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

Session 75 Dr. Kelsey Hopkins works in rural private practice in Southern Illinois. Learn more about rural family medicine, what he likes about it and what he doesn't like, the unique environment, how to connect with other physicians, and so much more! If you have any suggestions for new guests to have on the podcast, just shoot me an email at ryan@medicalschoolhq.net. [02:00] An Interest in Family Medicine He actually realized he wanted to be a family medicine physician before he got accepted to medical school. Growing up in a small town in Illinois, he is the fourth of eight kids. Everybody was born at home after the first two. So there was no one in his family that was in medicine. Naive to the healthcare field in general, he didn't know there were different specialties so he just thought that as long as you went to the doctor, they give everything. Then he found out there was a rural medicine program, the RMED program at the University of Illinois - College of Medicine in Rockford. He explored this and it's where he ultimately went. And so, family medicine turned out as what matched what he thought just a general doctor was. He didn't know you could subspecialize. This was typical in a rural setting. Kelsey describes that they would travel 20-30 minutes or more to go to the doctor. And this is true in a lot of ways. In rural areas typically, there's not as many doctors around and certainly fewer specialties. So typically as primary care, they do more than they would in an urban area because they have less colleagues to assist them with things. So the training is oftentimes different and the role is different. “In rural areas, typically, there's not as many doctors around and certainly fewer specialties.” [04:05] The Decision to Go Back to a Rural Area After Training Having been born and raised in a rural environment, Kelsey thought he was comfortable with this kind of lifestyle. He felt it was where he was most comfortable and where he would want to raise a family. So when he found the RMED program, got in, and got into the residency in Indiana, doing the rural training track, he thought all this aligned to his life goals. As he got more training to do it, all the more that he wanted to get back to a small town and stay in that environment to live. On top of this, he realized the healthcare needs so he felt it would be a very rewarding career. He considers this not only as a career choice, but also as a lifestyle. For him, he was truly accomplishing what his initial dream was. And living that out is very rewarding for him. "I don't think I would be as rewarded or fulfilled working in a city environment." Painting the picture of a rural setting, Kelsey has one partner who is an internist and pediatrician, the only practicing pediatrician, until recently a hospital had another part-time one in the local area. Then there are three other family doctors. One has just retired. Then there are several nurse practitioners. They have a local hospital down a mile from his office, along with a couple of surrounding hospitals that are 20-30 minutes away in most directions. In terms of patient population, there are 7,000 people roughly in town. They call from a patient volume from around the area. He had even one patient that morning that traveled 100 miles who traveled from Missouri to come see him. They have a local niche so that patients within 20-30 minutes are able to see a doctor in the area. [07:25] Traits that Lead to Being a Good Rural Family Medicine Doc Kelsey says that especially if you're from rural, you seem to fit in better. You get it. You understand the lifestyle better. It's not just about practicing medicine, it's about the community. The patients' attitudes towards you may be different and their healthcare needs may be different. So understanding rural life is really important. "It's not just about practicing medicine, it's about the community." The University of Illinois College of Medicine in Rockford actually coined the term "rurality." This means being how rural somebody actually is. It's a way of life people understand when you're from that environment in terms of relating and communicating to your patients. Moreover, Kelsey thinks you also need to be flexible. You have to be able to like a variety of different things. Be able to shift gears quickly and this is a key trait in that you never really know what's going to walk in your door. Their walk-in clinic is open from 8-9 where their patients only can walk in in the first hour and it's all hands on deck. Then they see however many they have come in. So be as flexible as seeing up to 16 people. "Being able to shift gears quickly is really a key trait because you never really know what's going to walk in your door." Being a being good communicator is critical as well. You have to enjoy teaching and talking to your patients about things that may not even relate medicine. This is key to having a good bedside manner. Just be there with the patient. Don't just see them in their disease state but see them as a whole. [10:05] Other Specialties of Interest Kelsey knew that going into medical school, family medicine was what made the most sense for a rural town because as one provider, you can impact thousands of patients. More than 80-85% of what they're going to come to him for, he can synthesize the info, work it up, and