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Session 93 Dr. Potisek is an academic Pediatric Hospitalist. Today, he discusses the reasons he chose pediatrics, the different facets of his job, and the types of patients he sees. Also, please check out all our other episodes on MedEd Media Network. [01:10] Interest in Pediatric Hospitalist Medicine Dr. Potisek has always enjoyed being around kids. But it was during the third year of medical school that he realized there were so many things about pediatrics that he really loved. So by the end of that year, he was choosing between internal medicine and pediatrics. Ultimately, what drew him to pediatrics is the resiliency of kids. He also likes the incorporation of families as you also take care of, not just the child, but the family members as well. Before Dr. Potisek decided to go to medical school, his dad got very sick. He saw that the kind of communication a physician has with the loved ones, not only makes a difference for that individual but for the entire family as well. Additionally, Dr. Potisek describes himself as a good communicator. And so this was something he was looking forward to going into this career. [04:45] Traits that Lead to Being a Good Pediatric Hospitalist Pediatric hospitalists either work in a community hospital or in an academic setting. Oftentimes, you have to work well in a team. You have to be able to work well with your colleagues and be able to communicate well with patients and their families. Teaching is also an important skill, not only for learners but also for patients and their families so they can understand what's going on. [06:15] Hospitalist vs Outpatient Pediatrician What drew Dr. Potisek more to being a hospitalist over being an outpatient pediatrician is the acuity of care, which he likes more. He likes dealing with "sicker" children and some of the medical mysteries he deals with. He also likes working with numerous subspecialists as they try to figure out the problem. Hence, the two big things he likes about being a hospitalist is the acuity of care and the complexity of diseases he encounters. [07:30] Typical Patients During Fall through Winter, Dr. Potisek deals with a ton of respiratory conditions, with bronchiolitis as a heavy-hitter. He also deals with pneumonia (viral or bacterial) and other respiratory-related diseases that are more seasonal-dependent. He also takes care of neonates, infants 30 days or less. Other common cases would be skin and soft tissue, bone infections. They're also taking care more and more of medically complex children who are technology-dependent. [08:55] Typical Week Half of his time is geared towards pediatric hospitalist medicine while the other half is dedicated to teaching medical students and residents. He works seven days in a row. Mondays thru Fridays would typically start from 7am to 5:30 to 6pm. On weekends, he works for those same hours in the hospital and he'd just take calls from home for new admissions. He also works at night although this is not the majority of what he does. This only happens about 2-3 weeks of the year. When not doing patient care, he'd usually do curriculum development and other teaching activities. [10:19] Doing Procedures Dr. Potisek found that a lot of procedures are already done in the emergency department And if they aren't, they'd typically do a lumbar puncture. There are also pediatric hospitalists across the country that are trained in sedation, which they could incorporate into their practice. [11:12] Training Path After medical school, you would typically do a three-year pediatric residency. Then you can do a fellowship for 2-3 years. There are different options you can take such as additional master training, research, etc. So from the completion of medical, it takes around 5 years in total. That being said, Dr. Potisek has friends who are more outpatient-predominant. Currently, people are being grandfathered in. Because of the many pediatric hospitalists and the lack of fellowships, they see this as an opportunity. People can have a certain amount of hours leading into the board exam. [14:00] Subspecialty Opportunities and Bias Against DOs A lot of fellowships are actually allowing opportunities for pediatric hospitalists. As with bias against DOs in the field, Dr. Potisek hasn't really seen this. At their hospital, they have a number of residents who are DO-trained. [15:44] Working with Primary Care and Outside of Clinical Medicine Dr. Potisek wishes to tell primary care physicians that they reach out earlier to them. Moreover, there are special opportunities outside of clinical medicine that pediatric hospitalists can do such as outpatient opportunities. [18:10] Most and Least Like Things About Pediatric Hospitalist Medicine What Dr. Potisek likes most about his specialty is working with learners – students, residents, pharmacists, and nursing staff. On the flip side, what he likes the least about his specialty is that sometimes you don't necessarily think that a child needs to be hospitalized all the time. But at the same time, he respects his emergency department colleagues. But at the end of the day, if this brings peace of mind to the family, he'd just have to honor the initial decision of his colleagues. That being said, he still finds that sometimes it's unnecessary. "Sometimes, I don't necessarily think that it needs to be hospitalized but that seed has already been planted for them." [21:55] Major Changes in the Field and Final Words of Wisdom It would be interesting to see more fellowships popping up and so Dr. Potisek is excited to see a more developed curriculum. Ultimately, if he had to do it all over again, he would still have chosen the same field. He wishes to impart to students that whatever it is you want to do, just remember why you decided to get into medicine in the first place. Remember what you love about it and where can you maximize the things that you love. It can be challenging at times so having that understanding at the forefront of your mind is helpful. "Just remember the joy and the love you have about the things that you do." Links: MedEd Media Network

Session 90 Dr. Philip Chan is an academic Infectious Diseases physician at Brown University in Rhode Island. He has been out of training now for about 8 years. He talks about his typical day, why he chose this specialty, the training path, and an inside look into this field. Meanwhile, be sure to check out all our other podcasts on MedEd Media Network. [01:22] Interest in Infectious Disease Philip recalls being interested in Infectious Diseases (ID) back during undergrad. With a Major in Microbiology, he was basically interested in bacteria, viruses, infections, and how to solve such problems. Although Philip's dad is a cardiologist, he was already interested in fixing things at an early age. So he went to college majoring in Engineering. Then he realized he wanted to go to medical school so he shifted to Biology. However, he thought it was too generic so he then changed to Microbiology, specifically focusing on genetic engineering. [02:40] Traits that Lead to Becoming a Good Infectious Diseases Physician Philip says you've got to have the ability to think through a problem from top to bottom. You also have to have a particular attention to details. He advises medical students, especially early in their career, is to think about a problem in a timeline. You have to be able to put things together in a timely fashion and think through the different problems and problem-solving critically. He initially got into the field of HIV early on in his career mainly due to the research aspect of it. But as he progressed, he had gotten so much interested in the intersection of HIV, social justice, and health disparities. A lot of his work is presently focused on public health at the community level and engaging populations across their state. [04:20] Other Specialties of Interest During medical school, Philip found everything to be interesting. He loved his surgical rotations as well as OB-GYN, Medicine, Pediatrics, and Oncology. But when he got to residency, he felt he was fully committed to Infectious Diseases. He did consider Oncology due to the genetic research he did at that time. But he eventually landed on his current specialty and he's happy he did. What he likes about ID is that it touches every part of the body. There's a broad overlap of lots of other fields and disciplines. You can actually cure a lot of infection. A lot of medicine now is managing chronic diseases. That's fine. But one thing that appealed to him about infections is that you can cure a majority of them. You can make people 100% back to normal. "A lot of medicine now is managing chronic diseases... but one thing that appealed to me about infections is that you can cure a majority of them." [06:00] Types of Patients Philip categorizes patient care in two types. He does consult in the hospital where he'd be dealing with "bread and butter infectious diseases" These include endocarditis, osteomyelitis, diabetic skin, and tissue infections. They also treat a spectrum of all other infections from malaria to TB and to many other sorts. Moreover, the outpatient side has become more of his "bread and butter." This includes HIV care. He started the prep/prophylaxis clinic at their site. He also runs their STD clinic. He didn't receive enough training in these through fellowship and residency. But the outpatient ID care has taken a lot of his time now. About a third of the time, there are clear culture data to help guide the decisions. Then a third of the time, they don't have culture data. Cultures may not be accurate, negative, or they're not drawn correctly. Then there are also lots of bugs that don't grow. Philip believes that about a quarter of the time, they're shooting dark and making their best guess. Then they're just guided by other aspects of the clinical patients. The other third of their time, they deal with random things that they get called for. Majority of the cases would be fever. For instance, there's a rising blood count. Others would be taking random questions that may be unclear to the primary care team. 10% of the time would be people getting diseases from other countries like malaria, TB, etc. And a small percent of that time, they're able to nail the diagnosis of some really random diseases. They give them the appropriate antibiotics and cure them. "You've given the appropriate antibiotics and you cure them. That's one of the greatest feelings in ID." [09:40] Is His Job Just Like the TV Show House? Funny how Philip thinks that none of it does look anything like his job. 1 out of every 10 patients, he sees the complete mystery and you try to piece things together. One thing they really love to do as ID doctors is to dive into the social history. This includes the person's demographics and how you frame them epidemiologic-wise. And just to be clear, there is no housebreaking involved. "For many parts of medicine, the social history doesn't necessarily matter quite as much. But in ID, the social history can really be everything." [10:45] Academic vs. Community Setting Philip believes there are pros and cons to each. Basically, it's about what you like to do. In private practice, there's incredible flexibility especially if you work for yourself. You can make much more in the private world depending on what you do. He describes his career as being very academic and research-oriented. He's also the PI of several NIH grants and other grants, which you can't do in the private world. For academic ID careers, you can get involved in research and public health. You have the chance to get involved in lots of other different committees and leadership roles and stewardship. You can work for the Department of Health. "There's a lot of other opportunities in the career of ID to really spread out." [11:50] Doing Research without a PhD Philip is doing a ton of research at a major Ivy League institution, yet he doesn't have a PhD. This is concrete proof that it is possible to do research without that PhD. After his undergrad, he got a masters in Genetics. So he has some research experience that he has built on. What he recommends to students is that if you're really interested in research, really collaborate. One of the keys to successfully writing NIH grant is he always leads the grant with a PhD person. The NIH loves this as there are two different complementary skill set – one a clinically oriented researcher and the other a PhD-driven researcher. [13:00] Typical Week Philip holds clinics on Thursday and Friday afternoons. For about 4-8 weeks of the year, he does inpatient service time where he sees most of the bread and butter disease cases. Then the rest of this time is spread out running various research and the programmatic aspects of what they do. He's spread across various institutions, pushing different agendas related to HIV and other STDs. [14:00] Doing Procedures and Taking Calls Compared to other fields, ID is a less procedure-driven field. But there are a lot of things you can do, which are quite parallel to what an internist does. For instance, they do lumbar punctures, thoracentesis, and other procedures. There are other physicians who feel comfortable doing biopsies.  Nevertheless, they routinely take cultures. "Compared to other fields, ID is a less procedure-driven field." According to Philip, the beauty of this field is that there's not many emergencies where you have to go into the hospital ever. Hence, this gives them a very good quality of life in terms of taking calls. He personally takes calls a couple of months where he has to answer phones through the night. However, for academic institutions, there's a fellow who takes all the calls. And if there's something they can't answer, they then refer it to the attending. And this happens to him only about 1-2x  a year. For a lot of the calls, they'd usually give the patient antibiotics and see them in the morning for evaluation. Philip says he has a good work-life balance. His wife works full-time so he actually does a lot of the childcare in their household especially in the evenings. Although you have flexible time, you have to put in the time to be successful. But you can be flexible in terms of how time is managed. He makes sure he exercises everyday. "As an academic ID physician, you have the flexibility of your time." [16:55] The Training Path and Competitiveness Infectious Diseases is a fellowship after internal medicine residency. You go through the traditional 3-year internal medicine residency. In general, you go through a two-year clinical fellowship after that. There are numerous variations such as research-oriented fellowships combined clinical research fellowships for 3+ years. Given that ID is an especially research-driven field, there are lots of places that combine clinical and research together. The typical pathway is two years of ID fellowship. A number of his colleagues come from Med-Peds residencies to do Adult ID and Pediatric ID fellowship over 3-4 years as well. Pediatric ID is a specialty so you can go from a pediatric residency into a pediatric ID fellowship. The top programs in ID tend to be competitive but there is not as competitive per se as Cardiology or GI. To be competitive, you should do well in residency as a rule of thumb. Be involved in something that really demonstrates your interest. ID is very diverse as there are a lot of people from various backgrounds and experiences that are interested in the field. For instance, there are people interested in infection control, antibiotic management, international health, HIV/STD pathway, etc. So try to explore these through residency. Do research or other projects with a mentor to really show and demonstrate your interest. Or to find out if this is really something you're interested in and that you want to continue this pathway. Just do something outside of your normal residency duties. If you're interested in academic medicine, you can get involved in some grants or publications. [20:45] Subspecialty Opportunities There are various routes to become certified in HIV care. One is to do a fellowship in Infectious Diseases. As an internal medicine doctor, there are certification programs where you can become a certified medicine physician in HIV care. This is generally a one-year fellowship. Once you've become specialized, there isn't any "next step" in terms of specialty. Those that really take the next level are research experts. These are people who have developed research expertise in drug resistance, for instance or a neurological complication-related to HIV/AIDS. Usually, these are people who have done research on a specific topic of HIV. These are world-renowned experts in a specific aspect of HIV. Within your typical ID fellowship program, there are usually no specific tracks where you can get certified in. Usually, it's based on where you spend your time on. There are elective months as well as clinical care. A lot of these are self-directed and self-driven. There are programs, workshops, and courses being offered at academic institutions where you can start to develop specific interest and focus within aspects of infectious diseases. "Most of what happens in how one develops one's interest and expertise, within infectious diseases, is based on where you spend your time." Alternatively, the people that develop expertise in meningitis or fungal inspection or STDs are people who have developed programs and research portfolios around those different topics. [24:15] Bias Against DOs One of Philip's mentors is a DO who runs infectious control at Rhode Island Hospital. He routinely calls him for pieces of advice. He knows other fantastic mentors who are DOs. "It's less about the degree after your name and more about what you make of yourself and how your career transpires." [25:10] Working with Primary Care and Other Specialties Philip also provides primary care himself to his HIV positive patients. The way medicine has gone, as he puts it, is that everything is subspecialized that it's so impossible to be good at everything. You can't just keep up with every single aspect of literature or every single disease. He found that through the years, he has become less comfortable managing aspects of diabetes and primary prevention related to cardiovascular disease. Moreover, there are some diseases like HIV that if you engage all primary care physicians, we would all have the potential to make huge strides in addressing the HIV epidemic. So they're trying to engage the primary care community in assisting patients with HIV testing and STD testing. Other specialties ID physicians work the closest with include internists/primary care and hospitalist internists. [27:22] Special Opportunities Outside of Clinical Medicine There are tons of opportunities for ID physicians to get involved. He has colleagues across the world who work internationally. There are people who provide care at international sites and those who consult with NGOs and the WHO. Nationally and locally, there are many health departments across the country that have consulting physicians. Some even have full-time physicians for infectious diseases within public health. Personally, Philip consults part-time for the Department of Health aspects related to HIV and STD. There are also opportunities at other outpatient health centers. Some of his colleagues provide consulting services related to Hepatitis C treatment, HIV care, and other aspects of ID care to community health centers, NGOs, etc. A lot of community-based organizations have medical director roles related to substances treatment, AIDS service organizations, STD clinics, etc. [28:45] What They Don't Teach in Medical School For Philip, leadership was something he had to learn on the fly. He currently manages a team of over a dozen people. The business aspect is something they don't teach you in medical school, as well as how to manage people and how to be a leader. They train you very well throughout medical school and residency to be a clinician. But for basic business/leadership/managing skill was something he had to learn on the fly. This was something he had to do everyday. That being said, it was something he wished he had formal training with given his current positions. What he has done though was to find key mentors or people who have been through this time and time again. He'd lean on them heavily and ask them questions about how to navigate different situations. "Seek out a couple of key trusted people that you can ask confidentially some tricky situations if you ever find yourself in them." [30:50] The Most and Least Liked Things Philip has gravitated more into the preventative side of infection, which was something he didn't anticipate through his training. He started their HIV preexposure prophylaxis program. He sees a lot of people that are at risk of HIV and one of his jobs is to keep them negative. He enjoys interacting with young HIV positive people. Preventative care wasn't something he saw doing 10-15 years ago. But he has now found this to be the most enjoyable aspect. "I feel like I do a lot of education, counseling, teaching, and mentorship to my patients – guide them through difficult situations, mostly, but not all related to their health." On the flip side, what he likes the least about his practice is the administrative aspect that can become sometimes overwhelming. At some point, the administrative side of medicine may start to weigh heavily on your career. So just set some clear boundaries and structures to help manage that time. In fact, Philip just sat on a panel for physician burnout and found that the EMR is one of the number of causes for physician burnout. [33:10] Major Changes in the Future Philip says that for those considering careers in HIV specifically, is to consider places where HIV is affecting people most, including the deep south. A lot of money and resources are now being redirected to such places where HIV is hit the hardest. In terms of HIV cure, Philip sees an optimistic future in the fact that it can be done. a couple of patients now have received bone marrow transplants with HIV mutations to make them resistant to HIV infections. And when implanted with a bone marrow transplant, these people can now be cleared of HIV. There could still be remnants of HIV but people in the field are considering this as functional care. However, this is not something really applicable to the general HIV population. Reason being is that in order to get a bone marrow transplant, you have to destroy one's immune system. Bone marrow transplant is for those with leukemia and other blood-borne cancers. Also, there's a 25% mortality rate with bone marrow transplants. And you wouldn't want to risk that percentage for putting HIV medication that can keep you controlled for life. All this being said, it has the potential to cure HIV. Ultimately, Philip would still have chosen to be an ID doctor if he had to do it all over again 110%. His advice to students is to do it early. It's a fantastic career and he's 100% glad he did it. There are tons of opportunities with some overlaps with international careers, public health, and public policies. "Try to explore a career in ID especially if you're interested in public health, social determinants of health, addressing health disparities." Links: MedEd Media Network

