even if you're eligible to do it. As for Denia, she doesn't think she would sit for the boards in peds. And what she has heard from those who did it, is that they're not sitting through the re-certification. Unless you're doing it for a daily basis, you're going to end up studying for a test. [16:51] Is Matching Competitive? Although competitive, Denia says there's plenty of opportunities. Pediatric neurology is a well-held secret. It could be because the five-year training may seem so long. But it really isn't as Denia would describe it. If you want to get into a field, you can get into a very good program with good letters of recommendation. But not to a point where there's one slot and 500 people are fighting for it. [18:10] Bias Against DO's and Other Subspecialty Opportunities Denia hasn't seen any bias against DO's, speaking for her field. "There's no bias. If you're good, you're good. We don't mind how you ended up finishing med school." Once you're a pediatric neurologist, there are other opportunities that you can specialize in including movement disorder, neuron EQ, and neuropedic critical care, pediatric neuromuscular, neuro immunology, epilepsy and neuro physiology, neurodegenerative diseases and white matter diseases, and mitochondrial and genetic diseases. When she was interviewing and trying to make her decisions to what she wanted to do, her mentor gave her this advice. "Once you're done, you essentially can do whatever it is that you want to do." And her mentor was indeed right. He also told her she can go wherever she wants to go since she's needed everywhere. And Denia thinks he's been right about that. She has a lot of friends in the field who have gone through different paths. And they're equally successful. It's a field that is very supportive and has a lot of opportunities. [21:35] Working with Primary Care & Other Specialties and Special Opportunities Outside of Clinical Medicine Denia explains that you need to work with them on getting rid of lot of myths regarding headaches. They see a lot of headaches. And they see a lot of children with headaches who could be handled at the primary care level. Another thing is when do you refer a child for seizures and when do you use your skills to reassure the parents that those are not of concern? Ultimately, Denia advice is that when in doubt, grab the phone, Give them a call. They're always available. Don't order tests because you're worried that you don't know how you're going to interpret the test. You're opening a can of worms for you and for that family. Other specialties she works the closest with include developmental peds, genetics, NICU, and PM&R. And in terms of special opportunities outside of clinical medicine, there are people doing outreach and volunteer work. In the next five to ten years, Denia sees telemedicine being one of the fields that is going to develop within neurology. This gives you the opportunity to still see patients in a different schedule. This would be great for parents who want to stay longer at home. Or for those who don't do well being in an office for certain amount of time. That said, you can provide the care from the convenience of your house. There are also opportunities working for federal agencies such as FDA. An ongoing discussion within the field is how they can diversify as pediatric neurologists in the way that other colleagues have. [25:35] What She Wished She Knew and The Most & Least Like Things Denia wished she knew how much the medical field was going to change then it would have helped her anticipate some of the things that came as a surprise to them. For example, how to measure for productivity. This not only touches pediatric neurology, but medicine as a whole. She also wished she would have taken a little bit more time to do all the things she wanted to do before going to med school. So she tries to pass this onto her students and to the residents. "You need to take time for yourself. It's okay to take breaks." What she likes the most about her specialty is working with the kids. She feels it's fulfilling to see how kids don't feel well and they let you know where they don't feel well. And then they'd feel better and start to recover. Knowing you've helped and have made a difference in their life is gratifying. What is equally gratifying for her is to see how kids, in the midst of difficulties, continue to push. They're fighters. It's amazing to see how they never give up. "It's amazing how they never give up. Kids never give up. And that is extremely touching." On the flip side, the least liked thing about her specialty is to deliver bad news. For years, she has tried to develop within her field in terms of research to say that she may be delivering bad news but people are doing something about it. She's trying to be part of the change so they can finally say what they can offer. You're going to have to walk the parents through the process of thinking that their child's life is going to look different than what they envisioned. But that's okay and you're there to support them. The one field she doesn't particularly enjoy is neuro oncology. So she tries to stay away from it as much as she can. But if she had to do it all over again, she still would have chosen pediatric neurology. [29:40] Denia's Advice for Premeds and Med Students Denia recommends grabbing every opportunity you have to observe and shadow someone in the community. Try not to go into the hospital. It has the most extreme cases and it's not going to give you a good idea or a real perspective of what child neurology is and has for you. For medical students, Denia recommends that if you're doing your peds neurology rotation, make sure you don't stick to the inpatient. Make sure you also go to outpatient. If you have an interesting patient as an inpatient, talk to your attending physician to let you get involved with it. Make sure you do a rotation. Make sure you express your interest and you're ready to get involved. Take as much as you can from those rotations. "Get a good perspective of what the field has for you because it's broad." [32:45] Final Thoughts Tell me what you think about this episode and shoot me an email at ryan@medicalschoolhq.net. If there's a particular specialty you'd like to hear sooner, rather than later, shoot me an email again. And if you have somebody you wish to recommend for me to interview, hit me up! Links: MedEd Media Network ryan@medicalschoolhq.net