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Play Episode Listen Later May 1, 2019 24:22

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

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92: A Community Allergist and Immunologist Shares Her Specialty

Play Episode Listen Later Apr 24, 2019 32:06

Session 92 Dr. Neeta Ogden is an allergist and immunologist. She has been out of training for about 13 years and she talks about her career as an allergist in a community setting. She shares some tips and tricks for you as you're going through the process to hopefully become an allergist if this is something you're interested in. [01:16] An Interest in Allergy There are two paths to Allergy fellowship – internal medicine residency and peds residency. Neeta took the internal medicine route. She remembers being in one rotation and the patient was very sick. He needed penicillin desensitization. And she found this very interesting that it was so specific. She describes the field as being precise, systematic, and specialized, which simply drew her to it. Then she did some HIV research at the hospital she was training at. Although she comes from a family of doctors, she never really came across Allergy until her residency. She also liked Dermatology at that time because there was an overlap between the two, but she hasn't really thought about doing anything other than Allergy. Otherwise, she would have just really chosen internal medicine. She thought Allergy was also a great lifestyle specialty. She didn't want to be taking crazy calls at the hospital so this was part of her thought process in choosing the specialty too. [06:24] Types of Patients With the huge rise of food and environmental allergies today, her day-to-day practice is mostly private practice. She sees a variety of both children and adult patients. She manages a lot of skin allergy. She also sees children with food allergies, allergic rhinitis, and asthma. She doesn't see a lot of complicated immunology although it could come up once in a while. "There's a ton of rashes and hives and allergic skin reactions more than I probably would have thought I would see." Allergy is driven by immunology and the immune system, the TH2 arm of our immune system specifically. But there's also a specific discipline of immunology like DBID. But she really doesn't see as much. That being said, immunology and allergy are both driven by the same pathophysiology. Immunology is rare and is a discipline that highly evolves in academic centers. In fact, Neeta would 100% defer to academic medical centers for immunology or complicated immunology. [10:16] Community vs. Academic Although Neeta still sees patients at the hospital, it's not the same thing as being in an academic setting which she also misses. Nevertheless, this decision was driven by a lifestyle choice. She joined her family of doctors, a multispecialty private practice, which gave her incredible flexibility of time and overhead. Being a mother, she also thought she'd be more successful in treating patients if she had this level of flexibility. [11:11] Diagnostics Neeta does diagnostics for almost every single patient. Patients are referred to her to find out what they're allergic to. 95% of patients end up getting bloodwork or allergy test in her office. [11:45] A Typical Day A typical day for Neeta would be walking into the office, rotating between three exam rooms. She does a variety of procedures – skin testing, patch testing, pulmonary function testing. Patients end up staying in the exam room for a considerable length of time. So what she does is bringing them on different days for specific testing. [13:05] Procedure Work Procedures done may vary from doctor to doctor. Neeta says procedures can be delegated to staff provided they're trained well. She does scratch testing, pulmonary function testing, and patch testing, application, and removal. They could also do variations of nasal endoscopy. [13:50] Taking Calls and LIfe Outside of Work Neeta takes calls at the hospital but it's not that often. She can get called for desensitization for patients who need it. Other issues she would usually encounter include endroedema and complicated asthma. But then again, it's not that often. "Internists, general doctors, and ER docs know how to get patients to a safe place and then discharge them with an instruction to see an allergist. Neeta describes this specialty as being one of the nicest specialties. You can have a rigorous work life but you can still spend time with your family. [15:50] The Training Path You obviously go through medical school for four years and then followed by a residency either in pediatrics or internal medicine. Around 3rd to 4th year, you will be applying for an Allergy Fellowship. At her time, the specialty was pretty competitive. The fellowship is really for everybody including peds and adults. Then when you ultimately go out, you treat both. To be competitive to match, try to find the chief of Allergy/Immunology at the hospital and get involved with research to show your interest. "Show some sincere interest and truly research. Dedicated work never hurts." [18:30] Subspecialty Opportunities and Bias Towards DOs There are medial centers that have a Food Allergy fellowship as well as other subsets where you may be able to go deeper. As for any negative biases towards DOs, Neeta hasn't really seen anything at all. There are just so many DOs everywhere and they're great doctors. [19:50] Working with Primary Care and Other Specialties Neeta wishes that primary care physicians wouldn't just test a battery food allergy test because people may leave the office thinking they're allergic to all these things and they need to stop. When in reality, we all have antibodies circulating in our bodies. So there isn't really any clinical relevance without a history of a reaction. So it's important for them to know how to interpret those tests or just leave it to the allergist. She also hopes they don't lead people to believe it's an immunology when it's actually an intolerance. She has seen a lot of primary care physicians though that know the updated food guidelines in terms of allergy that all infants should be started on. Hopefully, this is going to turn around peanut allergy cases that have been rising in the last two decades. Asthma is another one that she commonly hears where a primary care physician says they don't have asthma because they're not wheezing. But nocturnal hop especially in children is equivalent to wheezing. So she wishes she wouldn't hear as much of this as this makes the parents of patients doubt you. Other specialties she works the closest with include Dermatology, GI, ENT, Pulmonology, etc. She says asthma is either taken care of by pulmonologist or an allergist. But an allergist can probably help more since much of asthma is driven by allergy. "So much of asthma is driven by allergy and an allergist can do a bit more to help." Neeta further shares an advice to aspiring primary care doctors who would be consideirng whether to send their patients to an allergist or a pulmonologist. If the asthma is triggered, pulmonary may be the better route. But the medications they're going to use are just the same anyway. That being said, you can't go wrong. [24:50] Special Opportunities Outside of Clinical Medicine A big part of her life is doing work in the media. Neeta has done a lot of TV and educational media around the issue of allergy, which has become a hot topic. You could also write or have a podcast. [25:50] Most and Least Liked Things About Allergy What she wished she knew that she knows now going into the field is that the field requires a bit of being business savvy. What she likes most about the field is the ability to make people feel better. "Even though so many allergy medications are over the counter, I don't think people know how to use them efficiently." What she likes the least, on the other hand, are chronic issues that can make people feel miserable. In many cases, they don't respond to therapies. Treating the chronic asthmatic isn't also fun. [27:44] Major Changes in the Future Neeta has read about allergists fighting against an FDA regulation that allergists can no longer make shots for their patients. This would be problematic since this is a huge source of income if you're administering shots. Moreover, there's the automization of skin tests and the interpretation can take the allergists out of the picture. But that being said, you may think people may no longer need allergists. But people need that expertise. [28:31] Final Words of Wisdom If she had to do it all over again, Neeta would have chosen the same specialty. She simply loves it! She loves the "detective" aspect of it. One of the biggest medical mystery allergy-related cases she had seen was the drug reaction with eosinophilic systemic syndrome. Finally, Neeta wishes to imparts to medical students and premeds that allergists are needed. You have to be willing to make time for people. Empathy is also needed. Keep in mind how valuable you are. Realize how much difference your words and your education can make in the lives of patients. "It's a specialty that continues to be incredibly relevant because allergies are only going to get worse." Links: NeetaOgden.com MedEd Media Network

25: Analyzing a Passage That Uses Monsters as a Metaphor

Play Episode Listen Later Apr 10, 2019 16:09

We often associate the word monsters with scary movies. Yet, in this passage, monsters mean something different. Follow along and see if you can interpret the metaphor. Links: Full Episode Blog Post Link to article: https://aeon.co/essays/there-be-monsters-from-cabinets-of-curiosity-to-demons-within medicalschoolhq.net/jackwestin https://medicalschoolhq.net/meded-media/ (MedEd Media Network)

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90: What Does Academic Infectious Disease Look Like?

Play Episode Listen Later Apr 10, 2019 37:32

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

23: Do Charming People Still Exist? Using our MCAT Skills

Play Episode Listen Later Mar 27, 2019 28:35

Is the most charming person you know really charming? Follow along and use your MCAT CARS Skills to see if you can define what it means to be charming. Links: Full Episode Blog Post Link to article: https://www.weeklystandard.com/joseph-epstein/charm-is-a-disappearing-luxury-like-chivalry-and-good-manners JackWestin.com https://medicalschoolhq.net/meded-media/ (MedEd Media Network)

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88: A Look Into Nephrology With A Program Director

Play Episode Listen Later Mar 27, 2019 33:37

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

10: USMLE and COMLEX Prep: Physiology of Cystic Fibrosis

Play Episode Listen Later Mar 27, 2019 12:08

Session 10 This week, we're going to tackle respiratory stuff, specifically about cystic fibrosis. Again, we're joined by Dr. Andrea Paul from Board Vitals. This podcast is part of the MedEd Media Network. Please share us with fellow residents as well as medical students and premeds who are also on this path towards becoming a physician. [02:41] Question of the Week: An 8-year-old boy is presenting with a history of recurrent respiratory infections. His parents are complaining that the patient complains of fatty stools. Positive sweat chloride test confirms his diagnosis. The patient will likely have difficulty storing which of the following: (A) Folate (B) Vitamin B12 (C) Vitamin C (D) Vitamin D (E) Zinc [03:11] Thought Process Most students would easily be able to identify the condition here would be cystic fibrosis. But this is not what they're asking. So the "sweat chloride" would be a strong buzzword painting that picture of cystic fibrosis. Recurrent infection and fatty stools were also mentioned so that would make you think along the lines of fat digestion and fat storage. What happens here is it brings damage to the pancreas which impairs the production of fat-digesting enzymes or pancreatic enzymes. So you have decreased ability to digest as well as decreased mobility to store fat. This would be down the fat-soluble vitamin route. Then you should be able to pretty quickly identify Vitamin D. [04:35] Other Possible Questions They may ask about inheritance patterns with cystic fibrosis. They love to talk about microbiology with cystic fibrosis. What type of bacteria is commonly found in the sputum of patients with cystic fibrosis? They may also ask about the GI symptoms associated with it. They could ask the background of the symptoms and what tests could be done or what would be found for further diagnostics or imaging of the patients with symptoms that sound suspicious for cystic fibrosis. It could be the whole spectrum of things from presentation all the way through diagnosis and treatment for cystic fibrosis. [05:53] New Therapies Coming Out With so many new therapies related to cystic fibrosis right now, it's hard to say as to how long it would take for these new therapies to be included in the tests. If it's something that came out within that year, it could just be added as a beta question and not necessarily counted in the grading, and then they're just going to add it as a graded component the following year. [07:05] More Things About Cystic Fibrosis When thinking about presentation, look at the symptoms of a patient with cystic fibrosis such as recurrent infections, chronic productive cough, shortness of breath, GI symptoms, especially in infants and young children where you have probably greasy stools, malabsorption-type symptoms. There could also be pancreatitis. On exam, if the kids are not diagnosed yet, you would see failure to thrive. The question might describe that the skin tastes salty or their sweat tastes salty, another hint that they could have cystic fibrosis. Then think about things like chest x-ray seeing hyperinflation. They could put in there what test should you use or maybe they'd mention the results of that test. In terms of genetics, think about other primary cellular dyskinesia or other immunodeficiencies with recurrent infections. Those are the things to keep in mind as differentials. Also, think about prognosis and common complications. There are long term complications of cystic fibrosis such as infertility, drug-resistant infections from having antibiotics chronically from childhood. [09:10] Final Thoughts It could be overwhelming for students with all these bits and pieces of information. But it's doable. You're not expected to remember every single piece. The goal is to memorize them all but once you get to a certain point of knowing the most important or the most commonly tested effects, oftentimes, the other things are tied in there. So once your mind goes to the right direction, you'd have all these other associated things coming in. "Once you get the basics down, the rest is in there." [10:50] Board Vitals Check out Board Vitals if you want more questions. Sign up for a free trial so you can understand what types of questions, what the questions and explanations look like. Try out any of their 1-month, 3-month, 6-month plan. Use the promo code BOARDROUNDS to save 15% off. Links: Board Vitals (promo code BOARDROUNDS) MedEd Media Network

school positive prep med gi vitamin d physiology cystic fibrosis recurrent cystic fibrosis usmle comlex boardvitals meded media network

9: USMLE and COMLEX Prep: Renal Pathology Patterns

Play Episode Listen Later Mar 20, 2019 15:46

Session 09 In our renal question today we are asked to identify the pattern we would see on electron microscopy. See if you can find where the question leads you! Once again, we're joined by Dr. Andrea Paul from Board Vitals. If you're getting ready to start preparing for your Step 1 or Level 1exam, check out Board Vitals and their QBank. Use the promo code BOARDROUNDS to save 15% off your QBank purchase. For more resources, be sure to check out all our other podcasts on the MedEd Media Network. [02:50] A Challenging Area Renal tends to come up in the top 3 of questions where people are going back because they answered them incorrectly or that they're saving and redoing questions in this category. This indicates a level of less confidence or knowledge gap that needs to be filled for most students. Andrea thinks renal is a challenging area being a complicated system with a lot of memorization involved in the different syndromes. It's a combination of genetics and pathophysiology and pathology. You'd have to be able to do everything from figuring out the disorder and knowing what it would look like on biopsy, looking at diagnostic studies and the physiology involved in the different renal disorders. [04:22] Question A 16-year-old boy presents. He recently immigrated from Russiam, has no major medical problems. He does mention he had an episode of light red urine three weeks ago. At the same time, he had a mild cold. He has no known allergies, no recent drug use or medications. His family has traced positive for kidney disease in his maternal uncle, but both of his parents are healthy. He also mentions that he has had lately noticed that he has mild hearing problem but he's never thought much of that. It's asking a kidney biopsy. This patient would most likely show which of the following: (A) Linear pattern of IGG with fluorescent microscopy (B) Splitting of the glomerular basement membrane (C) Mesangial cell proliferation (D) Epithelial humps or a thickened basement membrane that looks like a train track [05:50] Finding the Diagnosis The first thing to note here is the hearing loss, which is something that would lead you down a specific road. So we're given a little hint here that can be very helpful. Based on history, the hearing loss would be due to Alport syndrome, which is a collage type 4 mutation resulting in abnormal basement membrane, that includes renal involvement, ocular involvement, and sensory neural hearing loss. In this question, the answer you'd look at is the splitting of the glomerular basement membrane. The other way to describe this is the basket weave appearance, also known as the glomerular basement membrane lamellation, characterized by the layering and splitting of the membrane. The key here is the Alport syndrome and remember what the findings would be and that specific disorder. [08:30] Potential Questions One possible question could be what other symptoms the patient may be experiencing. How is this commonly inherited because Alport syndrome can be inherited in a X-linked dominant way. You can also look through everything from genetics all the way through the pathology and electron microscopy for each disorder. Or maybe they won't mention hearing loss but vision symptoms or inheritance pattern they've seen in the family, which they did when they mentioned the maternal uncle. So they've hinted this as well. [09:50] What If There Was No Hint If the question would have left the hearing loss out, they would probably mention a more extensive family history so you could see the inheritance pattern. They're also mentioning hemoturia so you're led to a nephrotic syndrome. That would also help. But they'd probably give you additional information to lead you down a more specific road for one of these different nephrotic causes. [10:32] More Things to Know About Renal Stuff You need to know the different patterns for each of the different nephrotic syndrome causes. This is part of the reason people redo these questions over and over. There's a lot of memorization involved such as APGN and RPGN and what those look like, as well as microscopy. For this question, you would think through things like Goodpasture syndrome where you'd see a different pattern then you'd see that linear pattern which is that first option. And if it's in older males then you'd have respiratory symptoms because there's lung involvement. So you have to think through all the different associated organ systems with the different disorders and memorizing what the pattern looks like on each of them. As far as symptoms, inheritance, and treatment, there are different diagnostic studies and treatments and those are the ones you can reason through based on the different disorders and what the physiologic effects of each is. Lastly, keep in mind to know the demographics are. Some of them are more common in patients with specific histories, or ages or backgrounds – anything that can help you get to the answer more quickly will be helpful. The immigration component must have been put in there too since there's not a whole lot of medical history available. So they could actually put in things that could be helpful or completely just inserted for background information to make the case more robust, but not necessarily valuable. It's important to think through each piece of information in the question to make sure they tie together and you'd be able to eliminate something that clearly doesn't help you. So you don't focus too much on every specific part of the history. [14:32] Board Vitals Going over questions is the most beneficial thing you can do as a medical student preparing for your Step 1 or Level 1 exam. Check out Board Vitals for some help. They QBanks and over 1700 questions for Step 1 and almost as many for Level1. Have a free trial and check out their system to see if it works for you. Use the promo code BOARDROUNDS to save 15% off. Links: MedEd Media Network Board Vitals (promo code BOARDROUNDS) Specialty Stories Podcast

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87: What is Sleep Medicine? A Look at Academic Sleep Med

Play Episode Listen Later Mar 20, 2019 32:03

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

86: The Ins and Outs of Academic Cardiothoracic Surgery

Play Episode Listen Later Mar 13, 2019 40:57

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

85: An Academic Cardiologist Shares His Specialty

Play Episode Listen Later Mar 6, 2019 30:46

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

84: Cardiac Electrophysiology—What is it?