he can handle it most of the time so patients won't have to travel outside of town. During his fourth year as he was doing his rotations, co-rotations, and subspecialty selections, it became crucial for him to realize that everything is related to family medicine. There's nothing that's off limits. He also takes his education track into account for having been able to at least know something about most things. "Everything is relevant in family medicine. That's what I love about it but it also can be difficult to keep up with things. And if I don't know the answer, I know how to find the answer." Kelsey loved OB, Urology, Cardiology - so there was nothing he thought that he wouldn't do at all. There's also a huge need for Psychiatry in rural medicine and even nationwide. This is also a big part of primary care. He does like Psychiatry. He actually did some training in that during residency and he found it has helped him everyday. "Learning everything I could on all specialties just all continued to support the idea that family medicine is basic comprehensive specialty that encompasses everything." [13:40] Types of Patients Kelsey explains that rural family medicine deals with more complex disease states. You see more of the social determinants of health at play because there's a transportation issue, underinsured patients, and no insurance of patients. So you have to deal with the other things too while taking care of the person in a more social fashion than you do just the medicine. Oftentimes, rural patients would present "later to care." It doesn't always mean that everyone who's rural is a farmer. But there's a lot of that industry in most rural towns. That said, there are several businesses there, college, and all sorts of industry around. He'd also encounter patients like farming equipment injuries as well as those unrelated to trauma. Kelsey has observed that people tend to wait things out longer than maybe they would if they could see a specialist if they were just a few minutes walk. "Patients tend to present later with more complicated diseases." Additionally, Kelsey would see other cases like Neuropathy, COPD, obesity-related diseases, diabetes, hypertension, infections and allergies, etc. As well, they deal with the more complicated states. And he would still have to sometimes manage such conditions since the patients don't to leave town to go for a follow-up. Pretty much, he sees all specialties on a daily basis as well as a significant number of mental health. Moreover. he points out the importance of being thorough in that you're not always going to get the classic symptoms written on the textbooks. "You're going to see things that you may never see again in your career." [17:12] Typical Day and Work-Life Balance Kelsey's day usually starts at 7-7:15, having early clinic one day a week. The rest of the week, he starts at 8. He gets around 25-35 patients each day. They have a walk-in clinic and sees a lot of chronic disease patients with complicated check ups. And then he'd try to work up double or triple-booked people that need to be on the same day. He also works on acute cases within the same day. At the end of the day, he goes to the nursing home when necessary. Then he goes to his family with three children by 6:30pm. He puts the kids to bed then finishes his paperwork from 9-12. "Everyday is different. I don't know what the next patient is going to be." He basically long days in terms of paperwork. Patient care usually stops around 5:30, sometimes later if he needs to go to the nursing home. Sometimes, he might also do end of the day procedures like vasectomy. Wednesday is  typically a procedure day for him. He also does skin cancer removals and nail surgeries, and other surgical things. In terms of schedule, nothing really goes according to plan but then again, flexibility comes in here. Overall, he likes the excitement this brings, having busy days. Kelsey considers having enough work-life balance, especially that he's got the support of his wife. He was employed in a hospital for five years then he ended up doing private practice, which they did everything from scratch. He loves Tuesdays because he sets it for family time. He also has Saturdays and Sundays off. He makes sure he's super thorough at work otherwise he gets burned out if he doesn't take time away. So makes sure his family doesn't get to the back burner so he could still have a lot of time with his kids. The good thing about private practice is that he could take time off. There's more flexibility in your own decision making. You might feel like there's not enough time with your family, but Kelsey assures it's definitely doable. "Family medicine is about a relationship with patients and a well-rounded approach, but it's also about families. Family should come first, really." [22:30] Path to Residency Training Along the Rural Track The Family Medicine track is three years although you can opt to do more training in other subspecialties. One of them can be high risk, OB C-section track. ACGME has changed has change their core criteria in how many months of OB and the different things a program requires to have. But you can always do elective time to do more like an away rotation if you wanted to. The rural training track is an addition to the regular training, which they did during their second year. They went to a rural clinic with no resources where they did office procedures and EKG machines. This taught him a lot of things about decision-making when you're by yourself when there's no other help available. There's a lot of autonomy and realizing that the bottom line could stop with you.  