Podcasts about his interest

The Tomahawk Talk pod is joined by current TV Play-by-play announcer Brandon Gaudin as we discuss* His Interest in Broadcasting* His broadcasting icons* favorite road cities and stadiums* the infamous 'Ice Cream Man'* And More!Check us out on Youtube, like comment, subscribe and let us know how we're doing! Also check out the Tomahawk Talk Gaming channel! This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit jebmaize.substack.com

Natalie Earle is a Functional Nutritional Therapy Pracitioner with a BS in Physics. In 2013 Natalie was diagnosed with prediabetes, skin issues, and severe PMS symptoms. In 2015 Natalie enaged in the GAPS diet and in the subsequent years she was able to reverse her prediabetes and put her other symtpoms in remission. Over the last six years Natalie has supported hundreds of clients with autoimmune disorders, cancer, PCOS, edomitriosis, and nervous system disorders.   Andrew Earle has a MA in Marriage and Family Therapy. His Interest in natural health began while healing from chronic stomach issues that conventional medicine could not help him with.  He sought solutions of his own and found the GAPS diet which put his stomach episodes in full remission. Additionally, Andrew is passionate about learning how to interface with landscapes in a way that supports their regeneration.   Learn more about Natalie's work at nutritionwithconfidence.com

Join Sal Daher's Syndicate List: Click to Join Sponsored by Peter Fasse, Patent Attorney at Fish & Richardson Born out of COVID in 2020, TBD Angels is Boston's newest angel group. In its first seventeen months it has already invested in forty startups. Members David Chang and Yael deCapo spoke about what TBD offers startups and investors. Highlights: Sal Daher Introduces Yael deCapo and David Chang of TBD Angels TBD Angel's Process is Real-Time Not Batch “We try to match their velocity, which is pretty hard to do, but we occasionally succeed at that.” “There is a tool-based voting that if enough members vote that they're interested in hearing a pitch, we have an automatic way to schedule that pitch.” TBD Angels Invests via a Special Purpose Vehicle (SPV) “It's a little bit of an experiment from our standpoint. We started this group in the middle of a pandemic, the beginning of 2020.” Sal Daher Thanks Matt Fates for Introducing Him to TBD Angels In Seventeen Months, TBD Angels Has Invested in 40 Companies Choice of Startups Is Driven by Member Interest and Not by Rigid Criteria Sal Daher Introduces His Effort to Help Angels Invest in Life-Science Startups Sal Daher Credits the Research of Jeff Behrens, PhD on Biotech Funding “...I think it's a great value to the founders also, that they have that broader reach and it's not so siloed...” Sal Daher Continues to Be Involved with Walnut Ventures Which Has a Lot of AI Expertise TBD Angels Has Investors and Startups from Across the Country The Singular Opportunity of Purdue University and Its 500 Professors of Engineering AOA Diagnostics - Addressing Ovarian Cancer, a Silent Killer of Women Kytopen - Scalable Production of Gene Therapies How TBD Angels Connected with AOA Diagnostics Brief Bios of David Chang and Yael deCapo What Moved Yael deCapo to Write Her First Angel Check David Chang and His Interest in Student Entrepreneurship Boston as the World's Bazaar of Biotech Talent “...over a third of the CEOs that we've funded are women over a third, I believe are also people of color...” Topics: angel investing strategies, biotech, robotics / AI

Jason Waz shares with us his journey in becoming an entrepreneur and opening Competitive Edge Performance and creating NeuPT Technology. Make sure to subscribe to get updates on when it's released. Jason highlights a variety of topics such as: ✅Opening His Own Cash Based Practice  ✅His Interest in applying Science and Technology into PT ✅What is the NEUBIE? ✅ Important Tools in Growing a Business ✅ The Challenges of Being an Entrepreneur www.NeuPTTech.com You can find the podcast on Apple, Spotify, Google, Amazon, and Podbean platforms. Make sure to rate and subscribe!  Thanks Everyone!

We start by highlighting some favorite restaurants in Shelby, NC and Gaffney, SC. We also open up the nostalgia file for a couple of stories about gastrointestinal distress striking at inopportune moments. Then, Gardner-Webb University head wrestling coach Daniel Elliott comes aboard to talk about road trip fiascos and the extreme measures he took to make weight during his own wrestling career. Thereafter, Dr. Joseph Moore of DeadPeoplesMoney.com discusses his interest in financial history, rental property investments, and modern standards of living.This Week's Menu:Cavalcade of Sound (0:01-1:47)Opening Monologue (1:48-21:03) -Market Shout-Outs and Table Setting -Favorite Restaurants in Shelby and Gaffney -Nostalgia File Stories: Hamburger Steaks, Cheesesteaks, and Racing to Beat the Clock -Guest PreviewsThe Elliott Boys Get Ready to Wrestle (21:04-21:20)Daniel Elliott Interview (21:21-55:04) -Guest Intro -Members Only Mondays -How He Ended Up at Gardner-Webb -Highlights from His College Wrestling Career -The Most Extreme Measures He Took to Make Weight -Getting a Speeding Ticket in West Virginia -MRSA Talk -Coach Wince's Singing -Road Trip Fiascos -Coaching Philosophy -Marriage Advice -Raising Future Wrestlers -Sparkler Gate -20-21 Season PreviewBen Stein: "Anyone... Anyone?" (55:05-55:38)Dr. Joseph Moore Interview (55:39-1:38:46) -Guest Intro -Anticipating the 2008 Housing Market Collapse at the Last Minute -Investing in Rental Properties -The Origins of His Interest in Financial History -Modern Standards of Living -Standards of Living Today Versus Those of Millionaires in the Early 20th Century -Why It's Nearly Impossible to Predict Overall Economic Conditions -His Vision for DeadPeoplesMoney.com -His First Impressions of Gardner-Webb -Fondest Memories from GWU -The Future of Higher Ed -Tuition Pricing -Favorite Watering Holes in Shelby and Greensboro -Cold Beer for Sale in Boiling Springs & His Talk with Dr. Tony EastmanBen LaCroix Gets Overwhelmed at His Wedding (1:38:47-1:39:03)

Noah Geisel is an educator and digital badges consultant and the brains behind the annual Badge Summit. Noah started his career as a spanish language educator and coach. His Interest in recognition later became a career in consulting, where he specializes in digital badging ecosystems. Noah's previous projects include working on K12 initiatives with Aurora public schools and with Reelworks in New York City. Noah also organizes and leads the annual digital badge summit. Learn more about the 2020 badge summit here: * https://www.thebadgesummit.com/ "Micro-credentialism: Bite-sized stories from the world of digital credentials" explores the digital badging landscape and celebrates individuals that create opportunities for achievement for their communities. For more information, or to get started with Badgr, please visit https://www.badgr.com.

In this episode, Teri welcomes Awesome Aariv Modi, a 5th Grade student and excellent Amazon Alexa Skill Developer. Welcome, Aariv Modi!Awesome Aariv came on to talk about his experience as a grade 5 student creating Alexa skills and also creating videos to help educate the voice technology community.Awesome AarivOne of his favorite hobbies is playing chess. Went to his first tournament when he was six.He loves mystery books, plays basketball and loves video games.He has been coding since he was 7. He started creating basic programs using Scratch and Khan Academy, and then moved up to taking Codecademy courses on more complex topics.He has a YouTube channel, Awesome Aariv, where he creates videos about math, chess and books, and recently started creating videos on Alexa.He is very passionate about Alexa and loves developing new skills.His Interest in CodingWhen he looked at games he would wonder how they are built. He was always fascinated by the fact that just by typing code, one could create a game or any kind of great program. He wanted to learn that himself.His Interest in AlexaHe was introduced to Alexa 3 years ago when his parents first bought an Echo device. He always thought that Alexa has amazing abilities. He was most fascinated by Alexa’s smart home features.He was even more impressed when he learned that one could create their own skills for the whole world to use.As he was learning some more Javascript, he decided to create his own skill. He created his first skill, Kids Advice, during his winter break. Once he created one, he wanted to create more. He currently has 3 skills; Kids Advice, Meal Buddy, and Wheel of Fun.He also made a skill for his dad’s birthday as a gift.SkillsHe created Kids Advice using a fact skill template and added some extra code to it so that it asks the user whether they want another piece of advice after everyone. He created the skill to be introduced to AWS and the Amazon Developer Portal.His little brother wouldn’t eat no matter what his mother gave him, so Aariv was inspired to create his second skill, Meal Buddy, which entertains kids and also reminds them to eat. He learned more complex coding techniques from this.He created Wheel of Fun to show his parents that he could build more than a fact skill by himself. It gives users a random piece of advice, fact or fortune, and then asks the user whether they wanna spin again to get more. This is his personal favorite and he didn’t think it would be his most popular skill by a long shot. He has been adding more features to it and is currently working on adding monetization to it.How Alexa WorksThere are 3 main technologies that empower all voice assistants and they are ASR (Automatic Speech Recognition), NLU (Natural Language Understanding), and TTS (Text-to-Speech)When you say something to Alexa (Utterance), the Alexa device hears what you say and streams it to the Alexa service (which consists of ASR, NLU, and TTS). Once the utterance is in the Alexa service, ASR starts to work on it. ASR converts the audio into text for the rest of the service to use.NLU then starts to work on it by figuring out what you’re trying to do. NLU then sends a request containing the intent to your back end and your back end should have a handler for that intent otherwise the code will fail.All your code logic will then run and send a response back to the Alexa service which is json text, but Alexa can’t speak json, it can only speak audio, which is where text-to-speech comes in to convert the text to speech. With that, Alexa can say the audio response from the back end which you hear.That happens every single time we speak to Alexa.Creating Multimodal SkillsHe has been thinking of making Wheel of Fun more multimodal.Future PlansHis main focus is learning as much as possible.He wants to keep adding new features to Wheel of Fun.He wants to create more videos and update his blog posts with everything he learns.He wants to keep on working on monetization for Wheel of Fun, and hopes to complete it soon.List of resources mentioned in this episodeKids AdviceMeal Buddy Wheel of FunAwesome Aariv on TwitterAwesome Aariv WebsiteAwesome Aariv YouTube ChannelOther useful resources:Voice in Canada: The Flash BriefingComplete List of Alexa CommandsAlexa-Enabled and Controlled Devices in CanadaTeri Fisher on TwitterAlexa in Canada on TwitterAlexa in Canada Facebook PageAlexa in Canada Community Group on FacebookAlexa in Canada on InstagramPlease leave a review on iTunesShopping on Amazon.ca See acast.com/privacy for privacy and opt-out information.