Play Episode Listen Later Feb 27, 2019 40:03

Session 84 Dr. Edward Schloss joined me to talk about his journey to Cardiac Electrophysiology, what 17 years in the field looks like, and his likes and dislikes of his specialty. If you're a premed student, go check out all our other resources on MedEd Media Network. If you're a medical student, go check out our newest Board Rounds Podcast. [01:17] Interest in Cardiac Electrophysiology Coming out of undergrad as an engineer, Edward wasn't sure he wanted to be a doctor and only found out as he got further along. It was during second year of med school that he had an ECG class and they were already problem-solving instead of just plain memorization. He also got through different phases such as rheumatology, nephrology, and primary care. In fact, he recalls telling himself one evening that he wasn't going to be a cardiologist. He actually got interested in serial drug testing back in the old days, where they would take people who had cardiac arrest into a lab and they would pace their hearts in order to induce the arrhythmia. They would start the medication and bring them back and do it again. Until he got to the people that did electrophysiology and got mentorship. [04:05] Traits that Lead to Becoming a Good Electrophysiologist Edward says you have to be analytic. You have to be able to look at data objectively and there are going to be mountains of data and you have to sort through the good and the bad. In the lab, you have to be highly meticulous. You have to be focused and meticulous for hours on your feet to be able to get through that. Moreover, establishing relationships with patients is also super important. They don't meet patients on the table, but they meet them ahead of time. They deal with people that are very vulnerable and intimidated. Many of them have been through something life-changing. They're facing the risk of cardiac arrest or they've been through it. Or they're scared to death about their arrhythmias. So you need to humanize it and gather their trust before they hit the lab. And for many of these patients, you follow them for many years. Having a lot of device patients, they have metal in their body that he's responsible for, for the rest of their life. "These people have a hunk of metal in their body that I'm responsible for for the rest of their life so they're kind of married to me professionally." [06:10] Types of Patients and Diseases Edward illustrates a mix of patients coming in. There are young people with palpitations, fainting episodes, which are common. As they get older, you start to see patients who may be healthy but have developed atrial fibrillation from a variety of causes. As you go further to the older population, you'd see patients with myocardial infarction and then you get to the heart failure population as they get older. Edwards favorite is the 90-year-olds who may have a heart block and fainting episode and you put a pacer in them and they're good to go. Edward has a good number of referring physicians, mostly his own partners. When patients hit the door, it's not unusual for them to be ready to go. So they've probably had their echo or their medications, etc. A lot of times, they don't know what they need which is pretty common. So it's common for Edward that he'd have to craft the patients' expectations a little differently. "If they think they know what they need, much of the time they're wrong. That's not because they're not good doctors. It's just our field is so highly specialized." [08:55] Typical Day Edward arrives before 7 am, depending on how much is going on in the hospital. He runs around and sees his post ops. It's very important to see people the day after their procedure personally to cement the relationship. Then he makes it to the lab or the office by 8 am. His days are generally either all day lab or all day office. On an office day, he'll see patients from 8-8:30 and from 8:39 to 5 or so, he sees his patients. Some days can be light, others can be busy. On a lab day, they do procedures that can sometimes take a short amount of time. Sometimes, it takes several hours. It's hard to predict which number of hours. Typically, his day is done by around 6 pm. [10:29] Community vs Academic Edward chose the community setting over academic. He was one of the aggressive fellows who felt ownership over his patients. He jokes around that by the time he got done he was a "PGY-8" which just means that it takes a long time to become an electrophysiologist. So feel kind of ready for it and want to do things yourself. So he hated it when his attendings would lean over his shoulder and take control of the catheters or do access. He realized once he got out of practice that he wasn't going to change. So if he had to do an academic practice and had to teach fellows and give them control, then he would have a tough time with that. Then he found research later in his career but he tried to skirt away from it as much as he could. He did enjoy teaching but he wasn't sure if he was going to be patient about it. [12:33] Percentage of Procedures and Taking Calls If somebody hits his door as new patient evaluation, he does a procedure on them of about 75%. For the 25%, he sees a lot of people come to him for benign palpitations and sometimes all they need to do is put on a monitor and determine they're benign and reassure. This doesn't lead to a procedure. Basically, taking calls has evolved over the course of his career. Most electrophysiologists he's talked with would like to be purely electrophysiology on call. But it took a long time to get to that point. He'd take calls every fifth night and every fifth weekend. He used to do general cardiology call. Then as they got bigger and built an electrophysiology-specific call, the calls got less frequent. But as it got less intense, it became high acuity calls and in many cases, they're very knowledge-based, difficult, complex calls. [15:25] Work-Life Balance Edwards admits going through periodic retirement fantasies, not because he doesn't love his job, but because he just loves his home life. He's got a phenomenal family and a great place to live. So he enjoys being away from the hospital. Weekends he just shuts everything down so he can stay at home and have a nice time. "When you're here, you've got to be here. So you've got to actually devote yourself to that." [16:30] Training Path to Become a Cardiac Electrophysiologist You start out as an internal medicine resident after medical school which is three years. And then you decide whether you go to cardiology and get a cardiology fellowship which is another three years of general cardiology. Then you subspecialize and choose electrophysiology. Depending on what program you're in, that might be combined into the general cardiology program, or it might be a separate fellowship. For him, it was a separate fellowship that added two additional years. In total, it's eight years of postgraduate training before you finally get a real job. In terms of competitiveness, Edward thinks it's still the interventional folks are the most popular. But there are also attending EP (electrophysiology) spots. He thinks it depends on when you get out and what the path is. But just the cardiology itself is tough to get into. [18:16] Other Opportunities to Further Subspecialize "EP is a very narrow field but within that narrow field, there's a fairly significant breadth of knowledge." Edwards describes the specialty as cutting down in the middle between two basic worlds at least within procedural, namely: device implantation and ablations. The amount of research, attempts, and trials before ablation became actually refined to what it is right now, Edward would describe as the longest procedural research type of learning curve he has seen within his field. [20:23] Bias Against DOs and Working with Primary Care Physicians and Other Specialties The DOs Edward has met he'd consider as some of the best docs he had in practice during his fellowship. He personally didn't feel any bias at all. He hopes it's still as open as it was when he was there. They were just rocking and rolling it just like everybody else. Edward feels blessed to have a healthy referral environment. But what he could tell primary care physicians to help cardio electrophysiologists with patient care is first knowing when to refer. And this is true to a lot of other specialties. There are people who are out there but they haven't been referred. And some of their patients have been held onto too long before they could have done something food for them. So if you've got somebody who had heart failure and they haven't seen an electrophysiologist, please refer those folks out. Atrial fibrillation is a classic example where the evolution of how it's being treated has changed quite a bit and not every primary care physician may be aware that they've got great treatments for atrial fibrillation now but they need to get the people earlier rather than later. Additionally, basic testing is important and this applies more to his general cardiology colleagues rather than the primary care physicians. But simple things like just getting EKGs and people that are symptomatic. It's not unusual for him to see somebody who has had an echo, MRI, or cardiac cath, but has been six months since their last EKG and then they will find something that changes the whole game just because the EKG wasn't checked. "We've got great treatments for atrial fibrillation now but we need to get the people earlier rather than later." Edward says EPs are rarely referring out. But they have healthy working relationships with their general cardiologists and heart failure specialists. So it's 90% other cardiologists, although he does work with primary care physicians. But the pathway to a referral from primary care is to put them first into the cardiology system and then from within the cardiology system, they can then be referred to an EP. [24:15] Special Opportunities Outside of Clinical Medicine They work with very complex and technical equipment, very technically complicated. It may not be unusual in medicine but once patients leave the hospital, they still have that equipment inside their body. And that has to be maintained, serviced, and troubleshot. So pacers, defibrillators, biventricular heart devices are super complex. There are lots of things that could go wrong and lots of nuances to how they program the devices. So the industry is critical for them to be able to manage those appropriately. You will have an opportunity to work in the industry. At the MD level, you can consult. Some people work full-time with industry. "Done right, industry-MD partnerships are very healthy. Done wrong, obviously, it is the dark side." [26:23] What He Knows Now That He Wished He Knew Going Into EP What dawned on him as he went out to practice was that the overwhelming amount of information they had to deal with can become absolutely critical that you need to build a team around you and you need to reward and support that team. And they will return to you what you need to be able to take care of your patients. So you'd have to train these people and keep them otherwise you're going to be up the creek if the right people leave you. So take care of your people. "It's literally impossible to do this without this healthy group of supportive people." What he likes the most as a cardiac EP over his years of practice is appreciating the nuance of patient care. Coming out of college as an engineer, he didn't realize how much he liked patient relationships. Another thing he likes is the troubleshooting and complex management of devices. It's a big world that is somewhat impenetrable early on. But once you get in a little bit deeper, these things just open up into so many interesting things. "Barely a day doesn't go by that I don't see something I've never seen before and it just blows me away just how much nuance and difference there is in what we do." Electrophysiologists are very passionate, as Edward describes it. They love what they do and almost nobody knows what the hell it is that they do. And this keeps getting bigger and bigger as they people try to understand this and the world just opens up to you. On the flip side, what he likes the least is pleasing masters that don't have their best interest in mind. He doesn't like checking boxes or doing unnecessary documentation. He doesn't like following the rules of someone who doesn't literally understand why they wrote those rules – the faceless beaureaucrats – for lack of a better term. Regulatory requirements and fighting for thingsfor your patients from people that are not invested or informed or experts are very challenging. "It's very challenging to do the things that are necessary to do the job that have absolutely nothing to do with the delivery of health care." [31:11] Major Changes in the Field Edward says that if you're a medical student coming in, dive in! This is not going anywhere, and it's just going to get more and more interesting and more exciting. Their patient population is not going anywhere. In the field of devices, we're getting away from the traditional way of delivering energy to the heart which is through leads that pass through the vasculature and down into the heart. We now have very early stages of fully, self-contained pacemakers that go inside the heart entirely, the size of a big pill. This is still in its infancy but the leadless technology of where we're going with devices is getting bigger. It won't completely replace the traditional leads, but that's where we're heading and it's very cool. Plus, Edwards says they're fun to put in! On the ablation side, you'd have to figure out where the arrhythmias are arising in the heart and then how to isolate or eliminate the tissue causing that to arise. Most of those techniques are catheter-based and either freeze or burn. You do a lot of sophisticated mapping to try to figure out where to go. Another amazing thing now is a group partnerring with radiation oncology to external beam-radiate the heart and eliminate arrhythmias that way. Still under thorough investigation, but most of them are excited about how this is going to happen. It could revolutionize how abalation is done. [34:12] Edward’s Thoughts on the Apple Watch with the EKG Feature Edward is pro and informing patients and giving them access to data. But it is a challenge to do that correctly. The problem you can run into with Apple Watch is that you're casting an enormously wide net on a very low risk population. No matter how good the technology is going to be, you're going to see a lot of false positives, which are going to lead down rabbit holes and additional testing – not to mention the fear on the part of the patients and their families and the resources that are going to get used up in the process. Even in the true positives, you're going to see a lot of detected asymptomatic atrial fibrillation. Frankly, we have very limited information about what to do about that. We know a little something about asymptomatic atrial fibrillation because we see it in devices. There are people walking around with pacers in their heart who may not have a diagnosis of atrial fibrillation. But the device will pick it up. And there's still enormous controversy about what to do with that population. "We've got to justle as a discipline to figure out how to manage these folks." [36:28] Final Words of Wisdom If he had to do it again, Edward would still choose the same. There's nothing in medicine that he could imagine he would do more than electrophysiology. It's got all the techy stuff, troubleshooting, engineering, relationships, surgeries - all these that fascinate him along with the crazy good outcomes, seeing people rise up. It's gratifying how you can turn people around Ultimately, Edwards advice to those considering this field is that if you've got the bug like somebody shows you a crazy EKG or someone comes out with a dev.ice and looks cool,t hen don't be intimdiated. Seek out the right people. You're not going to figure this out on your own. He suspects it's going to be tough to get into fellowship unless you have some contacts. So find somebody like him who would be thrilled that you found this interesting as most people are scared away or just not interested. The stuff is going to look complicated and boring. But just hang in there. After a while and with the proper teaching, it's all going to open up and it's going to be just incredibly fascinating! And then you'll be part of the club. "If you get the proper teaching, it's all going to open up and it's going to just become incredibly fascinating! And then you'll be part of the club." Links: MedEd Media Network Board Rounds Podcast

community patients md seek types edwards depending traits apple watches mri procedures eps barely final words percentage major changes weekends ecg ekg primary care physicians atrial pgy ekgs cardiac electrophysiology other opportunities meded media network

83: What Does Community Pediatric Cardiology Look Like?