Session 88 Dr. Gilbert is a Nephrology Program Director at Tufts Medical Center. Today, we discuss traits that make a good Nephrologist and how to be competitive. If you haven’t yet, please do check out all our other resources on the MedEd Media Network for more podcasts to help you along this journey towards becoming a physician. [01:42] Interest in Nephrology Gilbert initially thought he was going to be a primary care doctor. It wasn't until his Junior year of residency when he got interested in Nephrology. He saw how it bridged his interests in primary care as well as the intellectual stimulation of the intensive care unit, transplant, and more. [02:17] Types of Patients Nephrology patients typically have multi-system organ disease. For instance, patients with kidney disease oftentimes have endocrinology diseases like diabetes. They can also have rheumatology diseases like lupus or vasculitis. Many times, they have co-morbid cardiovascular disease or pulmonary disease. Gilbert wasn't looking to be a specialist that focused on one small area. Instead, he wanted to care for the totality of the patient. And being a kidney disease doctor allowed him to do that. "They really touched on the breadth of what is medicine and that I find very attractive." [03:38] What Makes a Good Nephrologist There are many bits and pieces to becoming a good nephrologist. There are different elements of medicine involved such as critical care and procedures. A lot of times, you have to deal with an individual's goals. You must be interested in the holistic care of dialysis and transplant. You must have a solid grounding in the general aspects of medicine. You have to be organized, compassionate, and empathetic. You have to provide patient care on all levels. If your focus is in research, you have to have a track record where you know how to post questions and frame answers. You have to be able to recognize the core issues that need to be explored. "There's a whole host of different things that people can get out of a career in nephrology." If you're interested in critical care, you want to organize and prioritize complicated care that ensures the needs of your patients are met. They look for people with particular skills that align with what it is you want to do. You are usually evaluated based on your track record. They particularly look at past activities, performance in various roles during residency training, and organization affiliations. They look at your letters of recommendation, and a little bit goes to your board scores and academic performance. They look at everything to figure out whether they're a good fit for a particular interest they have in nephrology. Gilberts points out how applicants often focus on presenting what the programs are looking for. But they're looking for niche training when you go into a residency program or a specific specialty. You no longer have to impress anybody. Rather, you need to find the training to provide you with the skills needed to succeed in the career you want. So be honest enough to come out and tell them what you want. If they welcome you, great. If they don't you're a good fit for them, then don't train in a place that's not aligned with your career goals. At this point, applicants need to be self-aware of what they're looking for out of their career. They have to accept that some programs are going to be able to provide that kind of training while others may not. That's okay. The training is there to help you launch the career you want. [08:25] Gilbert's Thoughts on Poor Board Scores and Pass/Fail System If you had red flags in your application but still want to take this journey, you need to be accountable. Acknowledge that you didn't do well on an exam. Give them some background about what happened and it may be something they could look past. Be upfront about it. You can communicate this in the essay. Ideally, you can do this during the interview. But many times, the board scores might hold up your selection for an interview. So it has to be acknowledged before that. Some programs screen the applicants based on their board scores so those with poor board scores may not get the benefit of an application read. Gilbert believes this is unfortunate because the board scores don't really reflect somebody's potential to be an outstanding physician. "I don't think that the board scores reflect somebody's potential to be an outstanding physician." Moreover, Gilbert sees some benefits to a pass/fail system compared with a grading system. You usually use the former when the objective is to identify competency. At Tufts Medical School where he teaches, the first two years use the pass/fail system. You need to demonstrate a level of competency in your understanding of biochemistry and genetics. They're looking for foundational material that will prepare students later to perform clinical duties at a high level. Once you get into the clinical setting, then they give grades because they could now see people who can excel in different areas. Gilbert thinks there are challenges to making the boards pass/fail, which identifies a level of competency. There is data that people who do well on the boards are far more likely to pass their specialty boards. And those who have struggled on the boards have oftentimes struggled to pass their certifying examinations. So program directors are cautious about people who present risks of failing the certification boards. [13:00] Types of Patients and Typical Day Nephrology is a mixture of both outpatient and inpatient medicine. There is a lot of outpatient ambulatory clinic where they take care of patients with chronic kidney disease, chronic electrolyte disorders, hypotensive disorders, transplant patients, dialysis patients. Alternatively, nephrologists have a significant role in the inpatient hospital life setting. They take care of patients with kidney disease, kidney injury, and chronic kidney diseases who have been hospitalized. They also deal with electrolyte abnormalities, calcium and magnesium-related disorders, and acid-base disorders. There also get involved in the transplant setting where they adjust immuno-suppression. They manage infectious complications that occur in unique populations. When they design their fellowship training program, they prepare individuals for the breadth of nephrology in terms of clinical practice. They have about 50% of their responsibilities aligned with inpatient medicine. This could be in the form of consult services, ICUs, and transplant services. While the other 50% of the effort is in the outpatient setting. [15:10] Taking Calls and Performing Procedures When patients come critically ill into the emergency department and require dialysis, fellows may need to come in and evaluate the patients. They assess their candidacy for dialysis and sometimes this can happen in the middle of the night. They may have to do procedures such as placing dialysis catheters occasionally in the middle of the night. "There are times that fellows are performing home calls where they need to come to the hospital to evaluate very sick patients. But it doesn't happen very often." In terms of performing procedures, nephrologists usually replace non-tunneled catheters used for dialysis. They also attach dual lumen catheters that can take blood out and return into the circulation at the same time. Standard triple lumen catheters are very large catheters so they require experience in the placement of these. Nephrologists and renal fellows develop the skills to place very large catheters into the body. They also learn to perform kidney biopsies in both the native kidneys and transplant kidneys to understand the underlying pathology of kidney disease. Nephrologists also perform invasive procedures. There is a burgeoning field within Nephrology called interventional nephrology. Many people who enjoy doing surgeries may pursue a career in this area. Small surgeries can be performed as well as grafts, PD catheters, and vascular procedures such as angioplasty, stents, and fistulas. "There are more and more procedures that are finding their way into nephrology." [19:15] When to Start Exploring Nephrology For Gilbert, nephrology means a lot of different things to different people. As mentioned, he was initially interested in general medicine and family medicine. He wanted to be a physician in the community setting. He thought he'd do general medicine and then internal medicine at the end of his medical school training. He basically wanted to be the primary care doctor for a specialized group of patients. Then as he went on with his training, he was in a primary care track within an internal medicine residency. And as he explored a little bit more, he found it so interesting to do all the things a nephrologist does. Gilbert advises students to learn your interests and learn yourself then you will quickly recognize the field that's right for you. He knew what he wanted to do and when he finally heard what a nephrologist does, he knew it was the specialty for him. He knew nephrology would allow him to unite all of his different interests into a very satisfying and rewarding career. "When you know yourself really well and then you recognize the field that can bring that all together, you're almost assured of finding a profession that you're never going to get bored of." [22:55] The Fellowship Training Path Nephrology is a two-year accredited fellowship training program by the ACGME. Medical students need to do three years of internal medicine. Once completed, they can do a two-year nephrology fellowship. This is typically spent with one predominantly clinical year and a separate second year of individual exploration. This could cover areas like research, quality improvement, etc. Many programs offer a three-year training program. For instance, individuals want research training so they go through one predominantly clinical year and two years of research. After the two-year fellowship, they can do an additional year of subspecialty training in transplantation (1 year), glomerular fellowships (1 year), ESRD (end-stage renal disease)/dialysis care, procedural interventional nephrology (1 year). In total, fellowship training in nephrology is at least two years and this could go up to four or five years. [24:43] Bias Against DOs and Demystifying Misconceptions Gilbert explains that the training for DOs and MDs is very similar. There may be a difference in the structure of the curriculum of the two programs. But they have both DOs and MDs in their program. They feel very comfortable in either one of them. Moreover, there are a lot of misconceptions around nephrology and they're demystifying those in the residency program. These misconceptions basically push people away from the specialty that they work really hard to correct on the residency level. Misconception #1: Nephrology is very, very hard, with very, very sick patients. Talk about the differences between salt and water balance, hyponatremia vs. hypernatremia, and sodium overload vs sodium depletion, etc. The patients who develop acute kidney injury are oftentimes sick with multiorgan failure. But a lot of this is algorithmic. If you can keep the patients organized, there are ways these issues can be addressed. "There's this conception that nephrology is just really hard and with really sick patients. But a lot of this is algorithmic." Misconception #2: Nephrologists work really hard. They come in early and stay a bit later. But they're there for the patients. Their hours aren't any longer than any other specialist. They don't get called in any more than any other specialists. They're just taking care of their patients. Misconception #3. Nephrology is poorly reimbursed and nephrologists don't get paid that much. Nephrologists have dialysis, which is a money-maker. The reimbursement for dialysis is generous. [28:10] The Future of Nephrology Training Gilbert thinks that nephrology training is changing. The standard curriculum is evolving. In the future, nephrologists are going to really explore the wealth of where resources can be used. It could involve one year of core fundamental training. There could also be more opportunities for the future nephrologist to subspecialize in areas they find particularly interesting. For instance, onconephrology addresses all the forms of kidney diseases associated with cancer care. There are interventional suites where a nephrologist can perform angioplasties and minor surgeries in an outpatient surgical center. Transplantation has already been identified as a subspecialty. This way, trainees can really focus on immunosuppression and its complications. There are ballooning areas where nephrologists can offer their services. For example, they can be very commonly involved in critical care. For the subspecialization, trainees should really explore their interests and whether it's the heart of what they want to do. [30:44] Final Words of Wisdom Gilbert encourages students who might be interested in the field to immerse themselves in nephrology even over a short period of time. Gilbert describes this field as very intellectually stimulating. There's always something new. Dialysis patients are all different as well as transplant patients. That being said, this requires a lot of careful thought and commitment to these individuals. And that is so rewarding. In fact, he claims to have never been bored for a day in his career as a nephrologist. There are so much going on that it's just a lot of fun! "The field of nephrology is intellectually stimulating in so many different ways. Everyday is absolutely different." Lastly, nephrologists are very upbeat, positive, excited, and enthusiastic individuals who love what they're doing. They're happy to share their understanding of these disorders. He encourages students and trainees to find a way of finding a mentor, specifically someone within nephrology who can share this kind of excitement for them. Links: MedEd Media Network

Session 87 Dr. Jairo Barrantes joins Ryan to talk about Academic Sleep Medicine including what he loves about it, what call looks like, and why he chose academia. For more resources, be sure to check out all our other podcasts on the MedEd Media Network. [01:24] Interest in Sleep Medicine Jairo's interest in sleep medicine sparked during his pulmonary critical care fellowship, where their director was the head of the American Academy of Sleep Medicine. That being said, a pulmonary physician has too little exposure to what sleep medicine really is including the different diseases you come across. Sleep medicine involves 80%-90% of sleep apnea. While the training you get as a pulmonologist is the sleep apnea part and not so much exposure to all other diseases that sleep medicine entails. This opened up different doors such as narcolepsy, parasomnia, and insomnia, which may up the main problems of sleep medicine today– but there are more others apparently, especially in children. Jairo describes sleep medicine as a very fine specialty where you get the opportunity to see all patients. [03:31] Traits that Lead to Being a Good Sleep Medicine Specialist Jairo says that most people choose this specialty for being gentle in terms of not having any calls and you only get to work from Monday to Friday. You infrequently get phone calls from the sleep lab at night time. So many people choose this because of the lifestyle. However, what makes you a good physician is to have a good understanding of the pulmonary and brain physiology. We sleep 33% of our life so we sleep for many years. And that's part of the time that no one really cares about. That period of time, a lot of changes happen during our sleep. Metabolism slows down as well as your brain function and this has that recovery and immunology component. Jairo explains that the reason many people die during their sleep is due to surges of stress once your metabolism goes down and when your body is already deconditioned, this can cause a heart attack. [05:40] Types of Patients You may choose to do only adults or only pediatrics, or both as what Jairo does. For the children, the most common concern would be sleeping difficulties. Childhood insomnia composes 80% of his consults. The rest would be children with sleep apnea. Interestingly, sleep apnea in children is often misdiagnosed as ADHD by primary care physicians and pediatricians and they prescribe the medication like stimulants to keep them awake and focused during the day. But the reality is that these kids are sleep-deprived and have got poor quality of sleep. That could be sleep apnea that hasn't been treated for years and have been in medication to keep them awake. Suddenly, you go ahead to treat the sleep apnea and the kid's behavior improves. In fact, about 40% of children that have been diagnosed with ADHD were actually suffering sleep apnea. The rest of the patients would then be dealing with parasomnias, which are irregular behaviors during sleep time such as banging of the head or entire body during sleep. Obesity and narrow airways may cause sleep apnea and this is easier to notice among adults. However, there are other multiple solutions for this such as medication to help them sleep. Jairo also likes to use common devices like fitness trackers to help patients with insomnia so they can develop better sleep patterns. The key is to sleep right at the wrong time. For instance, teens go to sleep at around 1-2 am and wake up at 11 am. People think they're lazy, but they just have a different sleep pattern. Unfortunately, this is causing disrupting in schools. In fact, in Minnesota, people are having their children start school later at 9am-10am and they scored better in their standardized test because they perform better when not sleep-deprived. Some people with parasomnia may act their dreams and they think they're playing karate in the middle of the night. That can be dangerous for the bed partner, or they can injure themselves since they're pretty much asleep when they're acting their dreams. And they could hurt themselves with sharp objects in the house, or fall off the mattress. Hence, these disorders should be treated. [10:55] Taking Calls and the Golden Age of Sleep Medicine Jairo admits to never having been back to the lab. The only time he needed was during their pulmonary fellowship. Most of the centers are outpatient sleep facilities. This makes it very convenient for people. In pediatric medicine, most of the fellowship are three years. So it's very attractive for them to have a one-year fellowship. Moreover, Jairo describes the salary is not bad at all for the amount of extra training you do after your internal medicine, pediatrics, or psychiatry, so it's very similar to primary specialties. Depending on where you work, they bill time for sleep interpretation and you have your schedule close for a couple of hours so you can do the sleep studies for the night. Jairo also points out that many people stay away from sleep medicines due to economical reimbursement. It was better during its golden years some 20 years ago but Medicare adjusted the prices and now, you get a glorified internist salary without calls. Not bad at all, however, it wasn't as good as it used to be back then. That being said, still, it's a very mellow specialty to go through and the number of diseases is limited with about 20-25 conditions with different subdivisions compared to doing general internal medicine where you have to treat thousands of conditions. [13:30] Typical Day and Work-Life Balance Jairo would usually go to the office and most of the patients prefer to schedule their sleep studies early in the morning. So you do a sleep study interpretation from 8-11am. Then after the clinic from 11-12 for lunch, you go back to the clinic and finish at about 4 pm. You wrap up and then go home. This happens Monday to Friday. He still has enough time for his family as he still gets to take his daughter to ballet classes and other activities. [14:55] Academic vs Community Setting As to why he chose the academic setting, there are opportunities for research available. This is one area in the specialty where you can develop your career. And there are also plenty of areas to do research. Alternatively, you don't get the opportunity to do research in the private sector and you focus more on sleep apnea as that's where money is generated. So you need to be linked to an academy to be able to develop sleep research. There is plenty of themes or areas that you can do it, but in order to develop that, you need a little bit of protected time, access to key people doing statistics and interpretation. You also need people to help coach you how to write articles properly. While the academic centers get more complicated cases. Hence, case reports are easier for them to make when from the academic side. Additionally, Jairo loves to teach. He finds being attached to a center that has Sleep Fellowship as very gratifying. [16:35] The Training Path and Getting Getting Monetary Compensation There are different ways down the Sleep Medicine path. Initially, you have to have a base specialty and then you can apply for sleep medicine from there. You can become a sleep physician from being a general internalist or from general pediatrics. You can also come from pulmonary critical care, psychiatry, psychology, and neurology. So finish your basic specialty then do sleep medicine fellowship thereafter. You take the board for sleep medicine and become a Diplomate. Jairo says that it's easy to find a job in sleep medicine because, in the last ten years, the doctors who were practicing sleep medicine weren't board-certified. Hence, they didn't have any formal training. And when the boards came, it was very difficult for those physicians practicing without formal training to pass the board. Those people shied away and they haven't studied again to be able to take the boards. Nevertheless, people don't realize it's a good specialty since it's easy to work with the schedule because it gives you a lot of flexibility. Plus, he gets to have weekends off.  Also, the amount of RVU they can generate from the sleep is significantly higher than what you can generate from being a primary pulmonologist. This means they give you more forgiveness in time and still receive the same expectations from the hospital without working extended hours. Or if you're paid by incentive and reach a certain amount of RVUs a year, you're able to reach those RVUs with the sleep part which you will never reach just with the pulmonary part alone or psychiatry work, whichever specialty you have. Matching into sleep medicine is not competitive at all. People don't even know what sleep medicine is. But Jairo thinks it's going to surge once people getting paid with these RVUs. There are about 60 programs that are eligible and out of those, about 60% get filled. [21:00] Special Opportunities to Subspecialize There isn't much opportunity to subspecialize once you get into sleep medicine. You basically choose your niche of practice usually depending on your background. For instance, if your background is neurology, you usually focus on circadian rhythm disorders, seizures, and movement disorders during the sleep compared to doing sleep apnea. In Jairo's case, he does mostly sleep apnea and uses of non-invasive positive pressure ventilation at night. He also does what he calls as special populations like children who have facial malformations or other conditions that leave them with very narrow airways and have severe sleep apnea that requires tracheostomies, advanced ventilators, or non-invasive positive pressure ventilation at nighttime, especially patients with APS who become dependent on those during both nighttime and daytime. [22:25] Working with Primary Care and Other Specialties Jairo wishes primary care physicians would realize that sleep medicine is more than a sleep apnea. But that's not what just the sleep medicine entails. It's more than just prescribing the CPAP or the BIPAP. A lot of knowledge is involved and a lot of different opportunities to treat the patient better. Additionally, there are many diseases that are preventable or better treated when you have a better sleep pattern at night. For example, if you have diabetes and your sleep apnea is controlled thereby giving you good sleep, your insulin requirements go down by 30-40%. The same happens to people with hypertension where they notice some drop in the amount of medication required for hypertension when they're treated for sleep apnea or insomnia. If they're able to understand this, primary care physicians would be more enticed to know more about sleep medicine so they can do basic practice in their practice, says Jairo. As a general internist, you can prescribe the CPAP and sleep study. But if you have the basic knowledge and interest in that, then you won't have to refer to a sleep specialist, which can be very difficult to find these days. In fact, it may take up to 6-8 months to get a sleep specialist available. This actually discourages patients to pursue any longer since they can't find anybody to see them. Other specialties they work the closest with are mostly pulmonologist, bariatric surgeons, psychiatrists, and child psychiatrists. They also work with neurologists for patients with ALS or spinal trauma. They do work with cardiologists as well as endocrinology. They're trying to get better control of irregular heartbeat at nighttime or daytime and this decreases the frequency of relapses of atrial fibrillation after ablation when sleep apnea is being treated. [25:22] Special Opportunities Outside of Clinical Medicine One area would be commercial devices. They're looking for people developing new technologies. If you get to work with one of the companies that develop non-invasive positive pressure ventilation, there are opportunities to go into the commercial or research side. You would now be part of the protocol. But if your center is standardized and needs to forfeit all of the conditions of the American Academy of Sleep Medicine, you will be able to get research going on in your lab. There are private doctors who decide to devote all of their time or 80% of their practice to do the case being paid by the research study. [26:26] Most and Least Liked About Sleep Medicine When he did his residency in internal medicine as an intern, one of the sleep doctors gave them a talk about sleep medicine and didn't mention about it and he was making good money at that time. Today, the population they work with include patients that are very gratifying as it enhanced their quality of life. Although there are some that complain, the majority are still grateful for what you do for them. Interestingly, you don't need to see your sleep patients very frequently. You may only seem them every year and they can do very well with that. What he likes the most about his specialty is the schedule. Interestingly, Jairo doesn't find anything that he doesn't like about his specialty. He enjoys every single minute he's at work. Maybe, having patient with insomnia that is very difficult to treat can be upsetting for him so you can end up being a dispenser of control medications for them. But as far as you do your job right, most of your patients get well. [29:20] Major Changes in Sleep Medicine People are becoming more aware of the wellness and lifestyle so sleep medicine is going to start growing more and more. And perhaps in the next 10-20 years, physicians are going to be very aware of the benefits of having a good quality of sleep. Hopefully, there will be more physicians coming to learn what sleep medicine is and practice it. This will lead to better reimbursement and more opportunity to treat other people. If he had to do it all over again, he'd still do it. In fact, he would even do it first over the pulmonary part if he'd just have to take sleep medicine. Although he loves pulmonary, he finds sleep medicine as more gratifying. [30:33] Final Words of Wisdom Jairo says that sleep medicine is a wonderful field where you can achieve many personal goals in relation to your career. Career is significantly easier when you do it from the sleep part because there is a blank canvas to be painted compared to other specialties. So this is a fine specialty to pursue. Links: MedEd Media Network