There may not be anyone else to give you a second opinion at your beside. "When you're in rural practice, you can practice at the top of your training ability." After done with training, Kelsey though there's not enough time to train but the nice thing is when you've gotten extra training, you'd feel prepared for rural practice. And what's nice in the rural practice is you get to practice a lot of things on top of your training ability. You get to do a vasectomy, C-sections, etc. Things you can't normally do in an urban area. So when you've done enough of those and got trained to do that in your residency, that allows you to get credential when you're out in practice at a hospital or a clinic. You've done enough to say you're confident and you've been trained. As opposed to urban areas where there are subspecialists, you get to do all of this in the rural area since there's no one else around. And you're the go-to person. So having that extra intensity of training really helped him when Kelsey was in practice so he could do everything he was trained to do and not just let things go by the wayside because the environment didn't fit. [26:40] Forming Connections and the Network He Needs Kelsey is happy that most specialists are happy to receive a phone call from him so he could call different hospitals in the area, if he needed to talk to specialists. They also have specialists that come half day a week. For instance, a cardiology comes to them a couple of days a week where they'd do a stress test, etc. They're very receptive to him and the notes are awesome. They don't have a full-time surgeon as they'd have to share the calls to other local hospitals. So a lot of cases get sent out having no full time in-house surgeon. He also forms relationships by the quality of the institution and the group of partners and they have a good working relationship that way. [28:30] Other Special Opportunities One of the things he picked up long ago was a change in ownership of a local nursing home. Kelsey and his partner are the local nursing home directors. Outside of medicine, he was asked by a college to teach Anatomy. It's he something he does as a volunteer work. This said, you could do nursing home directorships, health department board, or hospital board, things that may not be employed positions. Sometimes, family doctors can fill in as hospitalists. He did this initially which he did for a couple of weekends. Then you could moonlight in the ER or outside of town. Others do wound care, doing more surgical stuff and just subspecialize in it. There's also sports medicine as service team doctors in small towns. [30:22] What He Wished He Knew that He Knows Now The one thing that comes to his mind is that it pays to be thorough and it pays to keep up on things. Just really take advantage of your training. One thing he wished he knew different was that when you're in training, you get told to get as much exposure as you can so that you're the most comfortable when you come out. He did some moonlighting in the ER. And this gave hime a ton of leg up for practice which involved quick decision making, seeing acuity, and solving a lot of primary care things. "It pays to be thorough and it pays to keep up on things. Just really take advantage of your training." Moreover, it really matters that you get the exposure to everything. Even when you're tired, if you have the opportunity to learn something, you should do it. When you're in private practice or even if you're employed, when you're out in practice, it's very draining financially on the company to have you get some new training that you could have received but you didn't. And telling yourself during residency that you're going to get that later, actually rarely happens. [33:10] What He Likes the Most and Least as a Rural Family Medicine Doctor Kelsey finds it very rewarding to see his patients and his employees from the perspective of him being in private practice. He describes this as being a family environment. There are stressful and long days but he still enjoys coming to work no matter what. "I still enjoy coming to work no matter what. And that's cool because this is the rest of my life. I have no plans to retire." He loves the fact he could make an impact on patients in a lot of ways. Every single day, you get to see different patients and different acuity and the different lengths of visits. So he likes how rewarding it is at the end of the day to sleep at night knowing that he did his best and some days, he saved a life. He realized that the things he was trained to do always matter. That being said, he feels very fulfilled and rewarded that he can offer a lot of services to patients. He feels very well-trained at his medical school and through residency. He loves teaching as well and students rotating with him. Two things he love doing. On the flip side, what he likes the least is the paperwork. It's something you can't get away from so it's about reframing your mindset about it. It's important in a lot of ways and it's a necessary part. And this is also part of doing service to the patient that is a reference point for the next visit. This completes