Play Episode Listen Later Feb 20, 2019 34:54

Session 83 Dr. Renee Rodriguez is a community-based Pediatric Cardiologist. She shares why she loves children’s hearts, a typical day, and whether she has balance in her life. Meanwhile, be sure to check out MedEd Media Network for more helpful resources. [01:25] Interest in Pediatric Cardiology The first time she realized she wanted to do pediatric cardiology was the second she started residency being her first rotation as a pediatric resident. For her, residency was the best thing that ever happened since she wasn't in school anymore. She did another rotation but it wasn't as fun as cardiology. From a physiology standpoint, Renee finds congenital heart disease super interesting. It's like a puzzle where you have to figure out where the blood flows based off of what the anatomy is. So she fell in love with congenital heart disease, to begin with. She also fell in love with the patients. For most kids with heart disease, they're neurologically intact. So Renee got to bond with each of the patients Renee would describe pediatric cardiologists as having a unique personality of being able to not only communicate with kids, but also surgical in nature, are cut to the chase, and have high expectations. And she felt she resonated with it as she wants things to be more hardcore. [05:08] Traits that Lead to Being a Good Pediatric Cardiologist Renee describes a good pediatric cardiologist as being constantly questioning what is happening and trying to evaluate things in multiple different ways. Try to understand how to use those different modalities to answer a good question. You could order all of those tests on every patient but that would not be good care. So you have to be thinking about what you're trying to answer and how you can best answer it in a non-invasive way to get the results you need. And if you need to have invasive testing, what is it going to gain, the timing of it. So you need to be able to decipher how you're going to work a problem up. You have to be able to be collaborative. In pediatric cardiology, you're working with surgeons, EP doctors, transplant, heart failure, pulmonary hypertension -- there's a lot of little subspecs when your patient is getting a little bit more complicated. As a pediatric cardiologist, you're needing to be the conductor in all of this between all of the different specialties when it gets pretty complicated. So be collaborative and be able to deduce how you need to work a patient up and what each test is going to give you. "Be a calming collective presence for families. Patients who come to see a pediatric cardiologist are petrified, even if it's just an innocent murmur or the kid has chest pain." Moreover, you have to be calm to the patients and their families as parents are walking in the door, worried and freaked out that their kids are going to die. Most of the time, the kids are totally fine. It's not going to be anything major. But if it is, it's going to be something they're going to live with. You're going to have to be able to dance that wine and speak with parents as you're trying to give them that information and guide them through it while not totally having them walk out of your office in shambles. [07:35] Types of Patients As an outpatient community pediatric cardiologist, she sees a lot of murmurs that are typically benign, like a small hole or small valve defects, nothing major, that typically doesn't require any procedures or intervention. One of the common ones that present later in life is a large atrial septal defect. You don't necessarily pick up murmurs unless there's a significant blood flow across the hole on top of the heart that it causes some rumbling across the pulmonary valve. A lot of those kids present a little later when you hear that murmur and it can be mistaken a lot for a typical murmur so physicians don't necessarily send them until later. This would be one of the things that would require some intervention like surgery or cath procedure based off of the defect size. She also sees chest pain which is rarely ever cardiac. In kids, it's typically musculoskeletal or lung-related. If it has something to do with exercise, Renee gets those referrals. She also does preventative cardiology, a large portion of her practice is cases with high cholesterol, obesity, pre-diabetes, family history of early coronary artery disease or hypercholesterolemia. She also does a fetal echo. That's a whole different realm of primary indications that a pregnant woman would need. [09:45] Diagnosing Patients The large majority of her patients come to her undiagnosed and then she sees them. She built up the fetal echo practice because of the way pediatric cardiology is today where we rarely pick things up post-natally. "Because of our imaging abilities now and good prenatal care, we tend to pick up most significant congenital heart defects in utero." If you're a pediatric cardiologist scanning a patient, they're doing a fetal echo and identify a defect or a patient needs to deliver, you become that patient's pediatric cardiologist once they're born. Meanwhile, general pediatricians will pick up as an outpatient such as murmur, chest pain, family history, etc. They may do an EKG before they see you but usually, it's the pediatric cardiologist that does the diagnosing, if anything needs to be diagnosed. [10:52] Typical Day and Taking Calls Renee comes in two and a half days a week. She comes in the morning. She basically categorizes her patients. Her heart-healthy lifestyle patients are her more preventative cardiology patients like high cholesterol or obesity patients. It's more about lifestyle counseling, nutritional, exercise, etc. For cardiology patients, she will have them get an EKG before they come in. She will review it and walk in the door and decide if they need any further testing. She starts at about 8 am with an hour-long patient slot for new patients. Return patients will have half an hour usually. She sees patients from 8 to 5 on Thursdays and Fridays, doing echoes, and doing EKGs in the clinic room, answering in-basket messages from patients or answering phone calls. Then she's done by about 5:30 pm after she has closed her charts. "I do a lot of pre-charting. I pre-chart on all my patients beforehand so that by the time I get to see them, obviously I will have reviewed the chart in its entirety and then I can just add in what I need to add in quickly. In terms of taking calls, she doesn't take any in-house calls. She's actually surrounded by two major universities with very robust surgical and inpatient hospitalization with certain pediatric cardiology patients. So if they need advanced care, they can go to the two children's hospital near her. She also has some privileges at a couple of local hospitals where she can just get called anytime. And she has the option to take it or not depending on her availability. For her group, she's on call probably once every 6-8 weeks. She can just get called by any of the pediatricians in the urgent care or in their clinics, usually reading EKGs or answering questions for them. If there's anything very dramatic where a kid needs to be evaluated immediately, she can have them go to the hospital she's privileged at and she can evaluate them there. Or if she knows the children need some advanced care then she could just send them to the children's hospital. In terms of work-life balance, Renee considers having great balance. She built her outpatient practice to make sure it's a 100% possibility, reason that she took the decision to be part-time. That being said, she's able to balance her outside creative interest, her family, and her own self-care very well. [14:44] Community vs. Academic Setting Renee felt she received excellent training in evidence-based, high-quality, very well-thought out pediatric care. Sometimes, when you keep that only in an academic setting, you don't get to disseminate that kind of care outside. It's important to bring that kind of care to a community-based setting to be able to provide that same type of care people who wouldn't be able to travel always to Stanford or UCSF, where they're located. She thinks this kind of care should be disseminated everywhere. These are the things that led her to be in the community. "Sometimes, when you keep that only in an academic setting, you don't get to disseminate that kind of care outside." [16:35] Training Path to Become a Pediatric Cardiologist After undergrad and four years of medical school, you do a pediatric cardiology residency followed by a pediatric cardiology fellowship. There are selective programs now where you can match in a path from medical school, you become a resident for 2-3 years and then automatically go to your cardiology fellowship, you're guaranteed a spot. But typically, it's a three-year residency in peds and 3-year fellowship in cardiology, and then a couple of years after that if you want to subspecialize. There is a hugely growing field in pediatric cardiology called adult congenital heart disease. There are people who do adult medicine first and then spend time rotating through pediatric cardiology to get a better sense of congenital heart disease. They clearly understand the adult onset issues, but they need to understand the pathophysiology and surgical management of the pediatric realm. This is what ends up happening from the adult side and then they treat adult patients more than peds patients. Renee thinks that people who do Med/Peds could do that. As to competitiveness, Renee describes pediatric cardiology as one of the more competitive specialties of peds. That being said, most people she knew ended up matching into some programs. To be competitive, a resident has to be hardworking in everything they do regardless of what kind of rotation you do. So work hard and make great connections. Be a good learner and be open to opportunities. People talk to each other so never burn bridges. So working hard is always the right answer. "Go the extra mile when you're on the pediatric cardiology rotation, but you really should do that across the board because you have no idea who knows who and who could say what about what." [20:55] Special Opportunities for Subspecialization After cardiology fellowship, other areas for you to subspecialize include electrophysiology or interventional cardiology, pulmonary hypertension. There's also CVICU, which you can do from PICU or you go and do additional training in cardiology. Or if you're a cardiology fellow, you can go from cardiology and do additional year in pediatric ICU. Or you can just do an ICU year. There are also some preventative programs coming up where you can do an additional year of preventative cardiology. And adult congenital disease as mentioned above, which you can do from the peds side. There's also advanced imaging. [23:15] Message for the Osteopathic Students Renee never saw any DO students getting any different treatment or thought process. She believes that if you work really hard, there's no such thing as luck. Be there, be present. Work hard. Take opportunities where you can. Show off as your best self every time and you can get typically what an MD student would get. "If you work really hard, opportunities present themselves from the hard work that you do." [24:05] Working with Primary Care, Other Specialties, and Opportunities Outside of Clinical Medicine "Pediatricians should feel comfortable developing a relationship with a pediatric cardiologist." Congenital heart disease, for instance, is a hard thing to understand unless you do a deep fellowship in it. That being said, feel comfortable calling somebody, even just asking what the pediatric cardiologist thinks. At the end of the day, it's about having a team-based care. A lot of what pediatricians see in the clinic would be really taking family history. So anytime you're seeing a kid complaining about chest pain, really take a detailed family history. And not just cardiac disease but general heart disease, like if anyone in the family has this certain disease or not. Renee advises primary care physicians that if at any time you worry about a heart problem, take a very detailed cardiac family history. "Lots of things are genetic diseases that are passed down." Other specialties they tend to work the closest with include those from the subspecialized cardiology field, interventionalists, EP doctors, sometimes surgeons, neurologists. In terms of special opportunities outside of clinical medicine, you can get involved teams doing heart screening. There would be a lot more opportunities in the future as with technology and monitoring. [28:30] The Most and Least Liked; and Major Changes in the Future Renee really thinks pediatric cardiology is a very interesting field. What she thinks is cool is that you still get to see the people who you only read about on textbooks. "It is a super interesting fast-paced, highly evolving field with a lot of really amazingly smart, fun people." What she likes the most about this field is the way she's connecting with the patients and their parents. They are terrified the moment they walk into the clinic. But she's able to tell them that they're going to be totally fine. Of if there is something wrong, Renee is the person who can lead through this whole thing. Being able to take their hand through it all is something humbling. Conversely, what she likes the least is feeling like no matter how much you do, you can never tell with 100% certainty that everything is okay. In terms of the major changes she sees coming into the future of this field, she mentions the power of the smartwatch where you can pick up certain things. Ultimately, if she had to do it all over again, she would definitely do it. Her message for medical students and residents is that don't discount anything along your path. Really check all over again even if you think you've found what you really want. Don't get tunnel-visioned and think like you have to do well it a certain rotation only. Instead, work hard because everybody talks and pediatric cardiology is a super small field and everyone knows everyone. So you've got to put on your best face always. Always be showing up with your best self! Links: Follow Dr. Rodriguez on Instagram @reneeparo. MedEd Media Network

community work student patients md types stanford rodriguez med traits icu pediatric conversely cardiology primary care ucsf major changes ekg premed congenital typical day picu ekgs pediatric cardiology pediatric cardiologist med peds meded media network

82: A Look Into Academic Endocrinology and Thyroid Medicine

Play Episode Listen Later Feb 13, 2019 41:19

Session 82 Dr. Brittany Henderson is a former academic Endocrinologist, just switching to private practice and today she discusses her specialty, what she loves, and more. Our goal for this podcast is to show you what is out there for you once you get through medical school. Too much focus is on the academic setting as you're going through medical school and the majority of medicine is practiced outside of an academic setting. However, medical students don't get that exposed that typically. Our goal here, therefore, is to compare and contrast different settings. If you’re still on your journey towards medical school, please also check out all our others podcast on the MedEd Media Network. Back to our episode today, Brittany is an endocrinologist who has been out of training now for five and a half years. She has mostly been in an academic setting but is now moving to a community setting, opening up her own private practice. [01:57] An Interest in Endocrinology and Finding a Mentor Brittany started getting interested in the field during residency when she did an elective rotation with an endocrinologist, although she decided between this and geriatrics. She liked the patient population in geriatrics a lot but didn't like the subject material as much such as incontinence and the like. She likes endocrinology due to her chemistry background. During her second year of residency, she worked with an endocrinologist who was in the community and was on staff at the hospital. She got more exposure to endocrine and general endocrine and tried to see what it looked like on a daily basis. She points out the power of mentorship. "Really narrow it down to subspecialties and really look for those mentors around you to try to see firsthand what it looks like in the real world." [04:00] Traits that Lead to Being a Good Endocrinologist One must be able to look at the big picture but also be able to look at the little intricacies of how hormone systems work. As with her, Brittany's chemistry background really helped. You have to have an inquisitive mind and be able to think through things. [05:25] From Academic to Community Setting When decided she wanted to be an endocrinologist, she started working on some papers and presentations at some of the national meetings. She sees this as a very important aspect to be able to get into a fellowship. Once you've identified your mentor, ask for cool cases that you're willing to write up. This would serve as your academic exercise. You're also going to be able to get publication case reports and poster presentations at some of these national meetings. Then you're able to put this on your application for a fellowship. Ultimately, this sparked her interest in doing an academic career. Brittany has always loved the academics but she had an awakening that although she liked it a lot, she didn't want to be in the laboratory for the rest of her career. She didn't want to be struggling for grant money, which is a very hard thing to do in their field. She then decided that as she joined the faculty, she wanted to focus more on clinical endocrinology. She was an academic endocrinologist for ten years and ran the Fellows Thyroid Clinic and the Thyroid Cancer Tumor Board, which are two institutions. She was the medical director for the Thyroid and Endocrine Patient Clinic. She loved it having had the time to do clinical work, write papers, and do research. "But when you're split between doing a lot of clinic and wanting to do research, it's really really difficult to do everything well and have enough hours in the day." All this being said, she pondered on what she wants better – clinic or research. She chose the clinic and decided to go to her own practice she wants to build a thyroid center. Most of her practice in the academic world focused on thyroid disease along with some general endocrinology. But she wasn't able to do some of the other components of thyroid medicine that she wanted to do like running specific programs, write a book about thyroid disease, and do integrated medicine approaches to conventional ones. Geographic location was another reason she had to consider. All this became the impetus for her transition to private practice. "Be confident enough to change your mind and go in a different direction." Coming from strong academics to a clinical career is like jumping off a cliff as she would describe it. She's just trusting that all is going to work out. Taking risk sometimes is a good thing. [10:48] Types of Patients Brittany deals with mostly autoimmune thyroid diseases as well as a lot of thyroid ultrasound and procedures in her clinic. She also sees a lot of thyroid cancer where she does lymph node mapping. They're also doing minimally invasive procedures such as sclerotherapy or alcohol ablation therapy for patients with thyroid cysts who don't want to undergo surgery. Alcohol is injected into the thyroid tumor within the lymph node or into the thyroid cyst. This kills the blood supply to the thyroid cyst wall or to the tumor. The patient can then avoid surgery. In fact, they see about 70-80% reduction in the volume of both cysts and cancer lymph nodes. They also integrate radiofrequency ablation they use for cases that deal with the liver or the spine. The FDA just recently approved a probe for thyroid nodules so surgery can again be avoided in patients with benign thyroid nodules but with symptoms or are less attractive. For thyroid disease, most of the patients that come to her already know they have an issue so they come to her for further evaluation. Other patients also come in who have thyroid symptoms and want to be assessed without previous diagnosis although this is relatively rare. "For the more rare endocrine disorders, you're probably starting at square one. For thyroid and diabetes, they usually have a diagnosis by the time they get to you." [14:17] Typical Week Back in academia, Brittany would be in the clinic for about four half days a week and she spends the rest of the time following up on labs and calling patients back. In the new EHR system, they're having an in-basket where they're getting patient emails and emails from nurses. This could take up a lot of time unless you have somebody dedicated to helping you with this. Wednesdays would be an academic day so she'd be teaching fellows and residents. And she'd write proposals and letters. You can also have options as to where your clinics are a lot of times. For instance, she'd have a clinic at the diabetes and endocrine center on Tuesday mornings and she'd see general endocrinology patients. And Thursdays, she be at the cancer center downtown where she'd be seeing all thyroid cancer and endocrine neoplasia patients. Then Fridays would be spent on a collaborative clinic with the ENT surgeon, seeing a lot of the parathyroid and thyroid patients and doing ultrasound and mapping surgeries. What she likes being in an academic center is to be able to do a multidisciplinary clinic which she did in both places she was at. You're able to have clinic right alongside your surgeon or neurosurgeons and look at scans together. For thyroid cases, she does ultrasound all day everyday. It's like her stethoscope where she's able to actually look at the thyroid gland to help her diagnose the disease. For biopsies and other minimally invasive procedures, she does it on a weekly basis for about 5-10 a week. And for general endocrinology, it's very procedure-based and technology-based. All of your monitors are talking to your iPhone while you're looking at trends and a bunch of data. "Where diabetes management is going, it's very technology-driven. Eventually, we're going to have a close-looped system where you really don't need to make as many decisions because of computer technologies." Ultimately, for diabetes care, it's more technology-based and for thyroid care, it's more of procedure-based. There are multiple subspecialties of endocrinology that can appeal to different personality types. [19:24] Taking Calls and Work-Life Balance Brittany says one of the perks of being an endocrinologist is the minimal number of calls. There are very few endocrine emergencies and even if there are, usually the endocrinologist is just a consultant. So the primary team is able to stabilize the patient and you're able to go in the next day to see the patient. In fellowship, Brittany recalls going once for a patient and had to make plasma freezes. A lot of diabetes ketoacidosis (DKA) treatment nowadays are now protocol-driven and the hospitalist or the admitting physician can start management for that patient. The endocrinologist comes in after their DKA and then gives recommendations on a home regimen the next day. All this being said, thinking through things and being inquisitive are great traits for an endocrinologist. Brittany considers having a great work-life balance and there is enough time for rest and relaxation. [23:25] Path to Residency Training Endocrinology is typically a two-year fellowship. Brittany did a three-year fellowship since there are programs that do this. When she graduated and joined the faculty and was a fellow, she would ask some of other biopsies, offering if she could do extra biopsies and ultrasound. She also got an ACNU certification acknowledged by the AIUM (American Institute of Ultrasound Medicine) as endocrine training for neck ultrasound. As a fellow, you're supposed to have a certain amount of ultrasound and biopsies and be able to complete the entire panel of ultrasounds and biopsies in your first year as an attending. Then you have to submit a 350-page PowerPoint or documentation that you have done all of it before they approve you for a ten-year ACNu certification. After getting certified, she was able to run thy hybrid clinic. She volunteered to run the Endocrine Tumor Board and the Thyroid Tumor Board to get more experience and to be able to lead a discussion on it. Also during fellowship, she elected to go up and do a couple of weeks at a cancer center with a thyroid specialist for thyroid cancer so she could get more advanced training that wasn't available at her fellowship. "That's possible to do some away rotations during your fellowship if your program director is amenable to that." And when she moved over to her last academic position, she had enough experience to be the medical director for thyroid and endocrine neoplasia and she was able to run some of the multidisciplinary clinics. Hence, she actually made her own path. Additionally, there is a one-year fellowship in some programs but it's on endocrine neoplasia focused on chemotherapy, prescription, and administration. As with the competitiveness in terms of matching, Brittany doesn't describe it as that competitive. They need more endocrinologists, some of the higher ranked endocrine programs are pretty competitive but there are slots of endocrinology and endocrine fellowships throughout the country. She describes it at 50% as far as the difficulty of getting in to match. "If you're going into this, you're going to be going into this because you enjoy it, not because of the paycheck." As far as reimbursement goes, sometimes even less than internal medicine and hospitalists. So you really have to love what you do. [29:45] Other Areas of Focus You're able to basically carve out your niche such as diabetes, and obesity and weight loss medicine (a really big and hot topic). Brittany recommends that if you're going into any fellowship of any type, branch out to other departments and figure out your niche. heat sets you apart from some of these other fellows and other endocrinologists out there. [32:53] Working with Primary Care Brittany does all of her thyroid ultrasound and assessment. A lot of times, patients will have a scan done for another reason then they found a thyroid nodule. Then the family practice doctors would send them to radiology. or to ENT for assessment. Figure out if they actually need an intervention or if it's benign. Because 95% of the time, thyroid nodules are benign and they don't intervention and they don't need surgery. Other specialties she works the closest with include general surgeons that do thyroidectomy, ENT, oncologists, nuclear medicine doctors, and pathologists, and nuclear medicine. "It's good to know who you're going to be working with. It's also good to know who your patient population is going to be." Most of Brittany's thyroid patients are women with an average age of about 41 years old. They are otherwise healthy and used to not being sick. For patients with diabetes, she would have a dichotomy of patients – young, type 1 and 2, overweight patients, etc. [36:10 Special Opportunities and Major Changes in the Field You can go down the route of pharmaceutical development or molecular testing. These could be pretty rare positions though. And usually, you'd have to build up your reputation as an academic endocrinologist. What she likes the most about being a thyroid specialist is her patient population, treating women and be able to put them into the right regimen. She finds it as very rewarding. On the flip side, what she likes the least is the number of labs, one on top of another. So you'd have to be looking at these labs frequently. The major changes to be seen in the future for endocrinology is more minimally invasive techniques that are going to be widely used across the United States. If she had to do it all over again, Brittany would still be doing it as she loves her specialty. That said, she believes that early exposure really helped solidify her interest in this career path that she had chosen. Ultimately, if this is something you're interested in, she recommends finding an endocrinologist that specializes in thyroid disease, as not all of them do, and so work with them and try to get your feet wet early on to try and see if this is something that you really want. Links: MedEd Media Network Fellows Thyroid Clinic Thyroid Cancer Tumor Board

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81: A Chairman Of Ophthalmology Talks About His Specialty

Play Episode Listen Later Feb 6, 2019 43:53

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

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2: What are the USMLE Step 1 and COMLEX Level 1 Exams?