  Session 81 Dr. Nicholas Volpe is the Chairman of Ophthalmology at the Feinberg School of Medicine. He joins us today to discuss his journey and his 25 years in the field! Today, we talk about the things necessary to match into this specialty and how to become successful in it. Be sure to check out all our other podcasts on MedEd Media Network. [01:44] His Interest in Ophthalmology During his second and third year rotations in medical school, Nicholas discovered his fascination with vision science. He liked procedures while recognizing that just being a surgeon that intervenes and disappears wasn't quite as satisfying as the kind of relationship that Ophthalmologists can have with their patients. So it was a unique blend of primary care of dealing with chronic patients with everyday needs and then superimposed on that is the chance to intervene surgically. [03:00] Traits that Lead to Being a Good Neuro-Ophthalmologist Nicholas describes this as a somewhat eccentric subspecialty within Ophthalmology as there are not that many Neuro-Ophthalmologists. It's one of the less popular subspecialties. In terms of choosing Ophthalmology, you have to have a certain interest, dexterity, and desire to do microsurgical procedures. In most Ophthalmology cases, it's 20% of their life. Unlike many other surgical specialties where you're operating three days a week and seeing patients one day a week, in Ophthalmology, there's still a fair amount of outpatient work in addition to the surgery. Moreover, you have to have a true interest in vision and helping people see. It's a lot more fun to be fascinated in the eye and how it works and understand the kinds of things that we can now do for people's vision. "You have to have this love for the primary care aspect of medicine." There are also pieces of the field beside vision science, which is public health issues, care delivery issues. The burden of blindness in the world is very different than the burden of blindness in developing countries. So there are great opportunities to provide insight and actual care to underserved people. [05:40] Types of Patients and Cases What Nicholas didn't initially recognize was that it was the most complicated aspect of Ophthalmology and interaction between the vision system and the brain. Currently, he's interested in the diseases of the optic nerve. "There are neurons that make up the optic nerve and there are lots of interesting and not well understood or well-treated conditions that affect the optic nerve." The second group of patients that he sees the most are those with acquired eye movement problems and misalignment resulting in double vision. Currently, his surgical expertise is limited to realigning or straightening eyes in patients with acquired misalignment of the eyes as adults so they're seeing double. A third of her patients he considers as challenging as they'd have to put up historical clues, exam findings, and diagnostic imaging. On the other end of the spectrum, there are patients that are packaged coming from other health conditions such as from a resected tumor that caused double vision. And then in the middle, are those people who thought they knew what they had or their doctors thought they knew what they had but had it wrong. These could also be things that were overcalled and got better on their own. "There's a good mix of diagnostic dilemmas within ophthalmology that make it a particularly challenging field." What's good with such field is they can take a picture of almost all their diseases so they can see what's happening, although there are still lots of nuances to consider when observing which patient is actually having such disease or which ones may require a different treatment. [09:10] Academic vs. Community Setting For Nicholas, the complexity of neuro-ophthalmology is often best served and best done in an academic medical center. That being said, his own preference has always been to practice in the enriched and more complicated environment which you can find in an academic medical center since they have learners, research, new knowledge they're trying to apply, and the most complicated patients. That said, there's a wide variety of things that he does making things very interesting for him with all the challenges and new learnings he faces each day. [11:00] A Typical Day As the chairman of an academic department of ophthalmology, he's responsible for the students, residents, fellows, faculty and all they do as researchers and educators, how their service interacts with the medical center, the community, the university. There's fair amount of fiscal responsibility as he runs a department that breaks even and is able to pay its salaries and take care of its patients at the same time. He also facilitates the work of lots of great doctors, scientists, residents, students interested in the field. Additionally, they're also responsible for many regulatory things they need to do as part of their stewardship of the academic unit in their department. "It's an incredible privilege to be able to be in a role where you are able to have a vision to take all these wonderful people, put them in that vision, and create something that is far better than any of us could do alone." [15:20] How to Stand Out and Get a Residency Spot in Ophthalmology First and foremost, you have to have a competitive board score. Be some kind of a researcher or be affiliated with the ophthalmology department of your school earlier on.  Just be able to demonstrate that you have the capacity to multitask and that you're really interested in this and you want to learn more about the field and you've immersed yourself in a project that's relevant. "There is a necessity unfortunately to create some type of a sorting process at everything in life." The ability to get honors in your clinical rotations helps to distinguish yourself from the rest as well. And the board scores are important too and there is a sorting process by way of board score cutoffs or thresholds since they're only able to interview people at a certain level. That being said, they have interviewed people with average board scores and don't stand out just based on their board scores, but for certain other reasons. So don't think that just having a low board score won't get you in. It may not get you to the most competitive programs but if you continue to demonstrate that you're great and interested with high emotional intelligence and are doing it for the right reasons, then you will get good letters and get noticed by the program that knows you until you make your way into Ophthalmology. Just recently, they had their matching at their program and 87% of first time U.S. senior allopathic applicants matched. [19:05] Elective Rotation: The Double-Edged Sword In their program, they don't really encourage students to do electives at their institution. Nicholas adds that he actually knows more than half of the people that end up matching the programs. Either they were students at their school or he had met them while they were doing senior electives. There is an advantage in that sense. On the flip side, if someone comes in for an interview and had done electives at three other Chicago programs that are not his, then he explains it may be obvious they're the student's fourth choice, hence they're less interested. So it could be a double-edged sword in that sense. Mostly, students undersell themselves that they don't have the confidence they should have based on what they've achieved. "There's a lot of misinformation out there whether it's on the internet or some website or from a buddy or from a school. They take some information and process it in a way that is not correct." [25:35] Their View on Osteopathic Schools Traditionally, Nicholas admits that students from osteopathic schools don't stand out as easily. That said, if they stand out for some reason, it's harder to judge them against the other applicants. There are some osteopathic ophthalmology residencies and have a separate path to be successful ophthalmologists. It's not impossible, but it's a hard position to start from. And this is based on his experience. [26:33] What Makes a Resident Stand Out "There are people that have that level of maturity about their learning and patient care that's very obvious right from the start that this person is going to be a great physician." Nicholas illustrates that in order for a resident to stand out, there should be a level of seriousness, attention to detail, teamwork, interest beyond just getting through, and learning to do extra stuff that nobody anticipates. It's much more about how they delivered care, how they take the responsibility, how they interact with patients and have that emotional intelligence. Nicholas advises applicants that of all the things they worry about in life right now, they may not be worried about whether they can be nice to patients or they can learn what they need to learn. But the last piece of your life is wondering whether you'll be a good eye surgeon. 95% or more will get there regardless of what you came with. And the reason the other 5% don't end up being good at it has nothing to do with their dexterity, but with something in the operating room that makes them nervous. For ophthalmology, even if they train you to be a surgeon, there are lots of good nonsurgical practices you can be in ophthalmology that only use laser and do incisional surgery. People will know whether they're good with their hands and you're going to be a good surgeon in general. But people who have tremors would be at a great disadvantage as a surgeon. Or if your eyes are not working together, there is most likely a pathway for you but it's just going to be harder than any normal individual. "We'll teach you. We'll get you there. And we'll make you into a good surgeon." [32:17] The Biggest Changes in Clinical Care in Ophthalmology "Ophthalmology is the home for some of the most incredibly revolutionized treatments that didn't exist for conditions that are the most common cause of blindness." The field now has a treatment for macular degeneration that prevent people from losing their central vision. They have also incredible advances in the technology they use to diagnose retinal problems. Nevertheless, they're making 10,000 new 65 years old a day for the next 20-25 years or so and how they're going to take care of those patients. So this is a challenge they all think about. Ophthalmology is the first to successfully treat people with genes. They have gene therapy now that corrects hereditary form of blindness and the eye is the perfect place for gene therapy for stem cells. On the flip side, they have diabetics who are going blind from a completely treatable condition that was undiagnosed because they didn't go to an eye doctor and there are disparity issues. How they provide care for those patients is an equally important challenge that they have to embrace in their field. Nicholas sees a huge need for ophthalmologists in the next 20-25 years so he sees the new breed of them to be very busy in terms of the number of patients they have to care for. At the same time, they have to be comfortable working closely with non-physicians in the care of patients. There are great opportunities for synergy with optometry in terms of optometrists being excellent at taking care of the eye. At the end of the day, it's about figuring out a way to care for the population. So the future is very bright for the field of ophthalmology. "Anybody can be taught anything with the right teacher and the right circumstances." [39:00] The Most and Least Liked Things The thing he likes most about the field is the unique ability to recognize life-altering conditions and be able to then alter those conditions that improve people in a way that could change the way they approach their world in the future. Conversely, what he likes the least is the necessity to have to see large amounts of patients in a short period of time than the time they would have wanted to spend with each patient otherwise. [42:10] Final Words of Wisdom This is an incredible specialty that you can get into it. Prepare yourself early. If it's on your list of things you may be interested in, seek out the student group in your medical school. Seek out mentors. Nudge your way in to get to know people so they'll start to see what you're doing. Know that this is an incredible time to be an ophthalmologist because of the clinical need for eye care. While we're also at the time of most exciting precipice of game-changing treatments based on clinical and translational research that is really impacting people's lives. Links: MedEd Media Network

Session 57 Dr. Tom Bice is an academic Pulm Critical Care physician in North Carolina. We talk about his specialty and what you should be doing if you're interested in it. Tom has been out of fellowship for four years now. By the way, check out all our other podcasts on the MedEd Media Network. [01:03] His Interest in Critical Care Medicine Not being able to decide on one topic, Tom knew he wanted to do a little bit of everything. And he has mild to moderate ADD. He also considered Emergency Medicine early on but he found he didn't enjoy people showing up at 3 am with significantly non-emergent problems. So when he focused more on internal medicine, he was doing his rotations in surgery and medicine. Then he realized that all of the patients and disease processes that were cool ended up in the ICU. What cemented his decision was his OB rotation with a young 26-year-old lade with sickle cell anemia came in at 29 weeks and went to the emergency section. She ended up in the unit for several days and intubated, septic shock. He was a third year medical student at that time and he was the one from their team surrounding the patient. And he realized he loved every minute of it. In fact, the attending OB was one of those who wrote letters for his residency. Since then, he got hooked. "I was hooked. Right away, I just love the excitement of the physiology and meeting a broad swath of knowledge about the various systems." In short, it was the acuity that actually drew him towards what he's doing now. He had this notion that patients are going to need you when they come see you. But that's not always the case in the emergency medicine. [04:55] Types of Patients Being part of a large academic medical center, they have different ICUs for all the different patient types. As with Tom, he works predominantly in the medical ICU. But they also have the cardiac ICU, neuro ICU, surgical ICU, and cardiothoracic ICU (where he spent the first two years out of fellowship). At medical ICU, they see patients with sepsis and septic shock of some kind. You also have those with liver failure, drug overdoses, and problems which you can't figure out what's wrong but they look real bad. What identifies all those patients is the need for fixing a deranged physiology. Neuro intensivists tend to go through neurology or emergency medicine and then do neuro critical care. The cardiothoracic ICU uses a bit of everyone including anesthesia and critical care. Cardiac ICU does cardiology and pulmonary critical care too. Tom explains that you get training during fellowship because your'e required to do so many months of ICU, that you can go and work in any kind of ICU necessary. Having done a lot of moonlighting during fellowship, and he saw that at the bigger community-based academic programs, intensivists rounds on all those ICU patients providing critical care. [09:15] Typical Week When Tom is o service, his typical week would be nighttime covered by the different intensivists where he is on from 7am to 7pm for seven days. And for the weekends, the ICUs have to have two attendings on so they split it between the two of them every other day. Tom tries to keep his rounds short. And there's a lot of work that need to be