the patient's care as you're putting down on paper what you did for them and what you plan to do for them. Just look at it as an extension of the physical exam of things that it's just part of taking care of somebody. It's a necessary evil. They're hiring some people that help them in some paperwork to help him out. They help out a couple of days a week and he sees this as great help. [39:05] Major Changes Coming to Rural Family Medicine He sees more hospitals merging with larger ones that gives access to more visiting specialists. The Electronic Medical Record is universal now. There may still be people using paper but this is going away. The communication in rural medicine may change but the quality of care remains the same. "Their perception of rural medicine is that it's antiquated, doctors are not well-trained. They don't provide good care... that's generally not true." Contrary to the misconception that rural doctors are antiquated, Kelsey begs to disagree, saying that in their office, they have the same technology that tests for influenza and strep that they could do in just 10-15 minutes. Rural doctors are on the ball with the latest updates on things because you have to stay up on it. Keeping ideas is no different than it is in the urban areas. It's just that he doesn't have somebody to bounce ideas off when he's in the hospital or in the lounge getting a coffee. This is part of the residency that he misses. That said, it's not antiquated there. If he had to do it all over again, he'd still do it 100%. As a doctor, you're considered a local expert on health and different things. You serve in the community. But it's not always about what he would want but what the community wants. So he wouldn't have wanted this any other way. And even beyond financial constraints, he still decided to push through with the private practice, seeing the needs of the community "It's not always about what I would want. It's about the community. In my book, that's how I view it." [43:00] Final Words of Wisdom If this is something you're interested in, Kelsey recommends looking at a program both for undergraduate and residency that may provide you with that kind of training instead of just traditional training. It's worth exploring. "It's not about the money. It's about what you want to do."  If you have a rotation in medical school that is not what you think it's going to be but you're really interested in it, then try to explore your options. And if you want to do it, there are ways to do it. There are different options to repay your debt and be able to work in a rural area. You can have a family regardless of what specialty, just be able to know how to carve it out. Lastly, try to connect with preceptors as they can really help you. Links: ryan@medicalschoolhq.net RMED Program - University of Illinois

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 35 Dr. Chris Fecarotta is a Pediatric Ophthalmologist. He has been in private practice for five years now. He shares with us his reasons for choosing the specialty and what you should think about if this is a field you’re considering. I would love for you to recommend The Premed Years Podcast to your premed friends along with our other podcasts on the MedEd Media Network. [01:30] Interest in Pediatric Ophthalmology Chris admits he didn't know he wanted to be a pediatric ophthalmologist until late in the game. He figured it out at the beginning of his fourth year. Knowing he always wanted to do kids, he went into medical school thinking he would be a pediatrician of some sort. But he didn't know exactly what. Then he discovered as he went along that he wanted surgery more. He had a friend who had some family members who were in ophthalmology. He talked to them about it and though it was an interesting field. So he decided to put the two together and thought about doing pediatric ophthalmology. He shadowed a pediatric ophthalmologist and went into residency thinking it was what he would do and stuck with it. "The eye is a very fascinating organ. It's a lot more complex than people think." Chris says he likes the very small surgery. He likes the patient environment considering he's not a huge fan of doing in-patient work. So pediatric ophthalmology fit all those things very well. He also likes how it can afford a reasonable lifestyle. There are not that many emergencies in it and you can really make a big difference in children's quality of life by improving their vision. These are the things that really appealed to Chris. [03:16] Traits That Lead to Being a Good Pediatric Ophthalmologist Chris stresses how important it is to enjoy working with children. It's a very challenging field as he describes it. It's not the easiest thing to convince them that it's okay to examine their eyes. So you have to be able to work well with children. You have to be very patient and have a very good rapport. He also adds the importance of being detail-oriented, especially for ophthalmology since they deal with a very small organ. Chris says there are people who have the natural ability to do surgery especially small surgery. But he doesn't think it's not something it can't be learned. It's not something you need superhuman dexterity for. Some with normal dexterity can do it with dedication and practice. "I don't think this is not something that can be learned. I think it's very possible to learn it." Chris explains