Play Episode Listen Later Jan 30, 2019 14:47

Session 02 Once again, we're joined by Dr. Andrea Paul from BoardVitals. In this episode, you will learn all you need to know about Step 1, how long to take it, when to take it, and what makes it different from the MCAT so you know what to expect before we jump right into the actual test prep! [01:10] More About Board Vitals If you need more help, check out Board Vitals and you get everything you need to expect from a board prep company including challenging questions, time and untimed question banks, progress tracker and advanced analytics and reports to help you direct your studying. This is something most students don't take enough advantage of. You really need to know what you're doing or missing, or what you're getting right to be able to know what to do tomorrow. Plus, you get to see how you rank with your peers. With over 1,750 questions in their USMLE question bank, BoardVitals will make sure you have access to the questions you need to be prepared and confident going into your USMLE exam. Don't worry DO students! They've also got over 1,500 questions in their COMLEX Qbank. Get 15% using the promo code BOARDROUNDS when you sign up for BoardVitals and they will donate a vaccine to a child in need through the Give Vacs Program. If you're not ready to use it yet, just buy now and you can start up to 6 months after purchase. [03:15] How Important is USMLE Step 1 Going through medical school, Andrea eventually realized that this was something she needed to pay attention to and start to prepare for quite early. And the stakes have gotten much higher since then. The goal for everyone is to get a residency they want in the specialty area they want. And for many students, that means being in a competitive location and a competitive medical specialty. So the scores serve as a gateway to get an interview for one of those positions. "It's a very high stake particularly if you're someone who is interested in a more competitive area, geography or specialty-wise." In fact, the NRMP match data suggests that those Step 1 scores are the determining factor if whether or not you're going to get an interview. [06:20] MCAT vs Step 1 Both are completely different tests in many ways. Andrea says that until you start preparing for it and seeing what format of questions are like, you wouldn't expect that people think of it as a more intense basic science exam similar to the MCAT. But in actuality, the new Step 1 exams are clinical and really require a lot of correlation between those basic sciences and actual medical practice. The MCAT is a test to see how well you can take the MCAT but when you get to Step 1/ Level 1, it's knowledge that you have to have to be a competent physician. You have to have that base knowledge so you can learn how to be a physician once you're out in residency. Moreover, the exam has changed a lot since. They have slowly transitioned now to a more practical and clinical correlation with basic science. [07:55] Breakdown of Step 1 Exams The USMLE Step one covers Anatomy, Behavioral Science, Biochem, Microbiology, Pathology, Pharmacology, Physiology. And they try to integrate those into a way to asses your knowledge of those things within the constricts of clinical medicine. COMLEX is similar as they do most of the subjects in addition to tests on some osteopathic-specific areas as well. They're now focused more heavily on "triple jump questions" or tertiary type questions where they could give you a clinical presentation but they're not telling you, not only what the disease entity is and what you would treat it with, but also something about that medication. These are a classic type of questions you need to practice. [10:00] Duration of the Exams Step 1 or Level 1 is a one-day exam. People usually take them at the end of their second year. They have some time off before they take the exam usually during the summer. USMLE Step 1 has 7 60-minute blocks that comprise a full eight-hour day. The exam has about 280 questions of an intense, rigorous full day of testing. COMLEX is similar with more questions of about 400 questions. It's taken in one day and it's broken down to 4-hour exam sessions with a break in between. You still need to know the various levels and anatomy involved in performing manipulative techniques which are often theory-based and in a straightforward format. You can select your day and location so there are flexibility and variation in as far as when people choose to take it. Just your personal preference as to what amount of time your school gives you. [13:00] Beyond Step 1 After Step 1, there's also another exam, Step 2. The COMLEX Level 2 is taken during medical school which most people take Step 3 afterward. Those are similar in the format of question-type based. They're more focused on the tertiary or three-jump types of questions and more in-depth on the clinical side. Links: BoardVitals (Get 15% using the promo code BOARDROUNDS when you sign up for BoardVitals.) NRMP match data MedEd Media Network

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80: A Community Urologist Shares Her Journey and Career

Play Episode Listen Later Jan 30, 2019 39:12

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

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1: Welcome to Board Rounds with BoardVitals

Play Episode Listen Later Jan 23, 2019 14:41

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

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13: Using Our MCAT CARS Skills to Learn About Hallucinating

Play Episode Listen Later Jan 16, 2019 22:46

In today's Atlantic article, we're putting Jack Westin's #MCAT #CARS techniques to the test to understand the author's ideas on hallucinating. Follow along with us! Links: Full Episode Blog Post http://www.medicalschoolhq.net/jackwestin (Jack Westin) https://medicalschoolhq.net/meded-media/ (MedEd Media Network)

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11: MCAT CARS and What's Happening to Scientific Research

Play Episode Listen Later Jan 2, 2019 17:00

Project Syndicate takes a look at what is threatening science. This is great for premeds to learn and use the MCAT CARS reading skills we're trying to teach you! Links: Full Episode Blog Post http://www.medicalschoolhq.net/jackwestin (Jack Westin) https://medicalschoolhq.net/meded-media/ (MedEd Media Network)

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9: Do Longer Books Equal Better Books? Using Our MCAT Skills

Play Episode Listen Later Dec 19, 2018 26:54

The Guardian has a great article about how books are getting longer. Follow along and use your MCAT CARS skills to break it down and increase your score. Links: Full Episode Blog Post http://www.medicalschoolhq.net/jackwestin (Jack Westin) https://medicalschoolhq.net/meded-media/ (MedEd Media Network) https://medicalschoolhq.net/thepremedyears/ (Premed Years Podcast)

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8: CARS Skills to Learn if All Famous People Have Footnotes

Play Episode Listen Later Dec 12, 2018 34:22

Commonweal Magazine has a great article about famous people and the footnotes, or patriarchal baggage, that they carry with them. Links: Full Episode Blog Post http://www.medicalschoolhq.net/jackwestin (Jack Westin) https://medicalschoolhq.net/meded-media/ (MedEd Media Network)

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7: How Can Beyonce Help Our MCAT CARS Reading Skills?

Play Episode Listen Later Dec 5, 2018 25:00

Our New York Times article today is a fun look at the world of celebrity gossip and reporting. Who talks and who doesn't. Follow along! Links: Full Episode Blog Post Text MCATCARS to 44222 in order to get notifications on how to sign up for that. https://medicalschoolhq.net/meded-media/ (MedEd Media Network) http://www.medicalschoolhq.net/jackwestin (Jack Westin) Link to the full article: https://www.nytimes.com/2018/09/19/arts/music/celebrity-profile-death.html

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6: Using Our CARS Skills for a Passage About the Printed Word

Play Episode Listen Later Nov 28, 2018 44:25

Our article this week, from Harpers, is an interesting look at the impact of digital screens on books and our life as a whole! Follow us at mcatcarspodcast.com. Links: Full Episode Blog Post Link to article: https://harpers.org/archive/2018/10/the-printed-word-in-peril/ https://www.jackwestin.com/ (Jack Westin) medicalschoolhq.net/jackwestin https://medicalschoolhq.net/meded-media/ (MedEd Media Network)

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78: Cornea Trained Ophthalmologist Talks About His Career

Play Episode Listen Later Nov 21, 2018 33:01

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

312: He Got Into Medical School and Didn't Have to take the MCAT!

The Premed Years

Play Episode Listen Later Nov 14, 2018 32:20

Dan, from FutureMDlife on Instagram, joined me to talk about his journey and struggles on his path to medical school as well as his Instagram journey. Links: Full Episode Blog Post Follow @medicalschoolhq on Instagram. Follow Dan on Instagram @FutureMDlife. Follow Steve on Instagram @premedmotivation. MedEd Media Network

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6: The Transition From a Community College to a 4-year School

Premed Diaries

Play Episode Listen Later Nov 12, 2018 18:29

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

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4: The Sacrifices Finally Pay Off When You Get Your Acceptance

Premed Diaries

Play Episode Listen Later Oct 29, 2018 15:43

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

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2: The Financial Pressures of a Premed Parent

Premed Diaries

Play Episode Listen Later Oct 15, 2018 20:13

Session 02 Today, we hear from a premed parent who has been accepted to medical school and is now worried about the financial ramifications and what to do next. Listen in as I share my thoughts as well as some possible options you can take if this is also something you’re going through. [01:16] Poster of the Week: Dealing with Financial Stress & Having Fear of the Unknown "I'm a premed student, have three kids. I'm married. I work full time, my wife works full time, so there's been a lot of stress. I graduated five years ago from undergrad. It's been a little while. I'm doing some postbac, work, and everything. But it's really stressful right now because we have three kids and they're all in daycare. We have to pay for it and we're trying to do bills, budgeting, debts. We're barely in the black in the idea of going to medical school and how to pay for everything. I got accepted to one medical school so I guess this is a trick to be a little bit of both - overwhelmed for everything but at the same time, being excited and having that security that I'm accepted somewhere. I don't know where to go as far as the financial things go. I'm not really sure what the best move is going to be. I'm still interviewing for other schools. I got accepted to one school so I'm really excited about that. But just trying to figure out the finances behind everything. What's going to be the best for my family to be able to put food on the table for at least just the four years of med school and residency beyond that. There are plans for my wife to work while in school but making sure there's going to be enough for everything. I've heard advice from other people on federal loans and if it can't take enough to cover everything then just do private loans. I'm at a loss as to where to even begin or what I should be doing right now. I’ve made some poor financial decisions in the past but we’re beyond that. I think it's just a little overwhelming. It takes away some of the excitement of finally getting an acceptance and still being excited about interviewing at other schools that are away from where we live right now. Just a lot of my mind trying to make sure that I keep everything together with my kids and spend time with my wife and we can actually still have our relationship. I know that med school is even going to be even harder than what the journey was to get to this point." [04:00] It's Tough Stuff! This is tough stuff. This is not easy-peasy. This is the really hard stuff of life. When you're working toward becoming a physician and also trying to put food on the table for your family, the stress and anxiety that come with that are huge. But first of all, congratulations on getting that acceptance. That is huge. After all, you only need one acceptance to become a physician. Many of us had one acceptance and that's where we went. If that ends up being your only acceptance then that's all you need and you'll make it work. "You only need one acceptance after all to become a physician." [05:08] Where to Begin Financially, it's hard. So I'm directing you to my husband, Ryan's podcast on MedEd Media Network in terms of where to start. Check out some of his episodes on The Premed Years Podcast such as Session 94, where he talks with Ryan Michler who runs WealthAnatomy.com. In Session 223, he talked with Dr. Dahle, the publisher of WhiteCoatInvestor.com. These can somehow give you ideas and thoughts about where to begin. Moreover, once you really know where you're going to medical school, there are great financial advisors at a lot of medical schools. Now that you have an acceptance, you're already in the door. So you can call the school, tell them you got accepted and that you really need some help figuring out how you're going to pay for this. "Just even talking to another person who knows the space may give you some peace of mind and some ideas. And that's always a great place to start." [07:35] Putting Food on the Table Ryan, my husband, is also a physician, and over the years, we have talked about our kids (we have two now). I remember our conversation before we even had children and he made some comment about how kids weren't expensive. And he has definitely changed his mind since that conversation. "Kids are very expensive." So having three kids, as this poster has, is very overwhelming, even just in and of itself. For any parent, that is overwhelming. Raising humans is the hardest job on the planet and I say that as a physician who works. So I feel for you with your kids. As you move forward, your kids are going to just be in awe of you. You're going to show them over and over again just how powerful you can be and you are because of how much you've already accomplished and how much you're going to accomplish down the road. You're going to show them just how much you can do in the face of fear and the face of the unknown. [09:50] Dealing with Debt We all have fears in life. But even wealth people have probably made a poor financial decision in their life. It's hard to be human and not make a poor financial decision at some point. The great thing is you have obviously learned from them and you are making it work. Also, you have awareness of the fact that you don't want to be in that situation down the road. So the whole fact you're planning for this, you're aware of it, you're already a leg up. It's a huge part of all of it. [11:15] More Acceptances, More Options Hopefully, you'll have more acceptances as this will give you even more options. Reach out to these other financial advisors at these other schools you're interviewing along the way. They may be able to give you other tidbits in terms of how to pay for this whole thing. There were so many of us in medical school who took out loans and there are a lot of loans and ways to do this. There are federal loans, private loans, as well as rural programs where you can go and agree that you're going to work for a specific time commitment. That way, you have a great deal of money saved because of that option. "If you want to be a doctor, you will find a way to pay for it. I know you will!" So many nontrads are in a very scary situation thinking about how to pay for this very expensive schooling. You already have jobs and mortgages and car payments. And you'll make it work. Because this is a calling. It's not just a job, it's a calling. And if you want it bad enough, you will make it work regardless of what you have to do and what you have to go through. [13:10] Strengthening Relationships And your wife who will also work can help. Leaning on a spouse during a time like this is important and so having that partnership with your spouse is huge. And that relationship will only strengthen during medical school. It's a very stressful time. But if you go in with a very strong relationship, to begin with, it's going to be fine. I've seen relationships break up back in medical school, but they're girlfriend/boyfriend and going different directions in life. But as a spouse, you've already committed to another individual and they're on this journey with you so it's a different deal. It's a matter of how you're going to make it work and get that time you need to have your relationship still take a priority. No matter what you're doing, whether in medical school or resident or an attending, you want to prioritize your marriage. How to make that work is different for everybody, but it's an important thing you want to prioritize. " No matter what you're doing whether, in medical school or resident or an attending, you want to prioritize your marriage." Again, you will make it work! In fact, those with families had a leg up than the rest of us back in medical school, because it's so important to get home and spend time with their kids. And when they were to study, they were super focused. Even though it seems scary and daunting - finances, children, relationship with wife - I guarantee that you're even going to be more focused as someone studying than others. I believe that having children demands that you focus your time in a different way because you just don't have the option. It gives you a different frame of mind. Many people out there go to medical school and residency with children already and they make it work. So you will too! [17:10] More Schools, More Options Lastly, try to get into more schools not because you need to but because it will give you more options. As humans, we feel trapped when we don't have options and it feels even that much scarier. So the more acceptances you get, the more options you have. So you can have different thoughts about where you can live. And maybe even if you don't have family in those other areas, you might have friends, Friends can really help with kids as well as relatives. So there might be other options you may not be even aware of. [18:00] Fear of the Unknown Sometimes, the unknown can be a good thing, There are things you don't know that are wonderful and are coming down the road. Your commitment and dedication to this whole calling of being a physician will guide you and it will keep you centered and grounded. Any thoughts? Call 833-MYDIARY and just let us know what episode you're referencing. And I will play your response so we can have a dialogue going. Links: MedEd Media Network The Premed Years Podcast PMY 94: Securing Your Financial Future as Premed and Medical Student PMY 223: Setting Yourself Up for Financial Success, Starting Now WealthAnatomy.com WhiteCoatInvestor.com

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145: Can I Recover From a Bad GPA to Get Into Med School?