done, procedures, consults, and activities for patients. Then before he leaves for the day, he ensures he has followed up everything and whatever action plans that needed to happen should have happened. [10:35] Is It Procedure-Heavy? Tom says it's a lot of procedures, with a caveat. To some extent, you can do as many or as few procedures as you want depending on how hands-on you want to be. But if you don't like procedures then it's not the specialty for you. Especially for the pulmonary side of things, they do thoracentesis and chest tubes as well as intubation, lumbar punctures, etc. If you really don't like procedures, then it's probably not the specialty for you." [12:00] Work-Life Balance Tom says he has a lot of work-life balance, and this is the reason he chose academic over private practice. He probably would have enjoyed private practice critical care for 2-3 years. But he enjoys about 12 weeks of ICU time a year. And the rest of his time is non-clinical, doing research. His focus is clinical research so it's still patient-focused. But the 24/7 grind is not constant. Nevertheless, when he's home, then he's really home. He likes the advantage of shift work. In fact, most of critical care is moving that direction around the country. In their state, what he notices is very much a day group and a night group. You're on when you're on and you're not when you're not. So it's easy to maintain balance that way. "There is generally recognized shortage of people that are critical care trained and most of the hospital quality folks would prefer that there was a critical care trained person in the hospital 24/7." [13:45] The Training Path Tom cites a few options available now. When he started his fellowship, he knew he was going to keep doing research and stay in academics, he did his three-year internal medicine residency and then a  two-year critical care fellowship only. Another options is for one extra year, you do pulmonary. This is mostly determined on whether you like clinic or not. People who do critical care only, tend not to have clinic obviously because there's no ICU followup per se. But if you want some of that longitudinal relationship with patients then you get to a little bit of both. That's why Tom also has a pulmonary clinic. This is three year after internal medicine residency, totaling to 6 years after medical school. "There is no particular disadvantage to hiring a critical care fellowship only." In terms of competition, Tom thinks it's getting more competitive, but it's not cardiology, or GI, or oncology. They get very competitive applicants every year at their program. He describes it as being competitive enough that requires some degree of forethought. He also thinks you have to have some research exposure if you go to an academic-type program. [17:24] Negative Bias Towards DO Physicians and Special Opportunities Tom has not seen any bias against DO doctors. In fact, a couple of his absolute famous attendings from residency were DOs that did pulmonary critical care. They've interviewed plenty of DOs. To them, it seems another way of getting the same training. There are further subspecialization both in the pulmonary care side and the critical care side. Under pulmonary, there's interventional pulmonology which is more procedure-based. There are no formal NRMP matching programs for lung transplants but there are a few places that offer fellowship and subspecialty training in that. There are not set training programs, but they are niches within pulmonary medicine. "As with everything, subspecialization continues to involve. There aren't formal training programs but emphasis or subspecialization has developed in recent years." [20:10] Working with Primary Care and Other Specialties Tom explains they do have interaction with primary care doctors in the pulmonary side. One of the balances they often run with primary care is the shortness of breath consultations, which cardiology and pulmonary like to point the finger at the other direction. His advice to primary care is to accept that both are probably wrong. And it's probably a little both of the lungs and the heart causing the shortness of breath. Other specialties he works with include Nephrology. One-third of patients through the ICU require dialysis at some point. Tom also underlines the importance of having a good relationship with critical care trained surgeons, which are different from your general surgeons. Sometimes, it's knowing when not to take the patient to the operating room. And sometimes, it's knowing that you need to take a patient to the operating room, no matter what. He may also work with GI/Hepatology. "In the medical world, having good relationship with your critical care trained surgeons makes a big difference." Outside of critical care, there are other opportunities that are available. Pulmonary gets involved with high altitude medicine which also includes diving (low altitude medicine). Personally, he has had some experience traveling and training in resource-poor environments. Knowing how to provide critical care in those environments can be very handy. You can also do research. Critical care is relatively a new specialty. So there's still a ton that we don't know about how to do things right, according to Tom. You can also do quality and leadership initiatives through that. [23:40] What He Wished He Knew that He Knows Now The one thing he didn't know as much early on about critical care is how much time spent with families of dying patients. He's glad though that it's something he enjoys having those conversations about end of life care and the expectations of what is going to happen. "Most of our medical training leading up to, and including in residency and fellowship, is find the problem, fix the problem. There's just so much of the time where we just can't." Tom stresses that unlike what they're taught during training to find the problem and fix it, there are times they just can't. And being able to have that conversation with patients or their families is really important. This is a good message he wishes to send out to primary care doctors as well is to have those conversations in clinic early. But recognize that they're flexible and people change right up until the last minute. [25:20] What He Likes Most and the Least and Major Changes in the Future What Tom likes the most about critical care is that there's always something to do. It's always a busy specialty. There's always going to be sick patients. And the acuity never stops because if you're going to get one patient better. And there's going to be three waiting in line. "Flu is one of the diseases that they know most of the symptoms of it, but they can just do anything later on and affect almost any organ system." On the flip side, what he likes the least is that the ICU never closes. So you have to know that you're going to work in the ICU on Christmas and all the other holidays at some point.  Know that going in. Although this has been growing over the last several years, you still see the inclusion of advanced practice providers like PAs and NPs in the ICU. This is primarily because of the shortage of critical care providers. It's a numbers problem that a number solution can help with. Ultimately, if he had to do it all over again, he still would have chosen the same specialty. Tom wishes to tell students who might be interested to explore this field that they'd love to have you. Contact your local critical care doctor for rotation. It's a good time even if it's busy. [29:30] Personal Takeaways Most students that love a little bit of everything go to emergency medicine. Yet, there's also this subsection of students who love the high acuity stuff. Go back and listen to Episode 2 of Specialty Stories where I interviewed an emergency medicine doctor where he revealed that the high acuity stuff only comprises a small percentage of an emergency physician's job. So if you like the high acuity stuff, and you like a little bit of everything, pulm critical care might be the specialty for you. If you have a physician you want to be interviewed here on the podcast, shoot me an email at ryan@medicalschoolhq.net. Links: MedEd Media Network ryan@medicalschoolhq.net Episode 2 of Specialty Stories

Session 46 Dr. Narayan Viswanadhan is a community-based Neuroradiologist in the Tampa area. We discuss why he chose the community, what his day looks like, and much more. He has been out of fellowship training for three years now. Also, check out all our other podcasts on MedEd Media Network. [01:15] His Interest in Radiology and Neuroradiology When applying initially for residency, he applied for internal medicine into several programs. And as he was doing his sub-internships, the was drawn more into radiology. What he likes most about internal medicine is coming up with the differential diagnosis. He likes figuring out the root cause of the problem. But as he kept going into internal medicine, he was going further away from it. And during his radiology elective, he realized he enjoyed being the diagnostician or the doctor's doctor. And this was what drew him into radiology. "I really enjoyed being the diagnostician or the doctor's doctor kind of thing. That drew me to radiology." Moreover, neuroradiology got him as he was continuing his radiology residency. He enjoyed the anatomy and the complexity of it. He found it an elegant system and so he thought it was something he was fascinated with. And with the crossroad between technology, anatomy, and medicine, this is what made him go into neuroradiology. Other specialties drew him were those with modalities overlaying with MRI. He enjoyed musculoskeletal imaging. He thought sports medicine was interesting since he loves basketball. They also had a strong training in body imaging and having that strong background, he thought it would be a good opportunity to do further fellowship training in neuroradiology. [03:55] Traits that Lead to Becoming a Good Neuroradiologist Narayan thinks that you initially have to have a strong knowledge base with a detailed and comprehensive understanding of anatomy. There are so many anatomic structures you have to be aware of. "You can't play the game if you don't know the players. That's definitely the case for all of radiology." Additionally, you have to have a good background of anatomy, physiology, and pathology. Narayan thinks radiology is a long residency which takes seven years in total. Attention to detail is also another critical thing. You need to think about not just common stuff but esoteric stuff can easily come into play which makes a big difference in patient outcomes. You also have to be an effective communicator. You will be working into interdepartmental conferences with neurologists, neurosurgeons, primary care doctors, ENT doctors, and oncologists. So it helps to have that personality that can effectively communicate. It's nice that they can feel you're somebody they can go to and rely upon to provide the best care for the patient. [06:05] Community versus Academic Narayan was actually torn between going into community and academic settings since he applied to an array of both settings. He did a two-year neuroradiology fellowship. People who do this are more inclined to do academics. And he actually thought this was the career path he was going to choose since he enjoyed working with other residents, medical students, and fellows. "Typically, people who do two-year fellowships are more inclined to do academics." However, he felt he was going to miss a lot of the aspects of radiology that he grew to love including body imaging and procedures. So while he thought of both avenues, in the end, he didn't envision a career where he was going to focus on one sub-specialty for the rest of his life. And this is because he enjoys all the different aspects of medicine. [09:15] Percentage of Practice, and Patient Types Narayan explains that the beautiful thing about being a neuroradiologist working in a general setting is that while he has a niche, he also has the ability to a little bit of everything. This is from a diagnostic standpoint as well as from a light interventional standpoint. He feels he gets to utilize a little aspect of medicine he studied which still affects his day-to-day work. As to what percentage of his practice is neuroradiology, Narayan would say that a third of his time is focused on neuroimaging. This includes reading MRI, brain CT, advanced imaging. Sometimes they do some profusion at some of their hospitals. A significant percentage of the cases they read are patients with back pain (surgical or low back). Other patients that go in have issues with headaches and trauma. When he was still doing residency in Albert Einstein Medical Center in Philadelphia, they saw significant amounts of bullet-related and other types of trauma related to that setting. But now they see more of motor vehicle accidents. So their bread and butter would be routine imaging. Moreover, they also have a cancer center. They have a neurooncologist in the community. So they see cases like gliomas and glio tumors, both initial presentation and follow up on those patients. This can include different therapies as well as evaluating and monitoring responses to treatment. Other cases are demyelinating disease and disorders like followup temporal progression or response to therapy. From the ENT standpoint, they typically see patients (pediatric and adult) for hearing loss. They get CT for the temporal bones or MRI of the internal auditory canals to look for varying causes. They also see head and neck pathology such as tumors of the oropharynx or upper area digestive tract and after-treatment followups. These being said, it's a broad scope amidst a focused niche. "Even in the community, several clinicians and consultants prefer to have neuroradiologist lead specific studies." But Narayan points out that even in the community, clinicians and consultants prefer neurologists to lead specific studies. Because of that added level of training, it significantly impacts patient care. [12:36] The Impact of Neuroimaging Mimics Narayan is doing a lecture for radiology assistance and one of the things he has in the training is neuroimaging mimics. This could have a significant impact. One of the cases he would show is the case of  a subacute infarct which was diagnosed as a tumor. If somebody interprets it as a tumor, the neurosurgeon may do a craniotomy. But if the imaging can overlap that infarct, that's a big difference in treatment. Another area which can mimic a tumor is called tumefactive MS. It's a demyelinating lesion but it looks like a tumor. And it does have some subtle imaging findings but it's important for the radiologist and neuroradiologist to distinguish these things. "It has significant implications on what they decide to do and patient outcome." [14:14] A Typical Day, Taking Calls, and Work-Life Balance Narayan describes his days as very varied at his practice because they rotate between hospital-based and outpatient practice settings. But since he tends to go about 50% of the time to hospitals, they will start with the inpatient list. Having a big practice, they have a big ER and inpatient mix. So if he's just assigned to ER rotation, he will just focus on ER. But his typical day would be reading anywhere from 100 to 150 studies. "A typical day for me might be reading anywhere from 100 to 150 studies." In his current practice, a third of it would be neuroimaging related studies which include CTs of brain, MRI of the spine, the temporal bone, the head and neck imaging, tumor followup. The rest of it would be bread and butter - abdominal pain, pancreatitis, appendicitis, and other routine cause of abdominal pain and complications for patients and inpatient settings. As a radiologist, he also does some light interventional procedures. He sees this as a