there are varying levels of natural ability just like with anything else. There are people that find they're just not really cut out to do surgery. But that's rare. Most people can learn it and do just fine. [05:35] Types of Patients and Typical Day Chris treats mostly children with strabismus (cross-eyed) or amblyopia (lazy eye). These are the bread and butter of pediatric ophthalmology as well as nasolacrimal duct obstruction. He sees all age ranges and premature babies who have retinopathy of prematurity all the way up to young children with strabismus and amblyopia. He also sees teenagers continuing their eye care. He also treats adult strabismus. So he treats all ages, mostly children. "Pediatric ophthalmologists also generally treat adults with strabismus from a variety of causes as well." As a private practice doc, Chris gets to the office between 8:00 am and 8:30 am. He sees patients through the day. He doesn't typically take a full lunch although he tries to sneak food in-between patients. Then he's generally done between 4:00 pm and 5:00 pm. He takes call but it's generally not very demanding. There are eye emergencies but there is not that many of them. Usually, most things can be triaged and then seen the next day. An example of eye emergency where he as to go in is an injury where the eye is ruptured globe. It's an emergency if the eye is cut and the contents of the eye are exposed. It usually needs to be surgically repaired that night. Another eye emergency is a retrobulbar hemorrhage from an orbit fracture or trauma to the eye. If there's bleeding behind the eye in the orbit, it can cause a compartment syndrome that can compress the optic nerve. So it needs to be decompressed. Angle-closure glaucoma is another one but this does not happen in children. So it's not a pediatrics problem but this is one of the other few emergencies in the ophthalmology field. Other than these emergencies, most things can be pushed off until the next day. [08:18] Private Practice and Work-Life Balance What caused Chris to move from academics to private practice was his friend offering him the job along with his wife. It was more of a personal decision for him than anything against academics. He mentions both private practice and academics have upsides and downsides. Only 10-15% of his patients are brought in from the outpatient setting to the operating room. Most of his patients are not surgical in pediatric ophthalmology. In general or adult ophthalmology, there is a higher percentage of surgical patients. Most of the adults are there for cataract surgery. Pretty much everybody, if they live long enough, gets a cataract and needs surgery. "The volume of surgery for pediatric ophthalmology is less than general ophthalmology." In terms of work-life balance, Chris thinks it's one of the most ideal fields for that. If you like surgery and you like children and you want a reasonable life, Chris thinks it's a great choice. There is also a big need for them. There's not that many pediatric ophthalmology so it's easy to find a job, not to mention that it's very rewarding. [10:12] Path to Residency and Fellowship The path to ophthalmology residency includes an intern year. Most people do a transitional year but you can also do a medicine year. Some programs will let you do a pediatric year if you want to specifically do pediatrics. Then you would have to do ophthalmology residency consisting of three years. Then a year after that, you can do a fellowship in pediatric ophthalmology of strabismus. So it's five years after medical school graduation. It's not as long as other surgical fields. Chris says ophthalmology is competitive to match in out of medical school but pediatrics is easy to get a fellowship in. "It's not a very popular fellowship so there's open spots usually. Most people can get a spot if they want." There are a couple of reasons Chris thinks the fellowship is not as popular. First, he doesn't think most ophthalmologists go into the field looking to deal with children. He thinks he's an exception but most are not that thrilled about seeing children. They didn't go into it for that reason. Children are much more difficult to examine than adults so it's challenging. And he thinks a lot of people are intimidated by it or don't want to deal with the hassle of examining the child. Another possible reason is that it pays less than general ophthalmology for a variety of reasons. One, is there's less surgery. Just because the field is less surgical, a lot of children are on medicaid. So the reimbursement for pediatric ophthalmology is not as strong as for general ophthalmology. So Chris things these things discourage people from choosing it. But if you like children and it's what you want to do then it's a great field to choose. He would still encourage anyone to do it if they like kids. Like all the competitive fields, the most important thing to be competitive for ophthalmology is to do well in your classes and your USMLEs. Chris thinks it's your letters of recommendation that can get you in the door to an interview. Then have a good interview where you're likable and people can see working with you for three years. Chris believes that research helps but doesn't think it really makes or breaks anybody. "You get your foot in the door by your academics and your letters of recommendation. Then your interview is really what seals the deal." With