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

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

  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 80 Dr. Mary McHugh is a urologist who's been out in practice for a year and a half. She talks about her journey to urology, especially as a female, in a very male-dominated specialty. Also, be sure to check out all our other podcasts on MedEd Media Network to help you along this journey towards finally becoming a full-fledged physician! [01:21] Interest in Urology Mary was exposed early on to urology when she was a second-year student during a six-week general urinary block that covered OB/Gyn and Urology. She saw how urologists were fairly entertaining who showed videos of the robot. From that moment on, she got introduced to the concept of the specialty that she had never even considered or known much about. But this sparked her interest in learning more about surgical fields. "I just never thought about urology - period... I had always thought women didn't become surgeons." She always thought she'd do something that wasn't procedure-based or medicine-based. That said, she didn't really experience any gender bias when she took the course. In fact, there wasn't any single female lecture in the course. Every single person that came and talked to them was a man. So it was interesting she ended up down this path. What she really liked boiled down to medical management, procedures, and surgery. She likes the organ system, the anatomy, and that some of the problems had to deal with the quality of life. What she likes about it is that 100% of the issues people deal with is quality of life. And being able to make that impact and make it fairly quick, it leads to a lot of satisfaction to both patients and physicians. [04:20] What is Quality of Life? One of the biggest quality of life issues is overactive bladder urinary frequency. This would not be considered to be a life-threatening illness. However, it's something that affects how they carry out their daily activities. And some people get so bothered by this. Fortunately, there are things they can do for that to be fixed but they never even realized until they stepped into a urologist's office. Another example is stress urinary incontinence. This is leakage, or anytime there is an increase in intraabdominal pressure. So when a woman or man coughs, laughs, or sneezes, they may leak urine. Again, not a life-threatening condition, but can be ostracizing and can interfere with things they like to do like running, dancing, horse-back riding, hiking. They have things urologists can do to help improve that. [05:45] Traits that Lead to Becoming a Good Urologist You have to be a good listener and a good communicator, especially that patients that come to you have very sensitive issues that deal with sensitive areas of the body. And they want to feel like they've been heard and understood. As a woman, you get a lot of male patients that are very shy when they come in. But you have to make them feel at ease and like they can open up to you and talk to you, so you can get to the root of the problem. "Anybody who is going to be counseling patients on procedures, you really have to be a good communicator." That being said, you have to be able to set expectations and be very clear about what's happening, what the potential risks, complications, side effects, etc. So patients really know what they're getting into when they're signing up for surgery. Mary had other interests prior to urology such as dermatology to GI and then to peds, until eventually, she found urology after she took the course and went on her clerkships. She chose a clerkship path where surgery was second to rotation so she was able to make that decision right away. [08:18] Types of Patients Among her patients are those with overactive bladder, stress urinary incontinence, voiding symptoms in men due to enlarged prostate, erectile dysfunction, and recurrent infection (a big one she sees). She also sees a lot of chronic bladder pain syndrome or interstitial cystitis, stones, and hematuria workups. Mary is in private practice in northern New Jersey and she says 70% of her patients where an OB/GYN will identify a problem and send the patients to her. Then she goes from there and does everything on her own. The other 30% are looking for another opinion or have things done or they've seen another urologist. So about 70% are common and the other 30% come with some things done. [11:11] Choosing Private Practice over Community Setting Mary's husband came out of his training first and finished his fellowship. He wanted a specific job in a specific location so he moved while she was finishing her last year of residency. She has always envisioned herself going into private practice. She thinks it's hard to provide training and mentorship to residents when you haven't been out in practice or out in the world. She also likes the independence of private practice as she has always liked doing things herself and at her own pace. "It was the job market and my own style and personality that really influenced me to go into private practice." During Mondays, Mary is in the office seeing patients. Wednesdays are full days in the office seeing patients. Fridays are procedures they do in the office such as cystoscopy, vasectomy, urodynamics, and other procedures. She also does prostate biopsies and ultrasound and injection of Botox to the bladder. Tuesdays and Thursdays are a bit more variable. As a new attending in their area where they're saturated with physicians, it can be hard to get block time. So when she puts cases on her schedule, they get added to the hospitals she's on staff at. The way you get block time is either to acquire somebody else's block or to be employed by the hospital system. A lot of the consultations she gets sent are a lot of non-operative patients. About 20-25% of all the patients she sees end up having a procedure whether it be in the office or having surgery. This can be a little disappointing for her considering she wants to do surgery. "You do the cases that you can and you have the best outcomes that you can and that's how you build your reputation." She explains that one of the biggest things you have to realize coming out of training is that it takes time to build and it takes time to establish yourself and establish your reputation. Don't believe everything you see on Instagram where everyone has 10,000 cases on their first day. [17:55] Urology as a Male-Dominated Specialty It's just the perception of a lot of patients that only males will treat that part of the body or look at that part of the body. It has to do with traditionally, who was in the specialty looking back 20-40 years where even every specialty was even male-dominated. That said, women are still a rarity in the field but a lot more women are being trained now which is great for both male and female patients. [19:20] Taking Calls and Emergency Cases Mary is in a large urology group and in her care center, there's only two of them. Their call is going to be split by whoever is in your care center. So it's every other night for her. ER calls are determined by hospitals. One of the hospitals assigns ER calls a month at a time. She doesn't describe it as too bad. But based on politics, some hospitals keep a stronghold on the call and don't want outsiders taking it which she considers as a blessing in disguise. Some of the emergencies they see are necrotizing fasciitis of the genitals, testicular torsion, abscesses, the common ones they get consults for their scrotal abscesses, and septic stones. And retention -  a common one they get consulted for all the time. Oftentimes, they call you and patients are super uncomfortable so you have to go take care of it. [22:13] Work-Life Balance Mary considers having enough family-work life balance. Her husband's hours are pretty long as well. So they have that time when they go home at night where there's a couple of hours and then the weekends. Whatever weekends he's not working. It's a lot better than training she calls it. And there are things you can do to minimize your calls your make sure everybody's questions are answered and everyone is tucked in. If you're doing a procedure on a Friday, everything is taken cared of and you don't have any worries about that when you go on call over the weekend. It's a matter of letting people know that you're available but also explaining to them what kinds of things they should be calling you for. When they're not on call for the practice, it's not as bad. [23:35] Residency Path to Urology Urology is its own training program. Most of the programs are five years, some are six years. Although a lot of them have gone down to five years. The first year is a general surgical internship and then usually for four or five years of urology. A lot of the programs that are six years have built-in research year. "If you're applying, know how long the program is going to be. But it's all one program you match into the whole thing." The urology match precedes all the other matches, after the military. But urology matches in December. It's not through the NRMP, but through the American Urologic Association. They give you a number and you do it through its own unique match. The reason for this could be that it's a self-regulation issue. When you're in a specialty, you don't want to have so many people. This is just Mary's guess though. Urology matching is pretty competitive. Check out urologymatch.com and find a more specific breakdown. There are not a lot of applicants but it's a 60% match rate for those applicants and they break it down in general. You have to be really high performing as a student and have good Step scores. The process could be different now as well. Mary is a DO and a lot of the programs that were DO are now in the urology match accredited by the ACGME as a single graduate medical education system. And so it's gotten a lot harder than when she matched since it was a separate match. She applied into the urology match and applied to as many programs as possible. But they've done away with programs that are just AOA accredited. Mostly, all are ACGME-accredited at this point. [26:38] Negative Bias Against DO and Other Subspecialties Having been on both sides of the interview trail and as an interviewer, she thinks there are biases. The Specialty Stories breaks down per specialty, MD vs DO, and Mary thinks the data speaks for itself. It can be done as a DO but that's more of the exception than the rule. There are a lot of subspecialties you can do after urology such as oncology (2-year and 1-year fellowships), female pelvic medicine and reconstruction (2-year and 1-year fellowships), pediatrics (2 years), reconstruction and trauma (1 year), andrology and male sexual health (1 year), and fertility. Those are the general subspecialties. Urology is its own subspecialty. [29:30] Working with Primary Care and Other Specialties Mary says there are a lot more technology and a lot more procedures to help patients. She commends those primary care doctors for starting people on medication and working up a lot of the urinary complaints. For instance, Botox is for patients with frequency and urgency, indicated if you've failed to two or more medications. Sometimes, patients think that there's no solution or they're stuck with the medications. And people are always so surprised when they learn about their options. So just getting them into the urologist sooner and not being afraid to send in a patient to see if there's anything else they have to offer. "Sometimes, patients think there's no solution or they're stuck with the medications. And people are always so surprised when they learn about their options." Other specialties they work the closest with are general surgeons, OB/GYNs, family practice and other mid-level providers like PAs, NPs, etc. Opportunities outside of clinical medicine for urologists include speaking engagements, expert witness, write books, consults, etc. [32:15] What She Wished She Knew that She Knows Now Mary believes that one of the hardest parts of being a surgeon is that you become extremely disappointed when something doesn't go according to plan or someone has a complication. Dealing with that the most is one of the hardest parts of her job as it's emotionally taxing. So you have to learn how to deal and cope with that. When you go out, everyone is just so bright-eyed and bushy-tailed and ready to soar, but it takes time. It takes time to develop a rhythm. It takes time to develop finesse. So there should be patience and you should respect the process. "What you've done 10,000 times as a chief resident that you can do with your eyes closed suddenly becomes the hardest thing when you're an attending." What Mary likes the most about being a urologist is her patients which she considers to be very awesome and this adds to her job satisfaction 100%. She comes from an urban area in her training and so now it's different there. Now, she's out in the community and the suburbs. Patients listen to her and they take their medication. They make her job very enjoyable. The thing she likes the least is that sometimes you feel helpless in your ability to help people because you're constrained by what insurances will cover. This is an issue because people are on a fixed income and they can't afford these things. If she had to do it all over again, Mary would still probably do it. Again, on social media,  you see these people so happy after some procedures. But what it all comes down to is to think about what complaints or complications you're going to deal with. [37:30] Final Words of Wisdom Stay interested. Read as much as you can, when you can. Getting exposure early is key. If you're a medical student, it's doing all the things you should do to match into a competitive specialty. Learn the people who are on the faculty at your institution. Get involved with research. Meet the residents and get that chairman's letter if you have a department. Do as well as you can and you'll succeed! Links: MedEd Media Network urologymatch.com

Session 10 Today, our premed student is changing her career because she wants to change the scope of her practice. But she’s conflicted because she’s struggling with things concerning her age and wanting to have kids. Is it possible to have kids during medical school? [01:20] Caller of the Week: “Ever since I dove into this premed journey and stumbled upon all of the different things that are offered by Ryan Gray like the Premed Diaries and all premed podcasts. Both Dr. Ryan Gray and Dr. Allison Gray have just been... felt really supported by this online community and all the information that's out there. Anyway, the journey about myself that I wanted to share and the questions that I have for Allison and anybody else who's in a similar situation. It's related to just the challenge about my age... I'm 29 and had kind of a different journey. I was a traditional student with a degree in Biology. I graduated at 22. And I've always been tempted to go to med school. I've always wanted to be a doctor. But I felt like when I was in my early 30s, I just lacked a lot of confidence. I never even took the MCAT despite doing most of the prereqs because I never really felt like I could do it. And I think I never really wanted to put myself out there to find out. So instead, I actually completed a second undergrad - dietitian. I've been working clinically in a care setting as a dietitian for almost five years now. And I absolutely love my job. I work with a really unique population... the people I work with is a tribal population in a really remote part of the United States. I work in a hospital and over the past five years, I feel like I've grown so much life experience and so much confidence. I work with great health care institutions that always supported me and told me really I could do anything... I have been able to grow my role out of the hospital into our outpatient oncology palliative care clinic. Through this process, I've felt myself as feeling really confined by my scope of practice as a dietitian. I'm so interested and curious about medicine and about the unique cancers that my patients are struggling with and just find myself wanting to learn more and to know more. And to be able to go beyond nutrition to help my patient... I'm completing - the last prereqs that I needed was Physics class... so I'm just taking that last class and I'm scheduled to take the MCAT in March of this year and apply to medical schools in June. Really, the reason that I'm feeling conflicted and scared and worried is because I'm 29 years old. I'm about to commit to another goal beyond four years at school and the time you consider medical school and the residency. And I want to have kids. I've grown up in this great environment both growing up and worked where being a woman has never been the reason not to do anything at all. And I think this might be one of the first times that I've ever felt this burden of being a female... I don't want to take anything away from men who are doctors or medical students who have a huge burden on their shoulders with supporting family or a wife who's considering pregnancy. But it just comes along with a whole extra complexity when you're the one who will be going to medical school. When I told my mom who's a physician and was actually the first female medical director of one of our local hospitals that I wanted to go to medical school and be a doctor, she said, that's great. And her second comment was, so you've decided to forgo having kids then, which stressed totally threw me... Luckily I've worked with a lot of really supportive physicians and the people that I have chosen to share my plans with have told me - you can do it. It's possible. Everybody has stories about somebody they knew who had kids in medical school but I'm just so worried about it... get through medical school, get through a residency and be 36, 37 at best and I could find myself unable to get pregnant. And I'm worried about in the future, regret that I'll have. I have this career that I love that has a lot of promise as a dietitian... but I just know that I would love being a doctor and then I could do so much good of this population and provide so much continuity of care in our region and for all of our rural patients. I feel really torn given my age, I'm turning 30 next month. The other important thing to mention, the other part of this equation is my very supportive husband... really only been seriously deciding to take the plunge into applying to medical school since about August of this year. And when he brought it up, he supported me 100%. We've talked a lot about the question of kids because we both want kids - when do we have, when do we try, when is the best time, when should you have kids in medical school, should we wait... what's going to happen if we wait a few years until so I would be in medical school or even wait until I graduated from my residency to try or if he's going to hold it against me if I can't get pregnant. He said he won't but I just can't help but have that worry..." [09:55] Being a Mom and a Woman "As a mom, there's no greater gift than be able to have children and be a mom." I love what I do as a physician, but I think it's in our biology in terms of our desire to be parents. Although not everyone feels this way, but for many of us, it's a very powerful, important thing we want to do. It's definitely different as a woman vs a man. There are certain additional complexities that we have as women going through medical school, residency, and trying to juggle getting pregnant and all of the things that go along with that, plus having children. When you're parenting, just the mere pregnancy itself is unique to women. [11:20] Working as a Dietitian and Getting Family Support You talked about regret and do you think you would regret staying in what you're doing now forever? Otherwise, you would always potentially wonder and would have what ifs. This being said, I wonder if you'd regret not applying. Additionally, it's wonderful that your husband supports you. It's so important to have that support from day one. It would also be fantastic to be able to bring your skills as a physician back to the same population you're caring for. Being able to do more sounds really fantastic. [12:35] How to Do It All "Nobody really has their act together." As a child, teenager, and young adult, you'd think you can handle xyz when you're at this certain age. But then you realize that nobody really has their stuff together. And we're all just coursing through. So adding children, which is a huge part of that equation, is that there's never necessarily a right time. In fact, I don't think there's ever a right time, so to speak. There will be times it will be more challenging in which to have children. If you have a kid and starting third year of medical school, that is a challenging time. If you're starting your internship and you're about to have a kid, then you'd have to postpone your start date. Definitely, there are more challenging times on the path of medical school and residency, at which time having children would be harder. But as to whether there's a perfect time, probably not. [13:50] You Can Have Both: Kids and Medical School It's clear how much you want to have children and I would very disrespectfully disagree with your mom. I think you can have both. There are several people in their group who had kids in medical school. And the rest of us who did not have children yet would look at them wondering how they're able to do that. But they would usually figure out different ways of getting things done. It's not the same when you have children. You have to heavily prioritize what you're doing and really make things consistent and be very clear about what's happening when. So their ability to succeed in medical school just rested on the fact they had to make that work for their kids. They had to find those times when they could study. They have to find the time so they can be there for their kids. Is it possible to do it? Absolutely. It's just a question of making it work and figuring out who's going to do what - bath time, bedtime, study time, etc. And if one of you is in medical school instead of both of you, it's probably much easier than if you're both in school and trying to have kids. [15:57] The Pieces to the Puzzle First, this is very much something people do. It's just a question of figuring out how. If you can get through medical school. It's just a matter of making all the pieces altogether. Parenting is a lot of just feeling your way through life and knowing that your priority is your kid. Perfection and raising children, they do not go together... Perfection is something we strive for but certainly something that is not a reality. [17:20] Going to Med School at 30 Being 29 or 30 is different than starting med school when you're 20 or 22. However, I have kids and colleagues who had kids when they were 20. But you never know. Nobody can tell you what your fertility journey is going to look like until you're at that point. You might go and have one kid when you're 36. [18:40] Figure It Out with Your Husband When does it feel right for you to have kids? If having children sooner is something you really want to do, then do that sooner. Moreover, it is such a personal journal and a personal question for everybody. For me, I felt too stressed out about just the process of being a med student. I felt like I needed to grow some more. I was also too worried that if I had kids during residency that the stress would just be out of control. The kind of residency program I had trained was incredibly rigorous. And that was what scared me into not feeling I could. But that's just me. I know there are others who did really both. I remember one of our junior residents had a baby during the most challenging part of our residency. We were on call every fourth night for the entire year. And she had a baby! Any of these things are possible. It's just a question of how do you feel? If you're really in it and your husband, then it's really just a matter of when you both feel this is what you want to do and you will figure the rest out. If you wait just for the sake of it, it may not be the right time. So it's more a question of looking at how you feel and where you're going to medical school. Another thing to consider is to think about the support you have nearby. One of the things that help families going through medical school or residency is having support from an extended family nearby. No matter what stage you're at, it's huge to have that kind of support. [22:25] Final Thoughts I hear you. I appreciate the decision you're faced with as well as the concern and worry you have. Keep in mind that you have a very supportive husband and a very bright future in front of you as you've done very well so far. You know what you want. So it's just a matter of making it work. At the end of the day, push forward. Apply to medical school. Don't live with regret and see where it goes. Hopefully, you're able to get additional family support in that area. Otherwise, you're going to make that work too. In terms of fertility concern, when you feel you're ready to become a mom then make that happen too. You may find it's really hard to juggle, but you will make it work! The journey that you will take as a med student, as a resident - you'll have stressors throughout that period. But you will make it work. "Just go with your gut. Use your resources, the people around you and just keep your head up and you will get through it." Links: MedEd Media Network