nice break since he gets to interact with patients. He does paracentesis, thoracentesis, lumbar puncture, myelogram. He also does some biopsies at his particular setting. This is actually geographic in nature as to whether the subspecialty radiologist does this. But at his practice, even the specialty radiologist will do things like lung biopsy or participate on the drain. Because of this mix, Narayan enjoys his day-to-day setting yet he still gets to concentrate on one particular specialty. "We also just serve a large community so it makes for a busy day but we get through the work and try to do a good job." Narayan takes calls about once a month. They cover both days on the weekend. Because of the broad practice setting, they have many different physicians and many different types of call. But they'd typically go in and cover one set of calls, say focus on ER and others may focus more on inpatient and ER. Again, it depends on the location, the time of year, and the time of season. Nevertheless, he describes it as being quite busy. The volumes are high. Imaging utilization it seems can sometimes be high. Not to mention, they serve a large community so it makes for a busy day. Narayan can say he has a good work-life balance. Having three kids, he sees them as his priority. And choosing this specialty allows him to spend time with his kids. [18:25] The Training Path and Matching "The training path, you have to know initially that it's a long one and you have to be prepared for that." Narayan's great piece of advice is to try to be patient and try to reach that end goal at the outset. Take it one day or one step at a time. After premed, you do four years of medical school. Then you do a year of internship - either preliminary year in medicine or surgery or a transitional year. This is followed by four years of diagnostic imaging or diagnostic radiology. During your third year of residency, you would apply for a fellowship in neuroradiology. It's either a one or two-year fellowship. Narayan thinks majority of the fellowships are one-year training programs. But some still have two years. In total, that's seven years of training after medical school. In terms of competitiveness in matching, it comes in waves. It also depends on some academic centers where some are more competitive than others. But by and large, most radiology residents will secure a neuroradiology fellowship. In his case, Narayan submitted a rank list for residency. And most students would rank within their top three or four choices. And most get between eight to ten interviews. So he would describe it as competitive but not as difficult as getting into medical school. As a medical student interested in neuroradiology, Narayan recommends a few things to be competitive. It also helps during your fellowship interview to talk about certain highlights that you've had in the field that others may not have. This could mean participation in research related to neuroimaging. Narayan did a lot of posters and mini-abstracts related to neuroradiology he'd present at national meetings like the American Society of Neuroradiology. So think about pursuing research-related activities or even educational activities. He went to a very strong didactic residency focused on residency education. He would teach junior residents and they would have medical students come and rotate. He would create lectures on certain neuro topics. There also had opportunities to teach the CT and MRI technologists different aspects. "Participating in research, educational activities are all good steps to take to make yourself most competitive." [22:33] Bias Against DOs and Other Subspecialty Opportunities Personally, Narayan doesn't see any bias against DOs in the field. He doesn't actually realize whether one is a DO or an MD since it's not something that comes into fruition on a daily basis. That said, it doesn't matter whether you're an MD or DO. Once you're a neuroradiology fellow, other opportunities to further subspecialize include focusing on areas like functional MRI, profusion and imaging related to stroke or tumor, pediatric neuroimaging, pediatric neuoradiology, and pediatric neuro interventional radiology or neuro interventional radiology. So three additional areas in subspecialization may be pediatrics, head and neck, or neuro interventional. For many people, after their one or two years of diagnostic neuroradiology, they would do an additional year of pediatrics. Or if they're interested in doing interventional radiology, it's an additional two years of interventional neuro training. There are also those that exclusively wanted to focus on head and neck, so there are some places you could do additional training for a year. Moreover, in the practice setting, it depends on what path you want to create. [25:30] Working with Primary Care and Other Specialties, and Special Opportunities Outside of Clinical Work Narayan wishes primary care physicians to know that they're trying to provide the best, high-quality reads for their patients. Sometimes, with the increasing turnaround time demands and increasing volumes, it can become difficult. But he always does his best to provide the most accurate report in a timely fashion. But also, the more information neuroradiologists can have, the better report they can provide. If they could give additional history, this could be very helpful in localizing and targeting their search in finding pathology. "The more information that we can have, the better report I can provide." Other specialties they work the closest with include neurosurgery, neurooncology, and ENT doctors - being the three main areas they work with. Narayan also stresses that it's good to have a good rapport with other surgical or clinical colleagues. A lot of times they'd just call each other on the phone. They frequently communicate so they can provide quick access to each other. Oftentimes, it helps to have that interdisciplinary relationship to further improve the care of the patient. Narayan thinks there are many different avenues to pursue like the pharmaceutical industry. You can help to evaluate certain disease or therapies and drugs and response. Sometimes it's helpful to have someone with an imaging background and taking that into the pharmaceutical industry world. You can help evaluate both drugs and other contrast agents in response to therapy. He has also met neuroradiologists who have taken on working in fields like public policy. That said, he thinks the opportunities are endless. [29:11] What He Wished He Knew Narayan says he wished he knew it was a pretty challenging road. He thought it would have just been something he was going to do. But he never really anticipated the number of years it would take collectively. He never thought about the number of examinations he was going to take. After the three steps to get into medical school, there were also three board examinations. Then there also used to be the notorious oral board examination. Plus, after neuroradiology, there was another subspecialty boards he took called the Certificate of Added Qualification (CAQ) in Neuroradiology provided by the Board of Radiology. But the unique thing about neuroradiology is the endless educational cycle where it never ends. He's actually learning and reading to this day. And no matter how much you read or study, there's just so much body of knowledge that continues to change. "No matter how much you read or try to stay on top of it, there's just so much body of knowledge that continues to change." Plus, in the advent of artificial intelligence, some people may be hesitant. But Narayan sees this as an interesting opportunity to work side by side to help AI make them more effective and more accurate. So although it's an exciting field, he just didn't think he was ready for all the challenges. He also mentions a poster the ABR does that highlights the fourteen years of training that takes to become a neuroradiologist. It has the picture of the brain that shows each area and during which step they're in. Indeed, it's a long road but he's still glad he chose it. [32:43] Major Changes in the Future -  AI and Machine Learning Narayan says that if there's one body of people that are scared and thinking their field is going to end is radiology. But looking at their different radiology meetings and the leaders in their field, they're actually embracing machine learning. They think of different ways to have it improved. They already have steps in machine learning in terms of working with them. He found that while it's good in some areas, it has limitations inn others. So it just works in complement with the radiologist. Majority of the time, he thinks it's not the most accurate. There are some nuances to it that is not quite there yet. But there are definitely areas he can see where it can help them. This said, he thinks we should be embracing the leaders in the AI and tech companies. He thinks it would be nice to help the computer think about different algorithms and about the way they interpret the brain. Because some cases don't always nicely fit into some sort of algorithm that a computer may be able to pick. But for day-to-day portable chest xrays, it's a useful adjunct. Also, as you do more and more and read more and more, you start to learn some subtle patterns. "There are some areas the brain is still pretty good." [36:34] What He Likes the Most and Least What he likes most about being a neuroradiologist is finding things on people that's not always expected. He likes to provide the answer to a patient's problem as early as possible. While many times it's obvious to find something, it's rewarding to find them. And really this affects the patient’s cure early on in the disease. A lot of times, they always look at the whole study. But in fellowship, he remembers reading the MRI, the lumbar spine for back pain. But he had to define a Wilms tumor in the kidney. And the patient was able to get that resected and cured. And sometimes, you're the first one to notice that. He finds nodules when looking at shoulder xrays or just different pathologies all over. And the more you look, the more you find. So he finds this especially rewarding. On the flip side, what he likes the least about his subspecialty is the difficulty of multitasking. You can be looking at a complex case and then you'd have to juggle that with taking a phone call from a technologist for instance. But he tries to resist the temptation to rush through things. So he just takes it one case at a time. That said, you still need to be able to multitask. If he had to do it all over again, Narayan would still have chosen the same path. It goes in waves, but overall he's happy the path he chose is a wonderful career. It's one where you can have a tremendous impact on, both working with other clinicians and other doctors and also impacting the patient. "You may not really get recognition from the patients but it's rewarding when you find stuff." [39:45] Final Words of Wisdom Narayan leaves us with some pieces of advice. Something he learned from his mentor is "we got to get the list cleaned up." But you have to always remember that it's a list of patients. It's people's individual problems. They're going through certain conditions. So it's your responsibility that while you need to get the work done, remember that they're patients. It can easily get lost in that mentality of just cleaning up the work. Just stay grounded. Be patient. And try to learn and do as much as you can. For the medical student, and you might already know you wanted to be a neuroradiologist from day one, it's important to get knowledge in other areas. In fact, Narayan recommends that you do less in neuroradiology throughout your medical school and residency training. Because the more you understand what other specialties are looking for and what they want to know, the better neuroradiologist you're going to be. Same thing with doing more. Increasingly, you're going to be doing more procedures and be versatile. So doing your training, try to learn as much as you can. [41:46] Like This Podcast? Did you enjoy this episode? Shoot me an email at ryan@medicalschoolhq.net. I welcome any suggestions or specialty that you would like to come on the show. Better, send me a name so that I can interview him or her. Links: MedEdryan@medicalschoolhq.net Media Network

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

Session 36 Dr. Scott Steele is an academic Colorectal Surgeon and Chairman of the Colorectal Surgery Department at Cleveland Clinic. We discuss his love of the specialty. He has now been practicing outside of his fellowship for twelve years now. Dr. Steele also hosts his own podcast called Behind the Knife. Check it out as well as a host of all our other podcasts on the MedEd Media Network. [01:17] His Interest in Colorectal Surgery Scott knew he wanted to do surgery from the first time he got his clinical years and did some primary care. He also considered orthopedics since he likes sports. But colorectal surgery dawned on him when he met some mentors. Not being a sexy topic, he didn't really give it much time. But he found a mentor when he was in residency. Towards the end of his second year, going into his third year and on his fourth year, he began thinking about colorectal surgery. He hung around them and went to the meeting which he found an incredible experience. He thought they did both great in surgery and academics. They take care of patients that have diseases that he likes. They do some outpatient and inpatient surgeries, colonoscopies, and major oncological reconstructions. So it was something he was interested in. He initially thought about doing heart surgery but he thought he wanted a little bit more of variety. He knew he didn't want to do orthopedics in medical school after he did one rotation at the University of Wisconsin. Although he likes orthopedics and how it's related with sports, it just didn't trigger him. "I was more in the process of easily ruling things out." So Scott did this process of ruling things out. Surgical oncology is okay but colorectal did great cancer operations as well. Surgical oncology tend to not do the wide breadth of people. They tend to serve old people, a lot of them are dying in a lot of cases. It was something he didn't want to do. Minimally invasive surgery was a burgeoning fellowship at that time and it was its own fellowship. But he thought colorectal also does minimally invasive surgery. In fact, now minimally invasive surgery is a standard component of any particular field. So it's not in and of itself. So he made the jump from heart surgery to colorectal surgery. Scott was a general surgeon. He was in the military and he spent a year after his residency at Fort Hood, Texas where he practiced general surgery. So he basically did the vast bread and butter of general surgery. But growing up in a small town in northern Wisconsin that had amazing surgeons. And as a general surgeon, he didn't want to get pigeon-holed in being the hernia guy or the bowel obstruction guy or the lap chole person. He knew he wanted to do academics. He knew he wanted to do a subspecialty. So the more and more he went into colorectal surgery, the more he realized it fit his personality. It fit all the things he was looking for in a career. "The more I went into colorectal surgery, the more I realized it fit my personality. It fit all the things I was looking for in a career." [06:03] Traits that Lead to Becoming a Good Colorectal Surgeon Scott says that it's more on how we are as people. But what he found with colorectal surgeons is that they don't take themselves so seriously in broad, sweeping strokes. They have a ton of fun. They are generally good people. But they also have a side where they're really busy clinical surgeons in the community and academic centers. And for those that