regard to sub-I's, Chris thinks it's not a bad idea to make yourself known by doing a sub-I. But you have to make a good impression otherwise you've pretty much killed your chances of going there. So you better make an A+ impression or else you'll actually probably hurt yourself. [14:30] Bias Towards DOs, Subspecialty Opportunities, and Working with Other Specialties Chris thinks it's challenging for a DO to get an ophthalmology residency but it's not impossible. There are DOs in ophthalmology. There are specific DO ophthalmology residencies so it's definitely possible. And once you're in ophthalmology, getting a pediatrics fellowship is not hard at all as what Chris has mentioned. The hard part is if you were a DO and got into ophthalmology residency. After that, you can do pediatrics if you want without a problem. Once you're a pediatric ophthalmologist, there are other opportunities to further subspecialize. Although most people don't do it, you can do a second fellowship. But if you want to be very academic and you want to be the world's expert on pediatric glaucoma, you could do a second fellowship in glaucoma. You could do neuro ophthalmology and do pediatric neuro ophthalmology. There are only four or five of them in the country. And this can help you in terms of finding jobs and being an academic. "You can subspecialize within pediatric ophthalmology but the vast majority don't." Other specialties they work the closest with include pediatric ENT, pediatric rheumatology, and pediatrics. The general pediatricians are usually the referral source for a lot of patients. To make their job easier and provide more care for the patient, pediatricians being able to provide history always helps. He also thinks most pediatricians know they need to do that. So he doesn't really have much problem with that. He doesn't think most non-ophthalmologists are comfortable with the eye. So he would encourage them to refer to pediatric ophthalmology if they're concerned about anything. Better be safe than sorry. They would be happy to see any patient any time. So they should send patients to them if they feel uncomfortable and let them help. Moreover, Chris recommends to primary care doctors to have the book The Wills Eye Manual in their office. It's the most common manual of ophthalmology out there. Most eye providers have it in their office. They can look up the different diagnosis, treatment, follow up, differential diagnosis, etc. They can use this book as a reference for anything they want to look up about eyes. When it comes to special opportunities outside of the office, Chris says that if you're going to be an academic pediatric ophthalmologist, there's always good pathways to be a chairman. There's also lots of research you can do. [18:59] What He Wished He Knew and His Most and Least Liked Things about the Field Chris was initially discouraged from pediatric ophthalmology by other ophthalmologists who said that the pay wasn't very good. While it may be true they make less than general ophthalmologists, he doesn't think it's a reason not to the the field. He feels they get paid pretty reasonable. So he would probably go back in time and tell himself not to worry about that. "If you like kids, I think you should go ahead and do it and not worry about the money because the amount you get paid is reasonable." What Chris likes the most about being a pediatric ophthalmologist is being able to play with the kids everyday. It's a lot of fun. He thinks they're adorable. There's everyday that they say something that would make him smile or laugh. For him, it makes the whole day worth it. On the flip side, what he likes the least is the small 5-10% of children who are very difficult to deal with. He had to pry their eye open to get him to do an eye exam. [20:00] Major Changes Coming to the Field and Chris' Final Advice for Premeds Chris mentions some interesting things on the horizon for ophthalmology. recent research has been focused on treating amblyopia with a certain type of iPad game. It encourages stereopsis in using both eyes together to treat amblyopia. This is an exciting development in their field that he's waiting to see the results from. Retinopathy of prematurity is a disease they commonly encounter and there are some new treatment options in the last five years. They're waiting for really good results from it. So there's a lot coming around the corner.  It's a very rapidly moving and progressing field. "Ophthalmology is a very exciting field for technology and innovations. There's always new stuff going on." Lastly, if Chris had to do it again, he would have chosen the same field in a heartbeat. He thinks it's a really great field. His advice to premed students out there is to not jump into making a decision. Take time. Do rotations and explore as much as you can before making a decision. Once it's made, you can't really change it. It's difficult. [21:45] Last Thoughts If you are thinking about pediatric ophthalmology or any pediatric subspecialty for surgery, this gives you an idea of what is out there for you. If you have any recommendations for specialties we haven't covered yet or you know somebody you'd like to hear on this podcast, shoot me an email at ryan@medicalschoolhq.net. Links: The Wills Eye Manual by Adam T. Gerstenblith The Premed Years Podcast Specialty Stories www.medicalschoolhq.net/group ryan@medicalschoolhq.net