Session 78 Dr. Alex Voldman is an osteopathic (DO) physician who specializes in Ophthalmology as a cornea and cataract surgeon. Check out our latest episode to learn more. Also, check out all our other podcasts on MedEd Media Network. Please help us find a guest here on the podcast. Send me an email at ryan@medicalschoolhq.net. [01:35] Interest in Ophthalmology Alex didn't go to medical school thinking about such Ophthalmology Upon his path to being an orthopedic surgeon, presenting at a conference, he met an Ophthalmologist who encouraged him to spend a day at his clinic. Seeing their practice, he thought they're some of the happiest doctors he has ever seen in the years he spent as a student. He thought it was an organized environment where doctors and patients were happy. And he thought they were happy. Wanting to be happy as well, he decided to jump to the bandwagon. He also found them to be working at reasonable hours. They also got surgery and played with cool toys and lasers. When he found it was competitive, this drew him even more as it was something that challenged him. Thinking he was going to be a businessman, the father of Alex's friend called him and discouraged him from doing so. He was told that if he became an orthopedic surgeon, he was going to retire at 50 as a millionaire. It sounded great to him and thought the dad was great and living the life. So he literally switched his major and started taking science classes. He admits not really liking the business classes he was taking. Nearing medical school, he realized that advice the worst he had ever gotten. He was glad though because it brought him to medicine but to tell somebody to go to medicine to become rich is absolutely wrong. Sure, you could do well and be rich if that's the goal but that's not the way to do it. "To tell somebody to go to medicine to become rich is absolutely wrong." When he got into medical school, he started exploring the orthopedic surgery lifestyle but the personalities he met didn't seem to flow with his, as he describes it. He found people to be a bit more aggressive than what he would have envisioned a classic doctor. Personality-wise, he saw he was more aligned with the Ophthalmologists who are dorkier and laid back. [06:51] Traits that Lead to Being a Good Cornea Specialist Alex explains you have to be very meticulous although you don't have to start being one. Instead, you'd be forced to be meticulous. All of their surgeries and procedures are visible in the patient's eye everyday. So whatever result they have, they're walking around with it. They're looking through it. And if you're off by a small fraction, then a patient sees that for the rest of their lives. "Every calculation, whatever technology we're using... all have to be meticulously placed." [08:00] Types of Patients Although a cornea specialist, Alex also sees a lot of general ophthalmology. In reality, if you practice cornea in private practice, you're also more likely doing a lot of general ophthalmology because there's not that much cornea pathology to keep somebody all day long. For instance, in a day, he may see young patients for routine eye exams. The majority of his patients are also elderly. Common cases would be cataract, glaucoma, macular degeneration. And from a cornea standpoint, there are corneal diseases related to surgery such as patients with previous eye surgeries, multiple surgeries. If you have a sick eye and has had lots of surgery, it causes damage to the cornea which often needs corneal transplant. "If you have a sick eye and has had lots of surgery, it causes damage to the cornea which often needs corneal transplant." Sometimes, people have infections that cause scarring and corneal disease. So he may see contact lens wearers with corneal ulcers that sometimes have scarring so they need corneal transplants. Rarely, they will see certain corneal diseases like dystrophies people are born with. And often, they'd see those with corneal ectasia, also called keratoconus, characterized by thinning or balling out of the cornea if people are born with corneal disease. Their corneas become thin and pointed so they become weak and would nee corneal care either in the form of specialty contact lenses or corneal surgery. [11:20] Typical Day Alex's day usually starts at 8 am as his first scheduled patient and then see between 10 and 20 patients. He's in private practice, working about half an hour from his house. He has great support at the practice. He has a scribe and technicians that work patients out for him. He'd describe it as a pretty fast-paced practice. "To be able to get through 20 patients and make everybody happy around you, you have to be efficient." He'd usually finish around noon and the next patient is scheduled at 1pm. So he gets to have his lunch break (although he doesn't eat but doing other things). Then he ends at 430-5 pm. This is a typical clinic day For OR day, his first case starts at 7 and doing about 10 surgeries in a half day. He'd be done at noon, take a break, and then do clinic in the afternoon from 1-5 pm. [13:02] Taking Calls and Work-Life Balance In his practice, they have 7 physicians, they split their calls equally among 7 people. So he'd be called once a week and you're covering call for your practice only. It's usually light, too. Middle-of-the-night emergencies are rare and if they're happening, sometimes the person can be seen the next morning. He'd also cover call for the local university hospital occasionally where he gets to see trauma call with residents, which can be easy. They have the option to do it as much or little as they want so Alex is doing it one week a year only. "Generally, ophthalmology private practice call is not really intrusive in your life." When taking a call, it's very rare that he gets called in during the week since he can just see the patient the next morning. So he almost never has to go in during the week. On the weekend, he'd have a patient to bring every few weeks. So it's not very common. Alex illustrates his lifestyle as being very predictable and he thinks this is one of the biggest draws of the specialty. [15:22] The Training Pathway You have to do ophthalmology residency and prior to that, do your internship. As of now, they're separated. So you do one year of internship of some kind. Most people do traditional medicine or transitional. Very rarely would you see surgery or peds. Then you do three years of ophthalmology residency. Then for Alex, he did one-year Fellowship on Cornea. "Nothing is going to change the practice pattern so the lifestyle factor will always draw people and will make it competitive inherently because of that." He still thinks the specialty is highly competitive until now. He points out that the nature of the lifestyle is always going to draw people to it. To be competitive in matching, like any other field, you need to really know you want it and be able to show that you want it. The only way to do that is be involved - whether in research, clinical experience, shadowing, volunteering. These are all just ways to figure out whether you like it or not. Then build connections throughout the entire process and those connections are what can help you. You'd be able to get better letters of recommendation from people you spend a lot of time with. "You need to really know you want it and be able to show that you want it. The only way to do that is be involved." Undoubtedly, the first thing residency programs are going to screen you on is going to be your school and Step 1 that's going to get your foot on the door. Otherwise, it could be an uphill battle - not impossible, you could definitely do it. Next, is how well you interview. Ophthalmologists work tightly together and in a clinic environment side by side with your attending physicians, and a lot of times, with their private patients. So they want somebody they'd feel comfortable around patients. Lastly, Alex says that research always helps. For cornea fellowship, it's not as competitive. Good programs at anything are always going to be competitive. The same reason you could say that family medicine isn't competitive. But pick the best program in family medicine and it's going to be very competitive. Ultimately, in terms of competitiveness in ophthalmologic fellowships, it's probably middle of the road. [19:35] Other Sub-specialties There are new ones every couple of years. But for now, there are subspecialties like a 2-year fellowship in Retina or a 1-year or 2-year fellowship in Oculoplastics, a 1-year or 2-year fellowship in Oculoplastics, 1-year fellowship in Glaucoma and 1 year in Cornea. You could also do 1 year in Uveitis, 1 year in Pediatrics. You can also do Pathology or a special fellowship for Refractive Surgery. [20:35] Negative Bias in the Field and Alex explains that even as a DO the bias doesn't come up among his patients. The bias rather comes up when you're trying to apply for residency programs. The program directors of MD programs are not going to look at you first. You have to do something special to stand out among the MD applicants. "The bias undoubtedly is going to come when you're applying for residency programs because the field is so competitive." [21:27] Working With Primary Care and Other Specialties His advice to primary care physicians to refer early and don't just treat red eyes. The differential diagnosis of a red-eye when he sees one "Refer early and don't just treat red eyes." The exams he does and all the things he looks for are extensive. A lot of times, primary care docs see patients and they say it's probably a pink eye. Then they'd give somebody an antibiotic. Then send him his way. So he urges primary care physicians to refer early. Less is more. And don't just treat. Because a lot of times, this could make Alex's job a bit more difficult when they get to him and he's not sure where to really start. Other specialties he works the closest with include Anesthesia, Primary Care (as they manage a lot of diabetics), Neurology (taking care of patients with vision loss, cranial nerve palsies, etc.) He may also work with a Rheumatologist (autoimmune inflammatory eye diseases that need systemic management. [23:12] Special Opportunities Outside of Clinical Medicine One may get involved in the industry of surgical devices, doing trials, and testing new devices. You can also always be a business owner. [24:08] What He Wished He Knew that He Knows Now In one aspect, he has enjoyed building long-term relationships with patients. But as a practice, he is pretty tied to his geographic location because he's getting his self and name out there in building a patient base. So he can't just leave and decide in another part of the country, which is something other specialties can do such as Anesthesiologist or Emergency Medicine doc. "The private practice of Ophthalmology is much more community-centered." The best part of his specialty he describes is the one-day post-op where the patients come in and there's a smile in their face because they can see much better. On the flip side, one of the things he likes the least is the fact that he not infrequently does he have to talk to patients about money. For instance, he may prescribe eye drops that can't be covered by their insurance or offering different services not covered by insurance. [26:30]  Working with Optometrists There's a lot of uproar being seen right now with optometrists requesting and pushing for more and more ability to do procedures and things. In his experience working alongside optometrists throughout medical school up to his private practice, he thinks the majority have not been interested in getting involved in surgical intervention. He doesn't blame them because a lot of them actually went into optometry because they didn't want to be surgeons. They want their predictable lifestyle and hours and don't particularly want to go out of the scope of what they're comfortable with. "There's a push for some optometrists to have a piece of the surgical pie and I've seen mistakes made and I've seen things that were missed." Alex says he had seen mistakes made by optometrists. However, it has nothing to do with them being an optometrist, but it just had something to do with them not having years of surgical training and not actually knowing what you could be looking for, let alone, missing it. This makes him a bit nervous. It's scary for patients to walk in the door because half the time, they might not know who they're talking to and who's actually doing surgery on them. So for patient's safety, Alex believes it can be dangerous for optometrists to get involved surgically. [29:23] Major Changes in the Field of Cornea Surgery Particularly in the field of corneal transplantation, they used to take donor tissues and sew them into place. They hope that in the future, they will be able to take individual cells and replace just the damaged cells instead of the tissues. This is in the effort to have lower rejection rates, faster recovery, and better outcomes for the patients. Other things in the cornea sphere, specifically from the refractive side (getting better vision), technology is like lens and plans they put in during cataract as well as better techniques to do cataract surgery. Currently, they're doing laser cataract surgery. Lastly, Artificial Intelligence (AI) is already in Ophthalmology to help them make better clinical decisions. Finally, if he had to do it all over again, Alex says he would still do it. His advice to students who might be interested in this specialty, spend some time with enough ophthalmologists. "Anybody that wants any specialty always gets in eventually. I've never met anybody that really wanted something that just never got it. Whether it took more time or a different approach or using different tools, somehow they got there. So do not give up!" Links: MedEd Media Network ryan@medicalschoolhq.net

Session 06 What happens when you leave a comfortable school that fits you and feels like home, and transition to a large school where the premed culture is toxic? Meanwhile, check all our other podcasts on MedEd Media Network for more premed resources! [01:20] Caller of the Week: "I am premed, who studied at a community college. English is my second language and being in community college felt like home. There was not many premeds, no competition, cutthroat, or any of struggles that we go through for going to big university like where I am right now. At community college, I then struggled with comparing myself with others. I have a couple of premed friends. We always work together, help each other, and it felt like home. Right now, I transferred to a university and it's one of the biggest universities in the U.S. I started my first semester, this semester on campus. And it's been a great self-transition. As a Junior premed, there were many students compared to my community college. One of the biggest struggles is studying with other premeds and hearing them discussing their scores on exams, who got A and did not study as much, or those students who ask questions at lecturers and like, "I don't even know what you're talking about." It's been very tough. I know everyone struggles with different things but being surrounded by students who always get As, not really struggling, or at least, not showing that they're struggling. I spend hours on studying and trying to understand what's going on, especially as Englis is my second language. Sometimes, it's just hard to memorize a bunch of stuff in English. And sometimes, they need double the time that regular students who have been here and English is their first language, being easier on them but not me. I guess, I'm just trying to not compare myself to others. But being in this environment, it's much harder. Today, after my exams, I decided not to stick around and just go to my car. I didn't want to talk to anyone, neither before or after the exam. I didn't want to hear students saying I got an A's, I did not study. Oh this test was easy or that I wasn't ready. I didn't want to compare myself to them because I have my own struggles. I'm trying to overcome them. So I guess it's the premed world. Many people just say yeah, it's easy. But it's not really easy, especially if you're jumping from community college to a university. And it's a totally different environment. Almost everyone in my class is a premed. I know some of my classmates are struggling like me, while others find it easy. I don't know what else to do other than just walk away from those people or try to focus on me, my self-care, and trying to do my best. Because I know, probably the hours I'm spending learning this information, I'm actually learning for the long-term, not only for the test. And learning, from each struggle, something. Whether it's like how to study for a test or I should not leave all this stuff for the night before the test, or just learning from those trials and improving myself, while other people are not really learning from their struggle. I guess that's what's going on today." "Thank you so much for providing this collaborative environment. I listened to the first episode and it helped me a lot because I always feel stressed out and many of my family and friends are not really understanding what's going on, especially with the transition. It's not as easy as people might think. People shouldn't say that community college is much easier than a university. It's not. I study at a community college as well but I didn't really struggle with comparing myself to others. I struggled more on trying to understand and study the new material and new language and new environment." [07:17] Community College vs. Universities Switching from a community college to a university is really a hard transition. And when you feel like you have a family and you're comfortable and if you feel have friends and then you have to change to a big system where it feels scary and you don't have that collaboration anymore. It's really hard! It's nice to have that feeling of having a family in that community college as opposed to a cutthroat environment in large universities. Unfortunately, there's still that likelihood of competition. Don't care about people talking about how much they've studied and them sharing their grades. That can be bothersome. It just makes other people feel bad. Maybe people like to sit around and share about their grades because it gives them some kind of feeling of boosting themselves up. But it's a disservice to everyone. And who knows if people doing that are really honest. They might just be saying that, but the truth is they're insecure and they want to make themselves better than other people. So they say things that are not even true. "Sitting around and comparing your grades is just so not helpful. It makes everyone around just feel nervous and feel anxiety." In fact, we call these people "goners" because they tend to just talk about how easy it is and how great their scores are and the rest of us feel like we're wanting. So do whatever you can to just put blinders on or headphones. Do what you need to. Going to your car after the exams is a great idea because it keeps you focused on your path. [11:03] Don't Compare Yourself with Others It's so easy to get scared and bogged down. It's easy to compare yourself to other people. It's so human. But at the end of the day, just focus on what you need to do and you will be your best guide in terms of what you need. Then you can course-correct along the way. "Compare and compete with yourself. Don't worry about other people." Everyone has a different way of learning. Because we learn information from different pieces and we have different tools, what works for one person could be completely different from what works for another individual. That's why sharing your grades and how you studied would only breed competition and feelings of anxiety for everyone. [12:52] Thriving in a Competitive Environment It's really challenging to be going from a nurturing environment to one that does not. In this case, try to look for 1-2 classmates who share in your philosophy, who want to collaborate and not compete. See if you can have a study group. You don't have to necessarily study with them, but maybe just be able to sit across from one another. So each one is studying his or her own way and at their own pace, but just to have the company is great. It can be lonely to study for hours and hours and hours by yourself and to feel that isolation. So if you can find a friend or someone else who is on the same page as you. But it doesn't mean being with those talking about their scores and how they studied, as they're more into comparing than collaborating. [14:46] Community College is Hard! Just tune all that stuff out with regard to people saying community college is easy. People will just make statements about anything and everything. It's really, really hard to put blinders on all the time and just focus on what we need to do. "As human beings and as premeds. It's so hard to not get bogged down in other people's judgments and statements. Just try to tune it out as much as you can." Go to your car or do something nice for yourself that works for you. Keep listening to this podcast as well. Please do call in. The more of you that call in, the more people out there will feel that they have support. [16:25] Feedback on the First Caller Our caller today gave feedback on our first caller and she mentioned how other people in your life aren't just getting it. And so this is the avenue for all of you to be here for one another. And we are here to support you in whatever way possible. "If you're in the process, you really do get how very hard it is and how hard it is for other people outside the process to really understand at a deep level what you're going through." Hopefully, this community continues to serve you in this way. We're here to listen and support all of you! Call in your successes and failures with us, whatever that might be. Just call 1-833-MYDIARY. Leave a message for premed diaries by pressing 1. You have up to 30 minutes and if the call drops, just call us back and let us know. And if you'd like to leave feedback on a previous episode, just press 5 and let us know which episode you're calling in about. Links: MedEd Media Network

Session 04 Our caller today is sharing with us her triumph after getting into medical school. She actually dropped two posts. She called back after realizing she wasn't coherent with her first message. But we dearly loved it so we're playing both. Share your highs and lows with us! Please call in and share your experience. Call 1-833-MYDIARY. Press 1 if you want to leave an entry and 5 if you want to leave your feedback on a previous episode (make sure to tell us which episode you're calling about). Meanwhile, if you’re in need of other premed resources, please check out all podcasts on MedEd Media Network to help you along this premed journey! [01:40] Poster of the Week: I am going to medical school. I'm a nontraditional student who has been working at this for a couple of years. I guess I'm not that nontraditional, but I realized I wanted to be a physician super late. And I had to empty my savings account so that I could go to medical school. I'd have to take on four jobs. I've had to sacrifice so much. I was engaged and had my fiance break up with me during the middle of Biochemistry while studying for the MCAT. And I still did it. I still kicked butt. I still got everything I needed to. I interviewed a couple of weeks ago and I just received an acceptance call today. Honestly, I'm too happy... but I received my acceptance call today while I was at the dry cleaners and started crying hysterically because I've just been working on this for so long. And it's just been such a hard time. I just wanted to tell people, especially nontraditional students that you can do it and everything is worth this feeling. Everything is worth knowing that what you've been working for years has paid off and you're going to be a physician one day. [03:33] Congratulations! Congratulations! You don't have to be coherent. Obviously, you're so excited and overcome with joy. You've worked so hard to get to where you are and you've gotten acceptance to medical school. So enjoy that feeling! [04:42] Making It Through Hard Times It's so great how encouraging she is telling all of you that you can do it, nontrads especially. It's amazing, too, when she listed all the different things she's had to do to get that acceptance and how hard she's worked. It just goes to show the importance of keeping focused despite all the setbacks that are thrown your way during this process. She emptied her savings account, she talked about having four different jobs, and her fiance broke up with her during Biochemistry while studying for the MCAT. It's just really miserable. [06:00] An Unforgettable Feeling of Elation You will never forget that feeling. You will always have that memory of where you were being at the dry cleaners and getting that call about getting accepted to med school and crying hysterically. This is also something you might tell your kids. And others may find the same experience when you work so hard to get that acceptance, and when you do, that moment is just pure elation. Based on personal experience, I was studying at my parent's house and had been living there for the year. I was sitting upstairs to study and had no idea I might get acceptance through email. I thought it was a phone call or something in the snail mail. So the acceptance just popped into my email and I just started screaming. I was so happy that I started crying. The rest of my family were downstairs and they got so scared they thought something terrible had happened. As I came running down the stairs and told them about the news, we were all crying. "This is one of the first memories I have of truly having tears of joy." Indeed, getting accepted to medical school gives you a feeling of elation so keep that memory forever. [09:00] We Want to Hear From You, Highs or Lows! It's great to hear happy news. This podcast is really here to help you avoid and deal with burnout. We want you to call in and talk about the lowest lows - the hard, frustrating times that make you angry and upset. This place is intended to be a place for you to unload and just anonymously share that. On the other hand, this is also a place for you to be able to talk about the excitement and the wonderful moments. Don't feel like you have to wait to call in to talk about an acceptance. You can call in and talk about the excitement you feel when you have had a wonderful encounter with a patient when you're shadowing or when you got that first interview. Or maybe you had that great interview and you just want to share about that. Those moments are beautiful and wonderful. You should feel free to call. We would love to hear from you at any high or low points along this journey. Hopefully, this example will encourage all of you out there to also share whatever it is you want to share here. "This is what the diary is all about. It's not just to share all the sad things, it's there for you to share the good and the bad." [10:50] Give Us a Call No new feedback for today. But we encourage you all to send some feedback. Call 1-833-MYDIARY and hit 5 if you want to give feedback to previous episodes. And if you're out there and you would want to share your diary entry, please go ahead and share with us. We are here to support you in the premed journey! It's a vulnerable thing to do to call in and talk to an answering machine. So I hope that my comments here are a way of having somebody else talk to you. Again, call in the number and hit 1 to leave a message for premed diaries. [12:38] The Second Time Our Caller Left a Message I called earlier and I wasn't even coherent enough to tell my story. But I just received news that I have been accepted to medical school. And not just any medical school but my dream medical school. It is a feeling that I've never had before. I'm so happy and so excited which is why I'm not really coherent and can't speak English really well right now. But I'm a nontraditional student. I was on track to be a physical therapist when I decided that wasn't what I wanted. So I emptied my savings account and took on an extra job so that I could afford to pay for Organic Chemistry. And I'd finished up Organic I and II and Biochemistry and all that fun stuff. During that, I was engaged and my fiance broke up with me several weeks before I took the MCAT and several weeks before I had a Biochemistry class. That was one of the worst times of my life, if not the worst in my life. I even considered ending my life because I never thought I was going to make it. I never thought that I was going to be a physician. I thought I'd screw up my life totally. I was inside physical therapy school, I had this track going. I thought I was going to fail and that I was now alone without the love of my life. It's about one year since all of that was happening. It was all worth it to be here right now, to be in a place where I know I'm going to be a physician. And everything that I did, every hardship I had to face, all that was worth it because I'm going to be a physician. That's beyond what I put into words how happy I am, how surreal it feels. But all that was worth it. I hope that my story is something that could encourage somebody else out there who's going through so much harder. This is worth everything! Links: MedEd Media Network