did academics, it was great medicine. There was basic science research and others did hard core epidemiological research. He adds that when you walk into a clinic and pick up a chart or log on the EMR and see what they're doing, patients have a special part of their body. They may not even tell their spouses of many years about what's going on with them. It tends to be something that's very intimate and very personal. It bleeds or itches. They feel something and that patient in many cases think they have cancer or they think something's wrong. If your arm itched or bled or you felt something, you'd look at it. But that part of the body is so hard to look at. So patients have an extreme amount of trust in you. Within five minutes of talking to them, you're asking them to pull down their pants and look at their back side. A lot of things can be in that person's mind. And in all of those aspects, you have to be able to go in and establish patient rapport right off the bat. Make them understand that despite their misconceptions, it's okay. It's very routine. And many people experience the same type of symptoms they're experiencing. So you need to keep it a little bit light. Let them know you take their symptoms seriously and that you're going to walk them through the process. Keep in mind that in the United States alone, colorectal cancer is the second or third leading cause of cancer-related deaths every year. It's something we don't talk that much about. Scott says it's something they can intervene and interact with that given how serious the topic is, you don't yourself too seriously. "Colorectal cancer is the second or third leading cause of cancer-related deaths every year." [09:51] Types of Patients As a colorectal surgeon, you see all age ranges and a mix of benign and malignant diseases. Scott is the lead editor of The ASCRS Textbook of Colon and Rectal Surgery and in the book, they talk about how they organize colorectal diseases. The organize it into six folds. First, is endoscopy. It's a large percentage of what they do. They use scopes and they're able to do a lot of advanced procedures through it. Second, they see the plethora of anorectal disease such as hemorrhoids, fissures, fistulas, etc. It's the routine but stuff they do and a big part of the practice. Third subset is they see the malignancy - anal cancer, rectal cancer, colon cancer. Those are the major operations you can do minimally invasive procedures. You can use laparoscopy and open surgery. You can do robotics and all the different neat tools and tricks you do. Fourth, is they get to see a lot of the benign disease which includes a lot of the inflammatory diseases such as IBD, the Crohn's disease, ulcerative colitis, and diverticulitis. Fifth is you also get to see pelvic floor disorders. Those are the patients with obstructive defecations and those with rectal prolapse or fecal incontinence. And last is your miscellaneous type. But the first five types mentioned by Scott are the ones where when you talk about colorectal disease, you can break each of those down. You can see how you have all the plethora and combine that with scopes where you can do things endoscopically. They have one person in their department who is a very gifted and technical surgeon. He was able to take off early cancers through the colonoscopy and save people from having to go major surgery. It's that wide breadth of patient variety, ages, outpatient, inpatient, scopes, major operations that is the unique part of colorectal surgery. Contrast that with things like surgical oncology or cardiac surgery and that's what drew Scott into the field. “It's that wide breadth of patient variety, ages... scopes, major operations that is the unique part of colorectal surgery.” [13:20] A Typical Week For Scott, he spends his Mondays in the operating room. He has all-day clinic on Tuesdays. Wednesday is his admin day as the Chairman of the Department. He typically has a lot of meetings. Thursday is an operating day and Friday, he does scopes and some afternoon meetings. This is a pretty standard week for people where you have a mixture of clinics and other things. The person who started Relay for Life, Gordy Klatt, was a colorectal surgeon. He died a couple of years ago. He was a community colorectal surgeon and one of the last independent providers. Scott covered for him for seven years. Scott was in the military and would take some vacation and cover for him. He had a much different practice. He saw clinic a half a day everyday. He would operate on most days as well. The admin days are part of many private practices but it wasn't part of his. He ran his own business with his wife being his business manager. He would have major operating days maybe three days a week. And he would do colonoscopy on a certain day of the week. He would also always come back to his clinic. So there is a wide variety depending on where you're at and what is the practice you're in. If you have a big group practice or a multispecialty clinic such as the polyclinic in Seattle or if you're working at an academic medical center like the Cleveland Clinic. It has a very busy high volume center. "Depending on what your niche is and what you'll be able to do really would determine your practice." Somebody in his department that does pelvic floor may see a little bit more clinic than somebody who's an IBD specialist who may have a mixture of clinic and operating days. So this varies according to the individual unique practice that you want to set up. [16:00] Operations and Calls Scott says they treat colorectal disease. And as a part of that, the referral pattern you're in would determine a lot of how much medical management has already been done. Many pelvic floor disorders, for example, need medical therapy or workup. Fecal incontinence in many cases can be treated with bulking agents and some Imodium and some pelvic floor retraining. So they won't need an operation anymore. There's also a study that 50% of hemorrhoid consults are not hemorrhoids alone. Or there's something that never needs an operation. Diverticulitis can be treated with antibiotics. So you can see that a lot of these disease processes are treated with multispecialty type approach that medical management is a major part of it. So on a typical clinic, not accounting your post-ops or your follow-ups, anywhere between 20% or 30% depending on your individual practice may require surgery. But all of them have some semblance of needs for the colorectal surgeon to treat either surgically or medically. "They look at you as an "expert" of the hindgut to treat whatever is going on so you do have to know your medicine." With regard to calls, Scott says they vary more than anything else. It depends on who takes the call and how many people are there in the practice. It also depends if you're asked to do general surgery and colorectal or just colorectal surgery alone. It also depends if you have acute care surgery or you have fellows and residents. Scott thinks that they're one of the largest colorectal departments, if not, the largest in the United States and maybe in the world.  They have well over 20 colorectal surgeons. So for them, call is busy. But they can be extremely busy when you're on call because it's a major referral center. At their clinic, they get patients all over from the northeast Ohio to Kentucky, West Virginia, and all over the world. So a lot of the diseases that can happen that affect the colon in such a busy hospital. They have fellows and residents. It's a very busy fellowship and a very busy residency. Scott says they are up all night long. It's a busy call but they're not crushed with calls. He has been on call a lot more in other places that he has worked. Additionally, you have to determine that as a subspecialist, especially a subspecialist branching out from general surgery. This could include bariatrics or minimally invasive surgeon, surgical oncologists, colorectal surgery. In each of these, you're oftentimes asked to take general surgery call. When he was in the military, his call was colorectal surgery and also general surgery call. That mixes in your bowel obstructions, cholecystitis, appendectomies, hernias, etc. That can drastically change your call in terms of the number and the types of patients you see. Some people want to do that. Scott did general surgery call for seventeen years. But he doesn't do it anymore and he doesn't do trauma anymore. He's fine with that. But other people are looking for jobs as a part of their colorectal practice that they can still do a little bit of general surgery. Unless you're going to a major medical center where it's a colorectal call only, you may be asked to do some general surgery calls. And that has its pluses and minuses. Some of their east side hospitals take a bit of general surgery call. That's part of the institution you're working at. People primarily at the outer institutions away from the main campus take general surgery calls. But that's part of the hospital they're a part of. They also have other jobs in the hospital. You're working with people and you get to know the fellow doctors you're working with. You help out. You cover for them and vice versa. So that's a unique aspect of that. Scott took general surgery call because he liked it. At times it's rough. But he can say that especially earlier in your career and especially if you're going to a community based setting, don't be surprised that you're going to be taking some general surgery call. "If you're going to a community based setting, don't be surprised that you're going to be taking some general surgery call." [22:45] Work-Life Balance Scott explains that time is the most precious commodity that you have. That's why you need to prioritize. Really determine what do you want to do in life and what do you want to be. What are your goals? Regardless of your specialty, you have to prioritize and figure out what type of practice you have. What type of priorities do you have and where do you go? Earlier in his career, he knew he wanted to do academics. So he had a very hard time saying no. Anybody would ask him to write a chapter and he would do it. Or they'd ask him to review an article or travel or teach a course or cover a call, he'd do it. Being in the military, he started being deployed. And then he got deployed for a number of times. The next thing he knew, he has one daughter, grew up and realized he's missing a lot of her life. You're going to be busy. If you want to do academics, there's never enough time for academics. There's no such thing as protected time. And even for those who have "protected" time, everything else impinges on it. So you have to really set aside time to decide what you're going to do. Scott has had friends who started on academic career and did a bunch of stuff. Then they felt they didn't have the passion for it. So they stepped back from it or did it selectively. And that's great because it works for them. Scott likes academics a lot and says that unfortunately, you have to find time. He reviews for a number of journals and serves as an editor for several textbooks. He has traveled the world and has met wonderful people. He has operated in places he never thought he would operate on. He would have never thought he'd see some of those places and had the unique experiences. "Academic surgery has been a very fulfilling and wonderful career. " But Scott knew he wanted to be the guy who wants to be involved in the journal and the textbooks. He wanted to be involved in teaching fellows and residents. So when he sits down with fellows, he asks them who they want to be. Training is funny especially in medical school and residency. You constantly have people come up to you and say how you could chose this profession and that. You feel this angst that you can't talk bad about. Or you can't say what you really want to do. Especially when you're training in academic institutions, you feel this push to say that you don't want to be a community based surgeon but that's what you want to do. Scott believes over half of their specialty is made up of community colorectal surgeons. That's the socio-economics we have. That's the demographics and the geopolitical aspect we have. It's a big land mass. Many general surgeons cover a lot of things. Colorectal people may find themselves clustered or be in an independent town working on their own. When Scott went into his first week of surgical residency, he knew he wanted to be a program director. As he progressed along his residency, he knew he wanted to do academics. And he knew he wanted to be the chairman one day. He feels like he's the luckiest person in the world to be the chairman of colorectal surgery at the clinic. He finds it a really great job at a wonderful institution with extremely talented people in and our of his department. He has many other friends at other institutions that are lifelong friends outside of medicine. But he knew those are all he wanted to do. He knew he wanted to do the complex cases. And one of his best friends don't want to do it. He wants to be the guy that just does the bread and butter thing and take care of patients. He just wants to be a very busy person and get home at five so he can teach his kids softball. Now, Scott has the opportunity to do much more of this. But it's a matter of how you want to prioritize. His advice to people is to be true to yourself. There's going to be people telling you do this and that. They're going to fade in and out of your life as time goes on depending on those relationships. But you have to be happy. "The worst you can make is find yourself in a career that you never wanted to be in the first place." [27:42] Mentorship and the Path to Residency and Fellowship As a colorectal, you start out in the communities. This is the reason you see a lot of the major colorectal training programs are community-based clinics (Asher Clinic, Mayo Clinic, Lahey Clinic. University of Minnesota, where Scott trained, was one of the few universities that had a major training program. A lot of the university centers felt general surgeons could do it all and they didn't have the need for a colorectal surgeon. As medicine has changed as well as life in general, they have found there is a call for subspecialists. The call for having subspecialists, not always in every place, is a need. So the subspecialization in many cases has got a positive and negative effect on it. For example, you have people that think they're going to learn everything they want to learn in their fellowship. So they can just coast through their residency. But Scott disagrees with this. Their goal in fellowship is to refine and retrain people, not to teach them from the basics. The subspecialization has become a bit more prominent, And as colorectal surgery has really taken off and now found a niche, not only in the community but also in major academic centers, now they can go everywhere. Scott is proud to say that for the last several years, they've been one of the most highly competitive and sought after matches. That's when you consider the programs, slots available to the number of applicants that apply. "For the last several years, they've been one of the most highly competitive and sought after matches." Scott says when you look at some of these kids that come through and you see their CV's, you'd be surprised to see what they've done. You will hear many colorectal surgeons that if they had to apply now, they won't know if they'd get a spot. The point is that the field is now becoming more competitive. Scott's advice to those who want to get any fellowship, including colorectal surgery, it's important to plan ahead. It's important that you now have some research and have good board scores. It's important to have good mentors in life. Moreover, Scott says the best part about medicine is we