OldPreMeds Podcast

Play Episode Listen Later Sep 26, 2018 7:57

This week we have a very common dilemma for a student who struggled early but found a way to turn it around but is now wondering if she can still get in. Links: Full Episode Blog Post Nontrad Premed Forum Send me an email at ryan@medicalschoolhq.net. MedEd Media Network

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77: What is Preventive Medicine? A Look at Academic Prev Med

Play Episode Listen Later Sep 12, 2018 47:41

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

298: Professor to Premed, How Indentifing as LGBT Affected Apps

The Premed Years

Play Episode Listen Later Aug 8, 2018 41:02

Sarah is starting med school this fall and is excited to begin. Listen to her story and how identifying as LGBT affected her med school applications. Links: Full Episode Blog Post If you need any help in your medical school application, maybe we can help. Find out all the services we offer and let us be a part of your journey to medical school. MedEd Media Network

interview school professor lgbt apps med affected premed nontrad meded media network

74: A Community Prolotherapist Talks About His Specialty

Play Episode Listen Later Jul 18, 2018 42:24

Session 74 Dr. Ross Hauser is residency trained in physiatry and has gone on to train in prolotherapy. He talks about what it is and why it's the future! Ross is very passionate about prolotherapy. If you want to learn more about this, visit his website on Caring Medical. Also, check out all the rest of our episodes on MedEd Media Network, including The Premed Years Podcast, The MCAT Podcast, The OldPreMeds Podcast, Ask Dr. Gray: Premed Q&A, and some more coming in the future! [02:05] Interest in Prolotherapy In the last two months of his residency, Ross had an elective rotation which he did with prolotherapist Dr. Hamwell back in 1992. Then he joined the physician in 1993, so he has been a prolotherapist for over 25 years. Ross describes himself as always liking old people. Thinking he was going to be a geriatrician initially, it was during his chronic pain rotation in his physiatry residency that he discovered his love of the mystery of pain. He was told by the physician he rotated with that most structural chronic pain is from joint instability or ligament laxity. And the curative treatment in a lot of people was prolotherapy. So he wanted to go for the cure instead of pain management. [04:15] What is Prolotherapy? The term prolotherapy was originally coined by Dr. Hackett, in short for proliferative therapy. The treatment is designed to cause the proliferation of cells, which make the extracellular matrix made up of ligaments, tendons, cartilages, or whatever you're trying to regenerate. In the Webster's International New Dictionary, prolotherapy is defined as the rehabilitation of an incompetent structure such as a ligament or tendon by the induced proliferation of cells. So if a person has a tendon or ligament tear, you want to proliferate the fibroblasts, the actual cells in the body that make the ligaments or tendons. You want to proliferate those cells so they can then regenerate the ligaments or tendons. Ross goes on to explain that the body's response to an unstable joint is to try itself to limit motion. One of the ways it does is it causes synovitis resulting in a very low level type of inflammation in the joint. Since medical doctors have been trained to very quickly try to get rid of symptoms, that's why treatments have gone more toward a treatment that dissolves the pain quickly. "Medical doctors have been trained to very quickly try to get rid of symptoms, that's why treatments have gone more toward a treatment that dissolves the pain quickly." However, 97% of tendon tear, for instance, occur in a degenerated tendon. Under a microscope, a degenerated tendon has way less cells than a normal tendon. So there's fewer cells to regenerate for a degenerated tendon. So the best curative type treatment for this is prolotherapy. The problem is that beside physiatry, prolotherapy is now becoming one of the standards of care for pain treatment. But in other fields like family practice, a doctor has to get training after residency. But once you get into practice, you get too busy to even get training. Ross hopes medical schools and residency programs recognize that the cause of osteoarthritis or a degenerative disease is ligament laxity or joint instability. Apparently, they have to shift to this paradigm. Otherwise, they won't be able to emphasize prolotherapy. [08:22] PRP vs. Prolotherapy PRP stands for Platelet Rich Plasma. Ross explains the inflammatory cascade where when tissue injures and there's bleeding, platelets rush to the area and change their shape to stop the bleeding. When they do this, they release growth factors. To simulate the way the body heal for a degenerated joint, they take the blood out and centrifuge the blood. They get the plasma out and then you're left with just the platelets, which are then injected into the injured area like the shoulder or lower back. "Platelet rich plasma is one of the more natural solutions we use in prolotherapy to proliferate cells." [09:33] Traits that Lead to Becoming a Good Prolotherapist Ross explains that until that paradigm changes, until we stop trying to resolve symptoms and we start trying to treat the actual structural cause of the pain, which is joint instability, in medicine, we're going to be led astray. We're still going to use pharmaceuticals. "There's no pain that the underlying cause is a drug deficiency. We want to be healers in the truest sense and cure problems instead of covering up the symptoms." If you want to become a good prolotherapist, you've got to commit to it. He says that if you only do a bit of this and that, you're never going to be an expert. If you get the skill set to document the instability and treat it with prolotherapy, then the next visit, you look at the tissue. So if you find something to be true, commit to it. Treat your patients that way and document your results. That means if somebody doesn't come back, you have to call them. So you have to follow up and have to commit. [14:15] Types of Patients and Typical Day The average person they see is a middle age to older age that had a degenerated tendon that the tendon just tore. The more degenerated tendon means there's less and less cells to regenerate. A degenerated tendon is a lot weaker than a normal tendon. So it gets weaker and weaker until it tears. With prolotherapy, they use ultrasound guidance to put the PRP into where the tendon tear is. They're also doing comprehensive prolotherapy into the ligament support of the shoulder. So they're resolving the joint instability and also helping the tear repair. The've also done pubis ligament. Ross explains the more children a woman has, the looser the pubis. And a lot of people think this is a hip or back problem but it's really a loose pubis. What they do is have them put on compression shorts to keep it tight and then they do prolotherapy to tighten the ligament support. Most people also don't realize there's a disc in the pubis. Ross describes this as a strange joint, since you don't typically talk about it in medical school. "100% of them think they know the problem the doctor gave them. But 75% of the time, they're wrong." Ross points out that with ultrasound technology, it can locate all the nerves of the body. It's very easy by history to tell when it's a compressed nerve and what's a joint problem. But with our technology now, they can already tell whether the nerve is swollen or not and measure it. Ultrasound scanners now are so detailed. He can even now see the vagus nerve in the carotid sheath. It's unbelievable what a doctor in their own office can see. Ross would work half a day with patients, like 5 solid hours seeing patients. He would see patients at 8 am. His staff gets the patients going although they review the patients the night before. Some are new, others are follow ups. They try to figure out whether a patient needs a motion scan. In that case, they'd have to numb the musculature in the back of the neck so the muscles can't limit the joint motion. Then they'll do a fluoroscopic evaluation of them moving their neck to see where the instability is. So the first thirty minutes, he'd do emails and by 8:30, he'd begin seeing the patients after the staff had gotten them ready. Then he will start treating people. Whoever gets scanned, his assistant does ultrasound exams. He'll also go over some of the scans with the patients. On average, he'd see 10 patients in a five-hour stretch. The rest of the day, as the editor in chief of the Journal in Prolotherapy, he'd review studies and does his research and writing in the afternoon. He'd have some clinical trials going on with regard to surgical instability and some research projects. He's currently in the middle of a thousand-paged joint instability book as well. Eventually, he hopes this will be the gold standard. [21:46] Taking Calls In private practice where you do procedures on people, Ross believes you should be available after hours for them. In his practice, there are two prolotherapists and another two in their office in Chicago. So there's a total of four prolotherapists and they do calls one month at a time. They're available 24/7. But you could get one call a week, not a lot. And since they do a good job in educating patients what to expect, they get less and less calls. "In private practice, if you do procedures on people, you should be available after hours for them." [23:05] The Training Path Ross thinks some of the best training is in the University of Wisconsin. The Hackett Hemwall Patterson Foundation, named after Dr. Hackett, who was at the University of Medicine for many years. They have a training in October. Ross recommends going to this. Once you go to that four-day training, they have trips all over the globe so they normally have experienced prolotherapist and you get to go to Peru, Latin America, etc. There might be 100 people with 30-40 doctors getting trained and there are charity clinics there. So you have experience prolotherapists working side by side with doctors wanting to learn prolotherapy. "I think mentorship or hands on training is the best training... a cadaver is so much different than a live person." If this is something you're interested in, Ross recommends getting a mentor that's in your area or go to a place overseas and do some mission work. Through the foundation, Ross went to Honduras where he did 150 cases of prolotherapy, which means he did thousands of injections. After two weeks of intensive training and all those patients, he really got to hone his skills. There are also other organizations you can get involved in. Ross is the member of the American Academy of Orthopedic Medicine. They have training there. There's also the Osteopathic Prolotherapy Association. So go to several of these. You may have to go through some courses. You'd also have to learn ultrasound courses and go through training in Central America or Mexico. You'd want to be training with an experienced prolotherapist by your side. Ross also mentions the neuromuscular residency in osteopathy and in this you'd have to do a bunch of prolotherapy training. If you're going to be a family physician or a physiatrist, Ross recommends you spend your elective time with the prolotherapist like what he did for two months. [27:30] Working with Primary Care and Other Specialties Ross says it's really about primary care physicians understanding the degenerative cascade and that the model of just relieving information that doesn't cure people of pain has to change. As a family physician, you have the obligation to the patient to really understand why a person has an autoimmune disease or why they have chronic pain. He explains that osteoarthritis is a whole organ disease. You've got to address all the causes. "You have to have the skillset of being able to evaluate the whole structure and correct what needs to be corrected and try to cure the person of the problem instead of managing it." Ross stresses that pain management is not working. If you're able to address the cause of the problem instead of the symptoms, you're going to really alter the course of people's lives. Prolotherapists work closely with chiropractors who understand that if they adjust a spine and they can't hold the adjustment, it means there's ligament laxity. To him, the specialty that thinks most like the prolotherapists are chiropractors. In regard to traditional, they'd work with other physiatrists. [33:00] The Analogy of the Door Hinge Ross uses the analogy of prolotherapy to the door hinge. If one of the screws is loose on a door hinge and there's a another screw and you don't take a screw driver and tighten that screw, the other screw is going to loosen too. Once the hinge is loosened, the next hinge is going to get loosened too. That's why somebody has knee pain and eventually they have ankle pain and then hip pain or neck pain progressing up and down the spine. "Joint instability is a progressive disorder. So you can't not do something about it. You have to correct it and the treatment to correct it is prolotherapy." [33:48] What He Wished He Knew and the Most & Least Liked Going into prolotherapy, what he wished he knew is how much people are struggling in their daily lives. He encourages young people going to medicine that you've got to learn about what's going on with your patients. There are so many broken homes. People are struggling as human beings. We are supposed to be in health care. As physicians, we have got to know about care. And what care is you have got to ask your patients about what's going on. And one of the best questions he asks his patients is, what have you been thinking about lately? "People are struggling as human beings. We are supposed to be in health care. As physicians, we have got to know about care. And what care is, is you have got to ask your patients about what's going on." So he wished early on he would have really gotten to know his patients better and he finds this to be so rewarding. What he likes the most about being a prolotherapist is the Christmas card he gets that somebody has been pain-free for ten years. His office is just inundated with gifts and letters from people appreciating them. What he likes the least is the business side of it. The average number of visits to a prolotherapist is 4 so you'd have to explain it to people. They get one visit and they're not better and then a lot of stress comes with that. If you don't help them in just one visit then they just don't return. Hence, the reason it's important to talk to them about what's going on in their lives. When you're in the chronic disease business, things aren't going to get better typically with one visit. The hardest part is when people spend money since prolotherapy is not covered under medicare so people have to spend their own money. So sometimes, they don't come the second time. [38:30] Reception in the Insurance World Ross sees the trend that there's going to be more self-insured companies. And what they're going to cover is stuff like this because it's so much less expensive. It's all 1/10 of the cost when it's all been said and done. Hopefully, Medicare will also review this eventually. So private insurance they cover prolotherapy but for government insurance, it's a non covered procedure. "More and more companies are going to go to this so it's definitely the future. And eventually Medicare will wake up and they'll really review prolotherapy openly." [40:30] Last Words of Wisdom Ultimately if he had to do it all over again, he'd still be a prolotherapist and he's still continually learning stuff which he really loves. He goes on that chronic pain and osteoarthritis are the most disabling of lost years working. So he encourages students to research, is joint instability the cause of that? And if it is, you have got to resolve the joint instability to cure chronic pain. And if you do give it a try in your future practice that you will see that everything he said on this podcast is absolutely correct. Links: MedEd Media Network The Premed Years Podcast The MCAT Podcast The OldPreMeds Podcast Ask Dr. Gray: Premed Q&A Caring Medical American Academy of Orthopedic Medicine Osteopathic Prolotherapy Association

christmas university community chicago school mexico thinking medicine wisconsin patients journal medical treat types peru latin america med medicare joint traits honduras american academy central america last words reception specialty primary care ultrasounds analogy hackett prp premed platelet platelet rich plasma prolotherapy physiatry orthopedic medicine oldpremeds podcast meded media network the've

64: What is Private Practice Internal Medicine-Pediatrics?