Session 62 Dr. Brock Howell is a community-based joint replacement trained Orthopedic Surgeon. We dive in and talk about his path and what you need to know about joints. Brock has been out of Fellowship now for two and a half years. Also, be sure to check out all our other podcasts on MedEd Media Network. [02:00] Interest in Being a Joint Specialist Throughout his third year of clinical training, Brock had no clue as to what he wanted to do. Although he found himself in between medicine and surgery. He knew wanted to go into surgery, just not what exactly in surgery he wanted to do. What he gravitated him towards orthopedics is that it's very tangible when for instance, you see a broken bone. And then it gets fixed. As opposed to things in medicine or GI where you tinker a bit and still have to wait for a result. Hence, there is that sense of instant gratification. As to why he chose joint replacement surgery, he liked that it's not a small surgery so you get to walk away and look at an x-ray and be able to change someone's life. Plus, you can do it in an hour or less. It's not a scope procedure where you just look at the sutures. And seeing patients before and after the clinic makes him happy. [05:05] Traits that Lead to Being a Good Joint Replacement Doc Brock says you have to be comfortable around older population. In some instances, you have to be real patient when it comes to those kinds of your patients. They would usually try conservative therapy for a long period of time before the surgery. That said, you have to be willing to go in and just make things work. You have to be able to adlib and be comfortable at times. "Sometimes in the big revision surgery, you're not necessarily knowing what you're getting into and you just have to be comfortable getting into a giant mess and trying to figure a way to get your way out." Revision surgery is where patient has already had a joint replacement. But for whatever reason, the joint replacement has failed. It could be that it's gotten infected or that the parts have come loose. A lot of times, you have to go in and deal with something someone else has been before. You may also have to get implants out of the bone whether they're grown into the bone like most hip surgeries or whether cemented in place. So you have to get implants out and deal with extensive bone loss. You'd have to get new implants in and use different types of implants into your normal primary or first time having a joint replacement surgery. So this is a big surgery and this can be tough. "It's a big surgery. It can be tough. You can run into a lot of things real fast and you just have to think on your feet to get your way out." [07:33] Situations Patients Need a Replacement Patients who undergo joint replacement would usually have undergone arthritis in the joint, whether primary degenerative osteoarthritis or something post traumatic for whatever reason. Brock often tells patients that it's not heart disease or cancer so it's not going to kill them. If they didn't have a joint replacement, they're not going to die. So he really doesn't rush anybody into it. He sees no reason to push someone into the replacement if they're not ready for it. Most patients coming in complain that they're not able to do the activities they want to do. They can't walk anymore or play tennis. So he leaves it up to the patient to assess their quality of life and if they're not able to handle it, then they could have the surgery done. [08:45] Community versus Academic As to why he chose community versus academic, the major factor was proximity to his family. He's in his hometown that he grew up in and his wife's family is less than two hours away. Also, you're an employee in most university setting practices so he wanted more of the private practice model where he could control things more on a day to day basis. Brock also cites the difference in the private practice as a joint replacement surgeon. You'd do a lot of primary joint replacements. You'd also be doing revision surgery but majority of the cases consist of primary. A lot of times, academic joint replacement surgeons do a higher percentage of revision cases than they do primary cases. This is mostly due to the fact that they're paid differently than what a private practice surgeon would be. Plus, revision cases take more time. In some instances, he can get three primary surgeries done in the same amount of time it would take to do a big revision. And you're not going to be paid significantly more for a revision surgery than a primary surgery. "A lot of times, academic joint replacement surgeons do a higher percentage of revision cases than they do primary cases." [10:22] A Typical Day and Percentage of Surgeries Brock would usually get up between 5 and 5:30 am. He'd go to the hospital to round if there are any patients. Mondays and Tuesdays will be his office days, seeing between 25 and 35 patients in the morning. He will do elective cases even at the surgery center or he'll have time to do one or two joints on a Tuesday afternoon. Wednesdays would be his big surgery day. He'd do 5-6 total joints. And every other Wednesday, he'd take calls so he'd leave his Thursday mornings open to do call cases versus other elective or non-urgent trauma cases like ankle fractures. Fridays, he does an all-day session of office. Brock says he's dealing with joints in 60-70% of cases while the rest of it would be dealing with issues like knee pain. It doesn't necessarily end up in a joint replacement but it could end up in any scope. He'd also take a lot of call cases as well as carpal tunnel issues. So his main surgeries are joint replacement (70%), arthroscopy of the knee (5%), and the rest would be trauma cases. For joint replacement, most of the patients that show up in the office with arthritis end up with the joint replacement but it's just a matter of when. Some may want to do it immediately while others would try not to getting surgery done. So you'd be injecting them for two years before they finally decide to do a surgery. "Most patients show up with really significant arthritis and have surgery and so it's just a matter of when." [13:10] Work-Life Balance Brock says having a work-life balance. He is married to an optometrist that works part-time and they have three boys. Although a lot of times, it is tough. There are some busy weeks but most of the time, he has plenty of time to do everything he needs to do. [14:05] The Training Path to Become a Joint Specialist Most orthopedic surgeons do five years of residency followed by a Joint Replacement Fellowship which is another year, for a total of six years of postgraduate training after medical school. As to competitiveness, Brock describes it as being average. And that most who go through it usually matches but it just depends on where they match and whether it's high up on their list or not. If you're interested in getting into joint surgery, Brock recommends trying to get some research done and try to do as much as you can joint replacement-wise. More than anything, you have to figure out Fellowship as to where you want to match. "Fellowship is a game, trying to match where you want to match, trying to get into the residency you want to get." This said, see if there are connections in your residency program to certain places you want to go. All it takes is picking up the phone and calling in a buddy or your fellowship director or a program director and that could get you a spot. Again, do your research. Do well in all of the services you work on. Don't just focus only on joint nor be a bad resident when you're in trauma. Just be a great resident and do some research. Figure out a way to make the connection you need to make. [16:25] Working with DOs and Special Opportunities Brock says he has been around plenty of DOs that were great orthopedic surgeons. In fact, he knows some very prominent orthopedic surgeons in the joint replacement field that are DOs. Hence, it doesn't really matter to him. Although admittedly, there is some bias out there. And it's harder for DOs to sometimes into competitive fields of fellowships. At the same time, there are also some very friendly DO programs out there in orthopedics. Just get out there with anybody else and do well. So Brock says DOs should not be discouraged and just go for it. In the Fellowship he did, he had met some DOs that went through it as well. As other further subspecialties for joint replacement, Brock mentions the Joint Hip Preservation Fellowship. This gets you into the realm of doing hip sculpts or hip resurfacing. Some joint fellowships like WashU and University of Salt Lake City, Utah, they specialize in patients with hip dysplasia and other hip scopes. [19:00] Other Body Replacement Options Brock solely does hip and knee replacement but as far as joints that can get replaced include ankles, hips, knees, joint replacement in the spine, cervical discs, shoulders (three different types), elbows, wrists, and almost every joint out there can be replaced. [20:10] Working with Primary Care Doctors and Other Specialties What Brock wishes to tell primary care physicians out there is to not be afraid to treat the joint replacement patient conservatively. Moreover, understand that joint replacement patients can be totally normalized after joint replacements. No restrictions are needed and they could go back to doing whatever they can do and want to do. "Joint replacement isn't signing up for sedentary lifestyle for the rest of your life." Brock's practice is built up mainly of general orthopedic surgeons but usually they deal with a large amount of trauma they do at their facility. So he deals a lot with the anesthesiologists and general surgery trauma doctors. [22:10] Special Opportunities Outside of Clinical Medicine Being a joint specialist, there's a plethora of different companies to use and each company has different implants to use. They're always looking for joint surgeons who deal with a lot of joints and have a lot of experience doing joints to help them design better implants and design better instruments to put the implants in with. Or help and teach surgeons who may not have done joint replacement fellowship as to how to use their products better and what opportunities the products present to patients. "There are a lot of design and teaching opportunities available in joint replacement surgery." [23:06] What He Wished He Knew that He Knows Now He wished he knew that not everybody does great. Even with the best of intentions, you can go in and do a joint replacement surgery and for whatever reason, a patient may not be happy with it. There are some studies done that show characteristics in patients that they won't do well after joint replacement surgery no matter what. There are a couple of studies done like if you look at the patient's allergy list and the higher number of allergies the patient listed, lower patient satisfaction scores and other scores post-surgery.  Another study done where they put a blood pressure cuff on a patient's arm and it would blow up to 200 mmHG and have the patient rate their pain on a scale of 1-10. The patients who recorded higher pain with blood pressure cuff on actually had some of the poor outcomes after surgery. [24:50] The Most and Least Liked Things and Major Changes in the Field Brock likes the immediate gratification he gets before and after surgery. He finds it awesome to see someone with a horrible arthritic joint do their surgery and they can already walk 500 feet the next day. On the flip side, what he likes the least about joint replacement surgery is some of the situations where patients are in a bad way. Whether the patient has a chronic joint infection you can't get rid of or when they're coming to you. Or they may have the perfect x-ray and they tell you everything but no matter what you do. It's just difficult to track some of the puzzles and figure out why are some of the patients are hurting and whether it's legitimate or not can be a struggle. As to the major changes coming in the field of joint replacement, Brock mentions two things - 3D printing and robotic surgery. They use 3D printing to print on the back of the implant's actual bone that improves the quality of ingrowth. They also started designing custom implants that are shaped just like an individual patient's shape instead of a one-size-or-shape-fits-all implant. On the other hand, robotic surgery is starting to push towards the front. You can get a scan of the patient's affected joints and then plant a surgery ahead of time. Then get into surgery and take the knee or hip through a range of motion, stressing it and making adjustments to your plan before you make a single bone cut. A robotic arm attached to it will guide you and make sure you make the bone cuts exactly how you planned it before surgery. This makes sure everything is as precise as possible. This system is also used for total hips and partial knee replacement. Brock describes how it's such an exciting technology. "It's all in the name of hopefully a better outcome for the patients." Ultimately, if he had to do it all over again, Brock admits he asks this question all the time. There are days he would probably have done it again. And there are other days he did his best and the patient is not happy with their joint, and it's a tough day. So you just have to take the good with the bad. Nonetheless, he would still have chosen joint replacement surgery. [29:11] Final Words of Wisdom for Medical Students and Residents Finally, he wishes to tell medical students who may be interested in joint replacement is to make sure you try everything. But if you really have your heart set on something early, try to get involved in that specialty whatever it is. Try to do as well as you can on Step 1 and just get involved in what you're interested in because that's going to help you always when you're trying to get into residency. As far as residents go, try to do well in all your rotations. Ask anybody for a letter and then try to figure out where you want to go and what type of fellowship you want to do. You may want to go to a fellowship where you watch another surgeon operate for a year or where you do all the operating for a year. Or something in between. See if there are any connections to those programs and start working on those connections. "Start working on those connections." 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 43 Dr. Venkat Gangadharan is a community based Interventional Cardiologist. We discuss his interests in cardiology and his thoughts about the specialty. He also gives his opinions on the latest changes in our healthcare system regarding reimbursement cuts as well as turf wars between specialties. Also, check out all our other podcasts on the MedEd Media Network, including The Premed Years Podcast, The MCAT Podcast, The OldPreMeds Podcast, and The Short Coat Podcast. [01:08] Interest in Cardiology Knowing he wanted to be a cardiologist right on his second year of medical school, Venkat did what he could to figure out. By the time got into residency, his mind changed and considered things like pulmonary critical care or cardiology. Then he got the chance what the cath lab was like and got to see what they do when they treat heart attacks. And he got sold right then. He's the type of guys that likes instant gratification in terms of treating patients. He wants to see them get better right then and there. So he found doing cardiology and interventional cardiology was the way to go. He knew he wanted to do interventional cardiology by his second year of cardiology fellowship. He recalls applying everywhere across the U.S. He thinks it was the toughest thing being one of the several thousands trying to get the same position. He has interviewed in at least ten different places. It was so difficult for him that he finally ended up matching in a program at the last minute. He decided to take it and to him it was the greatest decision ever. "No matter how competitive you are, you're one among several thousands that are trying to get the same position." What he really likes about cardiology is the physiology behind it. Plus, it required some amount of critical thinking and problem solving. But at the end of the day, there were define medications for certain purposes. There are risk factors you know you could treat. And the problems had definitive treatment modality and cure to some extent. Basically, he's fascinated by how the heart works. [04:40] Traits that Lead to Becoming a Good Interventional Cardiologist Venkat cites some traits in order for one to become a good interventional cardiologist such as being dedicated and hardworking. You need to be analytical and be able to think on your feet. In the cath lab and you have a patient's life in your hands, there are probably a million different decisions running through your head. With so many things running through your head, you just have to choose the right one and make sure the patient gets through it no matter what. With heart attacks, for example, the chance of people dying from it is so low nowadays. Everybody has got a chance. Compared to back in the days during the infancy stage of interventional cardiology, there were no facilities to treat people. There was no place to send them. “With the technology we have, there's not one person in the country that should not have the chance to live at the hands of a cardiologist.” That said, you have to be able to think outside the box. You have to be analytical and mechanical. Venkat explains that interventional cardiology is all about physics and the give and go. Additionally, having that adrenaline junkie kind of mentality is an edge. When you're taking an emergency call, you will have to wake up in the middle of the night to have of your faculties all ready to go. Drive to the hospital. Then have all of your fingers ready to go to and adept to put a stent or fix a blood vessel to fix a person's life. You need to love the rush for you to be able to mental faculties to take care of that problem in the wee hours of the night. [07:22] Private Practice versus Academic Setting Venkat explains the reason he chose private practice was being the easiest choice at that time. There are far more private practice physicians at that time than there are academic positions. Second, you have to have a certain mentality and persona to be an academic interventional cardiologist compared to a private practice physician. "I wouldn't say it's money driven per se, but I would say it plays a huge role in the decisions you make when it comes to the job you pick." As a private practice physician, you have the ability to dictate your own life as well as the ability to treat your own patients. You have the ability to learn things at your own speed without having to answer to anyone else but your own practice. These were what Venkat was looking for. [09:07] Types of Patients and  Typical Day in His Life As an interventional cardiologist, Venkat sees everything from valvular heart disease to atherosclerotic vascular diseases. It's truly mind boggling that the amount of coronary disease that is out there and how young a person can be by the time they get affected. Venkat finds it humbling to be doing intervention in a 34-year-old when you're the same age as he is and living the same kind of life he is. For him, this is eye-opening and it makes you realize how life is short and you need to take good care of yourself. So when he things sees on the screen, it makes him think twice. It's surprising to see how bad people's arteries could be at such a young age. As a private practice physician, Venkat says it's tough being just an interventional cardiologist. So he also practices a lot of general cardiology and interventional cardiology, But his mind is always focused on what he can do to fix something. He gets to the hospital around 6 or 6:30 in the morning and do some rounds. If anyone comes in with a heart attack or he's on call, he drops whatever he's doing and go and save that life. Then he goes to the office or clinic and trying to recruit patients to your practice so you can maintain a lifestyle and a career. "It's very rare in private practice to find a position where you just do interventional cardiology." You have to be ready to handle any situation presented to you. Venkat takes emergency calls about three to four times a week. Being a young doctor, his practice is made up of only two interventional cardiologists. He usually gets a call about three times a week. But not all private practice is like this. The larger the private practice, the less call that you're going to take. From a general cardiology perspective, he takes calls once a week and he does one week in the month. Initially, when he started out, it was pretty rough not realizing it was this much work. But Venkat explains that you will get used to it. [12:21] Work-Life Balance Venkat thinks having that work life balance is a million dollar question. Over the past three years, he had thought about what life was like outside of his work and the balance he had between work and his home life. He has a two-year-old son who misses him all day long. There are plenty of days he'd feel bad about coming home late or working as much as he does. But at the end of the day, being a young physician and knowing this is your career, this is the time to make a living. This is the time to earn for your family. After which, you can decide what's going to work for you and where you want to spend your time more. [13:33] The Path to Interventional Cardiology Residency and Fellowship Training Once out of medical school, you decide to make an internal medicine residency. When he was applying, he looked for decent cardiology fellowship knowing it was what he was going to do. The likelihood of you getting into the cardiology fellowship at the residency program you trained at is better than one than you'd get at another place. This is followed by another three years of cardiology fellowship. At this time, you're introduced to cardiac catheterization and different aspects of interventional cardiology. Also around the second year, you also make the decision if you want to become one and start applying to interventional cardiology fellowships. The difference between interventional cardiology fellowship applications and the general cardiology fellowship applications is that many of those programs are paper applications. This means you have to seek them out. Find out what their application process is. Do every step you can and apply. Then follow up several times if they've received your application. "Try to hone in on the programs that you really want to be a part of." Things they would usually look at are your degrees of research you've done during fellowship, your progress in testing during fellowship and training, and where you trained which goes a long way. As to why he thinks matching into interventional cardiology is so competitive, Venkat believes it's one of the more rewarding cardiology fellowships. The number one killer of people in the world is heart attacks. And interventional cardiology is essentially designed to treat those. So the amount of people applying to be an interventional cardiologist are far more than the people applying to be an electrophysiologist or a nuclear cardiologist. And for electrophysiology in particular, the testing is very difficult. It requires someone to be very cerebral and a mentalist to handle that kind of profession. [16:18] Bias towards DOs, Subspecialty Opportunities, and Turf Wars Venkat actually has not seen any bias towards DOs. In his own practice, he has a partner who is a DO. He took a very long way to become what he is today. But he's a successful interventional cardiologist. "At the end of the day, the MD and the DO designation is just a designation. The person you are is the physician that you are." Venkat adds that you can be an MD and be an awesome physician. You can be a DO, and still be an awesome physician. He really doesn't think this has any weight in terms of whether you have a chance of being an interventional cardiologist or not. It's about what you do with the time you spend and the training you spend that makes who you are. In terms of subspecialty opportunities after interventional cardiology, Venkat explains there is a new development in structural heart disease. In the country, there's only a handful of programs that are accredited structural heart disease fellowships. The ACC and the AVIM have yet to recognize a designated fellowship for this. Coronary heart disease is not the only thing that plagues people, Peripheral vascular disease is also what plagues people. So there are specialized fellowships to do a training in endovascular work. Venkat explains that as interventional cardiologists, they're actually an interventional cardiovascular physician. So the vascular aspect of things is largely untapped and majority of that training can be obtained after a fellowship. Venkat also admits having turf wars brewing between cardiovascular and vascular surgery. When it comes to peripheral vascular disease, it's a turf war between a vascular surgeon, an interventional cardiologist, and an interventional radiologist. He adds there are programs out there with long, trusted interventional radiologist to do the procedure or long, trusted vascular surgeon to do the procedure. As interventional cardiologists, they are making the push to take that on themselves. "The breadth of peripheral vascular disease is so poignant in this country. There's opportunities everywhere." But Venkat says that you won't see many private practice interventional radiologist or private practice vascular surgeons doing a lot of endovascular work. Majority of them have some sort of academic affiliation. You will see a lot of private practice interventional cardiologist doing all of that work. [20:10] Working with Primary Care and Other Specialities Venkat wished primary care physicians knew the breadth of disease they see and the complicated nature of disease present in their patients. He really wished they would understand the medications they use to treat these conditions. Unfortunately, Venkat lives in a place where managed care is a strong push in the area. By this. primary care physicians are limited in the medications they can offer their patients. Many of them end up changing the medication he places his patients on. Or they deny the stress test or deny the arterial ultrasound the patient needs to gather some more information for their complaints. It actually blew his mind when he first got there. But that was the reality. And in the three years there now, he still couldn't grasp the idea where primary care physicians are literally dictate a patient's life regardless of the symptoms the have. "I still couldn't grasp this idea where primary care physicians are literally dictate a patient's life regardless of the symptoms the have." Venkat describes it's like the patient has to show up in the hospital to get the real care they deserve. They go to their primary care physician because six times out of ten, they're going to get denied. This is saddening. Venkat says he had to rescue people at death's door when they could have been rescued two years earlier. Other specialties he works the closest with include pulmonary and critical care, infectious disease, and nephrology. [23:28] Special Opportunities Outside Clinical Medicine Venkat explains that the more senior you become as an interventional cardiologist or cardiologist even, the opportunities outside of medicine start to open up. When you're a part of a large hospital system and you have a good relationship with the hospital administration, most of those avenues are open for you. One of his partners is the chief of internal medicine in the hospital as well as the chief of cardiology at the hospital. It's a rotating door when it comes to that position. "Cardiologists are often taken in high regard because we have our fingers in every aspect of things." Other cardiologists have also migrated to other industries. His mentor has left interventional cardiology practice of 45 years and is now engulfed in an industry that promotes one of the products he helped design and bring to market. So you have the opportunity to migrate over to an industry and be a speaker and teach the world about what you do. [24:55] What He Wished He Knew and What He Likes the Most and Least Now knowing what the process is like to get better framed in what he does, he wished he probably should have sought out an extra fellowship at the end of his one year of interventional cardiology. Had he known the amount of opportunities out there, he probably would have given it a better shot. Secondly, although a private practice physician, he wished he had given academic interventional cardiology a strong push at the time he was making the decision for a job. He never knew it was this busy. But he's a young guy so he's pushing through it. What he likes the most about being an interventional cardiologist is doing procedures. He loves working with his hands. He loves the adrenaline rush of fixing a heart attack. For him, waking up at 2 am is not difficult. If he could save a life and they'd walk out the door the next day, alive, he feels he has done his job for the day. "To me, the procedural aspect of this whole profession is what makes the best thing everyday." What he likes the least, on the other hand, is the bureaucratic aspect of it. Running a private practice or trying to develop a career as a private practice physician is very difficult. Unless you have the business know-how or the business acumen, it's difficult to make yourself well-known in the community that has several people just like you. But it does teach you what the business of medicine is like. "One of the things we lack as residents and fellows is that nobody ever told you what the business of medicine is like." Reality is that everything costs money. Everything you do, you need to earn something from it. And you need to be happy doing what you do in a day in and day out basis. So you need to find a place that gives you the opportunity to grow as a physician. But it should also give you the security that you know this job is going to keep you happy for years to come. [28:00] Major Changes Coming in the Field One of the major changes that is likely coming over the next year or two is that CMS is bundling payments when it comes to cardiac procedures and cardiac diagnosis. For instance, myocardial infarction which used to be differentiated in terms of medications and procedures are now going to be bundled under one big heading called myocardial infarction. So the payment you're going to get is going to be far less than what you've gotten in the past. Over the last five years, Venkat explains how the field has been largely affected by the reimbursement and the cut in reimbursement. They've lost almost 40%-50% of what the normal reimbursement would be for a regular procedure. So it's not becoming more cutthroat in their field to do more work, find more patients, and treat more disease since you're not making as much as you used to. This is going to get worse as time goes on, Venkat suspects. Eventually, private practice is likely going to dissipate depending on where you live and hospital-employed physicians and hospital-employed practices are going to predominate in this country. The reason for this is because hospitals are able to negotiate their deals with insurance companies and pharmaceutical companies than a private practice will. So if you want to make a decent living, you might end up becoming a hospital-employed physician.As for Venkat, he's holding up for as long as he could but he's aware that it's just around the corner. "Hospital-employed physicians and hospital-employed practices are going to predominate in this country." [30:40] Reduction in Reimbursements CMS stands for Center for Medicare and Medicaid Services. Venkat personally thinks it doesn't make sense to reduce the reimbursement. At the end of the day, these procedures are being done by physicians who are taking the time out of their night to stay awake in order to save a person's life. The procedures continue to stay arduous. They don't get any easier. Although there's technology available to treat these conditions, these procedures don't happen in 30 minutes. It takes an hour or as long as four hours. So the work, stress, and the difficulty of your general lifestyle continue to exist and never change. Hence, reducing the reimbursement for these procedures is fostering an idea that medical management is better than risking your own life trying to do something. Venkat has seen a lot of his partners who were interventional cardiologists 30 years back when things were great. It changed the way they practice based on the reimbursement they're getting. He raises this question that, "why would you go and try to do something whether to save a person's life or to be good at what you do, when the government and insurance companies don't feel like it's necessary and don't feel like you should get paid for it?" Venkat thinks this kind of mentality is coming out a lot in newer graduates. The older generation is also catching up to it and realizing they can't make as much as they used to. So it's throwing a big stress in many of these private practice groups. "The idea of newer graduates to think that they're going to get paid like they did 30 years ago, it's never going to happen." Venkat's advice to the younger generation is that if you want to be an interventional cardiologist, you're doing it because you love what you do. Don't do it for the money because it's happening everywhere. [33:22] Final Words of Wisdom If he had to do it all over again, Venkat admits he would still have chosen interventional cardiology - 120%. For students thinking about becoming an interventional cardiologist, Venkat explains that cardiology is a specialty that is going to continue to grow. It will continue to become the most prevalent disease in this entire world. If your heart is in cardiology and you truly believe that you want to help people and the adrenaline rush is what you live for, interventional cardiology is the way to go. You're going to love working with your hands. You're going to love the equipment they use. And it's only getting better. You can do things with heart arteries that people couldn't even fathom 30 years ago. The things your'e going to be doing is just unimaginable. Research keeps happening and happening. So if you love cardiology and you love what you do and you live for excitement, you're not going to be disappointed. [35:02] Last Thoughts Venkat is the first cardiologist on this podcast. I hope to bring you many other subspecialties within cardiology so you can get a great picture of what cardiology looks like for you, possibly in the future. Our goal is to find all these different specialties and talk to them and find out what their job is like. So as you're going through your training, you get a better picture of what life for you will look like. You will hear what physicians like about their specialties and what they don't like about it. This will help guide you on your journey to choosing your specialty. Links: MedEd Media Network