never stop learning. Technology continues to evolve. Disease processes and what we know about them continue to evolve. "Link up with a mentor. Find out what they do. And you get a lot out of a mentor-mentee relationship." Depending on the general surgery you have, it usually involves five years of clinical time plus or minus research. Most programs are one clinical year. A few would be research year of colorectal and then a clinical year after that. Then post-training is one or two years. In many cases, they have a clinical associate year. It's like a super-fellow where after finishing your fellowship year, you spend another dedicated one-year training or six months doing reoperative surgery for example. But only a few selected institutions have that. [32:53] Bias Against DOs Scott notices that any bias has changed over time. He doesn't know if the MD versus DO is as prominent as it used to be. He recalls during training that there were programs that won't accept a DO student even no matter how great they were. He was in the military for a long time and they had both MD and DO residents. Some of the best kids he has trained were osteopathic students. He also had a roommate in Iraq. He is a DO ER doctor and toxicologist and he describes him as the one of the brightest physicians he has ever met. Ultimately, you have them in both sides of the fence. Scott went to Madigan Army Medical Center and he's proud to be in the military and trained in the military. But comparing it to training at Cleveland Clinic, he knew he had to distinguish himself. He had to be much better. So what he tells DO residents is that they have to be real. There still may be a stigma associated with going to an osteopathic school for medical training. And because of that, you may not get the interview or they may look at you as someone who should blow their socks off. So your scores have to be that much better. Your publication should be that much better. That doesn't mean you're not better than the person next to you. But take that stigmatism out of it will blow their socks off. Scott adds that if in a program somebody comes to you and has an automatic bias against you, then maybe that's not the program you want to train in anyway. Surgical residency is a fun time and it's a lot of growth. "Put yourself in a good position where you almost force them to take a solid look at you and put everything else aside." [37:45] Subspecialty Opportunities and Working with Primary Care and Other Specialities At Cleveland Clinic, they have teams. It's not all they do but they have a focus of things. They have a cancer team, an IBD team, and a pelvic floor team. They have a team of hard core basic science researchers who also still maintain a clinical practice. They run labs. Scott says you can make yourself and find your niche and do that. You can both that in an academic medicine as well as in the community. That's the unique aspect about medicine and about surgery, specifically, colorectal surgery. Another unique aspect of being a colorectal surgeon is you can transition into teaching or mentoring type program. You can also transition into primarily endoscopy only. Or you can do just outpatient surgery and focus on anorectal type of disease. You can also do mentoring and teaching medical students. Scott says that's the cool thing about colorectal surgery because there's such a wide range of patients and such a wide range of disease processes that you can take care of. It really fits at all stages of your surgical career. "That's the cool thing about colorectal surgery...it really fits at all stages of your surgical career." Scott explains that you become a doctor when you know more about walking in other people's shoes. You see what they do and get a feel for their care path or how they treat patients. It just allows them to be better care providers. This is especially true for primary care providers being the frontline care providers. The more they know about subspecialists, it saves the patient a lot of grief when they come and see them with rectal bleeding but they've never been treated with fiber. Or they have hemorrhoids but they've never been truly treated with a medical therapy. Patients come to him and they automatically think they need surgery. So Scott's advice to primary care providers is to take a look if their institutions have those and learn about them via algorithmic textbook. You're never too old to take a look at just a textbook and look at rectal bleeding. You could have been trying something else all along that could either help the symptom or conversely rule it out. So you can then move on to the next step of therapy. You mostly see this in the anorectal type of processes and disease states in colorectal surgery. Hemorrhoids are the classic ones. the anatomy can be confusing to people. Nobody is expecting you to be a subspecialist or to treat complex disease. But you need to understand the very basics about certain health problems. Other specialties Scott works the closest with include medical oncology and radiation oncology. They also work with pathology and radiology as part of the multidisciplinary team report. They also work with urogynecologists on pelvic floor disorders. They also work with general surgeons specializing in abdominal wall reconstruction. Other specialties they work with are urology, plastic surgery, neurosurgery, gynecology, and gastrologist. "We're all in this fight together to take care of patients. We all want our patients to have good outcomes." Scott's advice to students is for them to understand and appreciate what doctors do and the disease processes they treat and the tremendous amount of hard work they do. As you get older, these are the patients that refer patients to you. So have that good referral relationship because patients are your lifeline. So you realize they're not your enemies but your colleagues who have gone through a lot of training as well. [47:25] What He Wished He Knew About Colorectal Surgery Scott explains that at the end of the day, it comes down to patients. It's about understanding the degree of what a patient is going through. The medical journey is extremely fulfilling. You can do anything you want to from being a busy clinical colorectal surgeon to being a hard core academician. And colorectal surgery, like a lot of other things, provides you that. What's neat too is you get to mature as a physician. But if you've ever been sick or you've known somebody close to you as sick, sometimes you lose that perspective where you're in a job on a day-to-day basis. You forget that the person sitting next to you has so many things going on. "Keep in mind that that's a person there and not a case number or a sticky." Scott says it's easy to lose sight of this but keep all under perspective and it makes your job even much more fulfilling. What he likes most about being a colorectal surgeon is being able to operate. He loves the ability to do something. He tells his students there's no more intimate relationship you'll ever have than having the trust of somebody allowing you to cut into their bodies and operate on them. Somebody's entrusting to you that they're going to sleep. You're cutting into them. You're taking out the cancer. You can't get more intimate than that. You'll be inside somebody else's body. So it's an incredible amount of trust they have that you will hopefully take care of them. Understand that you're human and you're fallible. There are complications that can come up. On the flip side, what Scott likes the least about being a colorectal surgeon is the amount of time you have in medicine in charting. He likes seeing patients but the amount of time physicians have to do this is becoming less and less. Combine that with charting and EMR. Then you lose sight of the fact that you had a great interaction with the patient. This can somehow get diminished or lost in the shuffle. Scott finally says that time is probably the most precious commodity that we have in all things. It's something everybody needs to take a better look at. Realize what you want to do. How do you want to spend it in the most effective and efficient manner that you can? [52:45] Major Changes in Colorectal Surgery Scott explains that technology always changes and always drives. People have a curious mind and they will continue to drive. They see a problem. They think about a problem and try to find something to fix it. Some of those things revolutionize medicine and others fall by the wayside. Right now, the hottest thing is pushing the limits of endoscopic therapies for different types of diseases and minimally invasive surgery. As we go more towards natural orifice surgery, they try to decrease that. Finally, when asked whether he still would have have chosen colorectal surgery if he had to do it again, his answer was an absolute yes. All he can say is that it's a wonderful career. It's extremely rewarding. And he looks forward to doing it for a long time to come. His advice to premeds or medical students getting started on this journey is to find a mentor. Find somebody that can sit down and tell you the ropes and guide you a bit. You can read a textbook or listen to a podcast such as this or his podcast Behind the Knife. The information is out there and you have to have fundamental basic knowledge. But there's nothing that beats relationships and has that ability to have somebody guide you through that process. Have great board scores. Do research in the field you want to go into. And you have to be competitive. You have to have the baseline minimum. "Find a mentor. Find somebody that can sit down and tell you the ropes and guide you a bit." But the more fulfilling part of life is having and building those relationships and finding out what makes people tick and what makes the specialty so great. That's where the mentor-mentee relationship comes into play. Meet other people and truly get to know them. [58:15] Final Thoughts If you're interested in colorectal surgery, follow Dr. Steele's advice. Find a mentor. Find a colorectal surgeon out there that's doing what you want to do. And start connecting with those people. Don't forget to check out Dr. Steele's podcast, Behind the Knife. Links: MedEd Media The ASCRS Textbook of Colon and Rectal Surgery R elay for Life Cleveland Clinic Madigan Army Medical Center Dr. Scott Steele's podcast Behind the Knife

Session 12 Dr. Chung is a solo private practice Facial Plastic Surgeon. He discusses his path through ENT residency and what he likes and dislikes about his job. Today's guest on Specialty Stories is a solo private practice facial plastic surgeon. It's a great specialty, super sub-specialized specialty of ear, nose, and throat surgeons, or otolaryngology. And Victor, or Dr. Chung, is going to join us and tell us all about it. [02:15] A Personal Choice to Be in Private Practice Dr. Chung practices facial plastics and reconstructive surgery as a subspecialty of otolaryngology; ear, nose and throat surgery. He considers himself as one of the rare breed of private practice, truly private practice solo by himself, the only physician in the office which is an interesting kind of hybrid situation. As a specialist, he is affiliated with a number of the hospitals in the San Diego area, however, he’s not officially on staff who who has to be in the hospital all the time. Nevertheless, he does consultation and coverage for call and operate at those sites. Out of all the fellows who graduated in his year, only two of them went into true private practice and are opening practices. The majority are either joining multi-specialty practice groups. He thinks even looking for academic jobs was a tradition that's fallen by the wayside. As to why he chose private practice, Dr. Chung had his personal reasons. He had phenomenal training and wanted to practice medicine the way he was trained to do. “When you become part of a bigger group or even as small as a partnership,  there's a level of compromise. Otherwise, there's no way for you to be successful.” He further explains that what he likes in private practice is having that freedom to practice without restriction in the sense of delivering care to the best of his ability that gets to order the more expensive supplies and equipment or employ a technique he knows well. So his choice was natural for him and he sees being in a personal situation that he could do it is a luxury. Although joining a bigger group or academics is not a complete compromise, Dr. Chung says that oftentimes, you find that your patient population or the group you're in will dictate your niche and your future. Then you may start doing things that don't make you necessarily happy anymore in medicine. You start doing fewer of the cases that you like to do or take care of the patients that you like. You can find that ideal situation in academics in larger groups, but it's just more challenging. Victor has been out in his own practice just over twelve months. It actually took him a number of months just to get his place set up which involved a lot of logistics as well as a lot of things they don't teach you in medical school, or residency, or fellowship about applying for business licenses, insurance, and all the other type of regulations that are necessary to own and run a successful and safe business. [05:36] His Interest in Facial Plastic Surgery Victor always knew he was going to do surgery when he was in medical school. He enjoyed the aspect of thinking, being hands-on, its culture, and the lifestyle. But honing into a particular specialty was tough. He was looking at a number of sub-specialties that operate in the areas of ophthalmology, neurosurgery, plastic surgery craniomaxillofacial, and the ENT subspecialty, which he found very appealing. “Even within a single focus of the human body, it was challenging. And although facial plastics is a sub-sub-specialty within it, it's still an integrated part.” You will go out in the community and meet physicians who are ENT-trained, but not fellowship-trained, but they are still practicing as facial plastic surgeons. This is actually encouraged by the overall academy. The types of procedures can be reconstructing cancer that may have been excised on just the skin level, but others are doing larger reconstructions or rhinoplasty and face lift based on their skillset and their comfort level. Victor adds that the specialty overall gives you all the skillsets you need, As an individual, you get to pick the things that you are comfortable with  or you really enjoy doing and focus on those. Additionally, you'll meet other physicians in your community who like doing the other procedures that you may feel less comfortable with or ones you don't like as much. Victor points out the good camaraderie that goes on there and you're a lot happier treating the disease states and doing the surgeries that you like to do. [07:50] Traits of a Good Facial Plastic Surgeon Victor explains that you need to be both left brain and right brain. On one hand, you need to be analytical, be very objective, and be able to understand proportions and direct measures and changes. On the other hand, you have to be someone who has an artistic component in how you think about things and how you view them. When Victor performs a rhinoplasty surgery, he is not only looking at this overall picture. So it's just not just a nose and a good-shaped nose, but he has the entire face prepped in the field exposed. He looks at the relationship of the nose to the chin, the forehead, proportions to how wide the eyes are, and that overall aesthetic. Moreover, as a confirmatory measure, he does all these different measurements as to how far the nose projects out, the angles, and those that are within accepted values. So you need to be able to mind both sides and not be locked into either one. It's right in the middle of your