Play Episode Listen Later Feb 28, 2018 25:48

Session 64 Dr. Lauren Kuwik is a Med-Peds specialist in upper New York. She shares with us her desire to go into Med-Peds vs other specialty and so much more. Check out all our other podcasts on MedEd Media Network. We are constantly looking for people to guest here on our podcast. If you know a physician whom you think would be a great guest, reach out to them and give them my email address ryan@medicalschoolhq.net and have them contact me and we will get them on the show. Today's guest is a private practice Med-Peds doctor. Med-Peds is internal medicine and pediatrics combine specialty. Lauren is now practicing for five years in Buffalo, New York area. And she talks all about her journey with us today. [01:50] An Interest in Med-Peds Lauren grew up knowing a doctor who was a family friend who ended up being her internist when she transitioned from her pedia rotation and she was Med-Peds. Having always wanted to be an archaeologist and a teacher, she feels that Med-Peds allows her to be both. With internal medicine, in terms of the archeology part of it, you're always putting together clues to figure out what's going on with the patient. She loves the mental tenacity involved in internal medicine. While for the peds part, she loves children and thinks they're fun. She loves taking care of kids. And as with the teaching aspect, she loves educating patients on a daily basis. So she gets to do all the things she wanted to do together in one specialty. "You're always putting together clues to figure out what's going on with the patient." [03:08] Is Med-Peds Going Away Soon? And How It's Different from Family Medicine With the generality of it with both internal medicine and pediatrics, she doesn't really see any risk of the Med-Peds going away over time. There's a need for primary care doctors and specializing in both really gives you the opportunity to be a better pediatrician and a better internist. People really like to have someone that they can see themselves and their kids. They're both the doctor to the mothers and kids. So Lauren thinks this specialty is really here to stay. "Specializing in both really gives you the opportunity to be a better pediatrician and a better internist." How is the specialty different from family medicine then? Lauren explains it's similar to family medicine or family practice where they take care of the whole spectrum from babies all the way to patients in their 90s or 100s. But they don't do OB, so they don't deliver babies. They take care of pregnant patients but they're not involved in their prenatal and delivery care. They do very little surgery. And while family medicine may do a couple of months in pediatric training, Med-Peds would have to do a full residency in pediatrics and they're board-certified in pediatrics. They can subspecialize if they want to. So any specialty comes out of internal medicine, out of pediatrics. You can either subspecialize in the pediatrics and adults subspecialty or you can specialize in both. There are those that may want to take care of patients with compact heart disease as a kid. They're then repaired and now they're in their 30s. So there are people who will do a longer fellowship and combined internal medicine and pediatrics, cardiology and then they can take care of those people throughout their whole life. It's longer. If each fellowship in internal medicine or pediatrics three years, that's usually about a five-year fellowship. Other people just do adult cardiology but because they're pediatric certified, they feel very comfortable with those cases. There are other ways to do that without doing it for five years. Nevertheless, it's a lot of training. [06:00] Traits that Lead to Being a Great Med-Peds Doc Lauren explains that you have to be willing to talk to people. You have to be willing to build relationships and be comfortable speaking with specialists. This will help your patients out in the future. Additionally, you have to be able to apply knowledge to things that don't seem very straightforward. Some people like to have one specialty where they get a lot of deep knowledge in a very narrow pocket. You have to know a little about everything and be really willing to work hard. Alternately, if you're someone that doesn't like to do a lot of procedures or like to be in an operating room, this is where you can do minor procedures that are not heavy. So this is a good fit as well. "You have to know a little about everything and be really willing to work hard." Aside from Med-Peds, another specialty that actually drew her was Emergency Medicine. In fact, she thinks most people in Med-Peds, at some point, considered a career in Emergency Medicine. For her, a couple of things impacted her decision. First being was that her mother was an emergency medicine nurse practitioner. She spent a lot of time volunteering in the emergency department. She found it to be so much fun with a lot of variety. But ultimately, she likes controlling her time. She doesn't mind an emergency every once in a while or dropping everything to take care of it. But she doesn't lots of emergencies going on at the same time. She doesn't like feeling flustered. She really likes having control over her schedule in deciding the hours she wants to work without someone assigning those to her so she gets more time with her family. [08:05] Types of Patients and Typical Day Lauren sees a mix of patients from a one-day old baby to a 91-year old patient. She sees a mix of well visits or annuals. She sees people who are getting ready to go for surgery or those who come in for chest pain or for fever. It's just a variety of things. A typical day for Lauren is getting to the office 30 minutes before she starts her day. She'd do a lot of things between seeing patients like talking to her nurses, answering calls, checking labs, reviewing many documents, images, and sometimes prepping her notes in the morning. She sees patients in the morning for about three to four hours. And then she also sees patients in the afternoon. She has a late day where she's in the office until 7 at night, but she comes in at noon when this happens. So it's basically the same day just pushed forward. Lauren explains that where she lives, she does more of outpatient care. But for most outpatient primary care doctors, are having their patients taken care of in hospital by hospitalists. So she only goes to the hospital for babies born to her practice at the newborn nursery. Most pediatricians have their hospitalists and the nursery sees their patients. That said, she reckons it at 95% out patient for her. [10:22] Taking Calls and Work-Life Balance Lauren takes calls one day a week. She might get one phone call usually. In fact, one time, she went almost three months with no phone calls on that day. Sometimes, she gets two or three. And every fifth weekend, she's on call. She gets an average of ten phone calls. She doesn't necessarily have to be somewhere. She just has to be available by phone. If patients hear her kids talking, they know she's living her life. But it's not as time-consuming. Lauren has three kids and two of them, she had during residency. However, with the kind of schedule she has, she feels like she has a lot of time with her kids. "Anything after having two kids back to back in residency seems like a ton of time." [12:05] The Training Path As a Med-Peds doctor, you're taking a three-year pediatric residency and a three-year internal medicine residency. Then you're mushing them together into four years. Because of that, there's a lot of overlap especially in the first year about learning how to be an intern. A lot of the things that you learn are not really specific to one specialty or another. There's not a lot of time for electives or research months. They have a lot of inpatient and intensive care unit months compared to a traditional pediatric or traditional internal medicine residency. "There's a lot of overlap especially in the first year about learning how to be an intern and a lot of the things that you learn are not really specific to one specialty or another." For Med-Peds, there's a national guideline that you have to hit to both finish your pediatric requirements and finish your internal medicine requirements. And Lauren doesn't think this is a modifiable thing. She feels lucky though because her clinic "assignment" was at a private practice and a community where the other doctors are really happy in primary care. It gave her a great introduction to life as outpatient primary care doctor and talked her into that role. Lauren goes on to explain that Med-Peds programs are usually pretty small. She's from the east coast and most programs were 2-4 residents per year. Most people who graduate from her program would be one in the primary care. They only did dev specialty in internal medicine or pediatrics. And sometimes, they overlap stuff such as sickle cell care or cystic fibrosis care. She has seen people do both although she has no knowledge of the actual data. But speaking of her program, most people went into primary care. Lauren doesn't think Med-Peds is competitive. She went to state school and interviewed at top programs but she didn't think it was particularly competitive. Primary care in general, she thinks, is not as competitive too. Although she wished it was more competitive, but she assumes it has more to do with salary. "I wish they were more competitive. It probably has a lot to do with salary. I think they're the greatest field in the world, but not as competitive." [16:30] Bias Towards DOs, Special Subspecialties, and Working With Other Specialties Lauren doesn't really see any bias towards DOs. A lot of times, she forgets when she thinks about her colleagues that she did training with as to who went to DO school and who went to MD school. As to what's not available to a Med-Peds doc to do a fellowship in, there might be people who do a Med-Peds residency and then do a fellowship that is just within one sphere, for instance, pediatric ICU. But the practice both in the pediatric and adult realm, she does see this happen. But there's not anything that's cut out. When she was rotating in pediatrics and internal medicine, most of the attendings are happy to have Med-Peds on their teams knowing they're pretty academic and they work hard. Other specialties they work very closely with Cardiology, Oncology, Surgery, and sometimes Nephrology. Outside of clinical medicine, special opportunities would be telemedicine, college health, reviewers on different journals, etc. [18:55] What She Wished She Knew that She Knows Now Although not specific to Med-Peds, Lauren wished she knew so much more of how the business in medicine. Being a private practice owner and actively learning, she wished they taught this in medical school. She wished she got a wiser advice about her student loans before entering attending shift, although it's coming around and she plans on them being gone in a couple of years. "I wish I knew so much more of how the business in medicine because I'm a private practice owner and I'm actively learning but I wish that they taught this in medical school." What she likes the most about being a Med-Peds doctor is being someone's doctor. She likes taking care of families and she loves taking care of older adults in their 80s and 90s. She thinks there's so much to learn from them and she loves taking care of first time babies of families and guiding them through the process. On the flip side, what she likes the least is the reimbursement compared to specialists. Although there's not a lot to complain about, it seems like it's a fact that they pay more for procedural specialties than they do for those people who hold their patient's hands and talk to them when something's going on. And she really thinks the reimbursement playing field must be evened out. [20:15] Private Practice versus Academics The reason she chose private practice over academics is having control over her own schedule and over how things run where she is. Additionally, you get paid more, you get to have a better schedule, and so you get a better quality of life. You get to have more say over how your practice runs and you're not having an administration telling you what to do. Lauren recalls that in her particular practice for five years, the first four years, she was an employed physician. And then she became a Partner last year. And she basically realized she would never work for someone else for the rest of her life. [21:35] Major Future Changes in the Field Lauren mentions this thing called, capitation. It doesn't impact students but there's a change in the way that they're paying private practice. This is on a regional level, but a lot of insurance companies are interested in incentivizing in order to provide really good care to their patients. But then they pay you per month to be someone's doctor and they pay for sick visits when patients come in. "There's changes in the payment structure for private insurance right now." Overall, with the Affordable Care Act, this has not affected her practice in a negative way. So she's interested to see what happens in the new healthcare plans. Moreover, the one population she loves taking care of which are 80-year-old patients are on Medicare. They've worked so hard so you would want those to be available to those patients. [22:55] Final Words of Wisdom If she had to do it all over again, she'd still choose the same specialty 100%. Lastly, Lauren would like to impart to students that it's important to network and connect with attending physicians. Shadow them to see if this is something you're interested in. Most of them are really excited to share their specialty with people. So if you know someone that's a family friend or your pediatrician, or someone you met at a networking event for premeds, really take them up on the offer if they offer for you to shadow. Or reach out to them. Because they want to share that with other people who may be interested. Links: MedEd Media ryan@medicalschoolhq.net

62: What Does a Community Based Joint Replacement Specialist Do?

Play Episode Listen Later Feb 14, 2018 31:09

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

108: Should I Change My Major to Something More 'Premed'?

OldPreMeds Podcast

Play Episode Listen Later Jan 10, 2018 10:14

Today we have a student who is worried that her current major isn't preparing herself for medical school and is wondering if she should change majors. Links: Full Episode Blog Post www.medicalschoolhq.net/forums MedEd Media Network

school medical biology premed biochem nontrad meded media network

57: What Does a Pulm Critical Care Medicine Doc Do?

Play Episode Listen Later Jan 10, 2018 30:55

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

christmas school care north carolina medicine types ob internal personally med pas gi icu flu neuro emergency medicine primary care nps major changes pulmonary premed icus critical care medicine nephrology pulm nrmp cardiac icu his interest meded media network specialty stories

56: How Hard is the Neurosurgery Match? A Look at the Data.

Play Episode Listen Later Jan 3, 2018 24:49

Session 56 Neurosurgery follows the rules of economics. There are very few spots, so it is really competitive to get into. We covered the NRMP Match data for Neurosurgery. Neurosurgery is one of those residencies that are super hard to get into. Ryan has had an academic neurosurgeon previously on Episode 20 of this podcast. Please subscribe to this podcast. We're on Spotify now! Check us out there as well as on any Android phone, or on Stitcher and Google. Nevertheless, the podcast app on the iOS is the best way to subscribe on an iPhone or iPad. You will also find all our episodes on the MedEd Media Network. Let's dive into today's data... All information here are based on the NRMP Main Residency Match 2017, Charting the Outcomes 2016, Medscape Lifestyle Report 2017, and Medscape Compensation Report 2017. Ryan walks you through the data along with some commentaries. So you will know what it means and what it looks like and what you should be thinking about if you're interested in Neurosurgery. [02:30] Match Summary for 2017 Looking at Table 1 of NRMP Main Residency Match 2017 Summary, Neurological Surgery is how they list it. For this field, they have 0 unfilled programs. This means lots of people are applying for neurosurgery and they're getting filled. There are 107 programs. Comparing this to other fields, Emergency Medicine has 191 programs and Anesthesiology with 124 programs. So for neurosurgery there are 107 programs and 218 positions. It's just over two spots per program. Comparing this to Anesthesiology, it has 124 programs and 1202 positions. This is almost 10 spots per program. This said, there are not a ton of spots and programs for neurosurgery, but every program is super small on average. As you think about your journey, and you're dead set on being a neurosurgeon, all this data shows that you need to well. "If you're dead set on being a neurosurgeon, you better buckle down for medical school...to make sure you have great board scores, great grades." So for U.S. Seniors there are 212. Again, U.S. Seniors here means that it's somebody who's an allopathic/MD still a senior in school. So this doesn't include U.S. Grads who are now taking a gap year, doing research, or doing something else who have graduated. There are 311 total applicants for those 218 spots. Through this episode, Ryan will discuss where these other 99 students are coming from. And out of those U.S. Seniors, 183 matched. So it's 83.9% U.S. Seniors matching in an allopathic medical school. This tells you that they're favoring students at allopathic medical schools. [06:45] Summary of Students: U.S. Seniors, U.S. Grads, IMGs, Osteopaths Table 2 shows where these students are coming from. Again, 83.9% of those that matched are U.S. Seniors. And 15% of those students are U.S. Grads. This means they probably took a year off or they didn't match their first time around so they did research or whatever. There are 2 osteopathic students and 4 U.S. citizen international medical graduates matched into neurosurgery. Looking at this data, is going to a Caribbean school better than going to an osteopathic school? Thinking this alone is wrong. You can't draw these conclusions as to why the numbers say so. If all four of those students when to a DO school, they might have still matched because of who they are, not the letters after their name. "You can't draw conclusions that says going to Caribbean school, Australia, or Ireland better than going to a DO school if you want to match into neurosurgery." Non-U.S. citizens international medical graduates are 14 of those that matched. They are obviously strong students who crushed their boards that they were able to match almost as many students as U.S. graduates. [09:22] Yearly Trends Table 3 shows the yearly trend showing a slow, steady incline every year for the number of positions from 204 to 218 over the last five years. It's a 0.8% increase every year from 2013 to 2017. Looking at Table 8 shows the number of positions offered and the percent filled by U.S. Seniors versus all applicants. For 2017, 83.9% were U.S. Seniors and the numbers are pretty high every year. In fact, this is the lowest year since 2013. It's 92.6% in 2016, 89.5% in 2015, 91.7% in 2014, and 93.1% in 2013. This tells you a couple of things. That for 2017, less U.S. Seniors matched percentage-wise for the total number of positions offered. This tells you that either there were less qualified students applying this year or there are more qualified non-U.S. Seniors applying this year. Table 9 gives you scope of how big a specialty is. For neurosurgery only 0.8% of all applicants matched into neurosurgery. There are a total of 27,688 students and 100% of those students are matching. Another surgical subspecialty that is low is ENT with 1.1%. Not a ton higher but still higher. "Out of the 27,688, only 0.8% of those are matching into neurosurgery. So it's a very, very small specialty." [12:35] Unmatched U.S. Seniors and Independent Applicants, SOAP Looking at Figure 6, Neurosurgery has an unmatched percentage of 20.6% so one out of every five students is not matching into neurosurgery. 55.4% of the independent applicants go unmatched. So it's a large percentage of that are non U.S. Seniors. Only 10.4% of U.S. Seniors are unmatched. Comparing this with other specialties, plastic surgery is 16.3% for U.S. Seniors, Dermatology is at 13.8%. This is a high percentage but not the highest. Table 18 shows the SOAP (Supplemental Offer and Acceptance Program). Neurosurgery had 0 unfilled programs so no neurosurgery programs needed to participate in SOAP. [14:00] Charting the Outcomes 2016 Digging into the Charting the Outcomes 2016, looking at percent match by preferred specialty, Chart 3 shows that 76% of U.S. allopathic seniors matched into it. This the third lowest. Vascular surgery is 71%, Orthopedic surgery is 75%. This tells you that it's one of the most competitive specialties out there, at least for U.S. Seniors. Table 2 talks about the mean USMLE score for Step 1 and Step 2 CK (Clinical Knowledge) versus CS (Clinical Skills). The mean USMLE Step 1 score for all specialties combined for those that matched was 233 and 230 for those that did not match. Keep these numbers in mind. "To match, you have to rank a lot of programs. The more programs you rank, the higher the chance that you will match." Chart 4 shows that in Neurosurgery, the median number of contiguous ranks is at 16 while those that did not match only had a median number of 11. So you need to rank enough programs to match. If you want to match, you cannot be very picky. Are these people not ranking programs because of location? Or prestige? Or are they not ranking programs because they just didn't interview there and decided not to rank them. So there are many questions there. Again, the data is just data. You can't draw conclusions based on this data. We can only make some inferences and discuss what is behind these numbers. But there is no way of knowing specifically why the numbers are what they are. [17:23] Ranking by Specialty and Step 1, Step 2 Scores Ryan always tells students that if you want to be a physician, don't have a plan B of being a PA. Don't have a Plan B of being an NP. Don't have a plan B of using your Biology degree or something else. If you want to be a physician, figure out how to get there. "Don't have a plan B of being a PA... If you want to be a physician, figure out how to get there." Chart 5 talks about the mean number of different specialties ranked by U.S. Allopathic Seniors. This tells you that those who have a plan B did not match at a much higher percentage in most instances than those that didn't have a plan B. Looking at Neurosurgery, the mean number of different specialties ranked was 1.1. This means a large majority of students only ranked neurosurgery on their rank list. The mean number of those that did not match was 1.4. It means there are more of those students putting in different, most likely, surgical specialties. If you're applying for neurosurgery, that means you like the operating room. This probably means you're applying for maybe general surgery as a backup. And that back up might hurt you. Psychologically, it might hurt you. And the data shows it leans that way. Chart 6 looks at Step 1 scores. The mean Step 1 score for all specialties was 233. For neurosurgery, the mean Step 1 for those that matched was 249. Those that did not match was closer to 238. So you need to have great board scores to match into neurosurgery on average. The same thing for Step 2 scores. The mean Step 2 scores for all specialties was 244.8. For those that matched into neurosurgery, the number was upward to 251-252. For those did not match, it's closer to 242. "You need to have great board scores, if you're planning on being competitive for neurosurgery." [20:21] Scores, Research, Publications, AOA Table NS-1 shows that Mean USMLE Step 1 Score is 249 for those that matched and 238 for those that did not. Step 2 Score is 251 for those that matched and 241 for those that did not match. Research experience is 4.8 versus 4.2. Number of abstracts, presentations, and publications for neurosurgery is 13.4 for those that matched versus 8.4 for those that did not. This tells us that research is very important for neurosurgery. "Research is very important for neurosurgery." The number of students that are AOA (the medical student honor society) based on grades, almost 33% of those that matched were AOA versus only 11.5%. It's not just about having the AOA label, but having the grades that made you competitive and that led you to AOA. It means having the grades to give you the knowledge to do well in the boards. So you can look at this thinking you have to be AOA but you have to have a solid foundation of scientific knowledge of all those courses you've taken in medical school. And this leads to AOA. But it also leads to great board scores. So it's not just AOA. So 9.5% of those that matched have a PhD degree versus 7% who did not. Mean number of contiguous ranks is 15.7% of those that matched versus 10.2% for those that did not match. Again, you need to rank a lot of programs to increase your chances of matching. [22:27] Burnout Rates and Compensation Moving on to the data of Medscape Lifestyle Report 2017, Neurosurgery is not on the list since there are only a few number of them. And looking at Medscape Compensation Report 2017, it's the same thing, Neurosurgery did not have enough representation to be in this list. Anecdotally, Neurosurgery is one of the highest paid specialties out there. If this is something that's motivating you, which shouldn't be, neurosurgery is up there. Based on the NRMP Match Data, it's very hard to get into neurosurgery. But if this is what you want to do, start now. Make sure you have a solid foundation of your classwork. Get AOA as much as possible and get great board scores. Get those connections to neurosurgery programs. Make a great impression as you go through this process. Links: MedEd Media Network Specialty Stories Podcast Episode 20 NRMP Main Residency Match 2017 Medscape Lifestyle Report 2017 Medscape Compensation Report 2017 Charting the Outcomes 2016 The Premed Years Podcast

spotify australia google school phd research thinking data ireland iphone table md android match caribbean figure stitcher ios ranking ipads score comparing ent biology med digging plan b outcomes scores seniors soap chart charting emergency medicine specialty publications orthopedics dermatology np neurosurgery vascular grads anesthesiology psychologically premed aoa anecdotally usmle usmle step neurological surgery imgs meded media network soap supplemental offer

46: What Does a Private-Practice Based Neuroradiologist Do?