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

Session 34 Dr. Sushil Duddempudi is a community-based Gastroenterologist who specializes in interventional endoscopy. He has been in practice for ten years now and specifically as an interventional endoscopist for the last seven or eight years. He used to be in academic hybrid private practice. Check out what he thinks about the field and what you should be doing if you're interested in this field. Also check out all our other podcasts on MedEd Media Network. [01:45] An Interest in GI and Interventional Endoscopy Dr. Sushil Duddempudi knew early on that he was going to be in a procedure-based field. It's a running joke in the field that GI people aren't smart enough to do anything else so they use procedures as much as they can. Then leave the complex stuff to the nephrologists, neurologists, and everybody else. Sushil started residency leaning towards cardiology until realizing he hated EKGs. So he gravitated towards the GI field. He says it's not uncommon for students somewhere during their intern year where they're interested in one area. Once he started the GI fellowship, he knew he was into doing procedures. He found interventional endoscopy as a good fit for him because it lets him do procedures most of the time. But he still has this continuity with his patients which he loves. So about two-thirds to three-quarters of his time is spent doing procedures. Then maybe a quarter to a third is spent in the office seeing patients. "GI is a pretty cut and dry field compared to some of the other fields." Sushil describes they usually have a definitive diagnosis early on after seeing a patient and he likes the finality of it. GI borders that surgical mindset and a lot of GI's have mindset.They see a problem and they want to take care of it. Also with GI, there is finality. If the patient has rectal bleeding and you had a colonoscopy then you'd have an answer 99% of the time. When patients have abdominal pain unless it's functional, most of the time, they come up with an answer. Moreover, Sushil likes the opportunity to do procedures. Other specialties he did consider include ENT or Neurology which would have probably worked for him as well or one of the subspecialties that are procedure-based. Ultimately, he ended up in GI. [04:40] Traits that Lead to Being a Good Interventional Endoscopist Sushil describes how many of those starting GI fellowship often say they want to do interventional endoscopy. Then over their first year or two, they'll select out. "You have to enjoy doing procedures." Some fellows he has worked with and trained over the years come in with a certain special knack. Some people just have good eye-hand coordination better than others. 90% of it can be taught and trained. But the people they look up to in the field are born with a little bit of it. This is what Sushil differentiates them from the rest. They are the guys doing the hard core cutting edge stuff. So it's a bit of something you bring within you into the fellowship and then 90% of it is just practice. [06:15] Patient Types and Typical Day If you're an academic interventionalist, you can tailor your practice to focus on that. This could mean 75% of your practice doing procedures. Community-based interventionalist flip it all the way around. In gastroenterology, the bread and butter is still colonoscopy. If you're a community-based interventional endoscopist, you could be doing around 25-75% general and then the remainder is advanced interventional endoscopy. Then as you get older and you've done all the cutting edge stuff and you want to settle in a little bit, you can then focus on general gastroenterology. Then you can do the interventional stuff maybe 25% of the time. For general GI, the younger groups tend to come in with more functional disorders and abdominal pains. As they get older into their 50's, they start to do a lot of colonoscopy screenings. Also in the 50's and 60's, they start to see a lot of GI cancers. "Interventional endoscopy is very focused on GI cancer. That's where a lot of the techniques are being used." For general gastroenterologists, most of them will do roughly about a half day in the morning. They start at around 7 or 8 to about 12 or 1pm doing endoscopy. Generally, you are in an outpatient surgery center. Then the afternoons would be spent in the clinic. Sushil says that more and more gastroenterologists are coming out of the hospitals and staying in their office in surgery centers. Moreover, a new breed of GI hospitalists are starting to happen where you're focusing on inpatient training. This happens less in the big cities. But generally it's a mix of outpatient procedures an outpatient office visits which is 90% of what gastroenterologists do. While the other 10% would be composed of inpatient. If you're an interventional endoscopist, you'll me a little more focused on the in patients because that's where a lot of the work comes in. This involves cases like bile duct construction, GI tract tumors, etc. Although they see this in the office, a lot of work comes in the emergency room. In Sushil's practice, the way they do it in the group is that most time is spent in the hospital early on. Then after two years, you will transition out to the outpatient side. So the new guys coming in cover all the hospital work. Then the partners are just focused on the outpatient work. "Like many practices, it transitions over time based on your interests, time constraints, the type of practice you have." [10:56] Work-Life Balance Sushil didn't actually feel he had any work-life balance. But he would say that in general, interventional endoscopists are in the hospital the latest. "It's definitely a field that you're committing extended hours compared to general GI guys." This is because more of your work comes in in the inpatient setting which is always unpredictable. Your day could be extended. And the procedures you do tend to be a little longer . They are a bit less predictable than a colonoscopy or endoscopy which you can do in fifteen-minute blocks. Interventional endoscopy procedures are a bit harder to put into certain blocks. [12:30] The Path to Residency and Fellowship For interventional GI, sometimes called advanced endoscopy, you do your three-year medicine residency. Then you do three years of general GI fellowship. And then there is another year of sub-fellowship. This has actually has crept up in the last five to ten years. Currently, there is only one ACG-accredited post GI fellowship that is liver transplant. And there are are five non accredited which include interventional endoscopy, clinical hepatology, motility, inflammatory bowel disease. Interventional endoscopy is the most popular. Just a year or two ago, interventional endoscopy actually went into a formal match process. Previously, you just apply to all the programs in the country and you get interviewed, you get offers and pick one. Now, it's a formal match process. It's also expected that in the next couple of years, it will be a fully accredited ACGME fellowship just like interventional cardiology. If you didn't do the special training, you wouldn't be able to do certain procedures in GI. Currently, a lot of the older generation gastroenterologists still do ERCPs. Most of the younger people don't because they did numbers of them on their training of all GI fellows. So once it comes to full fellowship and board certification, it's expected that new trainees, if they don't do the actual training, won't be allowed to be allowed to do ERCP, EUS, and stents, and other interventional procedures. Interventional GI fellowships are pretty competitive as Sushil describes it. GI and cardiology balance it back and forth when it comes to post-medicine fellowships. "GI, number-wise, is the most competitive fellowship." When Sushil applied eight years ago, there were only about 30 program in the country. Now, it's close up to 75 with about 35,400 GI fellows graduating a year. So he reckons only 25% apply for the advanced interventional training. Although he wouldn't describe it as ultra-competitive but the majority of fellows he had trained that wanted to get it got in. Some may have to wait a year. But most fellows interested, eager, and did the right electives and the right types of research, got in. Sushil says you have to be focused and you need to take the right steps. Then there's a pretty good chance you're able to get into a spot. [16:37] What Makes a Competitive Applicant Sushil cites some qualities of a competitive applicant. He adds most interventional endoscopy directors look for people that have that extra knack (eye-hand coordination). Some of the hard skills are hard to train in one year. You need fellows that already have some experience. Moreover, you are gauged through letters from your program director and the number of procedures done during your general GI training. He adds it's important to consider who you want to hang out with for the whole year. "Unlike other fellowships, interventional fellowship is a one-fellow-a-year at any program." So it's basically just you and you're generally working with one to three core interventional endoscopy faculty. So you're spending a lot of time with just a couple of people. Compared to general GI training, you're rotating around different hospitals and different services. So you work with a number of faculty. This is different from interventional endoscopy training since you're only focused with one person or two. So who do you want to hang out with for a year? Lastly, be nice to them on your interviews. [18:30] Bias Against DOs and Working with Primary Care and Other Specialties Sushil had the opportunity to train alongside DO's throughout his career. There have been some who were awesome while there have been some who weren't so good. This is also true for MDs and just with any other specialty out there. But in terms of inherent institutional bias against DO's from the program directors, he doesn't think there is any. They don't look at it one way or another if a resident DO has gotten into general GI fellowship or interventional endoscopy. He adds that once you got to that level, you're met a lot of floors already. So he really doesn't think it's as relevant. Looking at interventional endoscopy fellows across the country, Sushil estimates that at least a third of them or maybe more are foreign grads. In terms of working with primary care physicians, Sushil explains how fellows complain all the time about nonsense or bogus consults. But because he thinks his career has been mostly private or quasi-private settings, his view has changed. "If a primary care or hospitalist called me, what I know and what they know are two different things." While he may see it as a simple question and answer and it's going to take him two seconds, they may see it as something more complicated. If you'd ask Sushil the protocols or the GNC7 or up to 9 in primary care, he would have a tough time treating hypertension diabetes. That's because he hasn't done it so long. Hence, he looks at it as something they don't do very often. They have a question. They need some help. So if a primary care physician has a question, the best thing to do is just call your local GI guy. Mostly, GI guys are laid back and not too uptight. His referral networks all have his number so they can always reach out to him whenever needed. As a specialist especially in GI (maybe more so in other fields), Sushil explains they're here to provide a service for them. They're here to do procedures and solve problems primary care physicians don't have the tools to solve. So when they call, help them out. Other specialties he works with the most are general GIs and surgeons for interventional endoscopy. They work a lot with specialty surgeons like biliary and colorectal as well as interventional radiologists. Things they can't take care of generally go to surgery. "That's where interventional GI has found its niche. It's at the interface between medicine and surgery." They don't cut on the surface or on the skin but they do almost all of their cutting inside. Sushil describes it as the next evolution from open surgery to laparoscopic to robotic. Now there's a new thing called NOTES (Natural Orifice Trans Endoscopic Surgery). They're doing surgical procedures through natural orifices. As a result, there is less incision time, and less recovery time. They're still trying to figure out where the interface is going to be. Whether it's surgeons doing these procedures or interventional GI guys or a radicalization of medicine surgery that are going to end up being guys that do these types of procedures. [23:57] The Most and Least Liked About His Specialty What Sushil knows now that he wished he knew back then is that anybody on their feet a lot for doing procedures have got to have very comfortable shoes. He wished he had bought a quality pair of shoes right after training. He went from one brand to another until just back to regular sneakers. What he likes the most about being an interventional endoscopist are procedures. He loves doing it. He loves the definitive nature of it. He likes that a patient comes in with a certain specific issue. And he's able to solve that issue most of the time. He likes to be able to give them definitive answer. What he likes the least is being oftentimes the first person to inform someone that they have cancer since they deal with a lot of GI oncology. Sushil explains it's very rare that an oncologist has to give someone a cancer diagnosis. Usually by the time they're going to an oncologist, diagnosis has been made. Unfortunately, they get a lot of referrals for lumps and bumps on a CT scan and they're the first one to have to break the news to the patient that they have cancer. No matter how many times he has done it, he feels terrible every time. Colon cancers are pretty terrible but a lot of stuff they do in interventional endoscopy is pancreatic, liver, and gallbladder cancers which are generally not so treatable. [27:00] New Changes in the Field of Interventional Endoscopy Sushil sees the field as having this continuous evolution. If you went in for a colonoscopy for whatever the reason and they found a four-centimeter polyp, they'd stop the procedure. They'd work the patient up. They'd give them a referral to go to see a colorectal surgeon. About ten to fifteen years ago, that changed. Gastroenterologists started doing advanced training, becoming interventional endoscopists. They started doing removing those polyps out themselves. It's relatively rare that a non-cancerous polyp in the colon is sent for surgical resection. It's relatively rare nowadays for a procedure called a PTC to be done. This was a procedure done routinely after cholecystectomy. The procedures they're starting to do now are coaching more and more on the surgical fields. Patients often went for surgery before for a lot of GI polyps and tumors, etc. A lot of that is now done more being minimally invasive that's being done by laparoscopic surgeons. But even more minimally invasive than that is where a GI guy comes in. "We're continually moving into this more and more non-invasive type procedures." A their technology is getting smaller and smaller, they're able to go into areas that thy were never able to go in before. Lastly, if he had to do it all over again, he still would have chosen the same thing. He enjoys GI and interventional endoscopy. He finds that it has the right blend of procedures but a little bit of continuity on the clinic side. He finds it as a good fit for him and what he enjoys. He doesn't think there's only one field a physician could go into but multiple fields. He thinks that people who enjoy the cerebral aspect of certain fields have a couple of different fields that would work for them. The same goes for those people that enjoy procedures. But all in all, Sushil has not complaints about the field he went into. [29:40] Final Words of Wisdom To those interested in going down this path, Sushil says it is never too early to start prepping your CV to get into GI. Consider that it's harder to get into GI given the numbers that is interventional endoscopy. When you start as an intern, go by the GI lab. Let the faculty know you're interested. Get involved. Get involved in research projects. They're not going to let an intern do that much. But there's always a need for someone to collect data, to collate data, to run statistics, to write papers. Get involved early on so that by the time you're second or third year role is around, you're seen as a junior fellow. You're part of the GI team. You're a resident but you're always hanging around the GI lab at any free time you have. "It is never too early to start prepping your CV to get into GI." Then when you move on to interventional endoscopy, the same thing. Go hang out with the interventional guys. Work on the papers with them. Come up with research proposals. Work on research projects, new ideas, new techniques. Be a junior interventional fellow. Links: MedEd Media Network