face, it's very obvious, so the stakes are a little bit higher. [09:28] Other Specialties in Mind Victor had not picked his residency specialty until very late in the process. He had gone through most of the clinical clerkships of my third year thinking that he was leaning toward orthopedic surgery as just a specialty within surgery. He didn't think he was going to do general surgery, but he knew it was some sort of surgical hands-on one. At that time too, interventional procedures were getting big. Interventional radiologists and cardiologists have very hands-on and very three-dimensional stereotactic type specialties as well. But thinking about which one to hone in on, Victor wasn’t exposed to it until the last quarter of the third year clinical clerkships. And it did turn around having interacted with some very stimulating cases as well as with nice residents and attending physicians who were open to sharing what they were doing and allowing him to participate. If you’re considering ENT, Victor recommends that you see if you're okay with boogers and earwax and all those bodily fluids. If you have no problem with them then you'll be okay. He explains how people have aversions to different things. So you have to pick what you’re comfortable with seeing everyday. You can't just base that purely on a good experience. You need to figure out what is the day-to-day kind of drudgery. “Pick what you are comfortable with seeing day to day, because if you don't like your day to day, you're not going to enjoy the highlights any more.” Victor tells students all the time check out the really dizzy patient that is struggling and you can't get a good exam on, but you still try to figure out how to treat them. It’s really, really tough sometimes to figure out if they're surgical or non-surgical, and yet they can take up more than a full appointment visit. So regardless of your specialty, be sure to examine, find those highlights, but also find what are the low points and if you're okay with those. [12:20] Patient Types and Typical Day in the Life of a Facial Plastic Surgeon Victor sees all kinds of patients, which is something that keeps him captivated and stimulated in his specialty. His patients range from very minor, very cosmetic to no medical emergency about it whatsoever, there's no urgency, it's purely elective, the changes are super subtle, super small, there's no life threatening thing that you're changing. Nevertheless, people gain quite a bit of benefit from them. Their attitudes change and their self-esteems improve with the subtle thing that bothered them that maybe no one else noticed. Moreover, Victor still participates in general ENT call. He does tracheostomies for people who have lost their airway or reconstructions for people who have lost major tissue from skin cancers or other disease or trauma. These are very drastic changes to improve someone's function and there's very little cosmetic aspect of that. So Victor likes that spectrum and he doesn’t see himself giving up on doing all those things. Overall, he likes the full gamut of complexity and simplicity because you can gain benefit for your patient on both ends. Being new in his practice, every day for him is pretty variable at this point in time. The idea is a clinic, a private-based practice, and so the majority of his patients would be seen in the office setting in a combination of consultations, follow-up visits, minor procedures, injections- injectables. Those types of visits are all in the office. “As the trends go, more and more surgeons are doing things in the office.“ Typically, a surgeon in his specialty will have block time or days set aside where they would be operating, maybe two days a week being in the operating room doing a number of cases. But the majority of them would be on the outpatient setting so most of those patients are going home. A select amount would be seen in the hospital as an inpatient and seen on multiple visits in the hospital before they're released. Moreover, Victor stresses how a lot of students and doctors don’t realize the business side of it. You can fill an entire day with administrative tasks, but it is about prioritizing and compartmentalizing. In his case, he picks one night a week where he does it until late of night and he doesn’t go home until everything on the administrative side is done then for the rest of the week, he sets up tasks and completes as many as he can. But when those tasks pile up, they will get all done on that one day. Otherwise, you can get pretty overwhelmed going from task to task to task so it's nice to have some structure in your day. [15:35] Taking Calls As a plastic surgeon, you don't have to take a lot of calls. It actually depends on where you are geographically located. Some hospitals require you to take a certain amount of call depending on the size of the call pool and how busy the hospitals are. But Victor is not required to take any call whatsoever, but it also depends. He explains that there are some financial compensation at some sites while others don’t so it's just part of requirement-maintaining privileges. Although there is no requirement in the San Diego area where he is practicing, Victor is participating. In terms of the percentage of patients he sees ending up in the operating room, his goal is close to 100%. He has seen surgeons who are well-established and basically they are turning patients away. “You want to get to that point in your career where you are selecting patients who they're the most appropriate, that you can exercise and perform the best surgeries for the best results.” Victor has patients who are not good candidates and he tells them that they are not appropriately going to be surgical patients. But he enjoys the fact that he gets to educate a lot of the patients coming in. He spends over an hour in his consultations with patients giving them all the facts including the raw details and the scary things that can happen in surgery in order for them to make an informed decision. At this point, he doesn’t feel that half of them are going to the operating room because they're just still in that information gathering stage. But as careers progress and you become very well known for particular surgeries or techniques, a lot of patients coming in have already done their homework and research. Especially with the availability of resources on the Internet, they've done their background on you. They know where you trained, they know what technique you do, and they've come specifically for that technique or procedure, and that ratio of conversion is much higher. [18:10] Work-Life Balance Victor describes having a good work-life balance whenever he chooses to have a good work- life balance. And that is very different from a lot of other physicians who are at the beck and call of their pager or their schedule, and therefore they don't have the same freedoms as he does. He can choose to work incredibly long hours or he can also choose not to be working those hours based on his specialty. There are still emergencies and so he won't operate for weeks before he goes out of town and out of the country on vacation, but that's the only limitation. Nevertheless, he can choose within his personal setting to take time off to tend to himself and his health. However, he is also participating in community volunteering and spends time with his wife which he thinks are two very important things. “When you start sacrificing your own personal health, your interpersonal relationships, then you're not going to be as healthy of an individual and therefore not a good doctor over the long run.” You're just going to get burned out, and that's an increasingly common phenomenon. Victor adds that good diet, nutrition, exercise, health maintenance, time with family, downtime are all things that should be scheduled and be consciously part of your day-to-day instead of things that are added on if you have time. [20:35] Residency and Fellowship Before you graduate to an otolaryngology head and neck surgery residency, it used to be an early match, and for many years now it's on time with everyone else's. It’s basically a five-year program which has an intern year but it's considered an integrated intern year. Typically at the same institution that you're doing residency, it does have general surgery components and rotations, however, increasingly more focused toward an ENT residency. The elective months would be Anesthesiology. You'll be in the ER and you'll be doing surgical ICU, all geared toward skillsets that will be beneficial for your residency versus a standalone general surgery or where you are on rotations that are purely dictated by the general surgery department. This is commonly seen in orthopedics and other surgical subspecialties. After which, there will be four years of ENT training. This may involve time at a children's hospital, at a VA institution, maybe a research block, but you'll be rotating through different sites and every year you're increasing your skillset. You're learning about all the systems, the ear, the nose, the throat, the different types of surgeries, seeing patients in clinic, and operating as well. But as you go through each year, your level of responsibility, and then as a Chief, you'll be running the service teaching and mentoring junior residents, and before you graduate you'll apply to a fellowship. This is typically within your fourth year. There are a number of fellowships you can pursue such as pediatrics, neuroethology, head and neck cancer, microvascular reconstruction, facial plastic reconstruction, and sleep medicine even. So the fourth year is an application that goes in around January through March and you interview between March and end of May, and then you'll match to a one-year fellowship program that would go after your graduation from your ENT residency. [23:37] An Alternative Route to Facial Plastic Surgery Outside of ENT Victor explains that if you wanted to just do plastics in the face area, you could definitely reach that goal through an alternative route, which is through plastic surgery. There are two pathways through plastic surgery. The first one is to complete general surgery and then apply to a plastic surgery program. The second one is an integrated plastic surgery program that you match right out of medical school knowing you're doing plastic surgery and that has a general surgery component to it. These programs are typically longer with research years as well. Victor believes it can last as long as seven years to finish those residencies. And then most individuals who want to operate in the face area will go ahead and do an additional fellowship on top of that. “You can reach the same goal in a sense, the same practicing setting, but you'll just have other skillsets bringing to that job as well.” [25:00] Competitiveness in Matching Victor describes matching in ENT has gotten to be one of the more competitive subspecialties to match. “I think all of the surgical sub-specialties have gotten difficult because it's just a pure numbers game, just from any type of academic application.” Kids are applying to more colleges. College students are applying to more medical schools. Medical students are applying to more residencies. Even when he was applying, he met people who applied to every single ENT residency in the country just to play the numbers. And so it's more applications on the Residency Director's table to leaf through and make a selection. In Victor’s case, they had a pretty small program. Only two residents are accepted per year, and maybe thirty people were applying per spot. Some programs only have one resident while big programs have four to five residents. And although some may say thirty people may not be a lot, but each one of those individuals have published research, phenomenal USMLE Step 1 score, letters of recommendation from the Chairman, have done research rotations, have really stacked their binder full of accolades. There’s now an ENT student interest group that starts guiding students from the first day they get to medical school. And so it has gotten increasingly competitive to apply to any of these residencies. Victor feels ENT has a popular swing recently. It had a big swing before he applied, but it's always been up there along with the other types of subspecialties that are maybe competitive to get into. [27:32] How to Be a Competitive Applicant Victor outlines that in order to be competitive goes down to all the basic things that everyone is always striving for. This means maintaining good grades regardless if you're a pass or fail system. Getting into AOA as another marker on your application showing that you stand higher in your class than other students. Then the USMLE Step 1 score. Before it was just about generally trying to get in some research but if you can get on a research project that is related to the residency that you want to apply to, that can only help more. Publications, participation, posters, presentations, attending meetings, getting involved in the department, attending conferences because there's always academic conferences every week within that department. Just make a personal connection with the attendings in that department. All of those things can make you more visible and create a level of investment, not necessarily to get you accepted into your home school's department, but also, they may be invested in getting you into their alma mater, or another program that they're aware of that would be a good match for you, or a geography that you're interested in. “It is a time investment because you're spending so much time already studying and trying to do all those basic things. But by investing yourself personally, that will give you an additional edge.” But there's also a gamble. Victors knows of people who've done that and then decided they wanted to actually do a different specialty too so you're not locked into it. But if you know early on, that will behoove you to create those. Create that rapport, create that link to those individuals early so they can really get to know your medical school career. [30:12] Osteopaths and Subspecialty Opportunities Victor says there are only very few osteopathic ENT physicians out there. He has interacted with some and they're all great, but within the world of facial plastic surgery, it is still a very small community. He thinks the majority are going down the MD path. However, the individuals operating in the head and neck facial area is growing. There are oral surgeons who perform cosmetic facial plastic procedures. There are general plastic surgeons who do those and there are those in the field of oculoplastic surgery who want to do face lifts and rhinoplasty. There are dermatologists who want to do more surgical procedures in the face. Then there are general surgeons, other surgeons who take cosmetic courses and get boarded under the Board of Cosmetic Surgery and perform those. “There is an increasing number of individuals out there who have not gone down a traditional path of training and are performing those procedures.” In terms of subspecialties available after ENT, there is a phenomenal opportunity to sub-specialize, not only by pursuing a fellowship but also many departments are strong in all fields within otolaryngology. It's not a necessity to have a fellowship training because it's not as formal. There isn't a required board certification for all the subspecialties, not all of them are ACGME certified either. You can pursue a fellowship in facial plastic and reconstructive surgery, head and neck cancer with or without microvascular reconstruction, pediatric otolaryngology, otology or neuroethology that involves an ear surgery, sinus rhinology, laryngology professional voice. If an individual has graduated and they've had strong training, they can go out and they can become a sub-specialist. They