Play Episode Listen Later Oct 25, 2017 42:25

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

community school ai practice ms philadelphia board er impact student md attention medical tampa shoot ent med traits oftentimes certificates mri american society majority participating residency imaging primary care final words private practice percentage radiology abr major changes cts premed narayan media network typical day taking calls wilms neuroradiology neuroradiologist albert einstein medical center his interest meded media network

44: A Look at Academic Pediatric Neurosurgery

Play Episode Listen Later Oct 11, 2017 46:05

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

god new york university kids school bible british doctors miami brain ny er student medical types mt stranger long island med cv academic traits functional residents sinai pediatric micheal tumors pediatricians percentage competitiveness stony brook university neurosurgery stony brook neurosurgeons premed do no harm hydrocephalus chiari taking calls acgme cerebrovascular rrc future changes avms henry marsh pediatric neurosurgeon his interest heart not meded media network be competitive

43: Community Based Interventional Cardiology

Play Episode Listen Later Oct 4, 2017 36:23

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

running reality research drive hospitals student patients md medical types bias medicare traits acc majority reduction cms ic cardiology primary care final words private practice cardiologists peripheral community based premed medicaid services coronary venkat interventional interventional cardiology interventional cardiologist field one oldpremeds podcast meded media network

42: Academic Neuromuscular Neurologist Talks About Her Specialty

Play Episode Listen Later Sep 27, 2017 44:18

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

41: A General Pediatric Neurologist Discusses Her Specialty

Play Episode Listen Later Sep 20, 2017 33:28

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

university kids school child student medical types costa rica fda traits eq pediatrics neurology pediatric nicu specialty generalists neurologists aap premed pmr typical day denia pediatric neurologist subspecialty her interest meded media network east tennessee children's hospital

39: Academic Pain Medicine From an Anesthesiology Background

Play Episode Listen Later Sep 6, 2017 38:13

Session 39 Dr. Bunty Shah is an academic Pain Medicine Physician at Penn State. He completed his residency training in Anesthesiology. He shares the specialty with us. Back in Episode 17, we interviewed a community-based pain medicine doc who came from a radiology background. So you get to hear some differences between these two episodes. Bunty has been out of fellowship training now for two years. He now serves as the Associate Program Director for the Fellowship at Penn State. If you haven’t yet, please check out all our other episodes on MedEd Media Network. [01:33] An Interest in Pain Medicine When he was in his surgery rotation in medical school in his third year, there was no actual anesthesiology rotation. But it was built into the surgery rotation. It was by chance that he actually encountered anesthesia during his surgery rotation. He met an anesthesiologist during third year rotation in medical school. He learned that anesthesiology was all about an interplay between physiology and basic sciences. It was very procedure-oriented and he enjoyed it. That was his first experience with anesthesia. And so he decided to pursue that. He also wanted to do emergency medicine initially being formerly an EMT. He thought emergency medicine was very exciting. He still thinks it is but the finds anesthesia to have combined all the different specialties he was interested in. He could be a cardiologist, a nephrologist, an ICU doctor, and all these things at once in the operating room. As far as pain medicine goes, he didn't know anything about it back in medical school. It was a subspecialty so he didn't have much exposure to it as a medical student. It wasn't until his CA two year being his third year of anesthesiology as a resident. He rotated through the pain management clinic and he saw all the different procedures done for pain of different causes. It married what he likes about anesthesia which is procedures. A lot of the procedures they do in anesthesia are carried over to pain medicine such as skills when doing epidural injections. So this gravitated him towards the pain medicine. Another thing he liked about pain medicine that was missing when he was doing anesthesia was having more face-to-face time with patients while they're awake and talking with him. The other thing about anesthesia was he would do a case and take of a patient for one surgical procedure and not see them again. He considers this as a good thing in the grand scheme of things. Because it means they improved or did well. "I like the continuity of care I get with some of my patients in pain medicine and establish relationships that is more long-lasting." Again, it's the patient interaction along with the procedures that led him to pursuing a career in pain medicine. [04:54] Learning Hand Dexterity and Other Skills Bunty says you have inherent coordination skills to be able to do these procedures but you do learn by practicing. So the things that to some degree, it can be taught. But the most important thing to be masterful with procedures is understanding your limitations. You have to develop an overall sense of safety, knowing when you can advance a needle, and when you have to be a little bit more cautious. You have to understand the relevant anatomy. He recommends to medical students and residents that knowing your functional anatomy is very important to doing procedures. "Knowing your functional anatomy is very important to doing procedures." Bunty adds that your knowledge of the anatomy is your road map for doing a procedure. Aside from having dexterity and manual skills, your knowledge of the anatomy is a major factor in making sure you can do a safe procedure for a patient. [06:13] Community vs. Academics Bunty chose to stay in Academics because he likes to teach. He believes that if you can teach something, you can do something. He chose to stay at a program where he trained both in anesthesiology residency and in his pain medicine fellowship. Currently, he's the Associate Program Director for the Pain Medicine Fellowship. He is tasked with training fellows going to go out in practice within one year. So he has the opportunity to shape these fellows to some degree. He also has a hand in the patients they treat since he's responsible for teaching them. For him, this is a tremendous responsibility and it's one he doesn't take lightly. He feels humbled to know that they are shaping fellows who are going to go out and practice pain medicine on their own. They're touching other patients through them. And this is the major motivating factor for him. Another reason he stayed in academics is he's able to get exposure to educational resources he wouldn't have gotten elsewhere. Because they're a training program, they have educational conferences. They have journal clubs where they review relevant articles. They're always learning. Not to say that you're not always learning in private practice, but he feels as an educator, the impetus is on them to do as much learning as they can. "It's my responsibility to teach others so I need to stay abreast of developments in my specialty." [08:15] Traits that Lead to Becoming a Good Pain Medicine Doctor Bunty cites some traits that lead to becoming a good pain medicine physician. One is patience. As an educator, you're working with fellows and residents who may have limited exposure to some of the procedures and conditions they see at the center. You can't do everything yourself so you need to be able to teach the fellow. Allow them some autonomy at times but within a safe window. Other traits include inquisitiveness and curiosity. [09:20] Types of Patients and A Typical Day Being a major referral center at central Pennsylvania, they see a wide variety of cases and conditions. But being a large part of what they see is back pain, especially low back pain but also pain from the cervical spine and thoracic spine. They see a good deal of neuropathic pain related to conditions of the nerves and nervous system. They deal with things like neuropathy related to diabetes. They also treat pinched nerves of the spine which is considered neuropathic pain. They treat them with injections and medications. Additionally, they also see pain from other causes like cancer pain, arthritis of the spine and knees. They treat pain of all sorts and kinds. If there's a condition that's painful, they see it. A typical day for Bunty starts at 8 am when he arrives in the clinic. He has half a day of procedures that would include ultrasound-guided procedures, fluoroscopic-guided procedures, which would be x-ray-guided procedures. The second half of his day is seeing new and return patients. He works them up for different conditions and making recommendations about medications or possible procedures to help alleviate their pain. In cases when there are case conferences or journal clubs, he stays a little bit later until 6 or 7PM. But a typical work day for him is anywhere from 8am to 4:30pm or 5pm. [11:35] The Academic Side In terms of the academic side of things, they have medical students and residents and fellows. They are with them for a year at a time. They have several different rotations, most of which, are in the pain clinic. But for about a half a year, they rotate out of their pain clinic and onto other services such as spine surgery, palliative care, psychiatry, neuroradiology. So they get exposure in these other areas that are also relevant to their specialty. Their residents are part of the anesthesiology department and they rotate one month at a time. They come initially in their clinical base year, which is the first year of anesthesiology residency. And they return during their CA two year, which is their third year residency. The occasionally have a resident from neurology coming to their clinic and they also have fellows who rotate with them from rheumatology and orthopedics. They also have medical students rotating with them about every month or so. "A lot of different people coming in from different backgrounds but it's an educational experience for everyone." [13:25] Percentage of Patients that Go to the O.R. and Taking Calls Bunty estimates that 60% of their patients or maybe even 70% are patients who may benefit from a procedure and who are offered a procedure. The remainder of these patients are managed more conservatively with medications, physical therapy, sometimes pain psychology. It's a very multi-faceted approach. Especially in light of the opioid epidemic, they try to really approach issues from all different angles to really maximize benefit and minimize any harm they can cause to the patient. In terms of taking calls, Bunty takes a minimal amount of calls. He has a group of five physicians. So he takes call one in every five weeks. His call consists of seeing in-patient consults on days when he's on call. So gets a call one week at a time from Monday thru Friday. If he's seeing patients in the morning, after lunch break, he sees inpatient consults in the afternoon. This allows him to actually get out by 4 or 4:30 PM. The rounds on patients who have nerve catheters or epidurals on the weekends. It takes anywhere from 1-2 hours and he's free for the rest of the day when he's taking home call for that entire week (Monday-Sunday). If there are issues, they are first fielded by their fellow and if they have questions they can call him. Then they address these issues. Typically, they do this over the phone and it's only rare when he has to come to the hospital to take care of an issue. So he gets to have a good work-life balance and this is another motivator as to why he chose this specialty. "For the most part, the call is not very bad. It does allow a good work-life balance in my opinion." [16:05] The Path to Pain Medicine Pain medicine is a subspecialty, initially created within anesthesiology. However, it is a specialty which can be entered via several different routes. The traditional one is anesthesiology which is a four-year residency. Then that is followed by one year pain medicine fellowship. So pain medicine fellowships are all one-year long. Neurology is another route as well as Psychiatry, Emergency Medicine, and Physical Medicine & Rehabilitation (PM&R). These are specialties through which one can enter pain medicine. By and large, most candidates are coming from anesthesiology and neurology. Currently, they have three fellows in their program. Two of them are PM&R and one is Anesthesiology. So the fellowship doesn't differentiate between what residency they came from. There aren't separate pain medicine fellowships for different specialty backgrounds. It's all one and the same. In terms of treating patients, having one specific background doesn't necessarily give them an advantage over another. "Depending on the specialty you come from, you bring a different skill set." Bunty thinks PM&R residents and fellows have excellent examination skills of the musculoskeletal system. They come with good skills as far as procedures and ultrasound. They have a good understanding of the musculoskeletal system as far as dynamics and conditions that affect the system. On the other hand, Neurology residents and fellows come with a very good understanding of the neurologic bases for pain and neuropathic pain states. They're very well-versed in conditions like headaches. Anesthesiology residents come with very good understanding of analgesic pharmacology, basic physiology, as well as procedural skills as far as ultrasound goes. In anesthesia, they do a lot of peripheral nerve blocks and epidural injections. So Bunty thinks everyone brings something different to the table. That said, he wouldn't say one particular specialty is better than any other. In the end, he believes all of their fellows regardless of the specialty they originate in become excellent fellows. They're all on par with each other as far as becoming good pain physicians. [19:37] Competitiveness in Matching Bunty describes the Pain Medicine Fellowship as being quite competitive to match into. There are a number of pain medicine spots but it does happen to be one in high demand. One reason is particularly because the work-life balance is good in the specialty. You have an applicant pool that consists of candidates from multiple different specialties that may also contribute to the competitiveness of matching into the specialty. Being an associate program director, what he looks for in competitive applicants are strong academic record including good examination scores, and in-service examination scores, as well as board exam scores. He looks at the character, particularly assessed by interviewing the candidate but also reflected in the letters of recommendation. He looks for personality that will be compatible with working in a team. "Pain medicine is a team specialty that requires compatibility with working with members of other specialties, nurses, ancillary staff." Other traits include being inquisitive and having a good work ethic. He also adds that it's very hard to judge someone on procedural skills. You haven't seen them do procedures but instead, he looks into their experience in pain medicine. He sees if they've done rotations in pain medicine and what sort of procedural exposure they've had. And they also look at the letters of recommendation. Bunty uses the interview to see what the candidate's personality is like. He also tries to understand the candidate's motivation for pursuing a career in pain medicine. [22:55] Subspecialty Opportunities and Working with Primary Care and Other Specialties When you finish an interventional pain medicine fellowship, Bunty explains it's pretty much as specialized as you can get. One can also do another fellowship but Bunty explains this is pretty much where you end your training. Nevertheless, learning being a lifelong endeavor, you'd be required by the specialty to do CME (Continuing Medical Education). He thinks it's a good idea to go to conferences and meetings to continue your learning. But as far as fellowship training goes, there's typically no further subspecialization for pain medicine. In their pain clinic, Bunty describes a good relationship with their primary care colleagues. They have a good mutual understanding of what they can offer as pain medicine specialists for patients. He thinks it's important for primary care doctors to understand that they really strive to provide multidisciplinary care for their patients. Understand the indications for procedures like epidural injections. Understand that opioids are really the last resort and not proven in many studies to confer long term benefit in chronic pain. This is a major thing he'd like most primary care providers to understand. He also stresses that in terms of the use of adjuvant medications in the treatment of pain, it's important to think outside the box as far as pain medicine treatments go. Lastly, understand the benefits of physical therapy and pain psychology such as cognitive behavioral therapy and biofeedback techniques. The interplay of all these things in the treatment of pain and the holistic approach they give to patients is very important. Other specialties they work the closest with include primary care, neurosurgery, and orthopedic spine services since back pain plays a large part in why patients come to see them. [27:01] Special Opportunities Outside of Clinical Medicine If you're interested in research and has a PhD, there's a large need for research in pain medicine. Especially in the midst of opioid epidemic, research into the mechanisms of pain regulation and treatments are large areas that need a lot of research focus. What he wished he knew about pain medicine going into his training is how daunting it is to understand how low our success rate can really be. "For a lot of patients, even a small amount of relief can translate into a larger change in the quality of life." Now he appreciates it when he sees patients with a small increase in functionality or decrease in pain levels and how impactful this is in a patient's life. This is something he didn't appreciate early on which he does now. What he likes about being a pain physician is the ability to make a difference in patients' lives. Many patients come to them after having tried multiple different medications and even procedures. He starts from the beginning and he starts to understand why the patient is there. Sometimes they only want to be listened and to be validated in their thinking about their pain. Many patients are inappropriately labeled as medication seekers and so it's important to understand what the patient is saying. He takes the opportunity to really listen to the patient and get on the same page with them and what he can do for them. On the flip side, his least favorite part is getting coverage in certain procedures, doing peer-to-peer, and working with insurance companies which can be frustrating. He does his best to reach out to them and get procedures approved but there are times when he's not able to do so. Nevertheless, this does not diminish his enthusiasm for the specialty. "In any specialty, there's going to be some degree of dissatisfaction with working with insurance companies." Bunty clarifies that there are times when you can all insurance company for a peer-to-peer. You call someone from a completely different specialty. They often have policy guidelines to which they're obligated to adhere to. For instance, he has a colleague who did a peer-to-peer for a spinal cord stimulator. The physician he spoke with in the insurance company was a pediatrician. So you may not always speak to a pain physician although you will very often. It just depends on any given day that you may speak to someone from a different specialty. Then you argue your case to have it covered. [33:06] Major Changes in the Future Bunty illustrates a larger emphasis on procedures to treat pain and a move away from the prescription of opioids. Again, he stresses the importance of this since many people are dying from opioid abuse or misuse and overdoses related to this. It doesn't take a lot to appreciate the enormity of the situation. Many times, prescriptions are filled especially after surgical procedures or even dental procedures or oral surgical procedures. These pills don't fall into the right hands. Patients with multiple co-morbidities which may include cardiovascular or respiratory issues on opioids are at risk for overdose as well. He adds the general lack of study supporting the long term benefit of opioids in the treatment of chronic pain. Then you realize now there might be more harm from these medications. This is mostly for the treatment of non-cancer pain. This said, opioids have a long standing track record for being helpful in pain related to cancer. Still, you have to think out of the box and think about adjuvant medications and use the the World Health Organization ladder that emphasizes the use of weaker opioids and adjuvant medications (NSAIDS) before escalating to stronger opioids. "Many people are dying from opioid abuse or misuse and overdoses related to this." So what Bunty sees in the future is a renewed emphasis on the procedures to treat pain and pain psychology and physical therapy. He sees approaching the patient from a multidisciplinary way of thinking. Moreover, spinal cord stimulation is an exploding field. They now have high frequency stimulation applied to multiple painful states. They include neuropathic pain from complex regional pain syndrome. They're also having discussions about treating visceral pain with spinal cord stimulation. These stimulators use high frequency that don't depend on paresthesia. So the technology is opening up to many patients who previously would have never tolerated these vibrations. Bunty believes pain is an issue that affects so many of us and our loved ones. A lot remains to be learned about when it comes to pain. "It's an exciting time to be a pain physicians and it's an important time to be a pain physician." [36:47] Choosing the Specialty Again and Some Final Words of Wisdom If Bunty had to do it all over again, he would have chosen the same specialty. He's learning something everyday while being an educator. He says he's learning more from teaching than he is probably imparting. It's a humbling specialty but it's a very fulfilling career. Finally, Bunty parts the show with a message to all medical students and residents out there to be very curious. Always be learning to learn. If you like a specialty that combines procedures, medications, and working with multiple specialties, then pain medicine is something to consider. Links: Specialty Stories Episode 17: What Is Pain Medicine? A Community Doc Shares His Story MedEd Media