Session 32 Dr. Russell Babbitt is a Plastic Surgeon in private practice for the last seven years. He took the time to share with us his thoughts on what he likes and what he doesn't like about it and what you, as a premed or medical student, should start doing now to become a better applicant for Plastic Surgery. [01:18] His Love of Plastics Around that time when the show ER was popular, Russell started medical school thinking he wanted to do Emergency Medicine but realized it wasn't for him. Instead, he liked doing surgical rotation along with his plastic surgery rotation which he describes as gelling very well. He also started college as an art major so the visual-spatial aspects really appealed to him once he got into plastics because it wasn't just a cookbook, do-this-do-that case but it involves applying spatial problems to different situations which appealed to him. The second he got onto his plastic rotation, he knew it was where he needed to be. Russell went to UMass for medical school and during their third year surgery rotations, they had a three-month block spent on general surgery and the other half was subdivided into other subspecialties. Many of them ended up rotating through plastics. Other specialties he did consider include general surgery and vascular surgery. He likes the disease processes in general and being able to intervene into a lot of different illnesses and have the ability to take care of sick people across the board. Ultimately, he was meaning to be a well-rounded surgeon and the fact that plastics builds on that was nice. [04:30] Traits Leading to Becoming a Good Plastic Surgeon Russell cites meticulousness as the primary trait of becoming a good plastic surgeon as well as being a good visual-spatial thinker. Being a good communicator is also very important since. You need to be willing to sit down with the patient and explain the disease process, the problems, the solutions, how you're going to get there, oftentimes, there are many ways to get there and there's many different things that can happen. Russell further explains that the doctors who don't communicate tend to have more difficulties regardless of what the outcomes are and this is especially true in plastics. Beyond that, you also have to be a good technician and be able to develop a plan, know what you're going to do, and see the technical problem you're going to solve and actually execute it. Also, you must be able to see the long term outcome, not just the proper three-dimensional result but it has to look good three to four months and years down the road. Blood supply also has to be intact at the end of the day. One of his mentors once told him that when he's out in private practice, one of the things he has to do is while doing a skin graft, you have to make sure every mitochondria survives. "You have to just be really meticulous in every single thing that you do and that people are watching and the patients are watching. That's one of the things people look for in a plastic surgeon." Russell adds that another innate trait in a plastic surgeon is being anal. In terms of having an arts background, although not necessary when you become a plastic surgeon, a lot of people that go into medicine in general tend to be very agile-thinkers so Russell thinks a lot of it can be taught. But he personally thinks it helps a lot in terms of little shortcuts that allows him to know what to do before he even thinks about it. This may also help in certain other areas where it would have been hard to to teach it. [09:00] Types of Patients and Typical Day Russell sees a mix of 50% cosmetic and 50% reconstructive patients. To his surprise, he's doing a lot of breast reconstruction. They have a very busy breast reconstructive program where he's the director at a local hospital. This was something he didn't expect to be doing a lot but he ended up doing it anyway. The reason for breast reconstruction is almost always breast cancer in various stages or it may be due to genetic predisposition where the patient has a high risk of developing breast cancer in the future or maybe that the patient has an active diagnosis of breast cancer or very late stage precancerous lesions which would require mastectomy and therefore they would then need Russell to reconstruct the breast. He describes it as a very intense process and oftentimes, he is the one the patient sees the most of throughout the process. They see them after surgery and on a weekly basis to fill tissue expander that expands the breast's skin envelop after radiation and mastectomy. Nevertheless, Russell sees this as a nice aspect of what they do. Another thing they commonly do is reconstruction after skin cancer resections with dermatologists which can sometimes be very large defects. On the cosmetic side of things, they do a bit of facial cosmetics like face lifts, rhinoplasty, ear correction, fillers, Botox, facial rejuvenation, liposuction, tummy tucks, and a lot of breast surgeries. "15% of what he does involves taking care of complex cosmetic breast patients which is a fairly challenging field." Russell finds himself in the operating room at least two full days a week and even up to three full days a week. He works between 40 and 60 hours a week. During his office-only days, he gets in around 9 am and finishes around 6-7pm. His OR days start at 730am and finishes between 4 and 5pm. He does his larger cases first thing in the morning and then the local type cases like mole removals or lesion removals or skin cancer reconstruction in the afternoons. Russell has an amazing physician assistant who has been with him for about two years now that sees a lot of his postoperative patients in the office. They are very much on the same page and because of the high demands, they've gotten so busier across the board. Nevertheless, they try to balance things out to avoid burnout and try to make it sustainable. [15:00] Private Practice Goals for Work-Life Balance Russell would like to have his weekends off so he covers himself 24/7, 365 days except when he's on vacation. Other than that, he's available for patient issues that only he can answer unless his PA is available to answer it. He doesn't do office hours on a weekend and reserves it for family time and he tries to be home every night to help with the kids to bed and stuff. Pretty much, he's going all out throughout the week and works as hard as he can to get as many patients. Most importantly, he makes sure they're taking enough time with each patient. One reason he shies away from being employed is he doesn't want to be in a position where he's being told how many people he has to see a day. He's okay with this perspective. "I don't want there to be other metrics that I need to have to use. Other than that, the patients are happy. We're taking good care of them and that my bills are paid." Basically, this is how he likes to do it right now compared to his colleagues where it's not how they're living so he feel extremely fortunate for it. [17:30] Patients that Go to the Operating Room Russell estimates their conversion rate in the high 80%. These people come to his office because they want to see him and they're not doctor-shopping as much. They've waited a decent amount of time to see them so they're there to see him and are typically there to have surgery. Also, nobody goes to the operating room without seeing him in the office first with the exception of local anesthesia procedure where they get to meet him that day, he talks to them, and they'd have to wait for the procedure. But if somebody gets general anesthesia, they may see his PA first and then get a second appointment with him to have another formal sit-down discussion if they're going to go forward. He doesn't do internet-based consultations since it's not how he wants to do things in terms of how he wants to care for patients. Russell says there are patients coming in who are insecure about something and they come to see you for one thing. "Just because one thing that bothers. it doesn't mean there are other things that may be addressable as well. It is a strict policy in our office to not mention those other things or to try to market other things." In other offices, patients would come in for tummy tuck and then the surgeon there would ask you to consider getting a neck lift or breast done, or whatever. They basically walk in to talk about getting fillers in their lips and they walk out with $30,000 worth of clothes and a whole new complex because they didn't realize all those other things need to be addressed. "As a plastic surgeon or cosmetic surgeon, you have a lot of power to make somebody feel better about themselves or feel worse about themselves." Doing it ethically and conscientiously, Russell sends a lot of people in the office telling them they don't need surgery and don't listen to anybody that tells you that you do. He emphasizes that this is the right thing to do because at the end of the day, they're still physicians that took an oath to do the right thing for people and he feels it's job to make sure that if people need to do surgery, it has to be done safely and in the right circumstances. He needs to do it well and do it safely. He needs to do it under the right circumstances for the right patients. Russell admits he is bothered by a lot of plastic surgeons out there that are making a lot of decisions for financial reasons impacting other people's lives negatively and they're doing a surgery for that reason which makes them all look bad collectively, reason plastic surgeons and cosmetic surgeons have a bad name sometimes. [22:05] Taking Calls Russell is in a position where he doesn't cover much call at the surrounding hospitals. In metropolitan areas, most hospitals require call as a stipulation of privileges for credentials. He doesn't have to do that, which means being allowed to use their operating rooms. The majority of what he does would be at a freestanding ambulatory surgery center which is a facility not attached to or affiliated with a hospital but he still has to do everything that is like a major operation they do at a hospital. He also has a lower threshold for doing certain things in the hospital than some doctors do because it's cheaper to do things in an ambulatory center than it is to do at a hospital. He actually anticipated to take calls when he took the position he took but when he got there, he was told it wasn't necessarily expected. But he does stay on as a courtesy like if he's available for something thing where if he can go, he will. So he's like "always on, but always not on." This seems to work well and they like the fact he's available if he's available. Nevertheless, Russell describes having a symbiotic relationships with the ER, where he is available in the middle of the night if they need to call him and if they need to send a patient to his office later on for a suture removal. [24:35] Residency and Fellowship Training There are two typical approaches. One is to finish medical school and go into general surgery, neurosurgery, orthopedics, or ENT and then match after that into a plastic surgery fellowship. The other approach is matching into a categorical plastic surgery program, which is a dedicated program for plastic surgery. Neurology is the other pathway they can do it from. In Russell's case, he did his general surgery program at UMass and transitioned into the plastic surgery program so it was more of a traditional approach and a bit hybrid because he was able to transition out after his third year general surgery being the only type of residency you can do it from. With the traditional fellowship pathway, you don't have to finish general surgery but you have to finish all the other types of residencies before you go into a plastics fellowship. Russell was already at UMass for his general surgery training, did two years in the plastic surgery laboratory, and worked on various projects with them so he was a known commodity. Additionally, Russell says you have to be very competitive with the rest of the applying population. All in all, it was a seven-year pathway. Categorical might be six and then general surgery can end up being nine consisting of five years general surgery, two years of research, and two or three years of plastics although he thinks all plastic fellowships are now three years mandatory. Many will also do an additional year of hand fellowship because it's so competitive. The year he applied, there were only 92 plastic surgery fellowship spots in the country excluding the categorical spots but just post general surgery positions. Plastic surgery is among the subspecialties in surgery that are the most competitive. Dermatology might be the only one most competitive in terms of everything else but in terms of the categorical spots, plastic surgery, Russell believes, may be the most competitive now. [28:30] How to Be a Competitive Applicant Russell illustrates that to be competitive, you have to set yourself apart by showing interest in plastics early on. The good sub-I's  pretty much have an inside track to the spot because it's a month-long interview. Some international students even spend extra time doing research and this makes a huge difference. You're much more like to want to match somebody that you know and you know is good. Additionally, you want to show them that your hands are good and that you're conscientious and good with patients and the staff. Know that the staff can have a remarkable amount of power. "The chairman's secretary is going to have more say in the ultimate decisions of who gets into the program than potentially sometimes the junior faculty." You need to be nice to those people when you call or you're trying to coordinate something with the program since they have the ear of the program directors and the higher up's. Russell adds that we tend to focus a lot on research, volunteer work and stuff, but all that is part of the baseline. You have to be good at all those other intangible things on top of those.  These are the awesome people that can make your like a lot easier. Additionally, Russell recommends doing international volunteer work if you have the resources because it's very helpful as well as research in plastic surgery being at the forefront of tissue engineering so there are always labs looking for residents and medical students to do stuff.  There's a lot of data mining right now which can be a little dry but you can eventually find your way into something more interesting and surgical. And remember, this boring data stuff that nobody else wants to do it, could be your foot in the door. [32:40] DO's, Subspecialties, and Working with Primary Care and Other Specialists Russell thought general surgery was the way he would go, finishing it for five years and then decide later on if he wanted to do plastics then continue on. The  more he was doing rotations for general surgery and plastic surgery as part of it, the more he knew it was where he wanted to go. Then it went solidified by the time he went to the plastics lab and he finished his second year of residency. Whether there were negative biases towards DO in the field, Russell would describe it as rapidly diminishing if there was any. One of the strongest sub-I's they had in the program who ultimately did not match into their program, ended up as a major ambassador to this side of things.  Nevertheless, he sees it's diminishing. “Whatever factors may have led that person to that pathway had nothing to do with that person's academic strengths.” So he thinks it never should be a factor in the first place. What he also notices among DO's is they had to work twice to prove these MD's wrong and to dispel whatever biases they have towards DO's and it's unfortunate they have to do this but this tends to be the case. Moreover, Russell says there's a million of opportunities to subspecialize once you're a plastic surgeon including pediatric craniofacial,  general burns specialist, microsurgery. If somebody becomes affiliated with a children's hospital, they tend to stay very isolated in their pediatric craniofacial. But most people who do microsurgery fellowship for a year will still have to do a lot of general plastics in addition to microsurgery.  There's also hand surgery that overlaps a lot with orthopedic surgeons.  After most plastic surgery residencies and fellowships, you are pretty much qualified to do hand surgery but Russell happens to do none. But you specialize all the way up to the shoulders as a plastic surgeon. And of course, there's cosmetic surgery where a lot of people prefer to do strictly cosmetic, which they actually call aesthetic plastic surgery. In terms of working with primary care providers sending patients to him, what Russell wishes them to know is about general health maintenance stuff. Before most plastic surgical operations, smoking cessation (and all nicotine products) is huge more so than probably any other type of surgery because we rely so heavily on blood supply. Nevertheless, Russell says they tend to be treated well by most primary care providers and other specialties. In fact, he feels like they're "rheumatologists" of surgery that if they don't know where to send the patients they'd be sent to plastic surgeons. "I would probably approach it another way. I would go into a room of primary care doctors and say, how can I better serve you guys?" Plastic surgeons work the closest with general surgeons, surgical oncologists, and dermatologists.  In terms of opportunities outside clinical medicine, a plastic surgeon can do collaboration and consulting on research and product development. On the corporate side of things, you may collaborate with those products you really believe in a lot. [43:25] What He Wished He Knew and The Things He Likes Most and Least What he wished he knew before getting into plastic surgery, he wished he would have started saving earlier. He also gives a piece of advice to students thinking about going into medicine since people can be so quick to tell you to run away and to not get into this but it's a good life. What Russell likes the most being a plastic surgeon is being able to help patients in mostly happy stuff and not a lot of giving depressing and bad news. "What I like the most is I'm getting to use a unique set of skills to help make people whole again and it's extremely rewarding." Russell feels extremely very lucky to be able to do what he gets to do. Although there are patients that when you think about them can give you a lump in the throat but he has more of a handful of patients that make it all worthwhile. On the flip side, what he likes the least is the idea of people exploiting patients and securities for personal gain and with zero concern for the patient's well-being. At this point, there are a lot of 'cosmetic surgeons' that are not even in the core surgical specialties or plastic surgeons that are calling themselves board-certified cosmetic surgeons. "They're doing these massive operations in their offices and taking advantage of patients who don't know that there is no such thing as a "board-certified" cosmetic surgeon." There's no training program for that. That's not recognized by the American Board of Medical Specialties. They're taking advantage of patients. Number one, it's giving any physician who does aesthetic operations a bad name. Number two, it's exploiting people's insecurities and subjecting them to extreme danger. Russell exclaims that this is really very frustrating. He explains that when you see something in the news about a patient dying on the table, it is almost never a board-certified plastic surgeon. It's someone who's typically not qualified and who doesn't know what they're doing, and just trying to hand money, hand over fists, taking advantage of patients. Russell says this is very upsetting because it's going on in a deep level and they're usually a very good salesman and not shy about posting things on social media and would make claims as board-certified plastic surgeons when they shouldn't be because the Code of Ethics prevents them from making certain claims. But people with less ethics are taking advantage of patients. [48:55] The Future of Plastic Surgery At this point, they are using patient's own fat to reconstruct their breasts as well as other areas of the body. There also things like tissue engineering and cellular engineering that ebb and flow. So much of what they do is based on their skill set so a lot of the technology only tends to be complementary and not just a huge quantum leap kind of things. Many of the surgical advances come from the developing countries. All you really sometimes need is a good microscope and some good hands to do some pretty incredible surgical procedures and lose institutional ethic rules. Nevertheless, he sees the field more of a cognitive innovation versus technical. [50:20] Final Words of Wisdom If he had to do it all over again, he would definitely have chosen plastic surgery. He wouldn't think of doing it any other way. As his final pieces of advice, he recommends students to ask people who seem to like what they're doing, why they're doing what they're doing, seek out opportunities whenever you can, and do what you can to set yourself apart from your peers because that's the only way to get ahead but not in a cutthroat sense. But be a good person. Lastly, Russell gives the same advice he got from his mentor which is to go where you're needed. Get experience, get good. And then the word spreads and that's how you get busy. Do not give up and do not listen to the discouragement. The people discouraging may have met roadblocks you won't even be subjected to. The things that stop them are not necessarily that things that can stop you. They may try to beat you down repeatedly. Just ignore it and believe in yourself. Links: MedEd Media Network

Session 79 A common question among stressed out premeds – which do I choose, physician or PA? In this episode, I am sharing some insights into the differences between a physician and a PA as well as how to best choose between the two. [01:18] OldPreMeds Question of the Week: "I'm a new OPM (old premed), 31-year-old single, no kids. After taking a detour from the very traditional path, during my original undergrad 3.47 GPA in Biology, never took the MCAT, I figured out that I wasn't ready for medical school and started pursuing other interests outside of health care." * As a nontraditional student, you're allowed to go pursue other things. If you think you're not ready, maybe you're a little burnt out from the premed path (all of us are a little bit), go and explore some other interests which is what this person did. "Nearly a decade later, I am more convinced than ever that becoming a health care provider is the right career for me but I'm struggling with the decision of MD/DO versus PA. I don't have the requisite health care experience that would make me competitive for most PA programs but I'm going to have to spend one to two years full-time refreshing postbac coursework, taking the MCAT, etc. to go to medical school. So I could just easily spend the time working full-time as an EMT, CNA, or whatever. the problem is can't do both so I need to figure out which path I want to pursue sooner rather than later. I've read some compelling statistics about PA that appeal me - 90% job satisfaction, two times the patient interaction time, 42-hour work week, etc. But those tend to come from sources that seem incredibly biased towards PA over MD. Furthermore, I am not 100% sure I'd be happy long term with the relatively diminished status of PA and/or whether I could do the type of international work as part of my life plan. Any thoughts, feedback, etc. from the OPM community especially from those who have explored decision for themselves would be most appreciated." Here are my thoughts: [03:50] Don't Base It on Job Satisfaction or Work Hours! Deciding between being a physician and a PA -  the problem with this at that high level where you're just comparing work hours and patient interaction time and job satisfaction, that means nothing. Go look at somebody who has the best job satisfaction who's only working 40 hours a week and has great interaction with their clients. You can't choose your career based on job satisfaction, ratings, work hours per week, or patient interaction. If that's how you're going to choose your career then you're not going to be happy in the long run depending on if you made the right choice or not. [05:15] A Huge Difference Between PA and Physician Unfortunately, it's not talked about enough but there's a huge difference between being a physician and being a PA. The PA world will tell you there's not that big of a difference and the physician world will say there is. I am a little biased as I'm a physician. But in practice, depending on what you're doing and on what state you're in considering states have different laws regarding PA's, the work around what a PA can do can vary drastically. I've talked to PA's who want to go on to medical school and I've helped some of them get into medical school and the reason always comes back to not having enough knowledge to be able to treat the patients they want to treat. The physicians would usually tell PA's it's the doctor's job while they go take care of the minor stuff. So there's a huge difference in the types of patients you'll be able to see because your knowledge base is limited, your scope of practice is limited. The role of the PA was created to fill in more of the mundane, easier things that could be algorithmically handed over to a "mid-level" provider. There's a lot of rate around the term "mid-level' but we'll just call it that because that's the terms that's been thrown around for a long time and that's the term that I always use. The PA and NP are trained to take care of easier things. You can't go through PA or NP school and have the same depth of knowledge as a physician to be able to treat the sort of diseases that you would see that a physician treats. You can't. So if you are okay regardless of job satisfaction, hours per week, or any of that stuff, get rid of that. If you are okay working and treating patients who have the sniffles or aches and pains, it's going to be a lot of repetitive things. Medicine in general is repetitive even for physicians. But if you're okay with treating some of the lower acuity things then great, go be a PA. If you're okay not having the full knowledge base to be able to take care of your patients then be a PA. [08:17] How Should You Choose Between a Physician and PA We need PA's and there are plenty of people out there that want to be PA's. They have that mentality, personality, and goals in life that fit with being a PA. But my point here is do not choose physician versus PA based on job satisfaction, patient interaction, and hours per week. Don't base it on years of schooling. Choose physician or PA based on the scope of practice you want and the level of knowledge you want and go from there. The only way you're going to find our is by shadowing a physician or shadowing a PA. Shadow many physicians in different specialties in different areas or shadow PA's in different specialties in different areas and talk to a lot of people. Find out what they like and what they don't like about their job. This is the best way to go about it. [09:23] International Work I'm going to assume that a PA degree is not recognized throughout the whole world. If you're interested in doing international work as a PA, you may want to look into this. For instance, DO or the osteopathic medicine degree started here in the U.S. and it's most recognized here in the U.S. Now the American Osteopathic Association is working on getting more countries to recognize the DO degree and they're doing well. So now as a DO, you can practice in more and more countries but there is a limitation there. Whereas an MD can practice everywhere. So if you are truly interested in international work then really look into the recognition of a PA degree and what privileges and credentials you would have in another setting. [10:36] Final Thoughts Don't look at hours of work or patient interaction or at job satisfaction. Find out what you want based on the depth of knowledge, the skills you learn as a physician versus a PA. Look at everything else in there and you can only do that by shadowing enough. That's how you should choose between a physician or a PA. Links: MedEd Media Network