can focus their practice doing laryngology professional voice in an area that needs it and provide that care at that subspecialty level without fellowship as long as they're adequately trained and have a desire to pursue those patients. But Victor says this is rare. Most times, even those who are really focused, even nationally known for a particular field, those guys are always interested in doing other aspects of ENT as well. Some are doing more trauma, some may be doing head and neck cancer or they may be doing endocrine surgery but they're known for voice. They may be filling other roles within their group practice. Most of the otolaryngologists that Victor has met often miss doing other aspects, but find that, there’s no one else who's stronger in ear surgery so a lot of the ear cases go to that surgeon within the practice. Or someone else really enjoys sinus surgery, is savvy with it, is up with the latest techniques, and so that practitioner in that group will see more of those patients. But each and every one of the ENT doctors in that group is less likely to solely focus on a subspecialty and only, only do that. Most of the times it will be a little bit more well-rounded and be doing multiple aspects of ENT, but not necessarily all of them. Victor concludes it's getting tougher and tougher to be in overall general unless you're in a more remote area where there's fewer practitioners around. [35:06] Board Exams, Certifications, and Pass Rates Victor illustrates the board exam as consisting of a written and an oral exam component. The current format are separate examinations. At one point in time, they were done on the same setting, but currently you will take the written exam. I, it is a computer-based test that is administered in September following your June/July graduation from residency, and that is a multiple choice format test that tests all the aspects of ENT medicine and surgery. There is a pass/fail threshold for that test, and those who pass may go on to the April exam which is currently administered in Chicago. There are five rooms with a number of three or four modules in each one, and it's basically a mock simulation clinical case. They're integrating some technology CT scans. They used to give you photographs but now you can get a computer screen and you can flip through a couple slides of a CT scan, or lab tests, or histopathology, and you went through a case from, say, the patient presents as a child or an adult who had a car accident, or someone who's lost their voice, and then you ask questions, you proceed through the case, and you gain points based on your questions and responses. Then hey tally those up and then once you've passed both of those components then you're board certified for ten years. Through that ten years, you're doing maintenance certification through online modules every year, and then at the tenth year, you're re-certified again. So that is the board certification process for otolaryngology. You can also get board certified in neuroethology sleep and facial plastic surgery, and those consist of both of a written exam, an oral exam, and in some cases collecting case reports of patients that you've operated on in the first couple years of practice. The pass rates are pretty high for both exams. Although Victor doesn’t know the exact number, he thinks it’s less than 10% fail because there's quite a bit of preparation for these exams. [38:10] Working with Primary Care and Other Physicians Victor still gets to work with primary care physicians whenever he sees more of the general ENT type patients. He used to give a lecture to family medicine residents about HIV manifestations in the head and neck, and it's shockingly common, and this is from sores on the lip, to frequent sinus infections, to ear infections, skin lesions, lots of different changes in the head and neck area, and a primary care can pick them up if they're looking for them, and make the appropriate referral for both HIV specialists, infectious disease specialists, as well as an ENT doctor to get involved. So that's one of the things Victors thinks that can be missed, and it frequently is missed, but then can be detected and really initiate early care at that primary level. Other specialties he gets to work closely with depends on Victor personally. There could be dermatologists if they're removing skin cancers. This is the closest in his personal practice. However, there are a lot of ENT specialist surgeons who work with the head and neck cancer doctors that will interact with medical and radiation oncologists, the ear doctors. The neuroethology training will interact with neurosurgery for skull-based surgery. In the Intensive Care Unit where you're doing larger surgeries, the head and neck cancer surgeons will see patients again, admitted to the ICU for laryngectomy or tracheostomy management. “A fair number of patients are generally on the healthier side, and a number of procedures we’re doing are for improved quality of life, for better breathing, better functioning.” Victor adds that there is a close connection with ENT doctors in general with primary care doctors for sure. Absolutely, and oftentimes there's an unfair and sort of inverse ratio. There's tons of primary care doctors and you get a lot of their patients into ENT specialists and there are just very few ENT doctors available. And even with jam-packed schedules, there may be months' long wait lists. But all the time, he’d talk to primary care doctors who really need to get someone in urgently they will always make their best effort to get those in and not have them on the waitlist. [41:35] Special Opportunities Outside of Clinical Medicine Victor says there's always lots of research going on with the basic science level looking at wound care, tissue healing, in addition to the types of different injectable products, hyaluronic acids, botulism toxins. There's a lot of these things called PRP, Platelet Rich Plasma, and other types of different materials that are being injected for stability, safety, efficacy, improving them. There is a number of possibilities to pursue research and development of these types of products. Those who are more interested in the business side can become Chief Medical Officers for healthcare related corporations. There's actually a very small and probably should be more encouraged politically active doctors. “There's always lots of different opportunities that you can springboard from your specialty.” There are a lot of different opportunities based on what you're interested in. But there is always that idea of you're giving up that patient interaction and that normal typical doctor schedule, but maybe it's for more regular hours when you're becoming an executive in a corporation. [43:55] What He Wishes He Knew Then “One of the major deficiencies in a doctor's education is the business side.” Victor attended Tufts Medical School and they had a great health professional MBA integrated program that didn't really hold you back from graduating under four years. Although he didn't participate in it, he still thinks it should be part of more the regular curriculum. There are great doctors that can no longer practice because their practices get shut down and closed. Other individuals who have some phenomenal skillset and need to get out there, if there's this barrier that they can't set up their business and they don't think it's possible, or even you don't necessarily have to be a small business owner, but as a component within even an academic group or a multi-specialty group, if you don't understand the metrics of and the financial side of it, you can't practice effective medicine if you're running at a loss, and you're going to get shut down, and then what happens to all your patients? Hence, Victor thinks the economic side of medicine really needs to be a core component in addition to biochemistry, genetics, anatomy, and physiology because it's inevitable. Medicine has become more and more business. It may not be desired to be that way, but it's a reality and physicians really need to understand how to run it effectively and how to protect their business so they can continue to give great care to their patients. [46:05] The Best and Least Liked Part of Being a Facial Plastic Surgeon Victor loves the fact that he has the ability to look at something that a lot of people think they understand well, and bring just another level of understanding, another level of treatment to it. For example, when people talk about breathing through their nose, some may attribute it to allergy while others to structural issue like a deviated septum. Victor stresses that alone takes a higher level of understanding of nasal physiology, and the anatomy, and diseases that affect it. But a lot of really well trained people will stop at that point and they may treat the allergy, they may fix the deviated septum, and the patient still has a breathing problem going on. This is where Victor comes in and he loves understanding the true nuances of the facial structure. He says having that ENT background gives him the understanding of all the functionality, all the moving parts, all the components that need to work day-to-day being normal. “The additional training in facial plastics gives me the side of the aesthetics but also the skillset to create that structure, to improve the functionality while maintaining overall looks.“ Victor claims his best results are noses that have just gone away. The patient no longer notices that it's stuffy or they have difficulty breathing through it when they exercise, and they no longer stare in the mirror and look at their nose that they feel is so prominent, and some people feel like it makes them ugly. And so the greatest success for him is to see patients to have their nose essentially disappear and just be in harmony with the rest of their face. It's still their nose, it's not a beautiful or fantastic looking nose, it's just their nose. He loves the fact that they don't even have to think anymore about picking up a spray bottle, or an allergy pill because their nasal passageways are nice and open, and so they just go about and they do normal tests every day without a thought in their mind. Victor describes it as one of the pure joys of doing it that he notices and that the patient no longer has to worry about anything anymore. On the flip side, Victor thinks trauma is tough but there's a great opportunity to really make a major improvement. Someone breaks their jaw, or shatters their eye socket, but there is a limit of what the end result can be because of the nature of the original trauma. You can always make improvements but you can't really get them to a truly better place. “There’s a major psychological component related to trauma, so even with an improved physical state, mentally there's still a deficiency. There's still a pathology going on.” Victor thinks maybe a multi-specialty kind of care type of thing can get someone who's come back from major trauma to really get them healthy again, because mentally or physically there are just limitations from just those initial insults that they can't really get back to their baseline. If he had to do it all over again, Victor would still choose to do facial plastics. He loves what he does and he says he’s excited to get up every day to go and see what comes through the door and he thinks this will stimulate him for years and years. At the same time, he would look for other additional skillsets such as check out a neuroethology fellowship as well as other things that would complement what he already does. Or he may get into facial nerve reconstruction therapies and then advance outside of that. Victor feels blessed to be able to do this. He could have gone a lot of other ways and would have been fine, but if given the opportunity to go about this again, he would still pick the same residency, the same fellowship, and focus on the same things. Maybe small little tweaks here and there, but overall, that same path has been really beneficial for him. It has really played to his strengths and it has given him the skillset to be a successful practitioner. [52:15] The Future of Facial Plastic Surgery Victor isn’t sure if any major changes are coming to facial plastics whether in the technologies or just fundamental shifts in the way things are practiced. He admits though of being on social media, a lot of people are becoming aware of new products and technologies at a much faster rate. The initiation of that first treatment is getting younger and younger. There are twenty-year-olds getting Botox to prevent wrinkles and people getting surgery at a younger age. But the largest kind of shift going on around a lot of focus on non-invasive therapies such as energy devices, like injections to dissolve fat. “There’s a little bit of oversell on those stuff that get marketed as quick and easy, and when they add on cheap, quick, and easy, those results don't ever really match the promises of the outcome that they get.” They're often short-lived and have unforeseen complications. They affect your ability to do things later. They burn bridges in treatment pathway. One of the things is injection rhinoplasty. People are putting fillers in their nose, but fillers in the nose in that skin area don't behave as well or in the same way as it does in the other soft tissues of the face. Victor has even seen disastrous things like blood vessels being blocked off, and whole areas of the skin and tissue on the nose enclosing. And that can happen in other areas of the face. It will heal and leave with some scarring, but if it happens on the nose or near the eye, then you've lost more function. Victor thinks it’s revving up toward these office procedures, and some are great, but then they're being expanded to use in replacement of tried and true therapies, and he thinks it'll surge but then people will see so many issues with it and then it will come back. There will be better technologies, there will be better equipment, there will be safer mechanisms out there, and all for the good. Victor adds that's how medicine has always been. There's always been sort of a pioneering technology, or thought, or philosophy, and then new techniques come out, and then they kind of push the threshold of risk and complication, and they back off, and then there's a new push as new developments come on the horizon. But that's how you progress, and improve, and come up with new therapies for diseases that previously never had any treatment. So it has to be done but just in a careful way and more informed way. [55:30] Final Words of Wisdom from Dr. Chung Victor’s advice to patients is to take some art classes. It's one thing to understand the anatomy, but if you can translate that anatomy and the structures from your brain to your hands, and using your hands, those are all good basic skills that can translate into being a better surgeon, and choosing when not to upgrade. Everyone will study hard and everyone will get a high score on the test, and everyone will strive to get that letter, but you need to find one or two things like sculpting, or drawing, or it might be music, or something to really keep yourself active and in a unique sense to keep yourself motivated. You may bond with some big name doctor one day who's going to write you a letter based on that unique activity that you do that not everyone else is doing. [56:55] Final Thoughts If you are interested in ENT, or otolaryngology, or even the specialty or subspecialty of facial plastic surgery, I hope this episode was interesting to you. I love these conversations, I learn so much from them even as a physician, so I know that you as a premed or a medical student are going to get a ton of great information from these conversations to help steer you in the right direction for your career. Links: www.TheShortCoat.com