37: A Deep Dive into Dermatology Match Data and Surveys

Play Episode Listen Later Aug 23, 2017 21:28

Session 37 This week, we take a deep dive into the match data for dermatology. We cover the Match data from 2016 and 2017 to give you an idea of what you're up against. Dermatology is one of the hardest specialties to match into. Historically, it has been known as the ROAD specialties (Radiology, Orthopedics, Anesthesiology, and Dermatology). "Dermatology is still one of the more competitive residencies to apply to as a medical student." As we dive into this data, it gives you an idea of what you should be thinking about or doing when it comes to starting your journey. Hopefully, this will help you determine how much effort you put into getting the best possible board scores and everything else you need to get into dermatology. Also, check out everything we have at MedEd Media Network including The Premed Years Podcast, OldPreMeds Podcast, and The MCAT Podcast. [01:51] Match Summary As always, all of this data come from the NRMP Main Residency Match Results and Data First off is Table 1 which shows the summary of the match. It starts with PGY-1 positions and Dermatology has 11 programs, 26 positions. Don't freak out since there are actually a lot more dermatology spots offered. Dermatology has a prelim typically a medicine or transitional or surgery year that you do before you start your dermatology residency. As a medical student when you are applying to dermatology, you need to apply typically to a dermatology residency. This starts at PGY-2. Then you apply for a prelim year or an internship year which is your PGY-1 year at either a medicine, surgery or transitional program. So you can't go look at those numbers on Table 1 alone. Instead, go down to the continuation of Table 1 which shows the PGY-2 positions. There you will will see they have 121 programs and 423 positions offered. Looking at this chart across the column, the total number of U.S. Seniors applying out of those 423 spots is 479. So there are more U.S. Seniors than there are spots available. For this purpose, U.S. Seniors for the NRMP refer to students who are in an allopathic/MD medicine program and they're still in school. Now, out of those 479, 81.8% matched into Dermatology. That's a pretty good number and it's one of the higher numbers around. "If you are a DO student or an international medical grad, your chances are already starting off not that great." [05:00] U.S. Seniors, U.S. Grads, Osteopaths, and U.S. IMGs Table 2 shows that out of 423 positions, 415 were filled on the main match. 346 of those 415 were U.S. Seniors, 48 were prior U.S. grads, which means prior MD graduates. These are those that possibly didn't match their first time around and then reapplied. Or maybe they didn't apply to a residency program the first time around because they weren't very competitive. They wanted to do some research. Maybe they really wanted to go to one specific program so they went to do some research in that program, reapplied, and got in. There were 7 osteopathic students which makes up less than 2% of the 415 spots that were filled. It a very low number. Just to give you an idea, let's look at other specialties. Anesthesiology has 1,146 spots, 164 of which were osteopathic students. That's over 14% of Anesthesiology but less than 2% for Dermatology. It's possible there's still some bias tin the Dermatology world for DO's. There were 3 International Medical Graduates or IMGs who are U.S. citizens that went to a foreign or international medical school and 11 were non U.S. Seniors or non U.S. citizens that went to an international medical school. So it's high numbers for U.S. Seniors and good numbers for U.S. grads. Not good numbers for osteopathic students, and terrible numbers for U.S. International Medical Graduates. Lastly, it's pretty bad numbers for non-U.S. citizen international medical graduates. "High numbers for U.S. Seniors and good numbers for U.S. grads. Not good numbers for osteopathic students." [07:20] Growth Trends, Unmatched Applicants, and SOAP Table 3 shows the growth trend of each specialty from 2013 to 2017. Dermatology has been growing and growing with 13.3% in 2013. In 2017, there was a 15.8% year over year growth. There were 399 spots in 2016 and 423 in 2017. There are more and more programs opening up for Dermatology which is good for you if you're interested in Dermatology. "There are more and more programs opening up for Dermatology." Figure 6 looks at unmatched U.S. Seniors and independent applicants ranking all the different specialties. Dermatology ranks up as the second highest for all of the programs with 33.8% total unmatched. The majority of that are the independent applicants. They're outside of the U.S. Seniors and those were 47.3%. Almost half of the applicants were applying independently. Again, these are the IMG's and osteopathic students. I assume the U.S. grads are included here as well. The U.S. Seniors that went unmatched made up 13.8%. At a quick glance, it's the third highest behind Plastic Surgery and Orthopedic Surgery. So Dermatology is very, very competitive. Looking at Table 18 is the SOAP (Supplemental Offer and Acceptance Program) process, for PGY-2 positions, Dermatology had four positions available and all four were filled. [09:48] Ranking, Steps 1 &2, Research, AOA Chart 4 is one of the most telling charts when it comes to residency matching. When you match or apply to match, it depends on what programs you're applying to. A lot depends on how many program you are ranking. It's a big algorithm that matches you to programs. "You submit a rank list. Schools submit a rank list. And the magic happens." The median number of contiguous ranks is eight. This means that student that matched put Dermatology program eight times in a row. Those who did not match was only three. So you have a much lower chance of matching if you are much more selective when it comes to matching. The same goes if you're also being selective with the programs your'e applying to or you're interviewing at. Or you're not a competitive applicant and you didn't interview at a lot of program so could not select a lot of programs to actually match to. A lot of it comes down to how many programs you ranked. It's a numbers game. You apply to more medical schools, your chance goes up. You apply to more residency programs, your chances goes up. The same with fellowship programs. Chart 5 dives into the mean number of different specialties ranked. Typically, if you want Dermatology, apply to Dermatology programs. "If you have a Plan B, you're less likely to succeed in your plan A." There's a lot of psychology research that shows having a plan B decreases the likelihood for your Plan A to succeed. But the data here shows that those who matched in Dermatology applied to a mean number of 2.2 different specialties and those that didn't match is 2.3. So the numbers are not very off. This could be skewed since in dermatology, you have to apply to a categorical or prelim year. I wonder if that data is being included in this. It doesn't mention anything in the graph data, but I wonder if that's the reason the numbers are so high at 2.2. It's much higher than everything else except for radiation oncology. Looking at Table DM1, it gives us all the hard data behind Dermatology. The mean number of contiguous ranks is 8.9 versus 4.2. Mean number of Distinct Specialties was 2.2 versus 2.3. The mean USML Step 1 score was 249 for those that matched and 239 for those that didn't match. The mean Step 2 score is 257 to those that matched and 246 to those that didn't match. Sometimes, Step 2 score isn't really that useful. But the Step 1 score is huge here. The mean number of research experience is 4.7 for those that matched and 3.8 for those that did not match. Mean number of abstracts, presentations, and publications is 11.7. You need to get out there. You need to do your research. "You need a very, very strong Step 1 score and a strong Step 2 score... you need to do your research." AOA (Alpha Omega Alpha) comprised 2.8% of those that matched. This means they were very successful in their medical school classes early on. Their pre-clinical is 52.8% of those that matched and only 25.8% for those who did not match. Chart DM2 shows those that matched versus those that didn't with the number of contiguous ranks. You can clearly see that those that did not rank a lot of programs did not match. Then as soon as you get past that eight mark, it goes down. And after eight, only six people didn't match. So you have to rank a lot of programs. "You have to be competitive enough to get interviews and to rank a lot of programs." [15:40] Medscape Lifestyle and Medscape Physician Compensation Report The Medscape Lifestyle Report 2017 talks about the lifestyle of a Dermatologist. As to which physicians are the most burnt out, Dermatology is near the bottom at 46%. (See Slide 2)The lowest is Psychiatry at 42%. As to how severe is the burnout, Dermatology is hanging at the top at around 4.3. Highest is 4.6 with Urology. (See Slide 3). Slide 18 shows which physicians are the happiest and Dermatology is number three on the list at 43% happy at work and 74% are happy at home. The Medscape Compensation Report 2017 is the fun part. Highest salary is Orthopedics at $489K a year. Dermatology is number eight on the list at $386K. Below Orthopedics are Plastic Surgery, Cardiology, Urology, Otolaryngology, Radiology, Gastroenterology, and Dermatology. These are the top eight and all of these are procedure-based specialties. (See Slide 4) "The way our healthcare system is set up, those who perform procedures and do surgeries are compensated with more money." Even if what you're interested in is not within these eight, that's okay. You'd still make a good living as a physician. The lowest on this list is pediatrics at $202K. Dermatology pay according to this survey on Slide 5, only went up 1% (See Slide 5). Which physicians feel fairly compensated, Dermatology is the second highest at 65% (See Slide 18). Looking at slide 38, those who would choose medicine is up there at 80% and the highest is 83%. So Dermatologists are happy. They like being a doctor. They would choose it again. Who would choose the same specialty? Slide 39 shows it's Dermatology. They love their jobs. If you want to be a dermatologist, it might be good for you to check out Dermatology. [19:25] Be an Intern I'm looking for an intern. If this is something you're interested, email me at ryan@medicalschoolhq.net. I'm looking for one savvy for social media who can oversee my social media accounts and help me go out and find physicians to interview here on the podcast. It would be a great help to me and we can turn this into an extracurricular for you. We'll figure out a way to make it worth your time in helping this show succeed for every premed student, medical student, and even for residents out there looking for fellowships. In the subject line, kindly place Specialty Stories Intern. And I will get back to you as soon as you can. Links: MedEd Media Network The Premed Years Podcast OldPreMeds Podcast The MCAT Podcast NRMP Main Residency Match Results and Data Charting the Outcomes 2016 Medscape Lifestyle Report 2017 Medscape Compensation Report 2017

research data table student md schools medical deep dive match figure ranking highest plan b outcomes psychiatry seniors historically slide chart plastic surgery surveys cardiology orthopedics dermatology radiology dermatologists urology grads gastroenterology anesthesiology osteopaths premed orthopedic surgery otolaryngology aoa pgy alpha omega alpha imgs international medical graduates nrmp oldpremeds podcast meded media network soap supplemental offer

36: What Does Academic Colorectal Surgery Look Like?

Play Episode Listen Later Aug 16, 2017 59:18

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

35: Private Practice Pediatric Ophthalmology

Play Episode Listen Later Aug 9, 2017 22:43

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

children field student patients medical types ipads ent pediatric angle residency private practice ophthalmology premed retinopathy adam t pediatric ophthalmology meded media network

34: Community Based Interventional Gastroenterologist

Play Episode Listen Later Aug 2, 2017 32:09

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

52: The Specialty Stories Podcast is Live!

OldPreMeds Podcast

Play Episode Listen Later Dec 14, 2016 39:26

Session 52 This is a full recording of the first episode of the Specialist Stories podcast, which is another addition to the MedEd Media Network. The idea of this podcast was actually born out of The Academy where Ryan had several interviews with different specialists to help students get an understanding of what each specialty was like as well as their pros and cons. Through the Specialist Stories podcast, Ryan interviews different physicians from various specialties to help medical students and premedical students get different perspectives on what led them to their career path. Guests will be sharing with you stories of specialists from every field to give you the information you need to make sure you make the most informed decision possible when it comes to choosing your specialty. In this week's episode, Ryan talks with Dr. Michelle Hure, a dermatopathologist who has her own solo practice in her community. Here are the highlights of the conversation with Dr. Hure: When Michelle knew she wanted to be a dermatologist: From an interest in trauma surgery to dermatopathology Realizing the need for work-life balance Coming to a point of not wanting to do until her 4th years during rotation What she likes about her specialty: Changing people's lives and curing cancer Getting to do surgery Being able to get home at 5 Making use of her brain everyday What a dermatopathologist does: Two routes: Dermatology residency Pathology residency As a pathologist, it involves diagnosing conditions or interpreting biopsies that is key to a patient's treatment plan. You are the doctor's doctor Can do both clinical and pathology A day in the life of Michelle: Reading slides of biopsies she has taken personally or those from other doctors Seeing patients at 10 am Traits that lead to being a good dermatopathologist: Open mindedness: Being able to think of different possibilities and looking at slides without any biases Knowledge of clinical history and clinical medicine Curiosity Openness to different differential diagnosis A lot of thinking and investigation What makes a competitive applicant to dermatology and dermatopathology: Dermatopathology is very tough to get into since there aren't many programs so programs available are highly competitive. Be always in your game. Walk the extra mile. Do rotations in a place you're really interested in doing your residency as well as your fellowships. Be willing to take initiative. What residency was like for her: Collaboration as an important piece Pick a residency at the particular institution where that fellowship is to have a higher chance of getting in. What she wished she knew going into dermatology/dermatopathology: It's possible to have a family early on. Family comes first, residency and fellowship come second What she wished primary care providers knew more about dermatopathology: Training in dermatology and pathology What Michelle likes most about being a dermatopathologist: Intellectual stimulation Patient interaction Surgery Being able to cure cancer What she likes the least about her practice: Dealing with insurance companies If she had to do it all over again, would she choose another specialty? No, not at all. What is the future of dermatopathology? The pressure of being more noticeable to people so that biopsies must be done by experts in the field and not just "general" pathologists - It's not about money, it's about patient care! The saturation of the field Some pieces of advice to those wanting to be a dermatopathologist: Look for work-life balance. You have to be happy with the specialty you pick. In dermatology or pathology, you will do well money-wise, but you're also going to have a good work-life balance, which is one of the most important things you need to consider in going to a particular field. Pick a specialty that you're going to do well in and you're going to be happy with. Links and Other Resources: www.mededmedia.com Email Ryan at ryan@medicalschoolhq.net Specialist Stories Podcast The Premed Years Podcast The MCAT Podcast

family school training walk open academy student patients medical collaboration fellowship traits intellectual residency pathologies dermatology premed other resources dermatopathology dermatopathologist specialty stories podcast meded media network

1: What is a Dermatopathologist? Dr. Hure Shares Her Story