Session 21 General Surgery is gaining in popularity, which shows in its competitiveness for residency. You need to be on the top of your game to match. And similar to Internal Medicine, it is the gateway to a lot of subspecialties. As we're presenting the data here, remember that this is not just for those looking to be general surgeons their whole life but those who are looking into other subspecialties which we will be featuring here on the podcast in the future such as Surgical Oncology, Colorectal Surgery, Surgical Critical Care, Minimally Invasive Surgery, etc. There are certainly a lot of things you can go on and do after your general surgery residency. The 2017 NRMP Main Match Data is now available since the match happens in March of every year. [01:45] Total Number of Programs and Applicants For General Surgery, there are a lot of physicians available with 267 programs around. There are 236 Psychiatry residencies and 204 Pediatric residencies so that gives you an idea that there are more general surgeons than pediatrics. There are 241 OB/GYN residencies so there are a lot of surgical residencies. General Surgery has two categorical residency programs. A categorical program is one where you apply to the program from medical school and that's where you're going to do your five years of General Surgery residency. Then there are prelim surgery positions and there are more prelim surgery positions than there are categorical. Somebody doing a surgical prelim can do it because they're going into a surgical subspecialty straight out of medical school and they're required to do their PGY-1 year separate from their categorical residency.  In this episode, I will only tackle the full five-year categorical surgery programs consisting with 267 programs for categorical surgery. Out of 267 programs, there are 1,281 spots. There are almost 5 spots at each program. Interestingly, there are not a ton of U.S. Seniors applying for these categorical programs. And out of these spots, there were only 1,383 that applied and 2,388 total applicants. For the purposes of this data, U.S. Seniors equals Seniors at an allopathic (MD) medical school. Hence, this does not include graduates of an MD medical school. These are only students who are still in school. Those who took some time off to do some research or didn't match the first time are not included in the U.S. Seniors data. There were 3 unfilled programs which means a lot of of people are matching with 99.6% of the spots filled. I want to briefly mention that if you don't match in a categorical spot, it's typically pretty easy to do a Supplemental Offer and Acceptance Program (SOAP), which used to be called Scramble. There are only 61.7% of those spots were filled. So it's very easy to do a SOAP into a program if you don't match in a surgical program. But assuming your stats are decent and you're a good person, you're probably going to match because it's not overly competitive for U.S. Seniors which is interesting. [06:55] Types of Applicants Table 2 of the 2017 NRMP Match Data breaks down the types of applicants for each specialty. For categorical surgery, there were 1,281 positions and there were 1,276 were filled. So there were 5 empty spots and 3 programs that went unfilled. Out of the 1,276 filled positions, 1,005 were U.S. Seniors while 74 were U.S. Grads (students that either didn't match the first time or didn't apply because they were doing research or something else. Total number of U.S. Seniors (allopathic MD students) was 1,079 out of the 1,276 positions. The rest of it was filled by 64 osteopathic students and 62 U.S. International medical graduates. Something that is highly debated in the premed world is whether to go to a U.S. DO school or an international MD school, specifically Caribbean schools. If General Surgery is something you're interested in, there were 64 students that matched from U.S. osteopathic schools and 62 from international medical schools. Moving along, there were 71 Non-U.S. International medical graduates that matched into General Surgery. For me, this is a peculiar number and is not something I would have thought to see. It just goes to show that there is still a high demand for General Surgery spots so they're taking as many possible and the most qualified and a lot of those happen to be non-U.S. citizen international medical graduates. [09:47] Trends in Positions Offered and U.S Seniors (2013-2017) Table 3 of the 2017 NRMP Match Data illustrates the total number of physicians offered from 2013 to 2017. This is the fourth time I've looked at the Match Data and the numbers always seem to very consistent. Surgery is no different at 4.4 to 4.5 every year, going at a a good, steady pace and hopefully it continues that way. Table 7 shows the number of U.S. Seniors being accepted compared to all applicants over the course of the last five years. As the number of seats in each program has increased all the way up to 1,281 for 2017, the U.S. Seniors are increasing as well. This is a good thing in that more U.S. allopathic students are going into General Surgery to fill this increasing need for spots. It's not necessarily a good thing for DO students or U.S. International medical grads because the demand is rising among U.S. Seniors as there are more spots. Table 8 shows the actual percentage of U.S. Seniors for each of the programs. There were 80.8% of U.S. Seniors in 2013 and it dropped down to 76.5% in 2014, back up to 80% in 2015, back down to 76.4% in 2016, and then up again at 78.5% in 2017. This suggests that maybe the demand is not as high also looking at the data in table 7. Table 9 shows the percentage of applicants that matched into a given field compared to the rest as a whole. 4.6% of all applicants that matched in all fields matched into Surgery (categorical). So it's up there. Internal Medicine is huge at 25.6%, Family Medicine at 11.6%, Emergency Medicine at 7.4%. This gives you an idea of where Surgery lies. Interestingly, Psychiatry (categorical) is at 5.4% which is more than Surgery and Pediatrics at 9.7%. [13:25] Osteopathic Students, Unmatched U.S. Seniors, Independent Applicants, and SOAP Table 11 looks specifically at Osteopathic students who have matched into PGY-1 spots as a whole. This is similar to the last table but this one looks specifically at osteopathic students. As expected, General Surgery has a lot less total number of osteopathic students percentage-wise. Looking at all specialties adding up to 100%, Surgery only made up 2.2% of all osteopathic students that matched into an allopathic General Surgery (categorical) program. Students may think it's harder to go to an MD General Surgery residency as a DO student and if this is what they want to do, then they should probably only apply to MD programs. My different perspective on this is that if osteopathic schools are doing a good job at recruiting students that meet this "osteopathic" philosophy and are looking at recruiting and attracting more students that are interested in Primary Care, then there should obviously be a lot less that are matching into a surgical program. Figure 6 of the 2017 NRMP Match Data shows the percentages of Unmatched U.S. Seniors and Independent Applicants (outside of the U.S. Seniors which, for these purposes, are considered U.S. allopathic students who are still in school). General Surgery had one of the higher unmatched rate at 20.7%, which is 9th on the list. Majority of those are unmatched, independent applicants (non allopathic students, non MD Seniors). The unmatched U.S. Seniors was only 9.6%. This is still high compared to a lot of the other specialties. It seems it's getting more and more competitive and this is a trend that I've heard from speaking to others that General Surgery is becoming more and more competitive as there are more options available for these subspecialties and fellowships afterwards. Table 18 breaks down the SOAP process and looking into Surgery (categorical), there were 3 programs that needed to fill 5 spots and all 3 programs filled those 5 spots through the SOAP process. Looking at the National Matching Service Data for 2016 for the different program types, there were 49 programs for General Surgery for osteopathic students and 155 positions. 149 positions were filled and 6 went unfilled. The data given is not as robust at the NRMP so I'm uncertain if there were a lot more applicants than these 155 spots and a lot went unmatched or if there weren't just that many applicants. [17:43] 2016 Charting the Outcomes - NRMP Based on the 2016 Charting the Outcomes for the NRMP, Chart 3 shows the match rates and there was an 83% match rate for U.S. Allopathic Seniors for General Surgery. Looking at other specialties, Dermatology at 77%, Neurosurgery at 76%, Orthopedics at 75%, Plastic Surgery at 77%, and Vascular Surgery at 71%. So General Surgery is right there with all of the other surgery subspecialties. Chart 4 shows the Median Number of Contiguous Ranks of U.S. Allopathic Seniors. For students that matched and those who didn't, the chart shows you how many programs they ranked on their rank list when they submitted. Those that matched ranked 13 as a median number while those that did not match ranked 5. If you are picky about where you go or if you didn't get an opportunity to apply or to interview at a lot of spots, then you have a lot less chance of matching. Chart 12 shows the percentage of U.S. Allopathic Seniors who are members of AOA (the Honor Society for medical students showing good academic success in medical school). For those that matched only 17% of the U.S. allopathic Seniors were AOA whereas 52% for Plastic Surgery and 53% for Dermatology. So General Surgery is in the lower end for a surgical specialty. Looking at the Summary Statistics (Table GS-1) for General Surgery, those that matched have a decent Step-1 Score at 235 and those that did not match at 218, which shows a big difference in Step scores. This is one of those things where you need to be very realistic with your chances of matching. If you don't match, why? Could it be that because your Step score is not high enough? The mean Step 2 score is 247 for those that matched and 231 for those that did not. [21:20] Burnout, Happiness, and Compensation The Medscape Lifestyle Report 2017 and Medscape Physician Compensation Report 2017 are two separate reports that Medscape releases every year. For the Lifestyle Report, more than 14,000 physicians over 30 specialties have responded in the survey. The numbers are not necessarily the best data-wise because it's a survey so just take this with a grain of salt. Who is the most burned out? General Surgery is lower on the list at 49% which is more than halfway down the list. This is good. But looking at how severe is the burnout, surgery is higher up on the list at 4.3 from a scale of 0-4.5. Which physicians are happiest at work and outside of work? General Surgery is higher up on the list with 35% happiness at work and 69% happiness outside of work. So it's on the higher end of the scale. Moving on to the Medscape Physician Compensation Report 2017, General Surgery is higher up on the list with an average annual salary of $352,000. Above it is Anesthesiology and below it is Ophthalmology. So it's a decent living as a general surgeon. Although if you think about the lifestyle and everything else, it's harder. So you're compensated for that harder lifestyle. Looking at the rate of increase year over year,General Surgery had a 9% increase which is pretty decent. The number of physicians who feel fairly compensated for General Surgery is lower at only 48%. Whether a specialist would choose medicine again, General Surgery is right in the middle at 77%. While only 82% said they would choose the same specialty, which is a little in the lower half of all the specialties there. [24:50] Final Thoughts If you're not sure what you're interested in yet, go through these numbers. It's eye-opening to see what is going on in the world when it comes to matching and physicians that are happy and making money and those that aren't. Links: MedEd Media Network 2016 Match Data NRMP Supplemental Offer and Acceptance Program (SOAP) National Matching Service Data for 2016 Charting the Outcomes - NRMP Medscape Lifestyle Report 2017 Medscape Physician Compensation Report 2017 AOA

Session 15 This week, I speak with Dr. Fayyaz Barodawala, a community-based Interventional Radiologist from Atlanta, Georgia, about his career decisions, what an IR physician does on a daily basis, the struggles and triumphs that come along with his practice and specialties opportunities outside IR and other interesting topics like exclusive hospital contracts and artificial intelligence replacing diagnostics. [01:15] Choosing Interventional Radiology Practicing medicine since 2005, Fayyaz knew he wanted to be an Interventional Radiologist on one particular day during his third day of medical school. He initially found interest in plastic surgery, vascular surgery, and orthopedics. He had exposure to medicine growing up with his parents both physicians but it was on his third year, surgical rotation that he remembered being chewed out after having observed a surgical procedure passively for so long. During that same day, he went to see a family friend how happened to be called in for a pulmonary arteriogram and surprised at how quick the procedure was. At that point, he was considering orthopedics or radiology with the full intention of going into interventional, if he did the latter. What he likes about the field is the fact that you get to do different and relatively short procedures that make a difference and people happy. [04:10] Traits of a Great Interventional Radiologist Fayyaz says the things that make great interventional radiologists are knowledge of imaging and problem-solving. A lot of what he has to do is a lot of problem-solving. There may be defined pathways to do certain things but If they don't go as planned, then you have to improvise a lot. You have to be able to figure out how to accomplish your goal using the tools you have. A running joke during his fellowship was that IR was the last name on the chart so when everybody thinks a procedure is too high-risk for them, they'd call IRs to take care of it. IRs do so much work like put filters in, arterial work, oncologic work, spine work, etc. So they have their hands on a whole bunch of different places but problem-solving and thinking outside the box are good traits to have for Radiology. And of course, you need to know your Anatomy. [06:22] Types of Patients Interventional radiologists treat younger, healthier patients that they might see for as simple as venous access like a PICC or younger women who have heavy menstrual bleeding due to fibroids. They do uterine artery embolization. They treat veins for cosmetic and medical reasons like a vein ablation and sclerotherapy. They also treat older patients with spinal fractures for vertebroplasty or kyphoplasty. They treat a lot of oncologic patients which branches off into its whole own sub or super-specialty, even treating hepatic tumors such radio embolization, chemo embolization, or radiofrequency or microwave ablation or cryoablation. Hence, the see a full spectrum of patients who are younger and healthier to older and very, very sick. [07:32] A Typical Day for an Interventional Radiologist His current practice is less hard core and interventional than he would have liked. Bread and butter for them would be paracentesis, thoracentesis, chest port placement for chemo, various biopsies, vertebral kyphoplasty for spinal fractures. In his latest practice, he had gotten into a lot of pain management procedures such as epidural steroid injections, lumbar puncture, and myelogram. In between, he reads diagnostic imaging. Interventional radiologists do a wide variety of cases. Today, Fayyaz did paracentesis, thoracentesis, fluoroscopy, breast biopsies, and red PET scans. Other days, he could be doing a lot more like nephrostomies, biliary drainage, kyphoplasties. They're also currently ramping up their oncologic work at the new group he's in, doing ablations and radio embolizations that are starting to pick up now. Even if you're a little ADD, you can find stuff that's good because it's not monotonous. On the flip side, they do very heavy-duty cases like TIPS which do not occur as often but these cases could be longer. In their group of 4 IR doctors, they're on call every fourth so once per quarter for a weekend and random days here and there depending on the hospital setup. Fayyaz further says that if there's enough for two or three people to do full time interventional, the more interventional you want to do, the more call you have to take because in their practice, it's not full-time interventional all the time. [12:21] Work-Life Balance and Managing Expectations As reimbursements have fallen, IR does not generate as much income for the practice. Fayyaz thinks it's about managing expectations. You're better being a diagnostic radiologist if you simply want to go in there, punch a clock, and get out. There are also non-traditional options like the outpatient vascular access centers where they do dialysis interventions which are pretty regular hours. Then your work-life balance can be great. Fayyaz would describe his work-life balance as pretty good, starting work at 8 am and usually done by 4:30-4:45 pm. Diagnostic calls can be brutal but interventional calls are not as bad. Again, it's about managing expectations. If you prefer cool cases, then you might get called in the middle of the night for a G.I. bleed for instance. But if you're doing bread and butter cases, work-life balance is fine. [14:25] The Residency Path Back in the mid-90's, there was a time when internship was not required so you go right into Radiology. That changed in around 1995 when they've changed the mandate. The traditional pathway is a year of internship (surgery. medicine, pathology, transitional, pediatrics) then you do four years of Diagnostic Radiology and then one year Interventional Fellowship  It's a six-year thing. The direct pathway is for the Diagnostic and Interventional Radiology-enhanced clinical track. However, this is going away in favor of a pure IR residency right now as they shift into a new paradigm that's evolving more quickly. As more and more programs go towards that, you will match into Interventional Radiology directly from medical school, which includes more clinical time, cut down the diagnostic time a bit and increase the interventional time. (The first set of programs was just approved last year. so they're just starting.) This is great if you want to do something interventional but Fayyaz is not sure how this is going to work for the private practices so he has some reservations. He further explained that a lot of these plans are placed by academics which is a really different setup than private practice. It's tough for a private practice doctor that doesn't have a ton of interventional because they're not going to be as versatile. Hence, in huge practice, it's great but in a not-huge practice, that remains to be seen. The new model is to set up your own practice just as a surgeon or cardiologist would, see patients clinically and then bring them to a hospital. But that's probably they're going to end up. In order to compete, you can't have the old model just sitting there waiting for procedures to come to you. You have to market, you have to evaluate patients and do consults which not some of the older guys are used to. [18:14] Matching for Interventional Radiology Competition for interventional radiology goes in phases. As a job, the competition has tightened as more interest is starting to happen in interventional due to the difficulty of outsourcing it. People also enjoy doing procedures so it has been incredibly competitive in the last couple of years, to the point that people are not matching for Interventional Fellowships. To be competitive for matching, you have to be a hard worker and have a mentality of saying yes almost all the time. And if you say yes all the time and then you say no, then people respect your opinion. Be willing to get your butt kicked for a while so you will be ready to handle everything that comes at you. Other things that can make you competitive are being innovative, being able to do problem-solving, knowing the imaging, being clinical, willing to constantly learn new things, and understanding that there are things you don't know so just be able to take in what you can and learn as you go afterwards. Fayyaz doesn't necessarily believe that scores tell everything. It's one tool for weeding but it shouldn't be the only tool. Fayyaz went to a program where research was not a priority but if you're looking at research-heavy programs, it depends on what your goal is. If your goal is academic research and publish, then look for a program that can cultivate and nurture that. If you want to be a work horse, then you want something that gives you more clinical training. During his residency, there were very few Fellows so they had to do a ton as a resident. It's nice to have a highly resident-centric program when you're a resident and a very fellow-heavy program when you're a fellow. Nevertheless, research is important in helping the interventionalist. A lot of procedures are pioneered by radiologists but as they get more commonplace and more routinely and more lucrative, other specialties start snipping away at it so you're going to be experiencing turf battles. For instance, a lot of people might be fighting for a cerebral angiogram which can be done by interventional radiologist or a vascular surgeon, a neurologist, and neurosurgeons. [24:47] Bias Against DOs Fayyaz worked in New York hospital that had a deep Radiology residency DO program and would be joking to them about how MDs couldn't go into the DO programs and DOs could go into the MD program. On a serious note, he doesn't really see any distinct bias but it's there for some other people. [26:50] Special Opportunities for Sub-Specialties Some interventionalists would like to do peripheral arterial but that’s contentious because different specialties have gotten involved and everybody wants to do it thinking it's cool and reimbursements can be very high. Some people work with vascular surgeons and even joined vascular practices. But the big thing right now is Interventional Oncology and that's where everybody wants to get into. It involves stuff like radio embolization, chemotherapies, and various regimens. Other people do Neuro Interventional which typically requires a Neuro Radiology Fellowship and then Neuro IR Some also get involved in Stroke Intervention. There is some overlap between Neuro Intervention and IR next. You can also do Pediatric Interventional Fellowship. [28:48] Working with Primary Care and Other Specialties Speaking of clinical IR and not waiting for people to refer to you, Fayyaz meant not waiting for  a vascular surgeon or cardiologist or somebody else to refer to you. Peripheral vascular disease, for example, are marketed successfully by primary care physicians to family practice, internal medicine, pediatrists. He's not sure if they really understand exactly what  IRs do which has been a problem for them because they're not aware of the services they offer.  IRs hundreds of chest ports and they could probably do even better than surgeons sometimes as backed by evidence. They could do it faster and cheaper. So  IRs do more than just that, they do biopsies, spine interventions, peripheral arterial, biliary stuff and those people thought as surgical procedures. They also do fibroid embolization, venous disease, and gastrostomy in so all these things can be done. What feels frustrating is they sometimes feel just as a back up and they're only sought for because no one else is available to do it. It would be nice to have a great relationship between the primary physician and the IR. Check what  IRs are doing because you might be surprised what the interventionalist can do for you. Other specialties Interventional Radiologists work the closest with include Oncology, Orthopedics, Hospital/Critical Care. Fayyaz says the best way would be an alliance between vascular surgery and radiology and interventional competing against cardiology. [33:05] Diagnostic Radiologists Replaced with A.I. Interestingly, Fayyaz mentioned that there have been thoughts of merging Diagnostic Radiology and Pathology into one specialty. The argument is that given it's a lot of pattern recognition on the diagnostic side, those should be handled by computers and the physician would be instead be involved in the management. I personally believe that within 20 years, radiologists are going to be replaced with AI for diagnostic purposes. Fayyaz agrees it may come and could be scary. But there is a lot of grey zone for now. If computers could just highlight findings of questionable significance and let somebody go through it then that would be helpful in making their job faster and better. [37:00] Other Special Opportunities Outside of IR Radiologists have a lot of unique opportunities since they interact with a lot of specialties.  They can be very strong in administration. Fayyaz adds that  IRs are somewhat anchors for the group in the hospital because they're providing a lot of coverage that can't be easily outsourced. Again, it's important to not wait for things to come to you but to be out there somewhat marketing yourself, being available, getting your face shown so people know who you are and getting up there. If you're in the academics, you can get into the consulting industry. [39:37] Exclusive Hospital Contracts & Diagnostic versus Interventional Radiology What he wished he knew before going into Interventional Radiology is that you're being behold into a hospital for contract. One of the difficult things is that as people break off and form their own interventional practices, the model for Radiology is typically within exclusive contract so the group may have an exclusive contract in the hospital. So even if the IR guy is new to the city, you might be able to find a place to do your procedures since the radiology group in the hospital may block you from getting any privileges there. If you want to bring a peripheral arterial case into the hospital for instance, they'll block you from doing it because they would say they have an exclusive contract yet the cardiologist or the vascular surgeon who does the same thing and wants to get into the hospital can come in. Second, Fayyaz recognizes the difficulties in interaction between the diagnostic and interventional physicians because they have to realize that in order to build a good clinical practice, you do need some clinical time. But it can be very hard for the diagnostic people to see that and find that time but they have to realize that builds their credibility. Third, there are options to do some of the interventional stuff not through Interventional Radiology residency or fellowship but other fields can chomp at your toes but that keeps you fresh and innovative. [42:33] The Best  and the Worse Things About an IR Fayyaz loves helping people through their tough times and being there to help them and see them get better. He likes that he can calm somebody down and loves how quick the procedures can be and people get to see the results fast. He would love to expand his practice and get into the cosmetic side of IR or expand in Oncology. overall, seeing his patients get better is the most gratifying. The least thing he likes about being an IR is getting dumped on with cases other specialties are not willing to do. As frustrating as it seems, you can't let it get to you. In general, radiologists are happy and they do what they do. They can always find a niche depending on what you really want to do. If he were to choose another specialty again, Fayyaz doesn't actually know considering his interest in plastic surgery. Although Interventional Radiology could still be on top of his list, he could not deny the difficulties and risks related to doing private practice although that could depend on your geographic location. Overall, he likes what he does but some parts can be very frustrating specifically, the exclusive contracts and being behold into a hospital. However, Fayyaz sees that over the next ten years, more and more exclusive contracts will fall and you will get that new model where two or three interventionalists get together to bring cases in and not have a group that blocks you from being in a hospital. [49:25] Last Words from Fayyaz Do what you like and don't try to chase it because you think there will be a job afterwards. If you don't like it, don't do it. Second, try to spend time with somebody in that field or at least talk to them to see what their life is really like. Third, see what life is like after and see if this is something you can really do. Realize that a lot of practices may not be all high-powered cases all the time. Tap into resources to learn more about the kind of procedures we do. You're going to have to weigh money, time off, location, case mix, and with all those together, you would have to find the best mix and adjust the dials to where you can live with something and say this is good. There is no perfect job ever. You don't let people tell you no. If they say no then find a way to do it and give it a shot. Links: MedEd Media Network